Standard

Treatment
Guidelines
for Primary
Health Care
second edition

REPUBLIC OF GUYANA
Ministry of Public Health


These guidelines have been made possible through support

provided by the US Agency for International Development via
Supply Chain Management System (SCMS), under the terms
of contract number GPO-I-00-05-00032-00. The contents
are the responsibility of the Ministry of Public Health and do
not necessarily reflect the views or positions of the US Agency
for International Development or the US government.
Contents
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
Acronyms and Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv
How to Use the Standard Treatment Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix
Background. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix
How to Use the Manual. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xx
Prescription Writing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxi
SECTION I. COMMON EMERGENCIES AND TRAUMA
1. Emergencies
1.1 Acute Abdomen. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2 Acute Airway Obstruction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1.2.1 Acute Laryngotracheobronchitis (Croup) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.2.2 Acute Epiglottitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
1.3 Acute Asthma (Severe)/Status Asthmaticus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
1.3.1 Status Asthmaticusin Adults. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
1.3.2 Status Asthmaticus in Children. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
1.4 Acute Diarrhoea with Dehydration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
1.5 Acute Urinary Retention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
1.6 Allergic Reaction (Severe)/Anaphylactic Shock. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
1.7 Bites and Stings—Insects, Snakes, Animals, and Humans . . . . . . . . . . . . . . . . . . . . 20
1.7.1 Insect Stings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
1.7.1.1 Bees, Wasps, and Marabunta . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
1.7.1.2 Scorpions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
1.7.1.3 Centipedes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
1.7.2 Snake Bites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
1.7.3 Cat, Dog, and Wild Animal Bites. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
1.7.4 Human Bites. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
1.8 Cardiopulmonary Arrest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
1.9 Diabetic Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
1.9.1 Hypoglycaemia (Low Blood Sugar). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
1.9.2 Hyperglycaemia (High Blood Sugar) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
1.10 Febrile Convulsions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
1.11 Hypertensive Crisis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

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1.12 Poisoning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
1.12.1 Acid and Other Corrosive Poisoning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
1.12.2 Aspirin or Salicylate Poisoning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
1.13 Seizures and Convulsions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
2. Trauma
2.1 Abdominal Injuries. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
2.2 Chest Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
2.2.1 Rib Fractures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
2.2.2 Flail Chest. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
2.2.3 Fractured Clavicle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
2.2.4 Pneumothorax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
2.3 Eye Injuries. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
2.4 Head Injuries. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
2.5 Wounds. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
SECTION II. DISEASES AND DISORDERS ACCORDING TO BODY SYSTEM
3. Respiratory System
3.1 Acute Bronchitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
3.2 Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
3.3 Bronchiolitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
3.4 Coryza (Common Cold) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
3.5 Influenza. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
3.6 Pneumonia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
3.7 Sinusitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
4. Ears, Nose, and Throat
4.1 Ear Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
4.1.1 Foreign Body in the Ear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
4.1.2 Impacted Wax in the Ear. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
4.1.3 Otitis Externa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
4.1.4 Otitis Media. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
4.1.5 Chronic Otitis Media. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
4.1.6 Hearing Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
4.2 Nose and Paranasal Sinus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
4.2.1 Nasal Obstruction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
4.2.1.1 Foreign Body in the Nose. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
4.2.1.2 Nasal and Sinus Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104

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4.2.1.2.1 Rhinitis and Rhinopharyngitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104

4.2.1.2.2 Allergic Rhinitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
4.2.2 Epistaxis (Nose Bleed). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
4.3 Throat Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
4.3.1 Tonsillitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
4.3.2 Pharyngitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
4.3.3 Laryngitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
4.3.4 Hoarseness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
5. Eye Conditions
5.1 Red Inflamed Eye. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
5.1.1 Conjunctivitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
5.1.1.1 Allergic Conjunctivitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
5.1.1.2 Infective Conjunctivitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
5.1.1.2.1 Bacterial Infective Conjunctivitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
5.1.1.2.2 Viral Infective Conjunctivitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
5.1.1.3 Chemical Conjunctivitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
5.1.1.4 Neonatal Conjunctivitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
5.1.2 Keratitis (Corneal Ulcer). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
5.1.3 Foreign Body in the Eye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
5.1.4 Arc Eye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
5.2 Eyelid Infection—Stye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
5.3 Xerophthalmia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
6. Cardiovascular System
6.1 Angina Pectoris. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
6.2 Congestive Heart Failure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
6.3 Hypertension. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
6.4 Peripheral Vascular Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
6.4.1 Peripheral Arterial Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
6.4.2 Deep Vein Thrombosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
7. GastroIntestinal System
7.1 Anorectal Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
7.1.1 Anal Fissures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
7.1.2 Constipation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
7.1.3 Haemorrhoids (Piles) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149

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7.2 Gastroenteritis (Diarrhoea). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151

7.2.1 Diarrhoea without Blood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
7.2.2 Diarrhoea with Blood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
7.3 Bacterial Food Poisoning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
7.4 Epigastric Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
7.4.1 Gastro-oesophageal Reflux Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
7.4.2 Gastritis and Peptic Ulcer Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
7.4.3 Gastrointestinal Bleeding. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
7.5 Liver Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
7.5.1 Jaundice. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
7.5.2 Hepatitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
7.6 Parasitic Infestations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
7.6.1 Giardiasis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
7.6.2 Helminthiasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
8. Urogenital System
8.1 Urinary Tract Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
8.1.1 Urethritis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
8.1.2 Cystitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
8.1.3 Pyelonephritis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
8.2 Renal Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
8.2.1 Nephrotic Syndrome. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
8.2.2 Glomerulonephritis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
8.2.3 Haematuria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
8.3 Sexually Transmitted Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
8.3.1 Gonorrhoea. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186
8.3.2 Chlamydial Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
8.3.2.1 Genital Chlamydia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
8.3.2.2 Lymphogranuloma Venereum. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
8.3.3 Trichomoniasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188
8.3.4 Vulvo-vaginal Candidiasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
8.3.5 Syphilis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190
8.3.6 Genital Herpes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192
8.3.7 Chancroid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
8.3.8 Granuloma Inguinale/Donovanosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
8.3.9 Genital Ulcers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
8.3.10 Urethral Discharge. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197

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8.4 Testicular Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199

8.4.1. Scrotal Swelling. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
8.4.2. Torsion of the Testis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
9. Musculoskeletal System
9.1 Lower Back Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
9.2 Joint Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
9.2.1 Osteoarthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
9.2.2 Rheumatoid Arthritis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
9.2.3 Gout. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
9.2.4 Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214
9.3 Muscular Disorders—Myalgia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216
9.4 Tendon Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
9.4.1 Carpal Tunnel Syndrome. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
9.4.2 Tennis Elbow. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
10. Dermatology
10.1 Acne . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220
10.2 Candidiasis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
10.3 Contact Dermatitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226
10.4 Eczema. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228
10.5 Hansen’s Disease (Leprosy). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230
10.6 Napkin Rash. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233
10.7 Psoriasis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234
10.8 Scabies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
10.9 Tinea (Pityriasis) Versicolor (Lata). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
10.10 Tineas. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
11. Endocrine System
11.1 Diabetes Mellitus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
11.2 Thyroid Gland Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250
11.2.1 Goitre. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250
11.2.2 Hypothyroidism. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
12. Nutritional Disorders
12.1 Anaemia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
12.1.1 Iron-Deficiency Anaemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254
12.1.2 Iron Deficiency in Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
12.1.3 Iron Deficiency in Children 6–24 Months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260

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12.2 Malnutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262

12.2.1 Undernutrition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262
12.2.2 Overweight and Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264
13. Haemoglobinopathies—Sickle Cell disease�����������������������������������������������������������������267
14. Infectious Diseases
14.1 Chickenpox. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271
14.2 Dengue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273
14.3 Filaria (Lymphatic Filariasis) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275
14.4 Leishmaniasis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277
14.5 Leptospirosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279
14.6 Malaria. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282
14.6.1 Falciparum Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284
14.6.1.1 Mild to Moderate Falciparum Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . 284
14.6.1.2 Severe Falciparum Malaria. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287
14.6.2 P. vivax Infection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289
14.6.3 P. malariae Infection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290
14.6.4 Mixed Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290
13.6.5 Malaria in Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291
14.7 Mumps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 292
14.8 Tuberculosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 294
14.9 Typhoid (Enteric Fever) and Salmonella Infections. . . . . . . . . . . . . . . . . . . . . . . 302
15. Gynaecology
15.1 Dysmenorrhoea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305
15.2 Abnormal Vaginal Discharge. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306
15.3 Abnormal Vaginal Bleeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308
15.4 Pelvic Inflammatory Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
15.5 Vulvo-Vaginal Candidiasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312
16. Neuropsychiatric Disorders
16.1 Anxiety Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313
16.1.1 Generalised Anxiety Disorder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314
16.1.2 Obsessive-Compulsive Disorder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315
16.1.3 Panic Disorder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317
16.1.4 Phobias. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 319
16.1.5 Post-Traumatic Stress Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 320
16.1.6 Childhood Anxiety Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323

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16.1.6.1 Generalized Anxiety Disorder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323

16.1.6.2 Obsessive-Compulsive Disorder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 324
16.1.6.3 Panic Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 324
16.1.6.4 Post-traumatic Stress Disorder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 324
16.1.6.5 Separation Anxiety. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 324
16.2 Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 326
16.2.1 Major Depressive Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327
16.2.2 Dysthymic Disorder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327
16.2.3 Depressive Disorders not Otherwise Specified. . . . . . . . . . . . . . . . . . . . . . . . 328
16.3 Dementia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329
16.4 Nonpsychiatric Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
16.4.1 Migraine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
16.4.2 Meningitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333
17. Signs and Symptoms
17.1 Abdominal Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 336
17.1.1 Acute Abdominal Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 336
17.1.2 Chronic Abdominal Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 340
17.2 Fever/PUO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343
17.3 Headache. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349
17.4 Myalgia (Muscle Pain). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 353
Appendixes
Appendix A. Essential Medicine Concept . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355
Appendix B. The Heimlich Manoeuvre . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 357
Appendix C. Common Asthma Triggers and Avoidance Strategies. . . . . . . . . . . . .358
Appendix D. Tobacco Cessation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 359
Appendix E. The DASH (Dietary Approaches to Stop Hypertension) Plan . . . . 360
Appendix F. Guidelines for Calcium Supplementation. . . . . . . . . . . . . . . . . . . . . . . . . 363
Appendix G. Dietary Guidelines for Diabetes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 364
Appendix H. Guidelines for Iron Supplementation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367
Index of Diseases and Conditions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383

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Preface
The Ministry of Health is pleased to provide the second edition of the
Standard Treatment Guidelines (STGs) for Guyana. This publication is a
follow-up of the successful development and launch of the first Standard
Treatment Guidelines in 2010, which aimed to harmonize the treatment
and management protocols for the public health care system locally. This
edition builds on the lessons learnt and the challenges encountered when
implementing national standards in an environment where several providers
with various backgrounds of training and medical practice culture were
integrated in to a free common health care delivery system.

The first edition successfully addressed the issue where no guidelines

for treatment or standard approaches to the management of a number of
illness, conditions, and diseases existed locally. As a consequence, many of
these conditions are now treated in accordance with agreed-upon national
standards, resulting in compliance with rational medicine use practices and
prevention of wastage.

In this second edition, we have increasedfrom 60 to more than 120 the

number of common diseases and conditions affecting the population. As in
the first edition, a Technical Review Group was appointed to be responsible
for review the existing 2010 guidelines and for the drafting the new areas that
were selected. This process followed WHO–recommended practices that
involved consultation with physicians and specialists for both public and
private practice, review of evidence-based literature, and a validation process
with stakeholders.

This guideline, therefore, provides evidence-based, cost-effective treatments

for common medical conditions and guarantees standardised quality care
to patients with effective use of resources. It is envisaged once again that
the second edition STGs will be used to orient new prescribers, guide the
procurement of medicines, guide the use of medicines at the different levels,
prevent the unnecessary stocking of and consequent wastage of medicines,
and ultimately promote the rational use of medicines and good health care
practice.

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P re face

This edition, like the previous one, is also recommended for use by the private
sector as the minimum standard of treatment thereby truly resulting in the
provision of unified high-quality health care for all patients across Guyana.

Dr. Shamdeo Persaud

Chief Medical Officer
Ministry of Health

xii
Acknowledgments
This expanded and revised edition of the Standard Treatment Guidelines for
primary healthcare was made possible only through the invaluable contributions
of many persons. We express our sincerest gratitude to all those persons who
contributed in some way to the realization of this project. Special thanks to the
Minister of Health, Dr. Bheri Ramsarran, for recognizing the need for a more
comprehensive volume and for supporting this activity. The leadership and
technical expertise of the Chief Medical Officer, Dr. Shamdeo Persaud, is also
acknowledged. Thanks also to the other members of the STG Technical Working
Group: Colette Gouveia, Dr. San San Min, and Lee Van De Santos.

Special thanks go to Dr. Claudette Harry, who has once again worked with
passion and dedication to complete this project.

We would also like to express sincerest gratitude to the following persons for
invaluable contribution to the drafting and validation of both editions of the
Standard Treatment Guidelines.
From the Ministry of Health:
Dr. Cartya Persaud
Ms. Fabiola Robertson
Dr. Gumti Krishendat
Dr. Holly Alexander
Dr. Jadunauth Raghunauth
Dr. Janice Woolford
Dr. Jeetendra Mohanlall
Dr. Julian Amsterdam
Dr. Munesh Persaud
Dr. Nadia Liu
Dr. Nadia Ramcharran
Ms. Norma Howard
Dr. Reyad Rahaman
Mr. Wilton Benn
Ms. Zetta Alberts

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A c k no w l edgments

Pharmacists from the Regional Health Department:

Ms. Amanda Barker (Region 10)
Mr. Fayad Subhan (Region 5)
Mr. Gregory Ceres (Region 6)
Mr. Sookdeo Singh (Region 2)
Mr. John Larkin
Ms. Vanessa Johnson
Private Medical Practitioners:
Dr. Carl Hanoman
Dr. Rabindra Shiwnandan
Dr. Roger Viapree
From Supply Chain Management System:
Mr. Cecil Jacques
Dr. San San Min
Mr. Corwin Hunte
Mr. Lee Van Santos
From the Georgetown Public Hospital Corporation:
Dr. Bhiro Harry
Dr. Kishore Persaud
Dr. George Norton
Dr. Ruth Quaicoe
Dr. Sheik Amir
Dr. Sudhir Sharma
Dr. Vindhya Persaud

xiv
Acronyms and Abbreviations
ABC airway, breathing, circulation
AFB acid-fast bacillus
AIDS acquired immune deficiency syndrome
ASA acetylsalicylic acid
BCG bacillus Calmette-Guérin [TB vaccine]
BID twice a day
BMI body mass index
BP blood pressure
BUN blood urea nitrogen
CBC complete blood count
CD4 cluster designation 4
CFNI/PAHO Caribbean Food and Nutrition Institute/Pan American
Health Organization
CNS central nervous system
CPR cardiopulmonary resuscitation
CSF cerebrospinal fluid
CT computerized tomography
CXR chest x-ray
dL decilitre
DM diabetes mellitus
DOTS directly observed therapy short-term
DVT deep vein thrombosis
ECG electrocardiogram
EEG electroencephalogram
ELISA enzyme-linked immunosorbent assay
EPTB extra-pulmonary tuberculosis
ESR erythrocyte sedimentation rate
FBC full blood count
g gram
G gauge
GCS Glasgow coma scale

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GERD gastroesophageal reflux disease

GFR glomerularfiltration rate
GI gastrointestinal
GPHC Georgetown Public Hospital Corporation
h hour
HAART highly active antiretroviral therapy
Hb haemoglobin
HCTZ hydrochlorothiazide
HDL high-density lipoprotein
HF heart failure
HIV human immunodeficiency virus
HRZE isoniazid (H), rifampin (R), pyrazinamide (Z), and ethambutol (E)
HSV herpes simplex virus
ICU intensive care unit
IgG immunoglobulin G
IgM immunoglobulin M
IM intramuscular
IMCI Integrated Management of Childhood Illness
INH isoniazid
IU international units
IV intravenous
kcal kilocalorie
kg kilogram
LDL low-density lipoprotein
LLQ left lower quadrant
LP lumbar puncture
LUQ left upper quadrant
MB multibacillary
mcg microgram
MCH mean corpuscular haemoglobin
mcmol/L micromole per litre
MCV mean corpuscular volume
MDR multidrug resistant

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 A cronyms and A bbre v iations

MDT multidrug therapy

mg milligram
MI myocardial infarction
MIU million international units
mL millilitre
mmHg millimetres of mercury
mmol/L millimole per litre
MOH Ministry of Health
MSM methyl sulfonyl methane
MUAC mid upper arm circumference
N/A not applicable
NGT nasogastric tube
NSAID nonsteroidal anti-inflammatory drug
OCD obsessive-compulsive disorder
ORS oral rehydration salts
PAD peripheral arterial disease
PB paucibacillary
PCP pneumocystis pneumonia
PCV packed cell volume
PID pelvic inflammatory disease
PO per os (by mouth)
PPI proton pump inhibitor
PR per rectum
PRN when necessary
PTB pulmonary tuberculosis
PTSD post-traumatic stress disorder
PUO pyrexia of unknown origin
PVD peripheral vascular disease
QID four times/day
RA rheumatoid arthritis
RDT rapid diagnostic test
RLQ right lower quadrant
RPR rapid plasma reagent

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RR respiratory rate
RSV respiratory syncytial virus
RUQ right upper quadrant
STG standard treatment guideline
STI sexually transmitted infection
TB tuberculosis
TIA transient ischaemic attack
TID three times/day
TSH thyroid stimulating hormone
tsp teaspoon
TST tuberculin skin test
URI upper respiratory infection
URT upper respiratory tract
URTI upper respiratory tract infection
VDRL Venereal Disease Research Laboratory
VIA visual inspection (of cervix) with acetic acid
WBC white blood cell
WCC white cell count
WHO World Health Organisation
XDR extensively drug resistant

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How to Use the Standard Treatment Guidelines
Background
Over the years, the Ministry of Health has developed and implemented various
guidelines relating to patient care and management of a number of priority
diseases in Guyana. These guidelines have all been published individually, but
no single documents provided a standardized approach to the management of a
number of frequently seen diseases at the primary care level, until 2010, when
the first edition of the Standard Treatment Guidelines was published.

Since then, a review of the use of the STGs has been undertaken and the format
changed to provide a more systematic approach to the understanding of the
disease entities. Additional chapters have been added to include other diseases
commonly seen at the primary health care level including emergencies, trauma,
and neuropsychiatric disorders.

The medicines used in the management of the diseases are evidence based and
linked to the medicines available in the Guyana Essential MedicinesList. The
use of clinical practice guidelines is,therefore,a means ofproviding standardized
and quality care, and making more effective use of scarce resources. (See
appendix A, “The Essential Medicine Concept.”)

Treatment guidelines serve to—

ƒƒ Guide the procurement of medicines
ƒƒ Guide the availability of medicines at the different levels of health facility
ƒƒ Prevent unnecessary stocking of medicines and, hence, wastage
ƒƒ Provide a standardized approach to the management of diseases

Furthermore, STGs and EMLs provide inputs for the compilation of national
formularies.

It is envisioned that these guidelines will be applied systematically and, thus,

lead to improved care and outcomes of the diseases in the Guyana context.
These guidelines are meant for the use of medical and health professionals, (e.g.,
doctors, medexes, and community health workers), involved in curative care at
the primary health care level.

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How to Use the Manual

To use the STGs effectively, users of the manual must become familiar with
its content and layout. Diseases are discussed according to systems, disease
category, or signs and symptoms. Some diseases that already have existing
guidelines (e.g., AIDS) are, in general, not included in this manual, but where
such diseases are included, the disease-specific guidelines can be consulted
for greater details about prevention, community action, and follow-up.Where
relevant, the guidelines are consistent with the case management guidelines
of the Integrated Management of Childhood Illness (IMCI) Strategy and other
nationaltreatment guidelines.

The table of contents at the beginning of the manual provides the number
and title of each chapter along with its subsections and page numbers. The
alphabetical index lists the names of the diseases and page numbers for ease
of reference. Each disease is discussed according to the following format,
where applicable:

ƒƒ Description of the medical condition

ƒƒ Classification
ƒƒ Causes and risk factors
ƒƒ Signs and symptoms
ƒƒ Diagnosis (and, in some cases, differential diagnosis)
ƒƒ Investigations
ƒƒ Management objective(s)
ƒƒ Nonpharmacological management
ƒƒ Pharmacologicalmanagement—medicine, dose, duration
yy First line
yy Second line
yy Third line (if necessary)
ƒƒ Referral
ƒƒ References

When the disease entity is problem based (e.g., a sign or symptom), a

flowchart is provided to aid diagnosis. These charts are to be read from top
to bottom and from left to right. The boxes on the extreme left ask questions
that can be answered with a YES or NO. Depending on the answer, an arrow
leads downward with further questions or across to the next column of

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boxes, which provides the possible diagnosis. The next box to the right provides
treatment guidelines.

All the medicines cited in the guidelines are included in the Guyana Essential
Medicines List. The essential medicine concept and instructions on how to use
that manual are outlined in appendixes A and B.

Not all patients or conditions need prescriptions for medicines. In certain

conditions, simple advice and nonpharmacologicalmanagement may be more
suitable. Medicines should be prescribed only when they are necessary for
treatment following a clear diagnosis. In all cases, the practitioner must carefully
weigh the expected benefit of a prescribed medication against potential risks.
This balance is especially important when treating pregnant patients since the
risk to both mother and foetus must be considered.

Some of the material in this STG came from outside sources. To minimize
space and confusion, all references have been numbered by the order they have
appeared in this document, and the appropriate reference numbers for a section
are noted at the end of the section. The numbered list of references can be found
on pg. 367 in this manual. for example, if a section is followed by the notation—
references 22,24—please turn to the reference section on pg. 367 and look at
reference numbers 22 and 24.

Prescription Writing
All prescriptions should—
ƒƒ Be written legibly in ink by the prescriber
ƒƒ Contain the current date
ƒƒ Give the full name and address of thepatient
ƒƒ Specify the age of the patient
ƒƒ Note the patient’s weight on prescriptions for children
ƒƒ Be signed by the prescriber

In all prescription writing, the following instructions should be followed:

ƒƒ Write the name of the medicine or preparation in full using the generic
name.

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H

ƒƒ Limit the use of abbreviations to those generally accepted and listed in the
acronyms and abbreviations list (e.g., ASA, HCTZ, HRZE, and MSM) to
avoid misinterpretation.
ƒƒ Avoid unnecessary use of decimal points, and use them only when they are
unavoidable. A zero should be written in front of the decimal point if there
is no other numeral (e.g., 2 mg and not 2.0 mg; 0.5 mL and not .5 m).
ƒƒ State the treatment regimen in full, including the following information:
yy Medicine name, strength, and form
yy Dose or dosage
yy Dose frequency
yy Duration of treatment, for example—
ŠŠ Amoxicillin (250 mg tablet) every 8 hours for 5 days
ŠŠ Amoxicillin (250 mg tablet) 2 tablets every 8 hours for 5 days
ŠŠ Amoxicillin (250 mg tablet) 500 mg every 8 hours for 5 days
ƒƒ In the case of “as required” (PRN), specify a minimum dose interval (e.g.,
every 4 hours as required).

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1. Emergencies

1.1 Acute Abdomen

Description
Acute abdomen is a clinical term used to describe a syndrome in which the major
symptom is a sudden acute abdominal pain of unknown origin. Pain may occur in
any quadrant of the abdomen. Acute abdomen is a medical emergency requiring
urgent and specific diagnosis. Several causes need surgical intervention.
Management must be instituted before referral to hospital.

Causes
The pain may originate from the abdomen, or it maybe referred from an extra-
abdominal source. It maybe metabolic or neurogenic, both of which need to be
ruled out when making a diagnosis.

Pains originating in the abdomen may be a result of the following causes.

ƒƒ Inflammatory
yy Acute peritonitis
yy Acute appendicitis
yy Acute pancreatitis
yy Ruptured liver abscess
yy Pelvic inflammatory disease
yy Ruptured tubo-ovarian abscess
yy Acute pyelonephritis
yy Acute diverticulitis
ƒƒ Bowel obstruction
yy Strangulated hernia
yy Volvulus, adhesions
yy Intussusception
ƒƒ Perforations of hollow organs (e.g., stomach, duodenum, intestines)
ƒƒ Colic
yy Acute cholecystitis or gallstones
yy Ureteric stones

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ƒƒ Haemorrhagic
yy Ruptured ectopic pregnancy
yy Ruptured spleen
yy Twisted ovarian cyst

Signs and symptoms

ƒƒ Colicky abdominal pain that is either sudden or gradual in onset and
increase of severity suggests an obstruction.
ƒƒ Continuous pain when the patient lies quite still suggests peritonitis.
ƒƒ Fever is present in inflammatory conditions.
ƒƒ Other signs and symptoms can be—
yy Anorexia, nausea, and vomiting
yy Abdominal distension
yy Signs of dehydration
yy Signs of shock (i.e., cold, clammy skin; profuse sweating; tachycardia;
hypotension)
yy Anxiety or altered mental state

Diagnosis
ƒƒ Diagnosis is based on history or clinical symptoms, physical examination,
radiography, and laboratory tests. A detailed history is far more valuable
than an x-ray or laboratory examination.
ƒƒ Location of pain may indicate the following:
yy RLQ—appendicitis, salpingitis, ruptured ectopic pregnancy, tubo-
ovarian abscess
yy RUQ—cholecystitis, duodenal ulcer, hepatitis, pyelonephritis, hepatic
abscess
yy LLQ—sigmoid diverticulitis, salpingitis, tubo-ovarian abscess, ruptured
ectopic pregnancy, perforated colon
yy LUQ—ruptured spleen, pyelonephritis, aortic aneurysm
ƒƒ Other indicators include and point to the following:
yy Severe rebound tenderness and rigidity and guarding—peritonitis
yy Abdominal x-ray results may indicate the following:
ŠŠ Distended bowel—obstruction
ŠŠ Pneumoperitoneum—perforation
yy Full blood count and differential WCC—infection

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Note: Intrathoracic disease must be considered in every patient especially if the

pain is in the upper part of the abdominal cavity.

Management objectives
At the health centre—
ƒƒ Determine the cause
ƒƒ Start emergency treatment before referral (i.e., while waiting to transport
the patient).

Nonpharmacological management
ƒƒ Pass a nasogastric tube with drainage bag if vomiting or abdominal
distension is severe.
ƒƒ Give nothing by mouth.
ƒƒ Give oxygen if the patient is in shock.
ƒƒ Elevate the legs if the patient’s BP is low.
ƒƒ Pass a Foley catheter, and monitor urine output.
ƒƒ Secure IV access.
ƒƒ Obtain urine and blood samples for analysis.

Pharmacological management
ƒƒ Start an IV infusion of normal saline using a 16 G or 18 G needle or cannula.
Give 1 L every 1–2 hours if patient is in shock and every 4–6 hours if
patient’s BP is normal.
ƒƒ If fever is present, start the patient on a broad-spectrum antibiotic:
yy Ceftriaxone injection (500 mg, 1 g) 1 g IV daily
OR
yy Gentamycin (10 mg, 40 mg/mL) 5 mg/kg IV daily
PLUS
yy Metronidazole injection (500 mg/mL) 500 mg IV every 8 hours

Referral
Refer the patient to the hospital.

References—1, 2, 3

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1.2 Acute Airway Obstruction

Description
Foreign bodies in the throat (pharynx), voice box (larynx), trachea, or bronchi,
which can cause acute upper airway obstruction leading to the onset of
respiratory distress, constitute a medical emergency. Acute airway obstruction
is more common in children, who typically ingest objects they pick up and place
in their mouths.

Causes
ƒƒ Foreign body aspiration such as—
yy Coins, buttons, beads, marbles, toys and crayons, and similar items.
Children either swallow or aspirate these objects.
yy In contrast, adults are more likely to ingest food boluses, chicken or fish
bones, fruit pits, dentures, or toothpicks.
ƒƒ Infections such as—
yy Laryngotracheobronchitis (croup)
yy Acute epiglottitis
ƒƒ Secondary to other causes
yy Laryngeal oedema from anaphylaxis or trauma
yy Tongue obstruction in an unconscious patient

Signs and symptoms

Symptoms vary depending on the cause and site of impaction, but some
symptoms are common to all types of obstruction.
ƒƒ Agitation or fidgeting
ƒƒ Choking or inability to swallow
ƒƒ Confusion
ƒƒ Difficulty breathing
ƒƒ Gasping for air
ƒƒ Panic
ƒƒ Stridor (i.e., wheezing, crowing, whistling, or other unusual breathing
noises indicating breathing difficulty)
Caution: A total obstruction of the upper airway causes asphyxia and results
in rapid death. Total obstruction should be suspected if the patient exhibits
a bluish skin colour (cyanosis) or is unconscious.

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Persons with an object stuck at the back of the throat will have that sensation
and difficulty in swallowing. If the obstruction is in the oesophagus, the
sensation is felt lower down, and the patient may be drooling because of inability
to swallow.

Diagnosis
A diagnosis is made by a positive history, clinical signs, radiology, and diagnostic
laryngoscopy.

Management objectives
ƒƒ Ensure a clear patient airway
ƒƒ Remove the obstruction

Nonpharmacological management
ƒƒ Management depends on the cause of the blockage and is best carried out at
the hospital level.
ƒƒ Objects lodged in the airway may be removed with a laryngoscope or
bronchoscope.
yy A tube may be inserted into the airway (e.g., endotracheal tube or
nasotracheal tube).
yy As a last resort, an opening can be made directly into the airway (i.e.,
tracheotomy or cricothyrotomy using a large-bore needle).
Caution: Total obstruction of the upper airway is an emergency requiring
use of the Heimlich manoeuvre. (See appendix B.)
ƒƒ In a child <1 year: Removal of the obstruction should be carried out in an
operating theatre. Management while waiting for transfer—
yy First check the mouth for any foreign body, even if none is immediately
apparent.
yy Lay child face downwards, and give five blows on the interscapular
region, with the heel of a cupped hand. Check in the mouth again for the
foreign body.
yy If it is still not seen, lay the child face up and give five blows to the chest.
yy If the foreign body is still not seen or has not been dislodged, then give
five lateral chest blows.
yy If the child is still not breathing, then continue to administer CPR until
the ambulance arrives.

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ƒƒ In a child >1 year and in adults:

yy Stand behind the patient and give jerks with a closed fist at the upper
abdomen, below the sternum until the foreign body comes out. (See
appendix B.)
yy If the patient has a partial obstruction in breathing or dysphagia, do not
try to check in mouth by blindly inserting your finger in the patient’s
mouth—this may cause trauma or push the obstruction down the
oesophagus.
Caution: Pushing a brush or finger into mouth to check it or to induce
vomiting, causes more trauma, and the foreign body may become more
impacted. Keep calm and go to a specialist.
yy Small bones or foreign bodies are removed from the oropharynx using
forceps under proper illumination and may require 10% xylocaine spray.

Referral
Deeply impacted foreign bodies in the lower oropharynx, larynx,
laryngopharynx, oesophagus, and bronchus need endoscopic removal under
general anaesthesia.

References—4, 5, 6, 7, 8

1.2.1 Acute Laryngotracheobronchitis (Croup)

Description
Croup is an acute inflammation of the larynx, trachea, and bronchi, which can
lead to life-threatening airway obstruction in early childhood.

Causes
Most common pathogens are viruses.

Signs and symptoms

ƒƒ Very ill child—harsh barking cough
ƒƒ Inspiratory stridor
yy Drooling saliva
yy Unable to swallow
ƒƒ Intercostal and subcostal retraction of the chest wall—sitting upright with
head held erect

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Diagnosis
ƒƒ Base the diagnosis on clinical signs and symptoms.
ƒƒ Suspect croup if the child shows signs 1–2 days after the onset of an upper
respiratory tract infection.

Management objective
ƒƒ Maintain a clear airway. Use table 1.2.1A to assess the degree of airway
obstruction and to manage croup.

Table 1.2.1A. Assessment and Management of Croup

Signs Action
Grade 1—inspiratory stridor Observe.
Grade 2—inspiratory and expiratory Administer—
stridor yy Adrenaline, 1:1,000 diluted in saline,
nebulised immediately
yy Dilute 1 mL of 1:1,000 adrenaline with 1 mL
sodium chloride 0.9%
yy Prednisone, oral, 1–2 mg/kg, single dose
yy Refer
Grade 3—inspiratory and expiratory Treat as with grade 2.
stridor with pulsus paradoxus
Grade 4—apnoea Intubate and provide respiratory support as
above.

Nonpharmacological management
ƒƒ Keep child comfortable, and reduce anxiety.
ƒƒ Continue oral fluids.
ƒƒ Encourage parent or caregiver to remain with the child.

Pharmacological management
ƒƒ The infection is viral, so no antibiotic is required.
ƒƒ Give paracetamol, oral, every 4–6 hours, when required, not to exceed 4
doses daily (see table 1.2.1B).

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Table 1.2.1B. Paracetamol Dosages by Age and Weight for the Management
of Croup

Syrup
Weight (kg) Dose (mg) (120 mg/5 mL) Tablet (500 mg) Approximate Age
6–10 60 2.5 mL — 3–12 months
10–18 120 5.0 mL — 1–6 years
18–15 240 10.0 mL ½ tablet 5–8 years
25–50 500 — 1 tablet 8–14 years

ƒƒ If the child requires referral (i.e., grade 2 or higher), contact an ambulance

and doctor immediately.
yy Management while awaiting transfer—
ŠŠ Administer adrenaline, 1:1,000, nebulised, immediately using a
nebuliser. If there is no improvement, repeat every 15 minutes, until
the child is transferred.
–– Dilute 1 mL of 1:1,000 adrenaline with 1 mL sodium chloride 0.9%.
–– Nebulise the entire volume with oxygen at a flow rate of 6–8 L/
minute.
ŠŠ Give prednisone, oral, 2 mg/kg, single dose.
OR
ŠŠ Give a single dose of hydrocortisone (powder 100 mg/mL) mg/kg IV.
ŠŠ Start on oxygen.
yy Management during transfer—
ŠŠ Maintain oxygenation.
ŠŠ Continue as above.
ŠŠ Provide IV access.

Referral
The following require urgent referral:
ƒƒ All children with—
yy Stridor on breathing in and out while at rest
yy Chest indrawing
yy Nasal flaring
yy Rapid breathing
yy Altered consciousness
yy Inability to drink or feed

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ƒƒ Suspected foreign body

ƒƒ Suspected epiglottitis

References—3, 8

1.2.2 Acute Epiglottitis

Description
Acute epiglottitis is a rapidly progressive cellulitis of the epiglottis and adjacent
structures that can result in complete airway obstruction in both children and
adults.
Caution: Acute epiglottitis constitutes a medical emergency particularly in
children and should be handled at the hospital level.

Cause
Bacterial: H. influenza type B

Signs and symptoms

ƒƒ In young children—Acute epiglottitis is characterized by rapid onset of the
following:
yy High fever (i.e., >39ºC)
yy Severe sore throat and difficulty in swallowing
yy Excessive saliva due to inability to swallow
yy Rapid heartbeat (tachycardia)
yy Signs of respiratory obstruction—difficulty breathing (dyspnoea). Chest
indrawing may also be present and may progress rapidly.
yy Inspiratory stridor
yy Swelling of the lymph nodes under the jaw
ƒƒ In adolescents and adults—the illness is milder and often follows 1–2 days
of severe sore throat.

Diagnosis
Diagnosis is often made on clinical grounds.
ƒƒ Examination of the oropharynx using a tongue depressor and a light source
ƒƒ Swollen erythematous epiglottis

Management objective
Maintain a clear airway

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Nonpharmacological management
ƒƒ Do not lay the child down; keep him or her in a sitting position.
ƒƒ Avoid examining the larynx because of the risk of respiratory arrest.
ƒƒ Have the child breathe in a humid environment (e.g., next to a bowl of water
or a wet towel).
ƒƒ Have the child gargle with glycerine.
ƒƒ Give the child oxygen if indicated.

Note: Health posts and health centres should refer the patient immediately to
hospital where a physician is available. Start on first-line antibiotics in areas
where transfer to hospital may be delayed.

Pharmacological management
ƒƒ At the hospital level, start antibiotic treatment:
yy Administer first-line treatment: ampicillin IV (powder for injection 500
mg and 1 g) 200 mg/kg/day (divided into3 doses) every 8 hours for 1 day
then continue with 100 mg/kg/day every 8 hours for 6–9 days.
OR
yy Administer second-line treatment: ceftriaxone IM: (125 mg, 500 mg, and
1 g) 100 mg/kg/day (in 2 divided doses) every 12 hours for 7–10 days.
OR
yy For patients allergic to penicillins and cephalosporins, administer
chloramphenicol (powder for injection 250 mg, 500 mg). Give 25 mg/kg
every 6 hours. Change to PO when appropriate.
ƒƒ Give paracetamol (500 mg tablets; 120 mg/5 mL suspension). See table 1.2.2.

Table 1.2.2. Paracetamol Dosages by Age and Weight for the Management of
Acute Epiglottitis

Age Weight Dose (mg) Quantity Frequency Duration

3–12 months 6–10 kg 60 2.5 mL (½ tsp) 3 times/day 5–7 days
1–5 years 10–18 kg 120 5 mL (1 tsp) 3 times/day 5–7 days
5–8 years 18–25 kg 240 10 mL (2 tsp) 3 times/day 5–7 days
or ½ tablet
8–14 years 25–50 kg 500 1 tablet 3–4 times/day 5–7 days
>14 years >50 kg 1,000 2 tablets 3–4 times/day 5–7 days
and adults

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Management of the acute stage of epiglottitis

For significant swelling:
ƒƒ Give hydrocortisone, IV, 100 mg immediately as a single dose.
Caution: Setting up IV access may cause irritability, leading to respiratory
distress.
ƒƒ Follow with prednisone, oral, 40 mg daily. Prednisone can be stopped
abruptly after 3 days, once the swelling has subsided. If it is used for longer
than 3 days, taper by 10 mg/day until dosage reaches 5 mg, then stop.
PLUS
ƒƒ Give adrenaline 1:1,000, nebulized. Dilute to 5 mL with sodium chloride
0.9%, and administer every 4–6 hours.
ƒƒ Prepare for intubation, tracheostomy, or both.

Referral
ƒƒ If the ability to perform an intubation is not available, start on treatment,
and refer immediately.
ƒƒ Children exhibiting the following, require immediate referral:
yy Stridor or laboured breathing in and out while at rest
yy Chest indrawing
yy Rapid breathing, defined as—
ŠŠ <2 months, RR >60 breaths/minute
ŠŠ 2–11 months, RR >50 breaths/minute
ŠŠ 12–59 months, RR >40 breaths/minute
yy Altered level of consciousness
yy Inability to drink or feed

References—1, 8, 9, 10, 11

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1.3 Acute Asthma (Severe)/Status Asthmaticus

Description
A sudden intensification in the symptoms during an attack of asthma, not
responding to standard treatment of bronchodilators and steroids is called
status asthmaticus. (See also section 3.2 “Asthma.”)

1.3.1 Status Asthmaticusin Adults

Signs and symptoms
ƒƒ Long duration of present attack
ƒƒ Rapid, progressive dyspnoea
ƒƒ Excessive use of accessory muscles of respiration
ƒƒ Excessive wheezing
ƒƒ RR >30/minute
ƒƒ Decreased breath sounds
ƒƒ Cyanosis

Management objectives
ƒƒ Reverse the obstruction
ƒƒ Relieve hypoxia as soon as possible

Nonpharmacological management
In the health centre or hospital—
ƒƒ Start treatment, and hospitalize immediately.
ƒƒ Start oxygen if available.
Caution: Do not give sedatives.

Pharmacological management (in adults)

In the health centre or health post—
ƒƒ Administer a high dose of salbutamol: 5 puffs every 10 minutes.
ƒƒ Refer urgently to the district hospital.

In the hospital—
ƒƒ Provide immediate treatment.
yy Give oxygen 40–60%.
yy Administer inhaled salbutamol: 5 puffs every 10 minutes until
improvement; then every 2–4 hours.

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yy If symptoms are severe, consider using inhaled ipratropium bromide

(0.25%).
yy Set up an IV line (normal saline), and monitor fluid intake.
yy Administer hydrocortisone 100 mg IV; repeat in 2 hours PRN.
ŠŠ Continue to monitor the patient’s level of hydration.
ŠŠ Change to prednisolone PO as soon as possible: 0.5–1 mg/kg daily for
5 days.
ŠŠ Reduce dose over 10-day period, and follow up in 10 days.
ƒƒ If the patient has shown no improvement 20–30 minutes after starting the
immediate treatment, take the following steps.
yy Administer aminophylline IV infusion: loading dose of 5 mg/kg diluted
in isotonic solution over 30 minutes and then 0.5–1 mg/kg/hr.
yy Change to oral aminophylline after 24 hours.
Caution: Never administer aminophylline by direct IV.

Caution: If the patient has already been given oral aminophylline, do not
give the loading dose.
ƒƒ If the patient’s condition is severe and persistent, follow this procedure:
yy Provide continuous treatment with high-dose inhaled beclometasone
and inhaled salbutamol (1 puff 4–6 times/day)
PLUS, if needed
yy Give prednisolone tablets: 2 mg/kg/day, but not to exceed 60 mg/day. Try
to wean the patient off this medicine as soon as feasible.
yy If the patient still shows no improvement, intubation and ventilator
support will be required.

1.3.2 Status Asthmaticus in Children

Signs and symptoms
ƒƒ General signs and symptoms
yy RR >50 breaths per minute (>40 in children >5 years)
yy Pulse >140 beats per minute (>120 in children >5 years)
yy In younger children, use of accessory muscles of breathing
ƒƒ Life-threatening signs and symptoms
yy Cyanosis
yy Decreased breath sounds or poor respiratory effort

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yy Fatigue or exhaustion
yy Agitation or reduced level of exhaustion
yy Collapse

Management objectives
ƒƒ Reverse the obstruction
ƒƒ Relieve hypoxia as soon as possible

Nonpharmacological and pharmacological management

ƒƒ Start oxygen via face mask: 1–2 L per minute (if available).
ƒƒ Administer inhaled salbutamol: 10 puffs initially then 1 puff every 15–20
seconds until the child shows response to treatment.
ƒƒ Set up an IV line (normal saline).
ƒƒ Give hydrocortisone: 100 mg every 6 hours PRN.
ƒƒ Change to prednisolone as soon as possible: 1–2 mg/kg as a single dose in
the morning for 5 days; do not exceed 20 mg/day in children <5 years and 40
mg/day in children >5 years. Reduce dose gradually over a 10-day period.
ƒƒ If the child shows no improvement, intubation and ventilator support will
be required.

Referral
Presence of life-threatening signs or symptoms

References—1, 3, 10, 12

1.4 Acute Diarrhoea with Dehydration

Description
Acute diarrhoea is the passing of loose (i.e., liquid or unformed) stools >3
times/day. If more fluid is being lost than is being replaced, the result can be
dehydration (i.e., inadequate body fluids).

Signs and symptoms

Signs of dehydration
ƒƒ Floppy, weak
ƒƒ Drinks poorly or not able to drink
ƒƒ Eyes deeply sunken
ƒƒ Mucosa very dry
ƒƒ Skin retracts very slowly when pinched

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ƒƒ Skin turgor very diminished

ƒƒ Lethargic, comatose
ƒƒ Shock

Signs of shock
ƒƒ Tachycardia
ƒƒ Cold, pale extremities
ƒƒ Rapid deep breathing
ƒƒ Floppy, lethargic or comatose

Referral
Refer to hospital for treatment with IV fluids.

While waiting for transfer, take the following steps, if possible.

ƒƒ If you know how to set up an IV, start immediately.
yy Give Ringer’s lactate in the following amounts:
ŠŠ Child <12 months: 30 mL/kg for the first hour, then 70 mL/kg per
hour over next 5 hours
ŠŠ Child 1–5 years: 20–30 mL/kg for the first 30 minutes, then 70 mL/kg
over next 2.5 hours.
ŠŠ Older children and adults: 30 mL/kg for first 30 minutes, then
100 mL/kg over next 2.5 hours.
yy Reassess frequently, every 1–2 hours. If the patient has shown no
improvement after the first hour, increase infusion rate.
yy Feeding
ŠŠ For infants, continue breastfeeding throughout the process.
ŠŠ For bottle or cup-fed children, do not give food during the initial
4-hour rehydration period, but do not stop nourishment for more
than 4 hours.
yy Start ORS as soon as possible.
ƒƒ If you were not trained to set up an IV but were trained to use a nasogastric
tube, proceed as follows:
yy Start rehydration by tube using ORS solution, giving 20 mL/kg/hr for 6
hours (total 120 mL/kg)
yy Reassess every 1–2 hours.
ƒƒ If you were not trained to use a nasogastric tube, start ORS 20 mL/kg/hr for
6 hours. Reassess every 1–2 hours.

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1.5 Acute Urinary Retention

Description
Acute urinary retention is defined as a sudden onset of the inability to pass urine
even though the bladder is full. It constitutes a medical emergency requiring
prompt action. Chronic obstruction may result in permanent loss of renal
function. It occurs most often in men over 60 years of age.

Causes
Obstruction can occur from an intrinsic or extrinsic mechanical blockage or
from functional defects.
ƒƒ Obstruction in the urinary tract
yy Intrinsic
ŠŠ Urethral stone
ŠŠ Enlarged prostate—benign or cancerous
ŠŠ Infection (prostatitis)
ŠŠ Urethral stricture from previous gonorrhoeal infection or injury
yy Extrinsic
ŠŠ Pregnant uterus
ŠŠ Cancer of uterus, prostate, colon, cervix, rectum
ƒƒ Nerve disease or spinal cord injury

Signs and symptoms

ƒƒ Severe suprapubic or lower abdominal pain
ƒƒ Bladder distension, abdominal distension
ƒƒ No passing of urine or passing just a dribble

Diagnosis
Diagnosis is based on the patient’s history and a physical examination. A
distended bladder can be identified by percussion.

Investigations
Look for a cause using the following techniques:
ƒƒ Perform a rectal digital examination for an enlarged prostate.
ƒƒ Try passing a F16 or F18 catheter to identify strictures.
ƒƒ Take a urine specimen for evidence of infection or haematuria.

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Management objective
Re-establish a normal urine flow

Nonpharmacological and pharmacological management

At the health centre level—
ƒƒ Catheterize.
yy Use a sterile small (16 G) Foley catheter and sterile technique.
yy Lubricate catheter tip and urethra with KY jelly.
Caution: Make sure the catheter balloon is in the bladder and not the
urethra before inflating, usually with 7–10 mL sterile water.
yy If catheterization unsuccessful or not possible, use large bore needle 2
cm above pubic symphysis to drain the bladder.
yy After decompression, reattempt Foley catheterization.
ƒƒ If infection is present, start on an antibiotic: ciprofloxacin 500 mg tablet
every 8 hours.
ƒƒ Refer to district hospital for further investigation and treatment.

At the hospital level—

ƒƒ Perform suprapubic cystostomy.
ƒƒ Investigate cause of retention.

References—1, 3

1.6 Allergic Reaction (Severe)/Anaphylactic Shock

Description
Anaphylactic shock is a reaction, starting within seconds to minutes, following
exposure to a substance to which the patient had been sensitized. It causes a life-
threatening response involving the whole body. This response occurs when the
body’s immune system overreacts to a foreign substance (antigen). People with
asthma, eczema, and hay fever are slightly more likely to have an anaphylactic
reaction than people who do not have these conditions.

Causes
ƒƒ Venom of stinging insects such as bumblebees, honey bees, or wasps
ƒƒ Foods, especially high-protein foods—most commonly, shellfish, fish, nuts,
fruit, wheat, milk, eggs, or soy products

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ƒƒ Food additives, such as sulfites

ƒƒ Medicines (both prescription and overthecounter) especially penicillins
and erythromycin
ƒƒ Transfusion of blood or blood products
ƒƒ Dyes and contrast materials used during radiologic procedures or tests

Signs and symptoms

ƒƒ The most severe and life-threatening symptoms are difficulty breathing and
loss of consciousness.
ƒƒ Most anaphylactic reactions involve the skin producing—
yy Hives (can cause severe itching)
yy Welts
yy Wheals (i.e., raised bumps).
ƒƒ Generalized erythema (i.e., redness) Cardiovascular symptoms include—
yy Dangerously low BP
yy Rapid or irregular heartbeat
yy Other symptoms include—
yy Wheezing
yy Dizziness, sweating, nausea, and vomiting
yy Swelling in the face, eyelids, lips, tongue, throat, hands, and feet
yy Difficulty swallowing
yy Fear, feeling of dying

Management objectives
ƒƒ Maintain adequate airway
ƒƒ Maintain adequate BP

Nonpharmacological management
ƒƒ Ensure that the airway is clear. Intubate if necessary.
ƒƒ If the patient is hypotensive or in shock, lay him or her in a recumbent
position with head and upper body lower than legs.
ƒƒ Give oxygen 100%, at least 1–2 L/minute.
ƒƒ Start an IV infusion to keep vein open using normal saline or Ringer’s
lactate, and give 20 mL/kg.
ƒƒ Monitor the BP.

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Pharmacological management
ƒƒ Give adrenaline (injection, 1 mg/mL) stat.
yy Dosages—
ŠŠ <2 years: 0.1 mL IM
ŠŠ 2–5 years: 0.2 mL
ŠŠ 6–12 years: 0.3 mL
ŠŠ >12 years: 0.5 mL (maximum dose)
yy If the patient shows no improvement, repeat every 5–15 minutes.
yy Do not administer IV unless the patient fails to respond to several doses
of IM.
PLUS
ƒƒ Give chlorpheniramine maleate (injection, 10 mg/mL) at 0.2 mg/kg.
yy 2–5 years: 2.5–5 mg
yy 6–12 years: 5–10 mg
yy >12 years: 10–20 mg
PLUS
ƒƒ Give hydrocortisone.
yy 2–5 years: 50 mg IM or slow IV
yy 6–12 years: 100 mg IM or slow IV
yy >12 years: 200 mg IM or slow IV
OR
ƒƒ Give prednisone (tablets, 5 mg, 25 mg; syrup, 5 mg/mL).
yy Adults: 20–80 mg PO daily for 2–5 days
yy Children: 0.5–1 mg/kg PO daily for 2–5 days

References—3, 8, 13, 14

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1.7 Bites and Stings—Insects, Snakes, Animals,

and Humans
Bites or stings may be single or multiple and are often painful. Multiple stings
and stings in the mouth or throat are dangerous because they can cause airway
obstruction.

1.7.1 Insect Stings

1.7.1.1 Bees, Wasps, and Marabunta
Signs and symptoms
Injection of venom in the skin causes—
ƒƒ Localised pain and swelling
ƒƒ Severe allergic reaction may occur. (See section 1.6, “Allergic Reaction
(Severe)/Anaphylactic Shock.”)

Nonpharmacological management
ƒƒ Remove the stinger by scraping with a needle or a scalpel.
ƒƒ Do not squeeze or use tweezers to remove stinger.
ƒƒ Apply a cold compress or ice. For a sting in the mouth give patient ice to
suck.

Pharmacological management
ƒƒ Give chlorpheniramine (4 mg tablet) at the following dosages:
yy Adults and children ≥12 years: 4 mg PO
yy Children:
ŠŠ 2–5 years: 1 mg PO
ŠŠ 6–11 years: 2 mg PO
ƒƒ For anaphylactic shock, see section 1.6, “Allergic Reaction
(Severe)/Anaphylactic Shock.”

References—3, 15

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1.7.1.2 Scorpions
Elderly people with medical conditions as well as young children are more
susceptible to the venom of scorpions.

Signs and symptoms

Immediate, intense, localised burning pain. Pain can be intensified by tapping on
the affected area.
ƒƒ Nausea and vomiting
ƒƒ Paraesthesia (numbness), which may spread to the whole body
ƒƒ Muscular pains and cramps
ƒƒ Weakness and drowsiness
ƒƒ In severe cases, blurred vision, convulsions, respiratory failure, and
swallowing difficulties.
Caution: These severe case symptoms constitute a medical emergency.

Nonpharmacological management
In most cases, management of scorpion bites is supportive.
ƒƒ Monitor airway, breathing, and circulation.
ƒƒ Immobilize the affected part.
ƒƒ Remove any jewellery (e.g., rings).
ƒƒ Wash area with soap and water.
ƒƒ Apply cool compresses, usually 10 minutes on and 10 minutes off of the site
of the sting.
ƒƒ Do not cut into the wound or apply suction.

Pharmacological management
ƒƒ For pain, give adults paracetamol (500 mg tablet): 1–2 tablets every 6 hours
as required.
ƒƒ For severe pain apply a local anaesthetic: lidocaine (injection 2%) 2 mL
injected around the bite.

References—3, 8, 16

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1.7.1.3 Centipedes
Centipede bites are not dangerous for humans.

Signs and symptoms

ƒƒ Severe pain
ƒƒ Localised swelling
ƒƒ Erythema
ƒƒ Mild necrosis
Pharmacological and nonpharmacological management
ƒƒ Apply ice packs.
ƒƒ Give paracetamol (500 mg tablet): 1–2 tablets every 4 hours.
ƒƒ Treat with lidocaine (1%, 2% injection) if indicated.

Reference—3

1.7.2 Snake Bites

Guyana has many species of both nonpoisonous and poisonous snakes. The four
most common and highly venomous are the labaria/carpet labaria (Bothrops
atrox), the bushmaster (Lachesis muta), and the rupununi rattler (Crotalus
durissus trigonicus).

Signs and symptoms

Signs and symptoms of snake bites vary according to the species of snake
responsible for the bite and the amount of venom injected at the time of bite.
Identification of the snake should be attempted as far as possible. Some patients
may bring the dead snake or its head along for identification.

ƒƒ Nonpoisonous snake bite signs and symptoms

yy Pain
yy Redness and swelling
yy Laceration at site
ƒƒ Poisonous snake bite signs and symptoms
yy These bites produce a wide range of effects, from a simple puncture
wound to life-threatening illness and death.
yy A victim may have no initial significant symptoms and then suddenly
develop breathing difficulty and go into shock.

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Nonpharmacological management
ƒƒ Determine the type of snake (if available).
ƒƒ Calm the patient, and keep him or her perfectly still, in a supine position
(i.e., face up).
ƒƒ Monitor vital signs.
ƒƒ Clean the wound site, and apply cold compresses to the wound site.
Caution: Do not totally occlude arterial flow by applying a tourniquet.
ƒƒ If venom gets into the eye, wash thoroughly with a saline solution while the
patient rotates his or her eyeballs.
ƒƒ Do not rub the eyes.
ƒƒ Elevate the affected limb.
ƒƒ Establish an IV line using normal saline or Ringer’s lactate.
ƒƒ Intubate if patient has difficulty breathing.

Pharmacological management
ƒƒ Give paracetamol (500 mg tablet): 1–2 tablets every 4 hours for pain.
ƒƒ Administer antivenom, according to the manufacturer’s instructions. The
following antivenoms have been found to be effective against bleeding and
neurotoxicity:
yy Soro Antibotropico (Instituto Butantan, San Paulo, Brazil)
yy Antiveneno Polivalente (Instituto Nacional de Salud, Bogota, Colombia)
yy Antiveneno Polivalente (Higiene y Medicina Tropical “Leopoldo
Izquieta Perez”)

Referral
ƒƒ All children and pregnant women
ƒƒ Patients with respiratory distress and signs of shock (i.e., cold, clammy
skin; profuse sweating; tachycardia; hypotension)
ƒƒ Criteria for referral from the health centre and the district hospital (levels
2 and 3) to regional hospital and directly to Georgetown Public Hospital
Corp., from regions 1, 7, 8, and 9 are as follows:
yy Any signs of cardiopulmonary changes
ŠŠ Increase or decrease in BP of more than 15 systolic and 9 diastolic
ŠŠ Increase in pulse (above 90 beats/min)with changes in respiration
yy Any sign of bleeding (e.g., gums, wound site, under skin, bruising),
vomiting blood, or blood in urine or stool

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yy Signs of a worsening of the wound condition

yy Neurological changes

Note: Once the need for transfer is indicated, inform receiving the facility
immediately, relaying all pertinent clinical and other information. Arrange
transportation.

References—1, 3, 17, 18

1.7.3 Cat, Dog, and Wild Animal Bites

Cat and dog bites carry many serious infections. About 85% of cat and dog bites
harbour bacteria that can potentially cause disease. It is important to know
whether the animal is rabid or not. Consider any stray dog or animal and any
known dog that acts aggressively or strangely to be rabid. In Guyana, however,
such bites are not considered to be a problem.

Management objective
Lower the concentration of bacteria in contaminated wounds (and decrease the
chance of infection)

Nonpharmacological management
ƒƒ Clean the wound with soap and water, followed by an iodine solution.
ƒƒ Apply a dressing and advise the patient to have it changed every other day.
ƒƒ Do not suture wound if it is small and not actively bleeding.
ƒƒ Debride wound if it is deep and contaminated.
ƒƒ If wound is a large laceration or is bleeding profusely, apply a pressure
bandage, and refer to hospital for suturing.

Pharmacological management
ƒƒ Administer tetanus toxoid if patient had never been immunized or had his
or her last dose more than 10 years ago.
ƒƒ For pain, give paracetamol (500 mg tablets; 120 mg/5 mL suspension). See
table 1.7.3A for dosages.

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Table 1.7.3A. Paracetamol Dosages by Age and Weight for the Management of
Pain from Animal Bites

Age Weight Dose (mg) Quantity Frequency Duration

3–12 months 6-10 kg 60 2.5 mL (½ tsp) 3–4 times/day 5–7 days
1–5 years 10-18 kg 120 5 mL (1 tsp) 3–4 times/day 5–7 days
5–8 years 18-25 kg 240 10 mL (2 tsp) 3–4 times/day 5–7 days
or ½ tablet
8–14 years 25-50 kg 500 1 tablet 3–4 times/day 5–7 days
>14 years >50 kg 1,000 2 tablets 3–4 times/day 5–7 days
and adults

Prescribe a prophylactic antibiotic.

yy Amoxicillin (250 mg, 500 mg tablets; 125 mg/5 mL suspension)
ŠŠ Adults: 1 g 3 times/day for 5 days
ŠŠ Children: 100 mg/kg/day in 3 divided doses for 5 days
OR
yy In penicillin-allergic patients, erythromycin (250 mg, 500 mg tablets;
125 mg/5 mL suspension). See table 1.7.3B for dosages.

Table 1.7.3B.Erythromycin Dosages by Age for Prophylactic Antibiotic Treatment

of Penicillin-Allergic Patients for Management of Animal Bites

Age Dose (mg) Quantity Frequency

<1 year 125 5 mL (1 tsp) Every 6 hours
1–5 years 250 10 mL (2 tsp) Every 6 hours
5–12 years 500 1–2 tablets Every 6 hours
Adults 1,000 2–4 tablets Every 6 hours

References—3, 19

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1.7.4 Human Bites

Human bites can range from harmless to quite serious. They are more prone to
become septic or to develop complications such as cellulitis and gangrene than
animal bites because infection with anaerobic and aerobic bacteria is common.

Signs of infection
ƒƒ Increasing pain and tenderness of the affected area (1–2 days after the bite)
ƒƒ Increased or new redness
ƒƒ Fever
ƒƒ Pus drainage
ƒƒ Swollen lymph glands

Nonpharmacological management
ƒƒ Clean the wound thoroughly with soap and water followed by an iodine
solution.
ƒƒ Apply a dressing (if indicated), and change every other day.

Pharmacological management
ƒƒ Administer tetanus toxoid if patient had never been immunized or had last
dose >10 years ago.
ƒƒ Give paracetamol for pain. See table 1.7.3A for dosages.
ƒƒ Prescribe antibiotics.
yy Amoxicillin (250 mg, 500 mg tablets; 125 mg/5 mL suspension)
ŠŠ Adults: 1 g 3 times/day for 5 days
ŠŠ Children:100 mg/kg/day in 3 divided doses for 5 days
PLUS
yy Metronidazole (tablet 250 mg, suspension 125 mg/5 mL)
ŠŠ Adults: 500 mg PO 3 times/day for 5 days
ŠŠ Children 7.5 mg/kg PO 3 times/day for 5 days
OR
yy In penicillin-allergic patients, erythromycin (250 mg, 500 mg tablets;
125 mg/5 mL suspension). See table 1.7.3B for dosages.

References—3, 20

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1.8 Cardiopulmonary Arrest

Description
Cardiopulmonary arrest is the cessation of breathing and circulation, which
signifies clinical death. In children, it is usually the end result of a period
of circulatory or respiratory insufficiency and is seldom due to a sudden
precipitous event.

Causes
ƒƒ Cardiac conditions (e.g., myocardial infarction)
ƒƒ Airway obstruction
ƒƒ Severe haemorrhage and fluid loss
ƒƒ Head injuries
ƒƒ Anaphylactic shock

Signs and symptoms

ƒƒ Unconsciousness
ƒƒ Absence of pulse—check carotid and femoral
ƒƒ Absence of heart sounds
ƒƒ Absence of respiration
ƒƒ Fixed dilated pupils
ƒƒ Cyanosis

Management objectives
ƒƒ Get the patient breathing again
ƒƒ Restart the heart beating

Nonpharmacological management
ƒƒ Ensure an open airway.
ƒƒ Clear all foreign materials from mouth.
ƒƒ Start artificial breathing either mouth to mouth or using a face mask or
intubation.
ƒƒ Perform chest compressions at a rate of 80–100 compresssions/minute
yy In children <8 years: 5 compressions to 1 breath
yy In children >8 years: 15 compressions to 2 breaths
yy In adults: 30 compressions to 2 breaths

References—3, 8

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1.9 Diabetic Emergencies

A diabetic emergency can be the result of either low blood glucose
(hypoglycaemia) as a result of too much insulin, or high blood glucose
(hyperglycaemia) as a result of not enough insulin.

1.9.1 Hypoglycaemia (Low Blood Sugar)

Description
Hypoglycaemia is a clinical situation characterized by a reduction in plasma
glucose concentration to a level that may induce symptoms or signs related to
altered mental status, sympathetic nervous system stimulation, or both. The
glucose level at which an individual becomes symptomatic is highly variable,
although a plasma glucose level less than 50 mg/dL is generally considered
the threshold. Hypoglycaemia typically arises from abnormalities in the
mechanisms involved in glucose homeostasis.

Causes
The causes of hypoglycaemia are numerous, but are seen most often in diabetic
patients. The following are the most common causes:
ƒƒ Excessive or inappropriate treatment with insulin or oral hypoglycaemic
agents
ƒƒ Starvation (i.e., irregular meals)
ƒƒ Impaired food absorption
ƒƒ Lack of carbohydrate intake
ƒƒ Metabolic problems
ƒƒ Alcohol
ƒƒ Prolonged vomiting or nausea (unable to eat)
ƒƒ Medicines (e.g., quinine, salicylates, and sulphonamides)
ƒƒ Overexertion

Signs and symptoms

ƒƒ Early
yy Hunger
yy Tremors
yy Sweating
yy Palpitations

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yy Headache
yy Dizziness, faintness
yy Anxiety
ƒƒ Later features
yy Double vision
yy Slurred speech
ƒƒ Neuroglycopaenic symptoms
yy Drowsiness
yy Inability to concentrate
yy Confusion
yy Inappropriate behaviour
yy Restlessness with sweating
yy Convulsions (in children)
yy Unconsciousness

Determining the time of onset of symptoms relative to the time of meal ingestion
is crucial in the evaluation of a patient with hypoglycaemia.

Fasting hypoglycaemia typically occurs in the morning before eating, but can
also occur during the day, particularly in the afternoon, if meals are missed or
delayed.

Diagnosis
ƒƒ Based on history, signs, and symptoms
ƒƒ Blood glucose level of <50 mg/dL

Management objectives
ƒƒ Reverse the hypoglycaemic episode
ƒƒ Determine the cause and treat appropriately

Pharmacological and nonpharmacological management

ƒƒ In the health centre or hospital, for mild or moderate hypoglycaemia—
yy Adults: Administer glucose water PO (50–100 g glucose in 100–200 mL
water).
yy Children: Give 50 mL of 10% glucose or 10% sucrose solution (1 rounded
teaspoon of sugar in 3.5 tablespoons of water) PO or by NGT. Start milk
feedings every 30 minutes for 2 hours. Use ¼ of the amount of the regular
2–hour feeding each time.

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ƒƒ In the hospital, for severe symptoms or coma—

yy Administer glucose.
ŠŠ In young children (<12 years)—
–– Start IV of 10% dextrose (5 mL/kg).
OR
–– Give 50 mL of 10% glucose or sucrose by NGT.
–– Continue milk feedings.
ŠŠ In children >12 years and adults—
–– Start IV therapy, keeping line open with 5–10% dextrose water.
–– Give an immediate rapid IV injection of 40 mL of 50% dextrose.
Caution: Flush the lines with saline because dextrose can sclerose
veins.
–– If blood glucose level remains less than 50 mg/dL, give a second IV
injection of 40 mL 50% dextrose.
yy Continue IV therapy of 10% dextrose water.
yy Once the patient is conscious, ensure feeding or intake of carbohydrates.
ƒƒ Provide follow-up.
yy Educate the patient.
ŠŠ Re-enforce the need to check glucose levels at home.
ŠŠ Teach the patient the early signs of hypoglycaemia.
ŠŠ Clarify what the patient should do in case of hypoglycaemia.
ŠŠ Emphasise the need to carry sugar—sweets or small packets of
sugar—at all times.
yy Determine the cause of the hypoglycaemia, if it was unrelated to lack of
food or overexertion.
ŠŠ For patients on oral hypoglycaemic agents, reduce the oral
hypoglycaemic dose by 1 or 2 steps, depending on the severity of the
hypoglycaemia.
ŠŠ For patients on insulin therapy, reduce the appropriate insulin dose
by 4 units (e.g., if the patient is on a biphasic insulin 2 times per day,
and the hypoglycaemia occurs in the day, reduce the morning dose).

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1.9.2 Hyperglycaemia (High Blood Sugar)

Description
Hyperglycaemia is a condition in which an excessive amount of glucose circulates
in the blood plasma. It is generally a glucose level higher than 200 mg/dL.
Symptoms may not start to become noticeable until even higher values such as
250–300 mg/dL. A subject with a consistent range above 126 mg/dL is generally
held to have hyperglycaemia. Chronic levels exceeding 125 mg/dL can produce
organ damage (e.g., to the eyes, kidneys, heart, and nerves). It can also lead to
conditions requiring emergency intervention (e.g., ketoacidosis and coma).

Causes
ƒƒ Undiagnosed DM
ƒƒ Uncontrolled DM
ƒƒ Interruption of treatment or not following treatment plan
ƒƒ Infections
ƒƒ Stress
ƒƒ Not adhering to eating plan or diet

Signs and symptoms

ƒƒ Drowsiness
ƒƒ Varying degrees of loss of consciousness, mental confusion, stupor
ƒƒ Abdominal pain
ƒƒ Nausea and vomiting
ƒƒ Severe dehydration leading to increased thirst
ƒƒ Shock
ƒƒ Ketotic breath
ƒƒ Acidotic breathing (deep, laboured breathing)
ƒƒ Hyperventilation
ƒƒ Sometimes subnormal temperature

Diagnosis
Blood glucose 600–1,200 mg/dL

Pharmacological and nonpharmacological management

In the health centre—
ƒƒ Refer immediately.

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ƒƒ While awaiting transfer, start IV normal saline.

yy For severe hyperglycaemia with pre-coma, run first litre in 1–2 hours.
yy For hyperglycaemic coma and ketoacidosis 1 L in 30 minutes.
ƒƒ Over the subsequent hour, continue with 1 L normal saline.
ƒƒ If the transfer to hospital is delayed, continue with normal saline hourly
depending on clinical response.
ƒƒ Do not give any insulin unless the transfer to the hospital is delayed for
more than 2 hours.
ƒƒ Ensure that the airway and breathing are adequate.
ƒƒ Insert nasogastric or urinary catheter or both as required.

References—1, 2, 21, 22

1.10 Febrile Convulsions

Description
A febrile convulsion is a convulsion associated with a significant rise in body
temperature. It is age related and tends to occur in children 6 months to 5 years
of age. It presents with high temperature, but without signs of intracranial
disease. Males are at a slightly higher risk than females.

Classification
ƒƒ Simple febrile seizure
yy The setting is fever in a child 6 months to 5 years of age.
yy The single seizure is generalized and lasts <15 minutes.
yy The child is otherwise neurologically healthy and without neurological
abnormality by examination or by developmental history.
yy Fever (and seizure) are not caused by meningitis, encephalitis, or other
illness affecting the brain.
ƒƒ Complex febrile seizure
yy Age, neurological status before the illness, and fever are the same as for
simple febrile seizure.
yy This seizure is either focal or prolonged (i.e., >15 minutes), or multiple
seizures occur in close succession.
ƒƒ Symptomatic febrile seizure
yy Age and fever are the same as for simple febrile seizure.
yy The child has a pre-existing neurological abnormality or acute illness.

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Signs and symptoms

ƒƒ In the very young child—
yy Fever
yy Subtle signs of convulsion
ŠŠ Horizontal eye deviation
ŠŠ Repetitive blinking or fluttering of the eyes
ŠŠ Drooling or sucking
ŠŠ Rowing or swimming movements of the limbs
ŠŠ Apnoea
ŠŠ Abnormal cry
ŠŠ No bulging of the fontanel
ƒƒ In the older child—
yy Tonic-clonic convulsions affecting the whole body but usually not
lasting longer than 1 minute
yy No neck stiffness

Differential diagnosis
ƒƒ These three causes account for 85–90% of cases:
yy Viral infection (e.g., URTI, chickenpox, or nonspecific viral illnesses)
yy Otitis media
yy Tonsillitis
ƒƒ Other causes:
yy Urinary tract infection
yy Gastroenteritis
yy Lower respiratory tract infection
yy Meningitis
yy Post-immunization
yy Post-epileptic fever (likely only in seizures lasting >10 minutes)

Management objectives
ƒƒ Control the seizures
ƒƒ Determine the cause of the underlying illness and treat appropriately

Nonpharmacological management
If the child is still convulsing or not fully alert—
ƒƒ Place the patient in the recovery position. (See figure 1.10.) Lay the child on
his or her side, on a soft surface, with the face turned to one side to prevent

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the child from swallowing any vomit, to keep the airway open, and to help
prevent injury. Follow these steps:
yy Kneel on the floor to one side of the child.
yy Place the child’s arm nearest you at a right angle to the child’s body with
the hand upwards toward the head.
yy Tuck the other hand under the side of the head, so that the back of the
hand is touching the cheek.
yy Bend the knee farthest from you to a right angle.
yy Roll the child onto his or her side carefully by pulling on the bent knee.
yy The top arm should be supporting the head, and the bottom arm will
keep you from rolling the child too far.
yy Open the airway by gently tilting the head back and lifting the chin.
Check to be sure that nothing is blocking the airway.
yy Stay with the child and monitor breathing and pulse continuously until
help arrives.
yy If the injuries allow, turn the child onto his or her other side after 30
minutes.
ƒƒ Check and maintain airway, breathing, and circulation.
ƒƒ Check blood glucose.

Note: The use of cold sponges or fans is not recommended for treating a high
temperature. Little evidence suggests that they are effective.

Figure 1.10. The recovery position

Hand supports head

Knee stops body from

rolling onto stomach

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Pharmacological management
ƒƒ Give an antipyretic (paracetamol) if feasible (although no clear evidence
indicates that it prevents seizures) PO (500 mg tablets; 120 mg/5 mL oral
suspension). See table 1.10 for dosages.

Table 1.10 Paracetamol Dosages by Age for Management of Febrile Convulsions

Age Dosage (mg) Quantity Frequency Duration

2–12 months 60 2.5 mL (½ tsp) 3 times/day 5 days
1–<5years 120 5 mL (1 tsp) 3 times/day 5 days
5–8 years 240 10mL (2 tsp) 3 times/day 5 days

ƒƒ If the patient is seizing >5 minutes—

yy Give a rectal diazepam injection.
ŠŠ Adults: 5 mg/mL
ŠŠ Children: 500 mcg/kg per rectum stat
yy Diazepam injection may be repeated after 5 minutes if the seizure has
not stopped.

References—3, 23, 24

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1.11 Hypertensive Crisis

Description
Malignant hypertensive crisis is defined as elevated BP, a diastolic pressure of
>130 mmHg, or both. It can lead to progressive end-organ dysfunction such as
the following:
ƒƒ Unstable angina
ƒƒ Papilloedema and retinal haemorrhages and exudates
ƒƒ Hypertensive encephalopathy—severe headache, vomiting, and visual
disturbances
ƒƒ Cerebrovascular accident or cerebral infarction
ƒƒ Subarachnoid haemorrhage, intracranial haemorrhage, or both
ƒƒ Myocardial ischemia or infarction
ƒƒ Acute left ventricular dysfunction
ƒƒ Acute pulmonary oedema
ƒƒ Acute renal failure or insufficiency
ƒƒ Eclampsia in pregnant women

Causes
ƒƒ Primary (essential) hypertension accounts for about 90–95% of adult cases
ƒƒ Pregnancy induced (eclampsia)
ƒƒ Head injury
ƒƒ Intracranial haemorrhage
ƒƒ Secondary hypertension (renal, endocrine)
ƒƒ Failure to comply with established anti-hypertensive treatment
ƒƒ Drugs, medicines, and toxins (e.g., alcohol, cocaine, NSAIDs)
ƒƒ Adrenergic medications
ƒƒ Decongestants containing ephedrine

Signs and symptoms

ƒƒ Confusion, altered level of consciousness, or seizures; stroke, papilloedema,
or both
ƒƒ Pulmonary oedema
ƒƒ Severe chest pain with sudden shock (acute aortic dissection)
ƒƒ Acute chest pain with (angina) dyspnoea and orthopnoea, cyanosis cough,
fatigue (acute myocardial infarction)
ƒƒ High BP with seizures (during pregnancy)

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Caution: A hypertensive crisis is a medical emergency.

Management objectives
ƒƒ Correct medical complications
ƒƒ Reduce the diastolic pressure rapidly and thus reduce end-organ damage
such as hypertensive encephalopathy, acute ischemic stroke, acute
intracerebral haemorrhage, and subarachnoid haemorrhage. Reduce
diastolic pressure by one third, but not to exceed <95 mmHg.
ƒƒ Reduce the BP slowly (i.e., over 24–48 hours) in patients who have no end-
organ damage
ƒƒ Aim for a BP reading of 160/100 after the first day of therapy.

Nonpharmacological management
In the health centre—
ƒƒ Institute bed rest.
ƒƒ Start oxygen.
ƒƒ Refer to hospital urgently.
ƒƒ If transport is delayed for >4 hours, begin pharmaceutical treatment.

Pharmacological management
ƒƒ Administer methyldopa (250 mg tablet), 1 tablet PO every 12 hours, and
restart the hypertensive treatment that the patient had been receiving.
ƒƒ Administer furosemide (injection 10 mg/mL), 40 mg IV 2 times/day until
transfer.

References—1, 3, 25

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1.12 Poisoning
Description
A poison is any substance, including medications, that is harmful to the body if
too much is eaten, inhaled, injected, or absorbed through the skin. Poisonings are
either intentional or unintentional (i.e., accidental). The most common poisons
encountered in Guyana are malathion, household cleaners, and kerosene.

Causes
ƒƒ Accidental. Accidental poisonings usually occur in small children (<5 years)
and are due to ingestion of every-day items located in all areas of the home
(e.g., kitchen, closets, bathrooms, dining room, laundry room, or storage
areas). Ingested substances may include medications, cleaning materials,
disinfectants, toilet bowl cleaners, kerosene, insecticides, and rat poison—
anything that is not safely stored. In adults, insecticide poisoning is common
among farm workers when proper precautions are not observed.
ƒƒ Intentional. Intentional poisonings can be self-induced (i.e., attempted
suicide) using medications or industrial or agricultural chemicals, or
deliberately caused by someone else (i.e., attempted homicide).

Signs and symptoms

Wide and varied; dependent on the type of poison—
ƒƒ Sudden onset of illness, usually diarrhoea and vomiting
ƒƒ Increased or slowed pulse rate
ƒƒ Dilatation or constriction of pupils
ƒƒ Increased or lowered respiratory rate
ƒƒ Change in muscle tone, skin colour, and body temperature
ƒƒ Seizures, shock, drowsiness, unconsciousness or coma

Diagnosis
Based on the history and the findings—
ƒƒ From patient, family, friends, and witnesses, obtain information about the
nature and amount of the substance ingested.
ƒƒ Determine the names of all prescription and over-the-counter medications
the person is taking, and in the case of a child, all those available in the house.
ƒƒ Determine whether the patient has exposure to chemicals at home or at
work.

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ƒƒ Determine whether others in the family or at work have been similarly ill or
exposed.
ƒƒ Check clinical signs—
yy Pulse rate and regularity
yy Blood pressure
yy Temperature
yy Papillary size
yy Respiratory rate
yy Skin—dry, sweaty, jaundiced
yy Urine output

Management objective
Counteract the effects of the poisoning

Nonpharmacological and pharmacological management

If the patient is unconscious—
ƒƒ Maintain a clear airway.
ƒƒ Set up an IV line with dextrose saline.

For all patients—

ƒƒ Pass a nasogastric tube.
ƒƒ If poison is on the skin, wash with plenty of water for 10 minutes.
ƒƒ Use activated charcoal through the NGT at the dosages below. It will absorb
most poisons and prevent the poison from passing from the bowels into the
rest of the body. Repeat after 4 hours.
yy Adults: 50–100 g in 1 cup water.
yy Children: 25–50 g in ½ cup water
ƒƒ Do a stomach wash-out only if it can be done within 1 hour of poisoning.
Note: Stomach wash-out is contraindicated in paraffin, acid, or corrosives
poisoning. See section 1.12.1 “Acid and Other Corrosive Poisoning.”
Caution: Never make the patient vomit if he or she is unconscious, has
convulsions, or has ingested paraffin, acid, corrosives, or organophosphates.

Refer all cases of known or suspected poisoning to the hospital. If this is a case of
attempted suicide, refer the patient for psychological or psychiatric counselling.

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Provide patient and family education that includes the following:

ƒƒ Keep dangerous substances out of the reach of children.
ƒƒ Do not store medicines or poisons in areas used for storing food.
ƒƒ Clearly mark containers that hold poisonous material.
ƒƒ Never use soft drink containers for storing poisons.
ƒƒ Lock medicines and poisons in a cupboard.
ƒƒ Avoid contamination of food or drink when using insecticides or pest
control and agricultural chemicals.

1.12.1 Acid and Other Corrosive Poisoning

Many household cleaning agents contain acid or corrosive poisons (e.g., caustic
soda and drain and toilet bowl cleaners).

Signs and symptoms

ƒƒ Burning pain in mouth, throat, oesophagus, and stomach
ƒƒ Severe abdominal pain
ƒƒ Vomiting blood
ƒƒ Rapid shallow breathing, stridor
ƒƒ Rapid weak pulse

Nonpharmacological management
ƒƒ Do not induce vomiting.
ƒƒ Give milk to neutralize acid.
ƒƒ If the patient is in shock and hypotensive, set up IV to replace fluid loss.
ƒƒ Transfer the patient to the hospital.

1.12.2 Aspirin or Salicylate Poisoning

Salicylates are found in a number of over-the-counter medications and in
numerous prescription medicines, making salicylate toxicity an important cause
of morbidity and mortality. Tablets can contain 300–500 mg aspirin per tablet,
so 5–10 tablets can cause severe toxic effects in children.

Signs and symptoms

Early signs and symptoms include—
ƒƒ Nausea and vomiting
ƒƒ Excessive sweating
ƒƒ Tinnitus (ringing in the ear)

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ƒƒ Vertigo
ƒƒ Hyperventilation (rapid breathing)
ƒƒ Tachycardia
ƒƒ Hyperactivity

Later signs include—

ƒƒ Agitation
ƒƒ Delirium
ƒƒ Hallucinations
ƒƒ Convulsions
ƒƒ Lethargy
ƒƒ Stupor
ƒƒ Hyperthermia—an indication of severe toxicity, especially in young
children

Nonpharmacological and pharmacological management

ƒƒ Perform a gastric lavage with water (if aspirin had been ingested within the
past hour).
ƒƒ Give activated charcoal as soon as possible—100 g followed by 50 g every 4
hours.
ƒƒ If the patient is conscious, give 5% sodium bicarbonate solution PO
together with a high fluid intake.
ƒƒ If the patient is severely ill and unconscious, set up an IV of Ringer’s lactate
or isotonic sodium chloride 10–20 mL/kg/hr until a 1–1.5 mL/kg/hr urine
flow is established.
ƒƒ Give an initial IV bolus of 1 mEq/kg of sodium bicarbonate, and then start
a sodium bicarbonate intravenous infusion. Aim at making urine pH =
7.5–8.5.

References—1, 3, 8, 10

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1.13 Seizures and Convulsions

Description
Epilepsy is a condition characterized by recurrent seizures. A seizure is defined
as an involuntary contraction or series of contractions caused by abnormal
electrical activity within the brain and resulting in a temporary disturbance of
motor, sensory, or mental function. There are many types of seizures, depending
primarily on what part of the brain is involved.

Since epilepsy has many forms and causes, it is a clinical phenomenon rather
than a single single-disease entity. In some cases, there is no known underlying
cause (i.e., it is idiopathic).

Table 1.13 provides the classifications of seizures. One seizure type may evolve
into another during the course of the seizure. For example, a seizure may start as a
partial, or focal, seizure, involving the face or arm, but then the muscular activity
spreads to other areas of the body. In this way, the seizure becomes generalized.

Table 1.13.Nomenclature of the International Classification of Epileptic Seizures

I. Partial seizures A. S
 imple partial seizures 1. With motor symptoms
(i.e., seizures (without impaired 2. W
 ith somatosensory or
beginning consciousness) special sensory symptoms
locally)
3. With autonomic symptoms
4. With psychic signs
B. Complex partial 1. W
 ith impaired consciousness
seizures (with impaired only
consciousness) 2. With automatisms
C. Partial seizures 1. Secondarily generalized
II. G
 eneralized A. Absence seizures
seizures B. Generalized tonic-clonic seizures
C. Myoclonic seizures
D. Akinetic seizures
E. Atonic seizures
F. Tonic seizures
G. Clonic Seizure
III. Unclassified seizuresa
a
Unclassified seizures may include neonatal seizures and infantile spasms.

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Causes
Age is one of the most important factors determining both the incidence and
likely cause of a seizure or epilepsy.
ƒƒ During the neonatal period (<1 month), likely causes are—
yy Hypoxic ischaemic encephalopathy or birth asphyxia
yy Head trauma (intracranial haemorrhage) from birth injury
yy Congenital CNS abnormalities
yy CNS infection
yy Metabolic disorders
ƒƒ In infancy and early childhood (>1 month and <12 years), likely causes are—
yy Febrile convulsions (without evidence of CNS infection or other defined
cause)
yy Trauma
yy CNS infection (e.g., encephalitis, meningitis)
yy Developmental disorders
yy More often—idiopathic
ƒƒ In adolescence (12–18 years), likely causes are—
yy Head trauma
yy Cerebral infection
yy Brain tumour
yy Illicit drug use
yy Idiopathic
ƒƒ In young adults (18–35 years), likely causes are—
yy Tumour
yy Head injuries
yy Certain toxic chemicals or drug abuse
ŠŠ Alcohol withdrawal
ŠŠ Idiopathic
ƒƒ In older adults (>35 years), likely causes are—
ŠŠ Chemical imbalance such as—
–– Hypoglycaemia
–– Hypo- or hypernatraemia
–– Hypocalcaemia
ŠŠ Alcohol abuse, intoxication, or withdrawal
ŠŠ Malignant hypertension

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ŠŠ Stroke including cerebral haemorrhage

ŠŠ Brain tumour
ŠŠ Eclampsia during pregnancy
ŠŠ Electrolyte imbalance
ŠŠ Degenerative CNS diseases

Signs and symptoms

ƒƒ In epilepsy—an aura (i.e., foreboding of an attack) combined with a peculiar
taste in the mouth and dizziness
ƒƒ Loss of consciousness
ƒƒ Muscular contractions
ƒƒ Chewing movements of mouth
ƒƒ Urinary or faecal incontinence or both

Management objectives
ƒƒ Maintain an open airway
ƒƒ Support circulation
ƒƒ Stop the seizures
ƒƒ Determine and treat the underlying cause

Nonpharmacological management
During an acute episode—
ƒƒ Place the patient on his or her side. Oropharynx may need gentle suction to
clear secretions or vomitus.
ƒƒ Ensure that the patient is breathing. Give oxygen if necessary.
ƒƒ Support circulation with IV fluids. If signs of shock are present (i.e., cold,
clammy skin; profuse sweating; tachycardia; hypotension), give 20 mL/kg
of normal saline over 1 hour (both children and adults).
ƒƒ If fever is present, control with tepid sponging.

Pharmacological management
ƒƒ Begin first-line treatment.
yy Administer a diazepam injection (5 mg/mL).
ŠŠ Adults: 10 mg IV or IM
ŠŠ Children: 300 mcg/kg IV or 500 mcg/kg per rectum
yy Repeat after 2–3 minutes, if needed.

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yy If convulsions persist for 30 minutes or more or there are frequent

episodes of convulsions without regaining consciousness between
episodes, treat as status epilepticus and proceed to second-line
treatment.
ƒƒ Begin second-line treatment.
yy Administer a phenytoin injection (200 mg/mL) 20 mg/kg IV, in a
dextrose-free solution, infused over a period of 30 minutes.
yy Monitor for bradycardia, arrhythmias, hypotension. If any are present,
stop infusion until stable then restart at ⅔ the starting rate.
ƒƒ Refer all types of convulsions to hospital.

In the hospital—
ƒƒ Take a complete history including possible precipitating factors.
ƒƒ Rule out underlying causes.
ƒƒ Start anticonvulsive therapy.
ƒƒ Determine the underlying cause by performing the following tests:
yy Blood glucose
yy Urea and electrolytes
yy EEG
yy CT

References—1, 3, 8, 10

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2. Trauma

2.1 Abdominal Injuries

Description
Injuries to the abdomen are common. These injuries may be blunt or
penetrating. The abdominal cavity contains many important organs, vessels, and
membranes that can be damaged. These injuries may be life threatening.

Classification
ƒƒ Blunt, nonpenetrating injuries
ƒƒ Penetrating injuries

Causes
ƒƒ Blunt abdominal trauma may be due to—
yy Motor vehicle collisions
yy Blows to the abdomen (e.g., from fighting, punching, kicking)
yy Bicycle mishaps (e.g., being struck by the handlebar)
yy Sports injuries
yy Child abuse
ƒƒ Penetrating injuries are commonly the result of—
yy Gunshot wounds
yy Stab wounds

Signs and symptoms

ƒƒ Signs and symptoms of abdominal injuries may be general signs of shock
including low BP, tachycardia, or laboured breathing, or they may be
abdomen specific, such as—
yy Marked tenderness (localised or all over)
yy Rigidity or guarding of abdominal muscles
yy Rebound tenderness
yy Absent bowel sounds
ƒƒ Blunt trauma can affect any of the abdominal organs plus the intestines and
the diaphragm. Most frequently injured are the liver and spleen followed by
small and large intestines.
ƒƒ Penetrating trauma is more localised to the point of injury.

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Diagnosis
Based on history and physical findings

Investigations
ƒƒ Full blood count, urea, and electrolytes
ƒƒ Abdominal x-ray

Management objectives
ƒƒ Determine the extent of the injuries
ƒƒ Control resulting damage
ƒƒ Prevent further damage

Nonpharmacological and pharmacological management

At the health centre—
ƒƒ Take a clear history.
ƒƒ Examine vital signs: pulse, BP, respiratory rate, and level of consciousness.
ƒƒ Carry out a complete physical including head, chest, and cardiovascular
examinations. Check for hypovolaemia, fractures, and other injuries.
ƒƒ Examine the abdomen for abrasions or ecchymosis, distension, and bowel
sounds.
ƒƒ Check for local or generalized tenderness, guarding, rigidity, or rebound
tenderness, which suggests peritoneal injury.
ƒƒ If the patient is in shock—
yy Ensure a clear airway.
yy Start an IV line with 5% dextrose or Ringer’s lactate. IV fluids should be
titrated to a systolic BP of 90–100 mmHg.
ƒƒ If the patient has an open wound, cover and keep the bowel inside the
abdomen.
ƒƒ If the patient has vomiting or abdominal distension, insert a nasogastric
tube.

Referral
Refer the patient to the hospital urgently. Notify the destination hospital so that
the facility can prepare for the patient.

References—3, 28

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2.2 Chest Injuries

Description
Injury to the chest may be the result of blunt or penetrating trauma that may
affect the bony rib cage (i.e., ribs, clavicles, scapulae, or sternum), heart, pleurae,
lungs diaphragm, and mediastinal contents.

Classification
ƒƒ Blunt, nonpenetrating injuries. The most common cause of blunt force
trauma is motor vehicle accidents, when the chest comes into contact with
the steering wheel. These injuries result in damage to the structures inside
the chest cavity.
ƒƒ Penetrating injuries. Penetrating injuries disrupt chest wall integrity and
result in alterations in pressure inside the thoracic cavity. They usually
result from stab wounds and gunshot wounds.

Differential Diagnosis
ƒƒ Fractured ribs or flail chest (i.e., 3 or more consecutive ribs) or sternum
fractured in 2 or more places and a portion of the chest wall separated from
the chest cage
ƒƒ Pneumothorax, haemothorax, or pneumo-haemothorax
ƒƒ Diaphragmatic rupture
ƒƒ Heart injury, pericardial tamponade
ƒƒ Aorta and oesophageal rupture
ƒƒ Vascular injury

Signs and symptoms

Signs and symptoms vary widely, and the presentation depends on the
mechanism of injury and the organ systems injured. Obtaining as detailed a
clinical history as possible is therefore extremely important in the assessment of
a patient.

2.2.1 Rib Fractures

Signs and symptoms
ƒƒ Patient reports pain at the site of injury, increasing on inspiration or
coughing.
ƒƒ Patient indicates localised tenderness and crepitus on palpation.

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ƒƒ Patient exhibits shallow breathing plus impaired movement.

ƒƒ Antero-posterior compression of the chest produces pain.
ƒƒ Ribs 3 through 10 are most frequently affected.
ƒƒ Pneumothorax or pneumo-haemothorax may be present. If a pneumothorax
is present, breath sounds may be decreased and resonance to percussion
may be increased.

Management objectives
ƒƒ Relieve pain
ƒƒ Establish adequate ventilation

Pharmacological and nonpharmacological management

ƒƒ Look for signs and symptoms of a pneumothorax.
ƒƒ Provide pain relief.
yy Give paracetamol (500 mg tablet; 120 mg/5 mL suspension). See table
2.2.1 for dosages.

Table 2.2.1. Paracetamol Dosages by Age for the Management of Pain

Associated with Rib Fractures

Age Dosage (mg) Quantity Frequency Duration

2–12 months 60 2.5 mL (½ tsp) 3 times/day 5 days
1–<5years 120 5 mL (1 tsp) 3 times/day 5 days
5–8 years 240 10mL (2 tsp) 3 times/day 5 days
8–14 years 500 1 tablet 3 times/day 5 days
>14 years 1,000 2 tablets 3–4 times/day 5 days

OR
yy Give ibuprofen (200, 400, and 600 mg tablets).
ŠŠ Adults: 200–400 mg every 4–6 hours depending on severity of pain
not to exceed 3,200 mg/day.
ŠŠ Children: 4–10 mg/kg orally every 6–8 hours as needed not to exceed
40 mg/kg/day.
OR
yy Give diclofenac (25 mg/mL injection).
Caution: Do not strap chest.

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2.2.2 Flail Chest

Signs and symptoms
ƒƒ Severe chest pain over the injured area
ƒƒ Paradoxical chest movements
ƒƒ Severe dyspnoea
ƒƒ Tachypnoea with shallow breathing
ƒƒ Use of abdominal and other accessory muscles to breath
ƒƒ Decreased or absent breath sounds on auscultation of the affected area
ƒƒ Increased anxiety

Management
Management of flail chest depends on the state of the patient.
ƒƒ If the patient has no respiratory problems, observe closely.
ƒƒ If the patient has respiratory problems, intubate or ventilate as needed.
Suction if mucous is present.

Referral
Refer to hospital.

2.2.3 Fractured Clavicle

In 75–80% of cases, the clavicle fracture occurs in the middle third of the bone.

Signs and symptoms

ƒƒ Tenderness over the fracture site
ƒƒ Pain with movement of the shoulder or arm on the affected side
ƒƒ Anteroinferior positioning of the arm on the affected side as compared to
the other arm
ƒƒ The proximal segment of the clavicle is displaced upwards because of the
action of the sternocleidomastoid muscle

Management objectives
ƒƒ Realign the clavicular bone
ƒƒ Relieve pain
ƒƒ Nonpharmacological and pharmacological management
ƒƒ Immobilise the clavicle using a simple arm sling supporting the elbow.
ƒƒ Give oral analgesics to control pain—paracetamol (500 mg tablets; 120
mg/5 mL suspension). See table 2.2.1 for dosages.
ƒƒ Surgery is rarely indicated.

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2.2.4 Pneumothorax
Description
Pneumothorax is an abnormal collection of air or gas in the pleural cavity
between the chest wall and the lung, which may interfere with normal breathing.

Classification
ƒƒ Primary pneumothorax occurs without an apparent cause and in the
absence of significant lung disease.
ƒƒ Secondary pneumothorax occurs in the presence of existing lung pathology.
ƒƒ Traumatic pneumothorax may present as a—
yy Tension pneumothorax,when air leaks into the pleural cavity and cannot
escape during expiration
yy Haemothorax, when blood is in the pleural cavity
yy Pneumo-haemothorax, when blood and air are present together in the
pleural cavity

Signs and symptoms

Table 2.2.4 presents the signs and symptoms for the different classifications of
pneumothorax.

Nonpharmacological and pharmacological management

At health centre—
ƒƒ If the patient has a wound, dress it but do not suture.
ƒƒ Start an IV infusion with Ringer’s lactate or normal saline.
ƒƒ If the patient is in respiratory arrest or shock, resuscitate.
ƒƒ For tension pneumothorax, insert an intercostal drain. If no doctor is
available, the health care worker should drain the chest as follows:
yy Carefully insert a large needle through the chest wall into the pleural
cavity.
yy Insert the IV needle through the second and third rib space in the
midclavicular line just above the upper border of the third rib avoiding
the lower border of the second rib, which covers the neurovascular
bundle.
yy Connect the needle to an IV line, and prevent air from getting into the
pleural cavity by placing the end of the IV line into a bottle filled with
antiseptic fluid or sterile water.

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Table 2.2.4. Signs and Symptoms of Pneumothorax

Classification Signs and Symptoms

Pneumothorax— ƒƒ Closed pneumothorax
may be closed yy Inspiratory pain or dyspnoea
or open, the yy Pain at the sites of the rib fractures
latter being ƒƒ Open pneumothorax
more commonly yy Respiratory distress due to collapse of the lung on the
caused by a affected side
penetrating yy A chest wall defect that is larger than the cross-sectional area
injury of the larynx
yy Significant to complete loss of breath sounds on affected side
yy Mediastinal shift to the opposite side, decreasing the return of
blood to the heart leading to cardiac insufficiency
Tension ƒƒ Lung collapsed on the affected side
pneumothorax ƒƒ Mediastinal shift towards the unaffected side (i.e., heart is
shifted to the unaffected side)
ƒƒ Compression of the heart and large blood vessels resulting in
acute shock and cardio-respiratory arrest
Haemothorax ƒƒ Pain and dyspnoea
ƒƒ Decrease in breath sounds
ƒƒ Dullness to percussion over the affected area
Pneumo- ƒƒ Tachycardia
haemothorax ƒƒ Low BP
ƒƒ Cyanosis
ƒƒ Respiratory distress
ƒƒ Fast, shallow breathing
ƒƒ Rib retraction
ƒƒ Use of accessory muscles of respiration
ƒƒ Less movement on wounded side
ƒƒ Laboured breathing
ƒƒ Shift in the trachea and the apex of the heart
ƒƒ Decreased or no breath sounds on affected side

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Referral
ƒƒ Refer the patient to the hospital.
ƒƒ Inform the hospital of the transfer so that preparations can be made to
receive the patient.

References—3

2.3 Eye Injuries

Description
Eye injuries can range from the very minor, such as getting soap in the eye, to the
catastrophic, resulting in permanent loss of vision or loss of the eye. They can be
caused by blunt trauma (e.g., a fist) or by a sharp and penetrating object. All parts
of the eye can be affected and must be treated independently. Eye injuries often
occur in the workplace, at home, during other accidents, or while participating in
sports.

Causes
ƒƒ A foreign body (usually a small piece of wood, metal or plastic) in the eye—
can lead to corneal abrasions
ƒƒ Chemical exposures and burns can occur in a number of ways but are most
often the result of a liquid splashing into the eye. Acids and alkalis are
highly caustic and may cause severe and permanent damage to the ocular
surface.
ƒƒ Blunt object
ƒƒ Sharp object

Signs and symptoms

See table 2.3A.

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Table 2.3A. Signs and Symptoms of Various Types of Eye Injury

Indications Blunt Trauma Penetrating Trauma Chemicals and Burns

Symptoms ƒƒ Pain ƒƒ Pain ƒƒ Pain
ƒƒ Swelling of the eyelid ƒƒ Decrease in vision ƒƒ Decrease in vision
ƒƒ Decrease in vision
(rarely)
Signs ƒƒ Haematoma of the ƒƒ Laceration of ƒƒ Burn wound on the
eyelid the cornea or eyelid
ƒƒ Subconjunctival conjunctiva ƒƒ Laceration of the
haemorrhage ƒƒ Pupil size abnormal cornea
ƒƒ Bleeding behind the or irregular
cornea (hypaemia) ƒƒ Iris protruding out
ƒƒ Decreased eye of the wound
movement
ƒƒ Post-traumatic
infection
ƒƒ Contusion cataract

Nonpharmacological and pharmacological management

ƒƒ Do not exert pressure on the eyeball.
ƒƒ Cover with an eye pad.
ƒƒ For pain relief, give paracetamol (500 mg tablets; 120 mg/5 mL
suspension). See table 2.3B for dosages.

Table 2.3B. Paracetamol Dosages by Age for the Management of Pain

Associated with Eye Injuries

Age Dosage (mg) Quantity Frequency Duration

2–12 months 60 2.5 mL (½ tsp) 3 times/day 5 days
1–<5years 120 5 mL (1 tsp) 3 times/day 5 days
5–8 years 240 10 mL (2 tsp) 3 times/day 5 days
8–14 years 500 1 tablet 3 times/day 5 days
>14 years 1,000 2 tablets 3–4 times/day 5 days

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Referral
ƒƒ Refer the patient urgently to the hospital if—
yy The cornea is unclear.
yy The vision is bad.
yy The eye is leaking blood or clear fluid.
ƒƒ Possible conditions include—
yy Corneal abrasions
yy Injury to the iris
yy Injury to the lens
yy Injury to the retina

References—3, 30

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2.4 Head Injuries

Description
Even though it is protected by the bone covering of the skull, the brain is more
sensitive to trauma than most organs. The surface of the brain can tear or bruise
if it bumps against the inside of the skull. This bruising can damage blood vessels
and nerves and cause severe swelling of the brain tissue (i.e., cerebral oedema).
If the brain is severely damaged, it is unable to heal completely. Traumatic brain
injury that results from head injuries is a major cause of death and disability.
Brain injuries can have emotional, behavioural, and physical effects.

Causes
ƒƒ Motor vehicle and bicycle accidents
ƒƒ Gunshot wounds
ƒƒ Falls from heights
ƒƒ Blows to the head

Classification
The Glasgow coma scale (GCS) measures the level of consciousness. The scale
comprises three tests: eye (4 grades), verbal (5 grades), and motor (6 grades)
responses . (See table 2.4.) The three values separately as well as their sum are
considered. The lowest possible GCS (the sum of the first column in table 2.4)
is 3 (deep coma or death), and the highest is 15 (fully awake person). Generally,
brain injury is classified as follows:
ƒƒ Severe, GCS ≤8
ƒƒ Moderate, GCS 9–12
ƒƒ Minor, GCS ≥13

Signs and symptoms

The signs and symptoms depend on the severity of the injury and can include the
following:
ƒƒ Impaired level of consciousness that is not induced by drugs, medications,
alcohol, or an underlying disease process
ƒƒ Low GCS rating
ƒƒ Headache, drowsiness
ƒƒ Restlessness
ƒƒ Intolerance to light

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Table 2.4. The GCS Tests and Grades

Grades
Tests 1 2 3 4 5 6
Eyes Does not
Opens eyes Opens eyes Opens eyes N/A N/A
open eyes
in response in response spon-
to painful to voice taneously
stimuli
Verbal Makes no Makes Utters Is Is oriented N/A
sounds incom- inappro- confused, and
prehensible priate disoriented converses
sounds words normally
Motor Makes no Exhibits Exhibits Exhibits Localizes Obeys
movements extension abnormal flexion or painful commands
to painful flexion to withdrawal stimuli
stimuli (i.e., painful from
decerebrate stimuli (i.e., painful
response) decorticate stimuli
response)

ƒƒ Papillary dilatation; unequal pupils

ƒƒ Signs of elevated intracranial pressure (i.e., intracranial bleeding or
oedema)
yy Change in consciousness
yy Elevated BP
yy Slow pulse and respiration
yy Vomiting
ƒƒ Signs of fracture of the base of the skull
yy Otorrhoea (i.e., blood draining from one or both ears)
yy Rhinorrhoea (i.e., cerebrospinal fluid draining from the nose)
yy Peri-orbital bruising (i.e., raccoon eyes)
yy Subcutaneous bleed over the mastoid (i.e., behind the ears)
yy Deep scalp injuries with underlying fractures of the skull
yy Haemotympanum (i.e., blood behind the eardrum)
yy Open skull fractures and exposed cerebral tissue

Management objective
Ensure that the patient is fully conscious and coherent

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Nonpharmacological and pharmacological management

Most head injuries are of a benign nature and require no treatment beyond
analgesics and close monitoring for potential complications such as intracranial
bleeding.
ƒƒ Treating the conscious patient—
yy Examine the skull carefully for abrasions, contusions, and lacerations.
yy Search for other injuries.
yy If the patient had been unconscious, is confused, or is suffering from
amnesia, observe for 24 hours.
yy If the patient has improved, discharge.
ŠŠ Instruct family members to observe the patient closely for a few days.
ŠŠ Advise the patient to rest, drink enough fluids, and eat normally.
ŠŠ Indicate to the patient and family what neurological signs to
watch for.
ƒƒ Treating the unconscious patient—
yy Check and monitor vital signs.
yy Perform emergency resuscitation (airway, breathing, circulation), and
stabilize the patient.
yy Start oxygen.
yy Start IV infusion with normal saline or Ringer’s lactate.
yy Stabilise the cervical spine (i.e., affix a neck collar).
yy Insert a urinary catheter.
yy Place the patient with his or her head slightly elevated to reduce cerebral
oedema.
yy Lay the patient on his or her side to prevent aspiration of vomitus.

Referral
ƒƒ Refer any conscious patient who does not improve to the hospital.
ƒƒ Refer all unconscious patients to the hospital.

References—3, 31

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2.5 Wounds
Description
A wound occurs when the skin is broken or damaged because of injury. The skin
can be damaged in a variety of ways depending upon the mechanism of injury. It
may be superficial or deep and may be associated with broken bones, bleeding,
or both. It may be clean or contaminated by dirt or foreign bodies that can cause
infection.

Causes
ƒƒ Motor vehicle accidents
ƒƒ Occupational accidents
ƒƒ Fights
ƒƒ Stab wounds
ƒƒ Human and animal bites
ƒƒ Prolonged or chronic pressure on an area of the skin
ƒƒ Rubbing against an abrasive surface

Classification
ƒƒ Superficial (i.e., on the surface) wounds and abrasions leave the deeper
skin layers intact. They are usually caused by friction (rubbing against an
abrasive surface).
ƒƒ Deep abrasions (cuts or lacerations) go through all the layers of the skin
and into underlying tissue like muscle or bone.
ƒƒ Puncture wounds are usually caused by a sharp pointed object entering
the skin, (e.g., needle stick, stepping on a nail, or a stab wound with a knife).
Human and animal bites can be classified as puncture wounds, abrasions,
or a combination of both. (See section 1.7.3 “Cat, Dog, and Wild Animal
Bites” and section 1.7.4 “Human Bites.”)
ƒƒ Pressure sores (e.g., bed sores) can develop because of lack of blood supply
to the skin due to chronic pressure on an area of the skin (e.g., a person who
is bedridden, sits for long hours in a wheelchair, or has a cast pressing on
the skin). Individuals with diabetes, poor circulation (peripheral vascular
disease), or malnutrition are at an increased risk of pressure sores.

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Signs and symptoms

The most common symptoms of a wound are—
ƒƒ Pain, swelling, and bleeding. The extent depends upon the location of the
injury and the mechanism of injury.
ƒƒ Inflammation, which is the skin’s initial response to injury

Management objectives
ƒƒ Stop the bleeding
ƒƒ Prevent infection
ƒƒ Promote healing
ƒƒ Provide pain relief
ƒƒ Suture if indicated
ƒƒ Ensure a good cosmetic result after the wound has completely healed

Nonpharmacological management
Proper wound care is necessary to prevent infection and to promote healing of
the skin.
ƒƒ Stop the bleeding.
yy Apply manual pressure.
yy Raise the bleeding site above the level of the heart.
yy Suture larger and deeper wounds. Use lidocaine 2% to anaesthetise the
wound.
ƒƒ Prevent infection.
yy Remove all dirt and foreign bodies from the wound.
yy Clean the wound thoroughly with soap and water and diluted iodine.
ƒƒ Promote healing.
yy Leave small wounds open.
yy Dress larger wounds.
yy Elevate the wound.

Pharmacological management
If a wound is cleaned and cared for properly, there is often little need to prescribe
antibiotics. If the wound is considered to be contaminated—
ƒƒ Prescribe a broad-spectrum antibiotic if indicated.
yy Amoxicillin (250 mg, 500 mg tablets; 125 mg/5 mL suspension)
ŠŠ Adults: 1 g 3 times/day for 5 days
ŠŠ Children: 100 mg/kg/day in 3 divided doses for 5 days

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OR
yy In penicillin-allergic patients, erythromycin (250 mg, 500 mg tablets;
125 mg/5 mL suspension). See table 2.5A for dosages.

Table 2.5A. Erythromycin Dosages by Age for the Management of Wounds

Age Dose (mg) Quantity Frequency

<1 year 125 5 mL (1 tsp) Every 6 hours
1–5 years 250 10 mL (2 tsp) Every 6 hours
5–12 years 500 1–2 tablets Every 6 hours
Adults 1,000 2–4 tablets Every 6 hours

ƒƒ Give tetanus toxoid if patient has never been immunized or if last dose was
>5 years ago.
ƒƒ Provide pain relief. Give paracetamol (500 mg tablets; 120 mg/5 mL
suspension). See table 2.5B for dosages.
ƒƒ Suture larger deeper wounds.
ƒƒ Ligate or clamp arteries or veins with mosquito forceps.

Table 2.5B. Paracetamol Dosages by Age for the Management of Wounds

Age Dosage (mg) Quantity Frequency Duration

2–12 months 60 2.5 mL (½ tsp) 3 times/day 5 days
1–<5years 120 5 mL (1 tsp) 3 times/day 5 days
5–8 years 240 10 mL (2 tsp) 3 times/day 5 days
8–14 yrs 500 1 tablet 3 times/day 5 days
>14 years 1,000 2 tablets 3–4 times/day

Referral
If the wound does not show signs of healing after 5 days, refer the patient to the
hospital.

References—3, 32

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3. Respiratory System

3.1 Acute Bronchitis

Description
Acute bronchitis is defined as an acute inflammation of the lining of the bronchi,
most commonly caused by a virus, but sometimes caused by irritation from
inhaling gases, smoke, dust particles, or some types of pollution. Mycoplasma
pneumonia may be the cause in older children.

Signs and symptoms

ƒƒ Symptoms of acute bronchitis usually begin 3–4 days after an upper
respiratory infection, such as a cold or influenza. This infection is usually
characterized by—
yy A dry cough at the beginning, which later produces clear, white, or
yellow-green mucus. Sometimes nasal congestion and sore throat
appear before the dry cough. After nasal congestion and sore throat
improve, the cough continues and worsens, becoming wet and loose.
yy Shortness of breath with wheezing
yy Fatigue
yy Fever, usually low grade. If the fever is high, prolonged, or both, rule out
the presence of pneumonia or influenza.
yy Chest discomfort
ƒƒ Even after acute bronchitis has cleared, a dry, nagging cough may linger for
several weeks.
ƒƒ Even though symptoms may last up to 90 days, it can still be classified as
acute bronchitis; symptoms lasting longer, sometimes for months or years,
are usually classified as chronic bronchitis.

Diagnosis
The diagnosis is essentially a clinical one based primarily on signs and
symptoms.
ƒƒ A wheezing may be heard during the physical examination. If focal chest
signs are present, it could be pneumonia.

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ƒƒ A chest x-ray is sometimes done to exclude pneumonia, mainly if wheezing

is heard, the lungs are congested, or the patient is short of breath.
ƒƒ In children >2 years who have frequent episodes of acute bronchitis or
wheezing bronchitis, consider asthma. (See section 3.2 “Asthma.”) In
children <2 years, consider bronchiolitis. (See section 3.3 “Bronchiolitis.”)

Management objectives
ƒƒ Rule out serious illness
ƒƒ Alleviate symptoms, particularly cough

Nonpharmacological management
ƒƒ Promote hand washing to limit the spread.
ƒƒ Advise drinking lots of fluids and humidifying the air; suggest steam
inhalation.
ƒƒ Advise sunning pillows at least twice weekly.
ƒƒ Let the patient know that the cough might last a long time.

Pharmacological management
ƒƒ Treat the fever (if present).
yy First-line treatment: Give paracetamol PO (500 mg tablets; 120 mg/5 mL
oral suspension). See table 3.2 for dosages.

Table 3.2. Paracetamol Dosages by Age for Management of Acute Bronchitis

Age Dosage (mg) Quantity Frequency Duration

2–12 months 60 2.5 mL (½ tsp) 3 times/day 5 days
1–<5years 120 5 mL (1 tsp) 3 times/day 5 days
5–8 years 240 10 mL (2 tsp) 3 times/day 5 days
8–14 years 500 1 tablet 3 times/day 5 days
>14 years 1,000 2 tablets 3–4 times/day

OR
yy Second-line treatment: Give acetylsalicylic acid PO (300 mg and 500 mg
tablets). Give 1–2 (300 mg) tablets or 1 (500 mg) tablet 3–4 times/day,
not to exceed 2 g/day.
Caution: Acetylsalicylic acid (aspirin) is not recommended for children
<12 years old because of the risk of Reye’s syndrome.

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ƒƒ Treat wheezing (if present) with antihistamines: chlorpheniramine

maleate (4 mg tablets; 2 mg/5 mL syrup).
yy Children 2–5 years: 2.5 mL (½ tsp) as needed but not to exceed 4 times/
day
yy Children 6–12 years: 5 mL (1 tsp) as needed but not to exceed 4 times/
day
ƒƒ Consider antibiotics. Antibiotics are not indicated for otherwise healthy
patients suffering from acute bronchitis. Antibiotics may be considered if—
yy Patient is elderly or in poor general health with other conditions such as
malnutrition, measles, rickets, severe anaemia, or cardiac disease.
yy Patient has difficulty breathing, fever >38.5°C, and purulent
expectorations. These symptoms indicate a possible bacterial infection.
ƒƒ If warranted, prescribe antibiotics.
yy First-line treatment: amoxicillin PO (250 mg and 500 mg tablets;
suspension 125 mg/5 mL)
yy Adults: 3 g/day in 3 divided doses for 7 days.
ŠŠ Children: 100 mg/kg/day in 2 divided doses for 7 days
Note: Reassess the patient after 5 days. If no improvement, refer the
patient but advise continuation of medication until seen.
OR
yy Second-line treatment for penicillin-allergic patients: azithromycin
(250 mg tablet; 200 mg/5 mL suspension)
ŠŠ Adults: 2 tablets once daily for 7 days
ŠŠ Children: 10 mg/kg, once daily for 3 days

Referral
Health posts should give the first dose of first-line treatment and refer the
patient to health centre or district hospital if the patient has the following, which
may indicate a bacterial infection—
ƒƒ Difficulty breathing
ƒƒ Fever >38.5°C
ƒƒ Coughing up mucous containing pus

References—3, 8, 10, 34, 35

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3.2 Asthma
Description
Asthma is a chronic inflammatory disorder of the airways with reversible
narrowing or obstruction of the bronchi. The chronically inflamed airways are
hyper-responsive to a number of endogenous or exogenous stimuli resulting
in widespread narrowing of the airways. Airflow is limited, not only by
bronchoconstriction but also by mucus plugs and increased inflammation.

Classification
Asthma varies in intensity, and may be—
ƒƒ Intermittent. <2 episodes per week or 1 episode per night per month
ƒƒ Mild persistent. 2–4 episodes per week or 2–4 night episodes per month.
On examination: RR normal or increased, shortness of breath, few wheezes,
no chest indrawing, pulse <100 beats/minute; patient is able to walk or lie
down.
ƒƒ Moderate persistent. >4 episodes per week or 4 night episodes per month.
On examination: RR is increased, shortness of breath interferes with
speech, marked wheezes, chest indrawing, pulse 100–120 beats/minute;
patient is most comfortable in the sitting position.
ƒƒ Severe persistent. Continuous wheezing or frequent night episodes.
On examination: RR increased (>30 breaths/minute in adults and >40
breaths/minute in children 12 months to 5 years), difficulty speaking, chest
indrawing, high-pitched wheeze, pulse >120 beats/minute in adults; patient
is anxious. The attack can be life threatening if patient has no sounds on
auscultation, cyanosis, altered level of consciousness and reduced pulse
rate, or shock.

Causes and risk factors

The cause of asthma is unknown, but the following factors are associated with
the development of asthma—
ƒƒ Exposure to various allergens (e.g., house dust, mites, animals with fur,
perfumes, cockroaches, pollens, and moulds)
ƒƒ Occupational and chemical irritants
ƒƒ Smoke—tobacco, wood
ƒƒ Nonspecific irritating substances

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ƒƒ Infections (viral or bacterial)

ƒƒ Strong emotional expressions (laughing or crying hard)
ƒƒ Medicines (such as aspirin and beta blockers)
ƒƒ Exercise
ƒƒ Change in temperature
ƒƒ Family history
See also appendix C, “Common Asthma Triggers and Avoidance Strategies.”
Signs and symptoms
Typically most attacks are short lived, and the patient seems to recover
completely after an attack. Look for the following:
ƒƒ Common signs:
yy Recurring episodes of wheezing, breathlessness, chest tightness, and
coughing, (particularly at night or in the early morning)
yy Auscultation—expiratory rales in both lung fields
ƒƒ Danger signs: Consider admission to the hospital ICU if the patient
presents with any of these signs—
yy Inability to speak
yy Cyanosis
yy Severe distress
yy Confusion and exhaustion; drowsiness
yy Pulsus paradoxus
yy Decreased breath sounds
yy High pulse rate (children >140 beats/minute; adults >110 beats/minute)
yy High RR (children >60 breaths/minute; adults >30 breaths/minute
yy Repeat attacks despite good compliance or oral steroids

Diagnosis
The diagnosis is based on the characteristics, pattern of symptoms, and signs of
asthma in the absence of another explanation. The patient usually has a history
of periodic attacks.

Note: Diagnosis of asthma in children ≤6 years presents a particularly difficult

problem. The younger the child, the greater the likelihood that an alternative
diagnosis may explain recurrent wheeze. Always consider bronchiolitis,
congestive cardiac failure, bronchopneumonia, or airway obstruction by a
foreign body.

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Management objectives
ƒƒ Relieve the symptoms of the acute attack and maintain control of the
clinical manifestations of the disease for prolonged periods
ƒƒ Prevent acute attacks and hospitalization with maintenance therapy
because when asthma is controlled, patients can prevent most attacks,
avoid troublesome symptoms day and night, and keep physically active
ƒƒ Achieve and maintain normal or best possible long-term lung function
ƒƒ Identify and avoid precipitating factors
ƒƒ Develop a good relationship with the patient, the patient’s family, and
health care workers
ƒƒ Educate the patient

Management
Treatment depends on the severity of the attack. Good asthma care has three
interrelated components:
ƒƒ Assess the severity of attack. (See discussion of danger signs above.)
ƒƒ Identify and reduce exposure to risk factors. (See appendix C, “Common
Asthma Triggers and Avoidance Strategies.”)
ƒƒ Calm the patient.

Nonpharmacological management
ƒƒ Advise the patient—
yy Not to smoke and to avoid areas where others are smoking
yy To avoid contact with household pets and with bat, rat, and other
droppings
yy To avoid exposure to known allergens and stimulants or irritants
ƒƒ Educate the patient about early recognition and management of acute
attacks.
ƒƒ Reassure the patient, and place him or her in a semi-recumbent position.

Pharmacological management
ƒƒ If the attack is mild—
yy Give inhaled salbutamol (0.1 mg/puff )
ŠŠ Adults: 2–4 puffs at 20-minute intervals for the first hour, and then if
the patient shows mild exacerbation, 2–4 puffs every 3–4 hours
ŠŠ Children: 2–4 puffs at 20-minute intervals. If responding, continue
every 1–4 hours.

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yy If the attack is resolved, observe the patient for an hour.

yy If the attack is only partially resolved, proceed to treat as a moderate
attack (see below).
ƒƒ If the attack is mild but persistent—
yy Give continuous inhaled steroids (e.g., beclometasone dipropionate
0.25%).
yy Give inhaled salbutamol when symptomatic.
ƒƒ If the attack is moderate—
yy Give a high dose of salbutamol (0.1 mg/puff ) (e.g., 4–5 puffs every
10 minutes) until improvement or via oxygen-driven nebuliser (if
available).
yy Continue with inhaled salbutamol: 2 puffs every 6 hours for 24–48 hours
following an attack.
yy Add prednisolone (5 mg tablets) PO
yy Adults: 0.5–1 mg/kg once daily in the morning
ŠŠ Children:1–2 mg/kg once daily in the morning
ŠŠ Observe for 4 hours after symptoms stop.
yy Continue prednisolone for 10 days at tapered doses.
yy Follow up in 10 days.
yy Consider long-term treatment.
ƒƒ If the attack is moderate persistent—
yy Give continuous treatment with low- to medium-dose inhaled
beclometasone.
PLUS
yy Give inhaled salbutamol (1 puff 4 times/day).
ƒƒ If the attack is severe—
yy At the health centre or health post—
ŠŠ Give a high dose of salbutamol: 5 puffs every 10 minutes.
ŠŠ Refer urgently to the district hospital.
yy At the hospital—
ŠŠ Give oxygen 40–60%.
ŠŠ Give inhaled salbutamol 5 puffs every 10 minutes until improvement.
ŠŠ If symptoms are severe, consider inhaled ipratropium bromide
(0.25%)
PLUS

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ŠŠ Hydrocortisone 100 mg IV.

–– Adults: 200 mg repeat in 2 hours PRN
–– Children: 100 mg every 6 hours PRN
ŠŠ Change to prednisolone PO as soon as possible.
–– Adults: 0.5–1 mg/kg for 5 days
–– Children: 1–2 mg/kg in the morning for 5 days not to exceed 20
mg/day in children <5 years and 40 mg/day in children >5 years
–– Reduce dose over a 10-day period and follow up in 10 days
ŠŠ If the patient shows no improvement after 20–30 minutes, give
aminophylline IV infusion.
–– Administer with caution to children <30 months.
–– Give a loading dose 5 mg/kg diluted in isotonic solution over 30
minutes and then 0.5 to 1 mg/kg/hr.
Caution: Never administer aminophylline by direct IV.

Caution: If the patient has already been given oral aminophylline,

do not give the loading dose.
–– Change to oral aminophylline after 24 hours.
ƒƒ If the attack is severe persistent—
yy Provide continuous treatment with high-dose inhaled beclometasone.
PLUS
yy Give inhaled salbutamol (1 puff 4–6 times/day).
PLUS
yy If needed, give prednisolone tablets 2 mg/kg/day but not to exceed 60
mg/day. Try repeatedly to wean off.
ƒƒ For long-term management—
yy The goal is to achieve a stable, asymptomatic state with the best
pulmonary function using the least amount of medication. An important
step is to educate patients to participate fully in the management of their
disease.
yy Things that trigger attacks should be avoided or controlled.
yy Long-term treatment is not required for mild intermittent asthma.

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Referral
Refer patients with any of the following:
ƒƒ Unstable asthma
ƒƒ Inadequate response to treatment
ƒƒ A life-threatening episode (refer during or after)
ƒƒ Pregnant women with aggravated asthma
ƒƒ All children <6 years with recurrent wheeze on first presentation for
assessment and confirmation of diagnosis

References—3, 8, 10, 33, 34, 35

3.3 Bronchiolitis
Description
Bronchiolitis is caused by an acute viral infection of the lower respiratory
tract that occurs primarily in young infants. It may lead to fatal respiratory
distress resulting from lower airway obstruction. Bronchiolitis is seasonal
and, in tropical countries, tends to occur during the rainy season. All patients
recover once they are past the acute phase, as long as they are managed properly.
Recurrence is common.

Causes and risk factors

Bronchiolitis is usually caused by a respiratory syncytial virus (RSV), but could
also be caused by the viruses that cause the flu or coryza. Children <2 years of
age and those who have never been breastfed are more prone to infection as are
those who are exposed to tobacco smoke. A child with a compromised immune
system is also susceptible.

Signs and symptoms

ƒƒ General signs and symptoms—
yy Early symptoms are those of a viral upper respiratory tract infection
(URTI), including mild nasal discharge, and low-grade fever (38.5–39°C)
often accompanied by cough and wheezing. Adults, older children, and
many infants do not progress beyond this stage of URTI.
yy For those infants and young children who progress to lower respiratory
tract involvement, fits of coughing and difficulty in breathing develop
within 1–2 days.

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yy On listening to the chest, you will hear laboured expiration with diffuse
wheeze and, occasionally, fine, scattered crepitations during inspiration
in both lungs.
ƒƒ Signs of serious illness—
yy The most common physical sign: rapid breathing, often RR >50–60
breaths/minute
yy Cyanosis evident in the lips, buccal membranes, and fingernails
yy Nasal flaring
yy Periods of cessation of breathing, especially in infants <6 weeks
yy Poor feeding or refusal of feedings; difficulty drinking or breastfeeding
yy Altered level of consciousness
yy Chest indrawing
yy Silence on auscultation corresponding to an intense constriction of the
bronchi

Diagnosis
History and physical examination form the primary basis for the diagnosis of
bronchiolitis.

Management objectives
ƒƒ Recognize the severity of the illness
ƒƒ Alleviate symptoms
ƒƒ Refer appropriately

Nonpharmacological management
ƒƒ Position child in a half-sitting position to make breathing easier.
ƒƒ Do not sedate the child.
ƒƒ Keep the air humidified using a bowl of water or a wet towel.
ƒƒ Assist the child’s breathing by applying frequent subcostal pressure.
ƒƒ Advise oral fluids, 80–100 mL/kg/day in small amounts throughout the day.
ƒƒ Minimize the patient’s contact with other children.

Pharmacological management
At the health centre or health post—
Caution: Avoid the use of bronchodilators, antibiotics, and corticosteroids.
ƒƒ Salbutamol 2.5%, solution, 1–2 mL diluted to 2–4 mL with sodium chloride
0.9%, nebulised over 3 minutes

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ƒƒ Evaluate the response to salbutamol.

ƒƒ Send patient home on a salbutamol metered-dose inhaler if he or she has
exhibited a good response.
Caution: If the patient’s condition does not improve in ½ hour, it is a medical
emergency. Refer immediately.
ƒƒ Antibiotics are indicated only if bacterial infection is suspected (e.g., the
patient has a toxic appearance, fever >39°C, sputum containing pus, or
aggravation of respiratory symptoms).
ƒƒ According to the severity, give antibiotics orally or by injection for 5 days.
yy Amoxicillin PO or ampicillin IM: 100 mg/kg/day in divided doses or
injections
OR
yy For penicillin-allergic patients, erythromycin (125 mg/5 mL
suspension), 30–50 mg/kg/day in 4 divided doses for 5 days
ƒƒ Re-evaluate every day.
yy If the child is improving, continue with the same antibiotic to complete
treatment.
yy If there is no change or if the child’s condition is deteriorating, refer to a
hospital.
ƒƒ In children <2 months, treat as acute pneumonia. (See section 3.6,
“Pneumonia.”)
ƒƒ If the child has signs of serious illness, give oxygen at a rate of 1–3 L/minute,
and refer to the regional hospital.

Referral
ƒƒ Children at risk (i.e., <2 months of age, malnourished, or HIV infected)
ƒƒ Children with at least one sign of serious illness (e.g., toxic appearance,
fever >39°C, sputum containing pus, or aggravation of respiratory
symptoms)
ƒƒ Previous admission for the same problem

References
Desenclos, J.C., P. Biberon, and J. Rigal. 2007. Clinical Guidelines. Diagnosis and
Treatment Manual (7th ed.). Paris: Médecins Sans Frontières.

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3.4 Coryza (Common Cold)

Description
The common cold is an acute inflammation of the upper respiratory tract and is
usually afebrile and self-limited.

Causes and risk factors

Although often caused by the rhinovirus, a viral infection may also be caused
by parainfluenza and respiratory syncytial viruses. Transmission is person
to person and usually airborne. The viral infection can be complicated by
secondary bacterial infection (e.g., streptococcus, staphylococcus, Haemophilus
influenza).

Signs and symptoms

The signs and symptoms are similar to other URIs but not localised to one
particular anatomical location. Onset is usually sudden, mild, and self-limited,
lasting about 1 week. The common cold is characterized by—
ƒƒ Nasal stuffiness, tickling sensation in nose, and sneezing
ƒƒ Dry, “scratchy” throat, sore throat, or both
ƒƒ Profuse nasal watery discharge, often with fever and cough
Note: A thick purulent discharge suggests secondary infection.
ƒƒ For some patients, mild headache

Diagnosis
Diagnosis is generally clinical and presumptive. Allergic rhinitis is the most
important consideration in differential diagnosis. Resolution is usually in 5–10
days. If symptoms recur often or last >2 weeks, suspect an allergy.

Management objectives
ƒƒ Relieve symptoms
ƒƒ Prevent complications

Nonpharmacological management
Advise the patient to do the following:
ƒƒ Get bed rest.
ƒƒ Increase the humidity in his or her home.
ƒƒ Increase fluid intake, preferably warm liquids.
ƒƒ Use steam inhalation to clear the nose and ease breathing.

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ƒƒ Sooth irritated nasal tissue using commercial nasal saline solutions or a

homemade solution (i.e., 5 mL of salt in 250 mL of warm water).
ƒƒ Include adequate intake of fresh fruits and vegetables in the diet.
ƒƒ Practice frequent hand washing to prevent transmission.

Pharmacological management
ƒƒ The common cold is a viral disease and does not require use of antibiotics.
ƒƒ Give antipyretics and analgesics until fever stops.
yy Paracetamol PO (100 mg, 500 mg tablets; suspension 120 mg/5 mL)
ŠŠ Adults: 1 g (two 500 mg tablets ) 3–4 times/day
ŠŠ Children<1 year: 60 mg(½ tsp) 3 times/day
ŠŠ Children 1–5 years: 100–150 mg (1–1½ tablets or 5 mL) 3 times/day
OR
yy Acetylsalicylic acid PO (300 mg and 500 mg tablets)
Caution: Acetylsalicylic acid (aspirin) is not recommended for children
<12 years old because of the risk of Reye’s syndrome.
ŠŠ Adults: 1–3 g/day in 3–4 divided doses
ŠŠ Children>12 years old: 60 mg/kg/day in 3–4 divided doses
ƒƒ Give vitamin C tablets (500 mg tablets) 1 daily for 2 weeks. In patients with
nasal allergy, give chlorpheniramine maleate PO (4 mg tablet; 2 mg/5 mL
syrup) for no more than 5 days.
yy Adults: 4 mg tablet 3-4 times/day but not to exceed 24mg/day
yy Children:
ŠŠ <1 year: Do not administer
ŠŠ 1–2 years: 1 mg (¼ tablet or 2.5 mL) two times/day
ŠŠ 2–5 years: 1 mg (¼ tablet or 2.5 mL) 3–4 times/day, not to exceed
6 mg/day
ŠŠ 6–12 years: 2 mg (½ tablet or 5 mL) 3–4 times/day, not to exceed
12 mg/day
yy Advise the patient to return to the clinic if earache, tenderness, or pain
over sinuses develops or if cough or fever persists for longer than a week.

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Referral
Level 1 facilities should refer patients in the following situations:
ƒƒ If more severe symptoms develop, such as shaking chills, high fever
(>38.5°C), severe headache or neck stiffness, nausea, vomiting, difficulty
breathing, or chest pain
ƒƒ If the patient has a sore throat and a fever with no other cold symptoms
(possible strep throat)
ƒƒ If the patient experiences facial pain or yellowish-green drainage from the
nose accompanied by a fever (possible sinusitis)

References

3.5 Influenza
Description
Influenza (commonly called the flu) is a contagious respiratory illness caused by
respiratory viruses. It affects mainly the nose, throat, bronchi, and occasionally
the lungs. It can cause mild to severe illness and at times can lead to death.
Symptoms start 1–4 days after the virus enters the body, so persons with the flu
can infect others as early as 1 day before developing symptoms and up to 5–7
days after becoming sick.

Causes and risk factors

The flu is caused by the influenza virus. People at risk include the following:
ƒƒ Children <5, but especially children <2 years old
ƒƒ Adults ≥65 years of age
ƒƒ People who have certain medical conditions, including—
yy Asthma
yy Neurological and neurodevelopmental conditions including disorders
of the brain, spinal cord, peripheral nerve, and muscle such as cerebral
palsy and epilepsy
yy Chronic lung disease such as chronic obstructive pulmonary disease
(COPD) and cystic fibrosis
yy Heart disease such as congenital heart disease, congestive heart failure,
and coronary artery disease
yy Blood disorders such as sickle cell disease
yy Endocrine disorders such as diabetes mellitus

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yy Kidney disorders
yy Liver disorders
yy Weakened immune systems due to disease or medication—including
people with HIV and AIDS, or cancer, individuals on chronic steroids
yy People who are morbidly obese (i.e., have a body mass index of >40)

Signs and symptoms

ƒƒ Fever
ƒƒ Tiredness
ƒƒ Muscle aches (myalgia)
ƒƒ Headache
ƒƒ Runny or stuffy nose
ƒƒ Nonproductive cough
ƒƒ Sore throat
ƒƒ Children may have difficulty feeding

Diagnosis
Based on clinical signs and symptoms

Management objectives
ƒƒ Relieve symptoms
ƒƒ Prevent complications

Nonpharmacological management
ƒƒ Urge bed rest.
ƒƒ Instruct the patient to drink plenty of water and other fluids.
ƒƒ Encourage the patient to eat foods rich in vitamin C such as fruits and
vegetables.
ƒƒ Advise using salt water drops in the nostrils to clear mucus.
ƒƒ Encourage the patient to maintain good hygiene practices by washing
hands frequently with soap and water.
ƒƒ Urge the patient to cover his or her mouth and nose when sneezing and
coughing to reduce transmission.

Pharmacological management
ƒƒ For pain and fever, give paracetamol PO (500 mg tablet; 120 mg/5 mL oral
suspension). See table 3.5 for dosages.

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Table 3.5. Paracetamol Dosages by Age for Management of Influenza

Age Dosage (mg) Quantity Frequency Duration

2–12 months 60 2.5 mL (½ tsp) 3 times/day 5 days
1–<5years 120 5 mL (1 tsp) 3 times/day 5 days
5–8 years 240 10mL (2 tsp) 3 times/day 5 days
8-14 years 500 1 tablet 3 times/day 5 days
>14 years 1,000 2 tablets 3–4 times/day 5 days

OR
ƒƒ Give second-line treatment: acetylsalicylic acid PO (300 mg and 500 mg
tablets) 1–2 (300 mg tablets) or 1 (500 mg tablet) 3–4 times/day not to
exceed 2 g/day.
Caution: Acetylsalicylic acid (aspirin) is not recommended for children
<12 years old because of the risk of Reye’s syndrome.

ƒƒ Prescribe antibiotics only for patients who have a secondary bacterial

infection or for patients with underlying heart or renal conditions.
yy Start with first-line antibiotic treatment: amoxicillin PO (250 mg and
500 mg tablets; 125 mg/5 mL suspension)
ŠŠ Adults: 3 g/day in 2–3 divided doses for 7 days.
ŠŠ Children: 100 mg/kg/day in 2 divided doses for 7 days
ŠŠ Reassess the patient after 5 days. If no improvement, refer the patient
but advise continuation of medication until seen.
OR
yy For penicillin-allergic patients, prescribe erythromycin, (125 mg/5 mL;
250 mg and 500 mg tablets) oral, 4 times/day for 10 days
ŠŠ Adults: 1 g (2–4 tablets) 2 times/day
ŠŠ Children
–– <1 year: 125 mg (5 mL or 1 tsp)2 times/day
–– 1–5 years: 250 mg (10 mL or 2 tsp) 2 times/day
–– 6–12 years: 500 mg (2 tablets) 2 times/day
ƒƒ Follow up. Advise the patient to return to the clinic if he or she has no
improvement in 1 week.

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Note: Patients who are at high risk of serious complications and who are likely
to be exposed to others infected with influenza or who are themselves within the
first 2 days of illness onset should be treated with antiviral medications. Refer.

Referral
ƒƒ Patients with serious complications
ƒƒ Patients needing antiviral medicines

Reference—48

3.6 Pneumonia
Description
Pneumonia is an inflammation of the pulmonary alveoli. It can be caused by a
virus, bacteria, fungus, or parasite.

Causes and risk factors

ƒƒ Typical causes of pneumonia
yy Viruses
yy Bacteria (pneumococcus, Haemophilus influenzae, Mycoplasma
pneumonia)
yy Fungus (Cryptococcus, histoplasmosis)
yy Parasite (Pneumocystitis carinii in HIV infected persons).
yy Chemical (gases, fumes, dust, aspiration)
ƒƒ Persons at risk
yy Elderly
yy Immunocompromised persons (e.g., those with severe malnutrition,
HIV infection with CD4<200 cells/mm3)
yy Persons having—
ŠŠ Heart failure
ŠŠ Sickle cell disease
ŠŠ Severe chronic bronchitis

Signs and symptoms

ƒƒ Pneumonia in children <5 years
yy Difficulty with feeding
yy Chest indrawing

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yy Nasal flaring
yy Wheezing
yy Stridor in calm child
yy Fast RR
yy Fever
yy Tachycardia
ƒƒ Pneumonia in children >5 years and adults
yy The patient often gives a history of having had a respiratory condition
(nonproductive cough and low-grade fever) that got worse.
yy Cough, production of sputum (yellow, green, or bloody)
yy Fever
yy Chest pain during deep breathing and coughing
yy Rapid breathing may also be present
yy Anorexia
yy Sudden onset with high fever (>39°C) pain in the chest and oral herpes
are suggestive of pneumococcal infection. Symptoms may be confusing,
particularly in children with abdominal pain, meningeal syndrome, or
other conditions
yy In the elderly, the onset may be very gradual and may not suggest
pneumonia at all. They may have very little cough, produce no sputum,
and have no fever.
ƒƒ Signs of serious illness
yy Cyanosis
yy Nasal flaring
yy Intercostal or subclavial indrawing
yy Respiratory rate
ŠŠ Children <2 months: RR >60 breaths/minute
ŠŠ Children 2–11 months: RR >50 breaths/minute
ŠŠ Children 12–59 months: RR >40 breaths/minute
ŠŠ Adults: RR >30 breaths/minute
yy Heart rate more than 125 beats/minute
yy Altered level of consciousness (drowsiness, confusion)

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Diagnosis
ƒƒ On examination:
yy Decreased vesicular breath sound, localised crepitations, sometimes
bronchial wheeze
yy Dullness on percussion
ƒƒ Chest x-ray
ƒƒ Sputum smear to exclude TB

Management objectives
Management is guided by the age of the patient, his or her health status, and the
severity of the disease. In general, the objectives are to—
ƒƒ Treat the fever
ƒƒ Maintain an adequate level of oxygenation and hydration
ƒƒ Treat the infection

Nonpharmacological management
ƒƒ Encourage high oral fluid intake and nutrition. Use a nasogastric tube if
necessary
ƒƒ Provide oxygen at a rate of 1 L/minute
ƒƒ In the elderly, encourage postural drainage

Pharmacological management
In the health centre or health post, follow these procedures.
ƒƒ For all patients—
yy Clear nostrils if blocked with normal saline drops or Ringer’s lactate.
yy For fever, give paracetamol (120 mg/5 mL and 500 mg tablets). See table
3.6 for dosages.

ƒƒ In mild cases, give—

yy Benzylpenicillin procaine IM
ŠŠ Adults: 2 MIU 1–2 times/day for 5 days
ŠŠ Children: 100,000 IU/kg once daily for 5 days
OR
yy Amoxicillin PO
ŠŠ Adults: 1 g 3 times/day for 5 days
ŠŠ Children: 100 mg/kg/day in 3 divided doses for 5 days
OR

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Table 3.6. Paracetamol Dosages by Age and Weight for the Management
of Pneumonia

Age Weight Dose (mg) Quantity Frequency Duration

3–12 6–10 kg 60 2.5 mL 3 times/day 5 days
(½ tsp)
1–5 years 10–18 kg 120 5 mL (1 tsp) 3 times/day 5 days
5–8 years 18–25 kg 240 10 mL (2 tsp) 3–4 times/day 5 days
or ½ tablet
8–14 years 25–50 kg 500 1 tablet 4 times/day 5 days
>14 years >50 kg 1,000 2 tablets 4 times/day 5 days
and adults

yy In penicillin-allergic patients, give erythromycin, PO (125 mg/5 mL;

250 mg and 500 mg tablets) 500 mg every 6 hours for 7 days
ŠŠ Adults: 500 mg every 6 hours for 7 days
ŠŠ Children
–– <1 year: 125 mg (5 mL or 1 tsp) 2 times/day for 7 days
–– 1–5 years: 250 mg (10 mL or 2 tsp) 2 times/day for 7 days
–– 6–12 years: 500 mg (2 tablets) 2 times/day for 7 days
ƒƒ In mild cases if the patient has HIV and AIDS, give—
yy Co-trimoxazole tablet (800/160 mg) 2 tablets PO every 8 hours for 21 days.
OR
yy For sulfa-allergic patients, give clindamycin (50 mg, 300 mg tablets)
600 mg PO every 8 hours for 21 days
PLUS
yy Primaquine (7.5 mg, 15 mg tablets) 30 mg once daily for 21 days.

Note: In cases where the clinical presentation could be consistent with TB

or PCP, start the patient on PCP treatment while 3 samples for AFB are
obtained. If the samples are negative, continue with PCP treatment and
monitor progress. If TB diagnosis is confirmed, change co-trimoxazole to
1 tablet daily and begin TB treatment. (See section 14.8, “Tuberculosis.”)

ƒƒ In severe cases—
yy Hospitalize or refer to hospital
yy At the health centre level, give stat dose before transferring patient.

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In the hospital, follow these procedures.

ƒƒ Give benzylpenicillin procaine, benzylpencillin, and amoxicillin.
yy Adults
ŠŠ Benzylpenicillin procaine + benzylpencillin IM
–– 2 MIU 2 times/day for 2–3 days
–– Once fever or signs of severe illness disappeared switch to oral
treatment
ŠŠ Amoxcillin PO 1 g, 3 times/day to complete 7 days of treatment
yy Children
ŠŠ Benzylpenicillin procaine + benzylpencillin IM
–– 100,000 IU/kg once daily for 2–3 days
–– Once fever or signs of severe illness disappears, switch to oral
treatment
ŠŠ Amoxcillin PO 100 mg/kg/day in 3 divided doses to complete 7 days
of treatment
OR
ƒƒ Give ampicillin IV/IM (powder for injection 500 mg and 1 g)
yy Dosages—
ŠŠ Adults: 1 g 3 times/day by injection
ŠŠ Children:100 mg/kg/day in 3 injections
yy Change to oral treatment once fever or signs of severe illness disappear.
OR
ƒƒ For pencillin-allergic patients, give—
yy Erythromycin, PO (125 mg/5 mL; 250 mg and 500 mg tablets) 500 mg
every 6 hours for 7 days
ŠŠ Adults: 500 mg every 6 hours for 7 days
ŠŠ Children
–– <1 year: 125 mg (5 mL or 1 tsp) 2 times/day for 7 days
–– 1–5 years: 250 mg (10 mL or 2 tsp) 2 times/day for 7 days
–– 6–12 years: 500 mg (2 tablets) 2 times/day for 7 days
OR
yy Doxycycline (100 mg tablets). Adults and children >9 years (and >45 kg):
1 (100 mg) tablet 2 times/day for 7 days.

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ƒƒ If no response after 48 hours, administer chloramphenicol IM/IV

yy Dosages—
ŠŠ Adults: 1 g 3 times/day by injection for 2 to 3 days
ŠŠ Children: 100 mg/kg/day in 3 injections for 2 to 3 days
yy If the chloramphenicol fails to produce a favourable response then
administer a ceftriaxone injection (125 mg, 500 mg, and 1 g) 1 g IM or
slow IV (over 3 minutes) for 3 days followed by amoxcillin to complete 7
days of treatment.

Referral
ƒƒ Elderly
ƒƒ Signs of serious illness
ƒƒ Presence of other underlying disease(s)
ƒƒ Development of complications
ƒƒ Nonresponsive to treatment after 48 hours
ƒƒ No access to immediate transportation in case of sudden worsening of
condition

References—1, 3, 8, 10

3.7 Sinusitis
Description
Acute sinusitis is a transient inflammation of the mucosal lining of one or
more paranasal sinuses lasting <4 weeks. Although most cases of sinusitis
involve more than one sinus, the maxillary sinus is most commonly involved. If
unresolved, the condition can become chronic.

Note: Sinusitis is uncommon in children <5 years because the sinuses are not
fully developed.

Causes
ƒƒ Common infections: pneumococcus, streptococcus, staphylococcus, E. coli,
and H. influenza. The most common causes are H. influenza in children <5
years and pneumococci in patients >5 years.
ƒƒ Viral, bacterial, and sometimes fungal infection. The latter may be
associated with immune deficiency.
ƒƒ Allergy

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ƒƒ Rhinitis and nasal obstruction due to a foreign body

ƒƒ Dental focal infections
ƒƒ Swimming and diving

Signs and symptoms

ƒƒ Facial pain above the eyes and in the brow or forehead area in frontal
sinusitis; behind the cheekbones in maxillary; behind the bridge of the nose
in ethmoidal sinusitis
ƒƒ May also be accompanied by a discharge from the nostrils and into the
throat. The discharge is yellow (contains pus) if the infection is bacterial
and is clear if it is viral.
ƒƒ Nasal blockage sometimes present
ƒƒ Sneezing
ƒƒ Reduced sense of smell
ƒƒ Moderate fever
ƒƒ Malaise
ƒƒ On examination—
yy Pain on pressure over the forehead, under the border of the orbit or cheek
yy Purulent secretions in the nostrils and back of the throat and
inflammation of the mucosa

Diagnosis
ƒƒ Based on clinical signs and symptoms
ƒƒ X-ray of the sinuses at the hospital level (not routinely recommended for
the primary care level)

Management objectives
ƒƒ Relieve congestion and improve sinus drainage
ƒƒ Relieve pain and fever
ƒƒ Treat bacterial or fungal infection, if present

Nonpharmacological management
ƒƒ Inform the patient that the symptoms will resolve slowly but may persist
for 2–3 weeks whether antibiotics are used or not. Complications are rare.
ƒƒ Advise the use steam inhalations 2–3 times/day to help clear blocked nose.
ƒƒ In case of allergies, remind the patient to avoid situations that trigger an
attack.

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Pharmacological management
ƒƒ For mild sinusitis—
yy Advise 2 drops warm, 0.9% sodium chloride, or Ringer’s lactate in each
nostril 4 times/day to clear airway.
yy For relief of symptoms—
ŠŠ Give paracetamol (500 mg tablet) PO to relieve pain and fever. See
table 3.7 for dosages.

Table 3.7. Paracetamol Dosages by Age and Weight for the Management
of Sinusitis

Age Weight Dose (mg) Quantity Frequency Duration

3–12 months 6–10 kg 60 2.5 mL 3 times/day 5–7 days
(½ tsp)
1–5 years 10–18 kg 120 5 mL (1 tsp) 3 times/day 5–7 days
5–8 years 18–25 kg 240 10 mL (2 tsp) 3 times/day 5–7 days
or ½ tablet
8–14 years 25–50 kg 500 1 tablet 3-4 times/day 5–7 days
>14 years >50 kg 1,000 2 tablets 3-4 times/day 5–7days
and adults

ŠŠ Give chlorpheniramine (4 mg tablet; syrup 2 mg/5 mL) PO if the

sinusitis is associated with allergy).
–– Adults: 4 mg tablet 3–4 times/day but not to exceed 24 mg/day
–– Children: 2 mg/5 mL
‚‚ <1 year: Do not administer.
‚‚ 1–2 years: 1 mg (¼ tablet) or 2.5 mL (½ tsp) two times/day
‚‚ 2–5 years: 1 mg (¼ tablet) or 2.5 mL (½ tsp) 3–4 times/day, not
to exceed 6 mg/day
‚‚ 6–12 years: 2 mg (½ tablet) or 5 mL (1 tsp) 3–4 times/day, not to
exceed 12 mg/day
ƒƒ For severe infections (i.e., patients with systemic illness or patients whose
signs and symptoms worsen after 5–7 days), prescribe antibiotics—
yy First-line treatment: phenoxymethyl penicillin (250 mg tablet) or
amoxicillin (250 mg, 500 mg tablets; 125 mg/5 mL suspension)
ŠŠ Adults: 1 tablet (500 mg) PO 3–4 times/day for 5–7 days

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ŠŠ Children: oral suspension 125 mg/5 mL

ŠŠ <1 year: 2.5 mL (½ tsp; 62.5 mg ) 3–4 times/day for 5–7 days
ŠŠ 1–5 years: 5 mL (1 tsp) 3–4 times/day for 5–7 days
ŠŠ >5 years: 1 tablet (500 mg) PO 3–4 times/day for 5–7 days
OR
yy For penicillin-allergic patients, give—
ŠŠ Doxycycline (100 mg tablets)
–– Adults: 1 tablet twice/day for 7 days
–– Children >9 years (>45 kg):1 (100 mg) tablet 2 times/day for 7 days
Note: Doxycycline is not recommended in children <9 yrs and 45 kg.
OR
ŠŠ Erythromycin (250 mg and 500 mg tablets)
–– Adults: 500 mg 4 times/day for 7 days
–– Children: 250 mg 4 times/day for 7 days
‚‚ <1 year: 125 mg (5 mL or 1 tsp) 2 times/day for 7 days
‚‚ 1–5 years: 250 mg (10 mL or 2 tsp) 2 times/day for 7 days
‚‚ 6–12 years: 500 mg (2 tablets) 2 times/day for 7 days

Referral
ƒƒ Fever lasting >48 hours
ƒƒ Unilateral signs (e.g., unilateral polyp or mass)
ƒƒ Bleeding
ƒƒ Diplopia or proptosis (i.e., double vision)
ƒƒ Maxillary paraesthesia
ƒƒ Orbital swelling or erythema
ƒƒ Suspicion of intracranialor intraorbital complication
ƒƒ Immunocompromised patient
ƒƒ Dental focus of infection
ƒƒ Recurrent sinusitis
ƒƒ Severe signs and symptoms for >7–10 days

References—8, 10, 49, 50, 51

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4. Ears, Nose, and Throat

4.1 Ear Disorders

4.1.1 Foreign Body in the Ear

Description
A foreign body in the ear can be any small object that is inserted in the ear canal,
usually by the patient. It is relatively common and is seen most often, but not
exclusively, in children. The foreign object may also be a small insect that has
crawled into and irritated the external auditory canal.

Causes and risk factors

ƒƒ In small children, common objects include—
yy Beads, toy pieces, and ornament pieces
yy Small seeds, peas, peanuts, raisins
ƒƒ In adults, the foreign object is usually a cotton swab.
ƒƒ Infected ears encourage flies to lay eggs (maggots) on the pus that comes
out of the ear canal.

Signs and symptoms

ƒƒ Children, depending on age, may be able to indicate that they have a foreign
body in the ear.
ƒƒ Patients may present with complaints of ear pain or discharge from the
ear.
ƒƒ Patients may complain of nausea or vomiting if a live insect is in the ear
canal.
ƒƒ Patients may complain of hearing loss.

Diagnosis
Diagnosis is made mainly on physical examination, and physical findings vary
according to the object and length of time it has been in the ear
ƒƒ When an object has been in the ear a very short time, there is usually no
abnormal finding other than the object itself seen on direct visualization or
otoscopic examination.
ƒƒ Pain or bleeding may be present with sharp objects that bruise the ear

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canal or rupture the tympanic membrane or from the patient’s attempts to

remove the object.
ƒƒ Redness and swelling of the canal and a foul-smelling discharge may be
present.

Management objective
Safe removal of the object without causing any harm

Nonpharmacological management
ƒƒ Foreign body removal is made easier if the external auditory canal is made
straight. This can be done in children by pulling the pinna from its lobe in
the direction down, out, and laterally, and in adults by pulling the pinna
from its top in the direction up, out, and laterally. Shake the head with the
affected ear turned downwards.
ƒƒ In adults—
yy Small aural forceps can remove most foreign bodies.
yy Small pieces or objects can be taken out by aural syringing. Syringing
should be done only when you can see that the eardrum is intact.
ƒƒ In children—
Note: Never attempt foreign object removal on an uncooperative child.
yy Hold the child firmly, in a sitting position, in the lap of an attendant.
yy For a small round foreign body, syringing is the safest, easiest, and least
traumatic procedure.
yy For other objects, either use fine aural forceps or the ring of a Jobson
probe to hook it out by going beyond it and then pulling it out. This
should be done by someone who has experience or in the operating
theatre.
ƒƒ Methods of removal—
yy Irrigation with water is the simplest method of foreign body removal,
provided it is not tightly wedged or the tympanic membrane is not
perforated. Tap water or normal saline at body temperature can be used.
Note: Irrigation with water is contraindicated for vegetable objects,
organic matter, or seeds, which may swell if exposed to water.
yy Removal of live insects
ŠŠ Patients in extreme distress secondary to an insect in the ear require
prompt attention.

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ŠŠ The insect should be killed prior to removal, using mineral oil,

lidocaine hydrochloride (2%), or cooled boiled tap water.
Note: Do not use hydrogen peroxide.
ŠŠ Remove the insect carefully with crocodile forceps under direct
vision and only when the patient cooperates fully.
ŠŠ If removal was successful, check whether eardrum is intact, and
check for infection.
ƒƒ Removal of the foreign body in a theatre under general anaesthetic is
sometimes required.

Referral
In these situations, general anaesthesia may be required:
ƒƒ The patient is uncooperative, making removal of the object difficult.
ƒƒ The foreign body is deep in the ear canal.
ƒƒ Eardrum perforation is evident or suspected.
ƒƒ The patient has severe pain due to associated inflammation and oedema.

References—3, 52, 53, 54, 55

4.1.2 Impacted Wax in the Ear

Description
Wax is a natural product of the sebaceous and sweat glands of the skin lining the
external auditory canal mixed with the epithelial desquamated layer of the skin.
It protects the skin of the human ear canal, assists in cleaning and lubrication,
and also provides some protection from bacteria, fungi, insects, and water. The
ear canals are self-cleaning. In some persons, wax is secreted more and gets
collected, which requires cleaning. Impaction is, therefore, a collection of ear
wax to an extent of causing ear canal blockage.

Causes and risk factors

ƒƒ Enthusiastic, unnecessary cleaning of the ear
ƒƒ Pushing wax deeper into the ear with swabs, cotton wool, sticks, or other
items

Signs and symptoms

ƒƒ Having increasing difficulty hearing
ƒƒ Pain in the ear(s)

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ƒƒ Hearing a noise or ringing in the ear(s) (i.e., tinnitus)

ƒƒ An awareness of something blocking the ear(s)
ƒƒ Temporary deafness after swimming or having a shower
ƒƒ Pain or itchiness due to infection from bacteria trapped in the ear; infection
can lead to otitis externa. (See section 4.1.3, “Otitis Externa.”)

Diagnosis
Direct vision using a torchlight or an otoscope

Management objectives
ƒƒ Soften the wax making it easier to remove
ƒƒ Remove wax from the ear

Nonpharmacological management
For soft wax (coloured light to deep brown), syringing is the easiest and least
painful method.
ƒƒ Use a 10 or 20 mL syringe if an ear syringe is not available.
ƒƒ Use water or normal saline, a sodium bicarbonate solution, or a solution of
water and vinegar. Warm these to body temperature before use.
ƒƒ Use a kidney dish for collecting the water that will be coming out of the ear
after syringing.
ƒƒ Do not insert the syringe too far into the ear canal causing obstruction.
Leave space so that injected water can run out.
ƒƒ Inject water upwards and backwards slowly.
ƒƒ Re-examine frequently.
Caution: Do not syringe the ear if—
• The patient has severe pain (usually due to otitis media, otitis externa, or
impaction of the wax onto the eardrum).
• Eardrum is perforated.

For hard, dry wax, use a wax softener such as olive oil, almond oil, mineral oil,
baby oil, or various other organic liquids (glycerine solution) 2–3 times/day for
3–5 days.
ƒƒ Advise the patient to—
yy Tilt his or her head or lie with the affected ear up while the drops are
instilled.
yy Stay in that position for 2–3 minutes.

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yy Lie with the ear down to drain out the oil.

ƒƒ The action of chewing gum helps move the wax.
ƒƒ Try syringing again next day.
ƒƒ If the wax is very impacted, instil softener every 2 hours for 7–10 days.

Note: Do not use hydrogen peroxide or swab to remove wax. Ear cleaning swabs
are useful only if wax is at the external meatus.

Pharmacological management
Medications are necessary only in the presence of associated infection. If otitis
externa is present, treat before attempting wax removal. (See section 4.1.3, “Otitis
Externa.”) An associated URTI causing otitis media should also be treated first
before wax removal. (See chapter 3, “Respiratory System” and section 4.1.4,
“Otitis Media.”)

Referral
ƒƒ Treatment failure
ƒƒ Persistent or severe earache

References—3, 54, 56, 57

4.1.3 Otitis Externa

Description
Otitis externa is an inflammation of the external auditory meatus (i.e., the skin
lining the outer ear), and it can become chronic. It is caused by infection, usually
bacterial, although sometimes fungal, but it may also be associated with various
noninfectious systemic or local skin conditions. It is occasionally due to a foreign
body in the ear canal.

Causes and risk factors

ƒƒ Trauma (i.e., scratching, cleaning with sticks, cotton ear buds)
ƒƒ Bacterial infection secondary to scratching
ƒƒ Virus infections such as herpes simplex
ƒƒ Foreign substances (e.g., cottonwool, stones, insects, seeds)
ƒƒ Moisture in the ear (e.g., shampoo, soap, contaminated swimming pool water)
ƒƒ Fungal infections, especially in diabetes mellitus
ƒƒ Inappropriate use of antibiotic ear drops
ƒƒ Allergic conditions such as dermatitis, eczema

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Signs and symptoms

ƒƒ Ear discomfort that can range from itching to severe pain especially when
chewing
ƒƒ A scant white discharge in or flowing from the ear canal
ƒƒ Tenderness when touching or pulling the pinna
ƒƒ Hearing loss (i.e., ear feels blocked)
ƒƒ Examination with an otoscope generally reveals—
yy Inflammation and swelling of the canal
yy The tympanic membrane may be normal or slightly inflamed, if visible. If
not visible, use a cotton swab to gently clean secretions from the external
auditory canal. Note: Stop if it is very painful.
ƒƒ Examine for the presence of a foreign body.

Diagnosis
The diagnosis is based on the clinical signs and symptoms. There is no
diagnostic test to confirm diagnosis.

Management objectives
ƒƒ Relieve symptoms
ƒƒ Prevent complications such as mastoiditis

Nonpharmacological management
ƒƒ Clean the canal to remove debris to make topical treatment easier.
ƒƒ For inflammation, use 2% acetic acid or Ringer’s lactate: 3 drops QID for
5–7 days or 3 days after cessation of symptoms; more severe infections may
require 10–14 days.
ƒƒ Patient should not participate in water sports for at least 2–3 weeks.
ƒƒ If foreign body is present, remove it.

Pharmacological management
ƒƒ Give neomycin otic suspension with hydrocortisone: 2 drops QID for 5–7
days or for 3 days after cessation of symptoms; more severe infections may
require 10–14 days.
ƒƒ For pain—
yy Giveibuprofen (200, 400, and 600 mg tablets; 100 mg/5 mL suspension)
ŠŠ Adults: 200–400 mg 4–6 times/day depending on severity of pain
OR

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yy Give paracetamol PO (500 mg tablets; 120 mg/5 mL oral suspension).

See table 4.1.3 for dosages.

Table 4.1.3. Paracetamol Dosages by Age and Weight for the Management of
Otitis Externa

Age Weight Dose (mg) Quantity Frequency Duration

3–12 months 6–10 kg 60 2.5 mL 3times/day 5–7 days
(½ tsp)
1–5 years 10–18 kg 120 5 mL (1 tsp) 3 times/day 5–7 days
5–8 years 18–25 kg 240 10 mL (2 tsp) 3 times/day 5–7 days
or ½ tablet
8–14 years 25–50 kg 500 1 tablet 3–4 times/day 5–7 days
>14 years >50 kg 1,000 2 tablets 3–4 times/day 5–7 days
and adults

OR
yy Give acetylsalicylic acid PO (300 mg and 500 mg tablets). Adults:
300–500 mg every 4–6 hours PRN.
Caution: Acetylsalicylic acid (aspirin) is not recommended for children
<12 years old because of the risk of Reye’s syndrome.
ƒƒ Antimicrobial therapy should not be used unless there is extension outside
the ear canal or the presence of specific host factors such as diabetes or
immune deficiency that would indicate a need for systemic therapy. When
the ear canal is obstructed, delivery of topical preparations should be
enhanced by aural toilet, placement of a wick (only if swelling is severe),
or both.
yy If symptoms persist for 3 days, ask patient to return to be re-evaluated.
The patient may need to be placed on systemic antibiotic:
yy Give cloxacillin (250 mg and 500 mg tablets)
ŠŠ Adults: 500 mg 4 times/day for 7 days
ŠŠ Children >20 kg: 250 mg 4 times/day for 7 days
OR

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yy Give amoxicillin-clavulanate (125 mg + 31 mg/5 mL) or amoxicillin-

clavulanate(amoxicillin 500 mg/clavulanate 125 mg tablet)
ŠŠ Adults: (500 mg +125 mg tablet) 1 tablet 2 times/day for 10 days
ŠŠ Children: 90 mg + 6.4 mg/kg/day in 2 divided doses for 10 days

Referral
ƒƒ If there is no response to treatment within 4 days or if getting worse
yy Extension of disease outside the ear canal

References—1, 3, 10, 58, 59, 60

4.1.4 Otitis Media

Description
Otitis media is an infection of the middle ear that can result from dysfunction of
the eustachian tube in association with a number of illnesses including URIs and
chronic rhinosinusitis. There are two types, acute and chronic. If left untreated,
acute otitis media can lead to mastoiditis or become chronic. (See section 4.1.5,
“Chronic Otitis Media.”)

Causes
ƒƒ Viral infection of upper respiratory tract (e.g., rhinitis, common cold)
ƒƒ Bacterial infections (e.g., streptococcus, H. influenza)
ƒƒ Chronic allergy
ƒƒ Chronic enlargement of tonsils or adenoids

Signs and symptoms

Commonly, the patient presents with signs of an upper respiratory illness a few
days before presenting with an ear infection. Other signs and symptoms are the
following:
ƒƒ In adults—
yy Fever
yy Pain in ear
yy Headache
yy Malaise, weakness
ƒƒ In children<3 years—
yy Irritability
yy Waking at night

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yy High fever
yy Poor feeding
yy Runny nose
yy Problems with balance
yy Hearing loss
yy Acutely painful ear
ƒƒ In children ≥3 years and older—
yy Acutely painful ear
yy Drainage from ear
yy Hearing loss
yy Ear popping
yy Ear fullness
yy Dizziness

Diagnosis
Examination with otoscope reveals middle ear effusion. In a bacterial infection,
the tympanic membrane can also be inflamed with symptoms as stated above.

Management objectives
ƒƒ Prevent complications
ƒƒ Control pain and inflammation

Nonpharmacological management
Clear the nose as for rhinitis with 0.9% sodium chloride or Ringer’s lactate.

Pharmacological management
ƒƒ Treat fever with paracetamol or aspirin.
yy Give paracetamol (500 mg tablets; 120 mg/5 mL suspension). See table
4.1.4 for dosages.
OR
yy Give acetylsalicylic acid PO (300 mg and 500 mg tablets). Adults:1–3 g/
day in 3 or 4 divided doses.
Caution: Acetylsalicylic acid (aspirin) is not recommended for children
<12 years old because of the risk of Reye’s syndrome.

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Table 4.1.4. Paracetamol Dosages by Age and Weight for Management for
Otitis Media

Age Weight Dose (mg) Quantity Frequency Duration

3–12 months 6–10 kg 60 2.5 mL 3 times/day 5–7 days
(½ tsp)
1–5 years 10–18 kg 120 5 mL (1 tsp) 3 times/day 5–7 days
5–8 years 18–25 kg 240 10 mL (2 tsp) 3 times/day 5–7 days
or ½ tablet
8–14 years 25–50 kg 500 1 tablet 3–4 times/day 5–7 days
>14 years >50 kg 1,000 2 tablets 3–4 times/day 5–7 days
and adults

ƒƒ Provide antibiotic treatment.

yy For all children <6 months of age—
ŠŠ First-line: give amoxicillin orally at 80–90 mg/kg/day in 2–3 divided
doses for 5–7 days, extending to 10 days in case of complications.
OR
ŠŠ In penicillin-allergic children, use erythromycin PO (125/5 mL)
30–50 mg/kg in 2–3 divided doses for 10 days.
ŠŠ If there is no response in 48 hours, health care workers at level 2
should refer the patient to the district hospital. At the hospital, give
ceftriaxone IM (125 mg, 500 mg, and 1 g) 50 mg/kg daily for 3 days.
yy In children >6 months of age, the cause is usually viral. Prescribe an
analgesic only. If possible, re-examine 3 days after the initial visit.
ŠŠ If it is not possible to re-examine in 3 days or if the fever and pain
continue despite the analgesic, provide antibiotics as above.
ŠŠ If child has fever>39°C, moderate or severe pain, or both, prescribe
antibiotics as above.
ŠŠ If there is treatment failure at 48–72 hours with first-line
antibacterial agents, prescribe amoxicillin-clavulanate (125 mg +
31 mg/5 mL) 90 mg/kg of amoxicillin component and 6.4 mg/kg/day
of clavulanate in 2 divided doses for 10 days.
OR
ŠŠ In penicillin-allergic patients, give ceftriaxone 50 mg/kg/day IM or
IV once a day for 3 days.

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yy In adults—
yy First line: give amoxicillin PO (250 mg, 500 mg tablets) 500 mg orally 3
times day for 10 days.
ŠŠ For treatment failure, give amoxicillin-clavulanate (amoxicillin 500
mg/clavulanate 125 mg tablet) 2 times/day for 10 days.
OR
ŠŠ For penicillin-allergic adults, give—
–– Doxycycline (100 mg tablets) 1 tablet twice/day for 7 days
OR
–– Erythromycin (250 mg and 500 mg tablets): 500 mg 4 times/day
for 7 days
ƒƒ Watch for the following complications:
yy Acute mastoiditis
yy Meningitis (see section 16.4.2, “Meningitis”)
yy Subdural or extradural abscess
yy Brain or neck abscess

Referral
ƒƒ Failure to respond to treatment after 2 weeks
ƒƒ Severe fever, vomiting, and drowsiness in children
ƒƒ Swelling over mastoid area
ƒƒ Facial palsy or neurological signs
ƒƒ Stiffness of the neck
ƒƒ Perforated tympanic membrane
ƒƒ Suppurative otitis media

References—1, 3, 10, 61

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4.1.5 Chronic Otitis Media

Description
Chronic otitis media is characterized by persistent or recurrent serous or
purulent discharge from the ear due to chronic infection to the middle ear. A
purulent discharge is associated with perforation of the tympanic membrane.
It may lead to hearing loss due to secondary infections.

Causes
ƒƒ Failed treatment for otitis media
ƒƒ Perforated eardrum

Signs and symptoms

ƒƒ Chronically draining ear (>2 weeks)
ƒƒ History of recurrent acute otitis media
ƒƒ Traumatic perforation of eardrum
ƒƒ Usually pain or discomfort
ƒƒ Hearing loss in the affected ear (common)

Diagnosis
Diagnosis is made from the signs and symptoms.
ƒƒ The external auditory canal may possibly be oedematous and usually is not
tender.
ƒƒ The discharge varies from fetid and purulent to clear and serous.
ƒƒ Granulation tissue is often seen in the medial canal or middle ear space.
ƒƒ The middle ear mucosa seen through the perforation may be oedematous or
even polypoid, pale, or erythematous.

Management objectives
ƒƒ Relieve the symptoms—pain, if present, and persistent discharge
ƒƒ Keep the ear dry
ƒƒ Eradicate infection and close the tympanic perforation to prevent
complications such as deafness or mastoiditis

Nonpharmacological management
ƒƒ Use a syringe to aspirate the pus to restore drainage.
ƒƒ Insert a small amount cotton wool or a cotton wick into the ear to absorb
the discharge. Change cotton 3–4 times/day until the discharge has
stopped.

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Pharmacological management
ƒƒ Treat pain. Give paracetamol PO (100 mg and 500 mg tablets; 120 mg/5 mL
oral suspension). See table 4.1.5 for dosages.

ƒƒ Instil chloramphenicol ear drops 2 drops twice/day until pus dries up

(approximately 5–7 days).

Table 4.1.5 Paracetamol Dosages by Age and Weight for Management of Chronic
Otitis Media

Age Weight Dose (mg) Quantity Frequency Duration

3–12 months 6–10 kg 60 2.5 mL 3 times/day 5–7 days
(½ tsp)
1–5 years 10–18 kg 120 5 mL (1 tsp) 3 times/day 5–7 days
5–8 years 18–25 kg 240 10 mL (2 tsp) 3 times/day 5–7 days
or ½ tablet
8–14 years 25–50 kg 500 1 tablet 3–4 times/day 5–7 days
>14 years >50 kg 1,000 2 tablets 3–4 times/day 5–7 days
and adults

Referral
ƒƒ If pain and fever persist despite local treatment, the level 1 health care
worker should refer the patient to the next level facility, and treat as acute
otitis media.(See section 4.1.4, “Otitis Media.”)
ƒƒ Refer the following:
yy All sick children (i.e., those who are vomiting, drowsy, and showing
symptoms of more serious illness)
yy Patients who have painful swelling behind the ear
yy Patients who have a large central perforation
yy Patients who show no improvement after 1 week

References—8, 10, 62, 63

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4.1.6 Hearing Loss

Description
Hearing loss is a symptom of an underlying disease or condition. It can result
from disorders of the auricle, external auditory canal, middle ear, inner ear,
or central auditory canal. It can occur gradually with age (i.e., presbycusis).
Heredity and exposure to loud noises are the main factors that contribute to
hearing loss over time. It may also be secondary to the causes listed below.

Causes
ƒƒ Conductive hearing loss (i.e., obstruction of external auditory canal)—
yy Impacted wax in the ear (see section 4.1.2, “Impacted Ear Wax in the
Ear”)
yy Foreign body in ear canal (see section 4.1.1, “Foreign Body in the Ear”)
yy Perforation of tympanic membrane
yy Otitis externa (see sections 4.1.4, “Otitis Media” and 4.1.5, “Chronic
Otitis Media”)
ƒƒ Sensorineural hearing loss—
yy Aging (most common)
yy Intense noise
yy Meningitis (see section 16.4.2, “Meningitis”)
yy Otitis media with perforation
yy Trauma (head injury)
yy Congenital—genetics, maternal diabetes
yy Pre- and postnatal infections (e.g., rubella)

Signs and symptoms

ƒƒ Muffling of speech and other sounds
ƒƒ Difficulty understanding words, especially against background noise or in a
crowd of people
ƒƒ Frequently asking others to speak more slowly, clearly, and loudly
ƒƒ Needing to turn up the volume of the television or radio
ƒƒ Tinnitus—the perception of a sound (buzzing, roaring, or ringing) when
none is there

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Diagnosis
ƒƒ Diagnosis can be made from the history (i.e., duration, uni- or bilateral,
nature of onset, rate of progression, and signs and symptoms)
ƒƒ Tuning fork test—
yy Ability to hear by air conduction and by bone conduction
yy Identifying hearing in ears with stem of vibration tuning fork in mid-
forehead

Management objective
Improve hearing

Nonpharmacological management
ƒƒ Advise patients to—
yy Protect their ears in workplaces that have high noise levels.
yy Avoid listening to extremely loud music for long periods of time.
ƒƒ If the hearing loss is due to a blockage, treat the underlying cause.
ƒƒ Encourage yearly monitoring of hearing.

Pharmacological management
ƒƒ Only necessary if the hearing loss is due to an underlying infection
ƒƒ See appropriate disease section.

Referral
ƒƒ If underlying disease is suspected
ƒƒ If hearing loss is considered to be irreversible
ƒƒ For screening of hearing

References—1, 3

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4.2 Nose and Paranasal Sinus

4.2.1 Nasal Obstruction

Description
Nasal obstruction is the blockage of air flow through the nostrils.

Causes
ƒƒ Mechanical
yy Septal abnormality (e.g., deviation, haematoma, abscess)
yy Intranasal mass (e.g., foreign body, tumour)
ƒƒ Mucosal
yy Infection
yy Allergic

4.2.1.1 Foreign Body in the Nose

Occasionally, an object is put into the nose, where it may become stuck. This
occurs most often among children. Common objects include beads, seeds, small
toy batteries or toy pieces, and sponge pieces. This may occur in one or both
nostrils.

Signs and symptoms

ƒƒ Signs and symptoms may include the following:
yy Difficulty breathing through the clogged nostril
yy Feeling pain or irritation with the sensation of something in the nostril
yy Discharge from one nostril, which may become foul-smelling and
mucopurulent and sometimes blood stained if the object has been left in
the nostril a long time
yy Sneezing
yy Tears
ƒƒ Usually noticed by parents (in infants)

Diagnosis
ƒƒ Diagnosis is normally made from medical history and physical
examination.
ƒƒ Examine the nostrils using a lighted instrument.

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Management objective
Removal of the foreign body without making the situation worse

Nonpharmacological management
In a cooperative patient—
ƒƒ Gently press the unaffected nostril closed, and encourage or instruct the
child (if older) to blow the nose forcibly. Avoid blowing the nose too hard or
repeatedly.
ƒƒ Sponge or paper pieces can be pulled out by a small artery or tooth
dissecting forceps.
ƒƒ A round body or deeper situated foreign body, only if it is clearly visible,
should be hooked out by putting a blunt hook or a curved artery forceps
behind and beyond the foreign body and then pulling it out along the floor of
the nostril.
ƒƒ Avoid the following when trying to remove a foreign body from the nose:
yy Grasping the object with tweezers or other tools, which can harm the
nose
yy Squeezing or manipulating the nostrils
Caution: Do not attempt to remove an object that is not easy to see and
grasp. Doing so can push the object farther up the nose.

Caution: Do not try to push a foreign object back in nasopharynx. If the

child is uncooperative or is bleeding, the foreign body is not seen, or the
area is very infected, then it is better for the obstruction to be removed
under general anaesthetic.
ƒƒ Post-extraction bleeding is controlled by giving decongestant nasal drops or
putting adrenaline cotton pack in the nose for 10 minutes.

Pharmacological management
ƒƒ Antibiotics should be used only if there is evidence of an infection.
ƒƒ Give amoxicillin (250 mg, 500 mg tablets). Adults: 500 mg 3 times/day for
5 days.
ƒƒ Children: 100 mg/kg/day in 3 divided doses for 5 days
ƒƒ In penicillin-allergic patients, erythromycin (250 mg, 500 mg tablets;
125 mg/5 mL suspension).

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Table 4.2.1.1 Erythromycin Dosages by Age and Weight for Management of

Infection caused by Foreign Body in Nose

Age Dose (mg) Quantity Frequency

<1 year 125 5 mL (1 tsp) Every 6 hours
1–5 years 250 10 mL (2 tsp) Every 6 hours
6–12 years 500 1–2 tablets Every 6 hours
Adults 1,000 2–4 tablets Every 6 hours

Referral
Foreign body difficult to see or too far back to remove without making situation
worse

References—64, 65, 66, 67

4.2.1.2 Nasal and Sinus Infections

4.2.1.2.1 Rhinitis and Rhinopharyngitis
Description
Rhinitis and rhinopharyngitis are infections of the nasal or pharyngeal mucosa,
which occur with seasonal variation and are more frequent in cold and rainy
seasons. They can be complicated by a secondary bacterial infection.

Causes and risk factors

ƒƒ Most frequently due to viral infections
ƒƒ May be bacterial,which may be secondary (e.g., streptococcus,
staphylococcus, H. influenza)

Signs and symptoms

They are characterized by recurrent episodes of—
ƒƒ Blocked stuffy nose
ƒƒ Watery nasal discharge, which may be accompanied by a sore throat, cough,
fever, and diarrhoea in infants
ƒƒ Frequent sneezing, often accompanied by nasal itching and irritation
ƒƒ Conjunctival itching and watering
ƒƒ Mouth breathing
ƒƒ Snoring at night

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Note: Nasal obstruction may make breathing and breastfeeding difficult and may
be the early symptoms of measles, influenza, or another disease. The condition
may become secondarily infected or complicated by otitis media and acute
sinusitis in children <5 years.

Diagnosis
ƒƒ Made on history and signs and symptoms
ƒƒ In recurrent infections, consider allergies, iron deficiency, and exposure to
tobacco smoke.

Management objectives
ƒƒ Achieve and maintain maximum relief
ƒƒ Prevent recurrent attacks
ƒƒ Provide symptomatic relief

Nonpharmacological management
ƒƒ Advise the patient to—
yy Clear nasal cavities twice daily to remove crusts.
yy Syringe nose with warm 0.9% sodium chloride or Ringer’s lactate 4
times/day to clear airway. (A homemade saltwater solution can be
prepared by mixing 5 mL of salt in 250 mL of warm water.)
yy Avoid allergens and irritants.
yy Use steam inhalations when necessary.
yy Get bed rest if feverish.
yy Ensure plenty of oral fluids.
ƒƒ Advise patient to return to the clinic if he or she develops an earache or
tenderness or pain over the sinuses and if the cough or fever persists for
longer than a week.

Pharmacological management
ƒƒ To relieve pain and fever, give paracetamol PO (100 mg or 500 mg tablets;
120 mg/5 mL oral suspension). See table 4.2.1.2.1 for dosages.

ƒƒ For allergic rhinitis only, see section 4.2.1.2.2, “Allergic Rhinitis.”

References—8, 10

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Table 4.2.1.2.1. Paracetamol Dosages by Weight and Age for the Management of
Rhinitis and Rhinopharyngitis

Age Weight Dose (mg) Quantity Frequency Duration

3–12 months 6–10 kg 0 2.5 mL 3 times/day 5–7 days
(½ tsp)
1–5 years 10–18 kg 120 5 mL (1 tsp) 3 times/day 5–7 days
5–8 years 18–25 kg 240 10 mL (2 tsp) 3 times/day 5–7 days
or ½ tablet
8–14 years 25–50 kg 500 1 tablet 3–4 times/day 5–7 days
>14 years >50 kg 1,000 2 tablets 3–4 times/day 5–7days
and adults

4.2.1.2.2 Allergic Rhinitis

Description
Allergic rhinitis is an inflammation of the nasal passages, usually associated
with watery nasal discharge and itching of the nose and eyes.

Classification
ƒƒ Intermittent (seasonal), mild, moderate, or severe, and caused by inhalants
such as tree pollen, grass, or moulds
ƒƒ Persistent, mild, moderate, or severe and caused by house dust mites,
animal dander, cockroaches or food

Causes and risk factors

ƒƒ Allergic rhinitis usually occurs after exposure to dust or certain seasonal
pollens in people who are allergic to these substances.
ƒƒ Patient usually has a history of other allergic manifestations.

Signs and symptoms

ƒƒ Sneezing, nasal discharge, and obstruction of the nasal passages
ƒƒ Conjunctival, nasal, and pharyngeal itching
ƒƒ Conjunctiva congested and oedematous

Diagnosis
Diagnosis depends largely on accurate history of occurrences and association
with allergens

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Management objectives
ƒƒ Relieve the symptoms
ƒƒ Avoid contact with the triggering antigen

Pharmacological management
ƒƒ Identify and avoid allergen.
ƒƒ If conjunctivitis is present, clean eyes 4–6 times/day with previously boiled
water cooled to room temperature or sterile 0.9% sodium chloride solution.
(See section 5.1.1, “Conjunctivitis.”)

Provide symptomatic treatment only—

ƒƒ Give chlorpheniramine oral (4 mg tablets; 2 mg/5 mL syrup) every
4–6 hours for about 3–5 days
yy Adults: 4 mg tablet 4–6 times/day, not to exceed 24 mg/day
yy Children:
ŠŠ 2–5 years 1 mg (2.5 mL or ½ tsp) syrup 4–6 times/day, not to exceed
6 mg/day
ŠŠ 6–12 years: 2 mg (½ tablet or 5 mL [1 tsp] syrup) 4–6 times/day, not to
exceed 12 mg/day
OR
ƒƒ Give loratadine tablet or syrup.
yy Children 2–5 years (syrup): 5 mg once daily
yy Children ≥6 years and adults (tablet): 10 mg daily for 3–5 days
References—1, 3, 8, 10, 68

4.2.2 Epistaxis (Nose Bleed)

Description
Epistaxis is bleeding from the nose. The rupture may be spontaneous or as a
result of trauma. There are two types: anterior (the most common), which is
most often seen in children, and posterior (less common but more likely to
require medical attention), which is more often seen in adults. Epistaxis is seen
more often in children <10 years and adults >50 years of age. It appears to occur
more often in males.

Causes and risk factors

ƒƒ Idiopathic: commonest cause
ƒƒ Rupture of a blood vessel within the nasal mucosa

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ƒƒ Nose picking over the septum (common in children)

ƒƒ Severe bleeding is usually associated with trauma
ƒƒ Benign or malignant tumours of the nose, sinuses, or nasopharynx,
ƒƒ Systemic diseases such as—
yy Hypertension
yy Polyps
yy Cirrhosis
ƒƒ Blood dyscrasias (e.g., bleeding disorders such as sickle cell, haemophilia,
and coagulation factors; blood cancer [i.e., leukaemia])
ƒƒ Use of blood-thinning medicines such as aspirin or warfarin;
immunosuppressive medicines
ƒƒ Vitamin C or vitamin K deficiency

Signs and symptoms

ƒƒ The patient often has a history of bleeding from the nostrils.
ƒƒ The physical examination may reveal a bleeding point on the nasal septum.
ƒƒ If nothing is visible anteriorly, examine the pharyngeal area.
ƒƒ Diffuse oozing of blood, recurrent episodes, or multiple bleeding points may
indicate a systemic cause.
ƒƒ Check the skin for signs of bruising.

Diagnosis
ƒƒ A careful history and physical examination generally determine the cause
of the bleeding.
ƒƒ If a systemic cause suspected, carry out the following:
yy CBC, platelets, prothrombin time, partial thromboplastin time, bleeding
time, clotting time, and peripheral smear cell morphology.
yy Radiology
yy Biopsy for tumours in a guarded condition. Note: This procedure must
be done at the hospital level.

Management objectives
ƒƒ Determine cause of bleeding
ƒƒ Stop the bleeding

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Nonpharmacological management
ƒƒ Reassure the patient.
ƒƒ Advise the patient to sit with head forward and slightly down to prevent
bleeding into the pharynx.
ƒƒ Nasal bleeding usually responds to first-aid measures such as compression.
Apply direct pressure by squeezing the nostrils for 5–10 minutes. Do not let
go to check in between. In some cases, pressure may need to be applied for
up to 30 minutes.
ƒƒ Instruct the patient not to blow his or her nose.
ƒƒ In adults, placing an icepack on the forehead may be helpful.
ƒƒ When epistaxis does not respond to simple measures, the source of the
bleeding should be located and treated appropriately.

Pharmacological management
ƒƒ In nonemergencies—
yy Reassure the patient.
yy If direct pressure is not sufficient, gauze moistened with epinephrine at
a ratio of 1:10,000 or phenylephrine (Neo-Synephrine®) may be placed in
the affected nostril to help vasoconstrict and stop bleeding.
OR
yy For a mild bleed, put an adrenaline swab in the affected nostril and
apply continuous pressure to the nostril for at least 5 minutes. Have the
patient tilt the head forward while this is being done.
Caution: Do not use an adrenaline swab in hypertensive patients. Use
paraffin-soaked gauze instead.
yy After 10 minutes, remove the swab and look for any bleeding point.
ŠŠ If a bleeding point seen, cauterise it with a silver nitrate stick after
applying a local anaesthetic (4% xylocaine) topically.
ŠŠ An oozing point may need diathermy coagulation.
ŠŠ If no bleeding point seen, then investigate.
ƒƒ In emergencies—
yy In severe or profuse bleeding, the patient may also be in shock, so treat
simultaneously on principles of ABC (airway, breathing, circulation),
and do nasal packing with antibiotic-soaked (e.g., Neosporin® triple
antibiotic ointment) ribbon gauze for 48–72 hours.

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yy Give systemic antibiotics:

ŠŠ Amoxicillin PO (250 mg and 500 mg tablets; 125 mg/5 mL
suspension)
–– Adults: 1 g twice/day for 6 days
–– Children: 50 mg/kg/day in 2 divided doses for 6 days
Note: Macrolides resistance develops fast and frequently, so use it
only in penicillin-allergic patients.
OR
ŠŠ For penicillin-allergic patients, erythromycin PO (250 mg and 500 mg
tablets; 125 mg/5 mL)
–– Adults: 1 g (two 500 mg tablets) 2–3 times/day for 10 days
–– Children: 30–50 mg/kg in 2 to 3 divided doses for 10 days
yy Any associated conditions (e.g., hypertension, bleeding disorder, or
shock) should be treated simultaneously.

Referral
ƒƒ Uncontrolled bleeding—the patient needs hospitalisation because
postnasal packing or ligature of the bleeding vessel may be required
ƒƒ Vital signs decompensate
ƒƒ Bleeding recurs
ƒƒ Suspected underlying systemic condition

References—3, 69, 70, 71

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4.3 Throat Disorders

4.3.1 Tonsillitis
Description
Tonsillitis is a condition caused by the inflammation of the tonsils, secondary to
viral or bacterial infection. It is common in children and young people but can
occur at any age. It is spread by airborne droplets, hand-to-hand contact, and
kissing. Untreated streptococcal infection can go on to cause an abscess, acute
rheumatic fever, or acute glomerulonephritis.

Causes
ƒƒ Streptococcal bacterial infection—major cause; must be treated to prevent
complications
ƒƒ Many different viral infections, often those associated with the common
cold, influenza, and nasal infections
ƒƒ Infectious mononucleosis
ƒƒ Diphtheria

Signs and symptoms

ƒƒ Sore throat with pain; pain may radiate to the ear
ƒƒ Difficulty while swallowing (i.e., dysphagia)
ƒƒ Loss of voice or hoarseness
ƒƒ Swollen, inflamed tonsils with white patches (i.e., follicles)
ƒƒ Tender, enlarged cervical lymph nodes
ƒƒ Often associated with sudden onset of fever
ƒƒ Breath may be foul smelling

Diagnosis
ƒƒ Do a visual inspection of the throat using a torch and tongue depressor
ƒƒ Suspect streptococcal tonsillitis if the patient has no hoarseness, watery
nasal discharge, or conjunctivitis.

Management objectives
ƒƒ Alleviate the symptoms
ƒƒ Eradicate the infection completely
ƒƒ Prevent cardiac and renal complications
ƒƒ Prevent development of a peri-tonsillar abscess

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Nonpharmacological management
ƒƒ Keep the patient warm.
ƒƒ Advise the patient to gargle or use throat lozenges to ease the pain on
swallowing. Gargle with homemade salt mouthwash (2.5 mL [½ tsp] of table
salt in a glass of lukewarm water) for 1 minute twice daily.
ƒƒ Advise the patient to eat soft or liquid foods.

Pharmacological management
ƒƒ Give paracetamol PO (100 mg or 500 mg tablets; 120 mg/5 mL oral
suspension) for fever and pain. See table 4.3.1A for dosages.

Table 4.3.1A. Paracetamol Dosages by Age and Weight for the Management of
Tonsillitis

Age Weight Dose (mg) Quantity Frequency Duration

3–12 months 6–10 kg 60 2.5 mL 3 times/day 5–7 days
(½ tsp)
1–5 years 10–18 kg 120 5 mL (1 tsp) 3 times/day 5–7 days
5–8 years 18–25 kg 240 10 mL (2 tsp) 3 times/day 5-7 days
or ½ tablet
8–14 years 25–50 kg 500 1 tablet 3–4 times/day 5–7 days
>14 years >50 kg 1,000 2 tablets 3–4 times/day 5–7days
and adults

OR
ƒƒ For pain only, have patient gargle with an aspirin solution.
Caution: Acetylsalicylic acid (aspirin) is not recommended for children <12
years old because of the risk of Reye’s syndrome.

ƒƒ Patients <15 years who have sore throat, dysphagia, fever, and red and
inflamed tonsils with follicles or enlarged lymph glands need antibiotics.
yy Give benzathine benzylpenicillin (600 mg, 1 g injection) IM,
immediately.
ŠŠ <15 kg: 300 000 IU
ŠŠ 15–30 kg: 600 000 IU
ŠŠ >30 kg and adults: 1.2 MU
OR

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yy Give phenoxymethylpenicillin PO (250 mg tablet; 125 mg/5 mL

suspension) 2 times/day for 10 days. See table 4.3.1B for dosages.

Table 4.3.1B. Phenoxymethyl Penicillin Dosages by Age for the Management of

Tonsillitis

Age Dose (mg) Quantity Frequency Duration

<1 year 125 5 mL (1 tsp) 2 times/day 10 days
1–5 years 250 10 mL (2 tsp) 2 times/day 10 days
5–12 years 500 2 tablets 2 times/day 10 days
Adult 1,000 4 tablets 2 times/day 10 days

OR
yy For penicillin-allergic patients,give erythromycin PO (250 mg, 500 mg
tablets; 125 mg/5 mL suspension), every 6 hours before meals for 10 days
in the same dosage as phenoxymethylpenicillin.

Referral
ƒƒ Any suppurative complications (e.g., retropharyngeal or peri-tonsillar
abscess)
ƒƒ Suspected acute rheumatic fever
ƒƒ Suspected acute glomerulonephritis
ƒƒ Recurrent tonsillitis or tonsillitis accompanied by severe swallowing
problems
ƒƒ History of previous rheumatic fever or rheumatic heart disease
ƒƒ Heart murmurs not previously diagnosed

References—3, 8, 10, 12, 72

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4.3.2 Pharyngitis
Description
Pharyngitis is an acute inflammation of the throat particularly the tonsils and
the pharynx. It is a self-limited illness and spontaneous resolution usually
occurs within a few days.

Causes
ƒƒ The majority of cases are of viral origin.
ƒƒ Sometimes infection with Streptococcus pyogenes can occur, and this
infection can lead to rheumatic fever or glomerulonephritis.
Caution: Rheumatic fever may develop if a streptococcal infection is not
treated promptly and properly.

Signs and symptoms

Pharyngitis is characterized by a painful red throat without pus, with difficulty
in swallowing.
ƒƒ In children from 3–14 years, look for—
yy Cough
yy Runny nose
yy At least one enlarged and tender posterior cervical lymph node
yy Conjunctivitis (may be present)
yy Hoarseness
ƒƒ The following suggest a viral cause—
yy Fever >38°C
yy The absence of cough
yy At least one enlarged and tender anterior lymph node in the neck
yy Presence of an exudate
ƒƒ The following favour streptococcal pharyngitis, which is uncommon in
children <3 years and patients >14 years—
yy Difficulty in swallowing
yy Red and inflamed tonsils, pharynx

Diagnosis
ƒƒ Visual examination of the throat—tonsils may be red and swollen
ƒƒ Presence of cervical lymph nodes.
ƒƒ Throat swab if streptococcal infection is suspected

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Management objectives
ƒƒ Relief of symptoms
ƒƒ Prevention of complications of streptococcal infection

Nonpharmacological management
ƒƒ Keep the patient warm.
ƒƒ Instruct the patient to gargle with homemade salt mouthwash (2.5 mL
[½ tsp] of table salt in a glass of lukewarm water) for 1 minute 2 times/day.
ƒƒ If white spots are present on mucous membrane, have the patient gargle
with 3% hydrogen peroxide before gargling with salt water.

Pharmacological management
ƒƒ Treat fever and pain with paracetamol PO (500 mg tablet; 120 mg/5 mL
suspension). See table 4.3.2 for dosages.

Table 4.3.2. Paracetamol Dosages by Age and Weight for the Management of
Pharyngitis

Age Weight Dose (mg) Quantity Frequency Duration

3–12 months 6–10 kg 60 2.5 mL 3 times/day 5–7 days
(½ tsp)
1–5 years 10–18 kg 120 5 mL (1 tsp) 3 times/day 5–7 days
5–8 years 18–25 kg 240 10 mL (2 tsp) 3 times/day 5-7 days
or ½ tablet
8–14 years 25–50 kg 500 1 tablet 3–4 times/day 5–7 days
>14 years >50 kg 1,000 2 tablets 3–4 times/day 5–7days
and adults

ƒƒ No antibiotic therapy is required in viral pharyngitis.

ƒƒ For streptococcal pharyngitis, give benzathine benzylpenicillin IM
immediately (1.2 MIU powder for injection).
yy >15 kg: 300,000 IU as a single dose
yy 15–30 kg: 600,000 IU as a single dose
yy >30 kg and adults: 1.2 MIU as a single dose
OR

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ƒƒ Give phenoxymethylpenicillin PO (250 mg tablet; 125 mg/5 mL

suspension) for 10 days.
yy Adults: 1 g (4 tablets) 2 times/day
yy Children:
ŠŠ <1 year: 125 mg (5 mL or 1 tsp) 2 times/day
ŠŠ 1–5 years: 250 mg (10 mL or 2 tsp) 2 times/day
ŠŠ 6–12 years: 500 mg (2 tablets) 2 times/day for 2 days
OR
ƒƒ For penicillin-allergic patients, give erythromycin, (250 mg and 500 mg
tablets; 125 mg/5 mL suspension) oral, 4 times/day for 10 days in the same
dosage as phenoxymethylpenicillin. (See table 4.3.1B.)

Referral
ƒƒ Children who have suspected streptococcal infection
ƒƒ Any patient who has a persistent fever

References—1, 10, 73

4.3.3 Laryngitis
Description
Acute laryngitis is an inflammation of the lining of the laryngeal caused by
a variety of infectious and noninfectious processes. It is, however, caused
predominantly by the same viruses that cause many other URIs. It may involve
surrounding structures (e.g., the pharynx and trachea). The condition is usually
brief and self-limited.

Signs and symptoms

Onset is similar to any URTI. It is characterized by—
ƒƒ Hoarseness; stridor and chest indrawing may be present
ƒƒ Nasal congestion, cough, and sore throat
ƒƒ Inspiratory dyspnoea (difficulty taking a breath)
ƒƒ Restlessness, anxiety, cyanosis in severe cases
ƒƒ Mild fever

In spasmodic laryngitis in a child who has rhinitis or measles—

ƒƒ The onset is nocturnal with coughing fits followed by periods of suffocation
and difficulty taking a breath.

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ƒƒ The child may develop stridor and hoarseness after the attack.
ƒƒ The child remains afebrile.

Diagnosis
Diagnosis is based on clinical signs and symptoms at primary level.

Management objectives
Relief of symptoms

Nonpharmacological management
ƒƒ Use steam inhalations 2–3 times/day to help clear blocked nose.
ƒƒ Rest the voice.
ƒƒ For spasmodic laryngitis—
yy Monitor the child, and try to keep him or her calm.
yy Have the child breathe in a humid environment (e.g., next to a bowl of
water or a wet towel).

Pharmacological management
ƒƒ For uncomplicated laryngitis—
yy Instil two drops of 0.9% sodium chloride or Ringer’s lactate in each
nostril 4 times/day to clear airway.
yy Antibiotics are not recommended in uncomplicated laryngitis
ƒƒ For spasmodic laryngitis in children—
yy Use antihistamine treatment: chlorpheniramine maleate PO (2 mg/
5 mL)
ŠŠ Children 2–5 years: 2.5 mL (½ tsp) 4 times/day
ŠŠ Children 6–12 years: 5 mL (1 tsp) every 6 hours but not to exceed
4 times/day
PLUS
yy Give prednisolone (5 mg, 25 mg tablets), depending on the severity.
ŠŠ Adults and children ≥12 years: 30 mg/day for 3 days then tapering off
over a 1 week period
ŠŠ Children <12 years: 10 mg daily for 7 days
ƒƒ In children with severe dyspnoea, if a physician is available—
yy Give dexamethasone IM (4 mg/mL) 0.1–0.2 mg/kg in a single dose.
OR
yy Give hydrocortisone (100 mg/mL) 1 mg/kg as a single dose.

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ƒƒ In adults, for relief of fever or pain—

yy Give paracetamol PO (500 mg tablets) 1 g (2 tablets) 3–4 times/day for
5–7 days.
OR
yy Give acetylsalicylic acid PO (300 mg and 500 mg tablets—what is needed
to relieve pain) 1 tablet 3–4 times/day for 5–7 days
Caution: Acetylsalicylic acid (aspirin) is not recommended for children
<12 years old because of the risk of Reye’s syndrome.
If definite signs of infection are present—
ƒƒ Adults and children 12 years and over—
yy Give co-trimoxazole PO (400 mg + 80 mg and 800 mg +160 mg tablets)
960 mg every 12 hours for 5–7 days.
OR
yy Give amoxicillin PO (250 mg, 500 mg tablets) 3 g/day in 2–3 divided
doses for 5–7 days.
ƒƒ Children >12 years
yy Give co-trimoxazole PO
ŠŠ 6 months–5 years: 240 mg twice daily
ŠŠ 6 years–11 years: 480 mg twice daily
OR
yy Give amoxicillin
ŠŠ Children: 100 mg/kg/day in 3 divided doses for 5–7 days
OR
yy For penicillin-allergic patients, give—
ŠŠ Doxycycline (100 mg tablets)
–– Adults: 1 tablet 2 times/day for 7 days
–– Children >9 years (and >45 kg): 1 (100 mg) tablet 2 times/day for
7 days
OR
ŠŠ Erythromycin (250 mg and 500 mg tablets)
–– Adults: 500 mg 4 times/day for 7 days
–– Children: 250 mg 4 times/day for 7 days
‚‚ <1 year: 125 mg (5 mL or 1 tsp) 2 times/day for 7 days
‚‚ 1–5 years: 250 mg (10 mL or 2 tsp) 2 times/day for 7 days
‚‚ 6–12 years: 500 mg (2 tablets) 2 times/day for 7 days

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Referral
ƒƒ Children with severe dyspnoea (immediately)
ƒƒ If condition persists beyond 2 weeks, for laryngoscopy (at hospital level)

References—1, 10, 74

4.3.4 Hoarseness
Description
Hoarseness is a change in the normal voice to become breathy, raspy, or strained.
Changes in volume or pitch (depending on how high or low the voice is) are also
noticeable. Voice changes are related to disorders in the vocal cords of the larynx.
Hoarseness can be of sudden onset or chronic. It can be a warning of impending
airway obstruction.

Causes
ƒƒ Infections
ƒƒ Acute laryngitis (most common cause)
ƒƒ Acute epiglottitis
ƒƒ Diphtheria
ƒƒ Croup
ƒƒ Inflammation, oedema
ƒƒ Inhalation of irritants, such as tobacco smoke or chemicals
ƒƒ History of smoking, alcohol use, or both
ƒƒ Gastroesophageal reflux
ƒƒ Allergies or anaphylaxis
ƒƒ Misuse of voice for prolonged periods (too much or too loud)
ƒƒ Benign vocal cord nodules or polyps
ƒƒ Carcinoma of larynx or vocal cords
ƒƒ Thyroid problems, including thyroid cancer or hypothyroidism
ƒƒ Trauma to the larynx or vocal cords
ƒƒ Vocal cord paralysis

Signs and symptoms

ƒƒ Underlying URTI
ƒƒ General malaise or weakness
ƒƒ Fever, if infection present

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ƒƒ Cough and constant clearing of throat

ƒƒ Dyspnoea, stridor, wheezing

Management objective
Relieve the symptoms

Nonpharmacological management
ƒƒ Advise patient to rest his or her voice.
ƒƒ Look for signs of airway obstruction.
ƒƒ Look for signs of an underlying cause, fever, or tenderness in the lymph
nodes.
ƒƒ Recommend steam inhalation 3 times/day.
ƒƒ Counsel the patient to stop smoking (see appendix D, “Tobacco Cessation”)
and drinking alcohol.

Pharmacological management
ƒƒ Usually no antibiotics are necessary.
ƒƒ Do not give decongestants or antihistamines
ƒƒ If there is an underlying cause, treat it as appropriate.

Referral
If the hoarseness has lasted for >3 weeks, investigation is required to rule out
malignancy.

References—3, 75

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5. Eye Conditions

5.1 Red Inflamed Eye

5.1.1 Conjunctivitis
Description
Conjunctivitis is an inflammation of the conjunctiva and is the most common
cause of red eyes. Conjunctivitis may also be associated with measles or
rhinopharyngitis in children. It is a viral infection that can be highly contagious
and easily spread by contact with hands, towels, or face cloths.

ƒƒ Causes
ƒƒ Allergies
ƒƒ Infection
ƒƒ Trauma—
yy Chemicals
yy Injury

5.1.1.1 Allergic Conjunctivitis

Signs and symptoms
ƒƒ Usually bilateral
ƒƒ Excessive tearing
ƒƒ Eyelid oedema
ƒƒ Intense itching
ƒƒ Red conjunctivae

Diagnosis
ƒƒ Base the diagnosis on history clinical signs and symptoms.
ƒƒ Always check for foreign bodies.

Management objectives
ƒƒ Identify and remove the cause
ƒƒ Relieve itching and swelling
ƒƒ Treat secondary infection if present

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Nonpharmacological management
ƒƒ Recommend cold compresses (i.e., ice packs) for oedema of the eyelid.
ƒƒ Educate the patient about the correct method for eye cleansing.

Pharmacologic management
Adults and children—
ƒƒ Recommend sodium chloride 0.9%, eye washes or irrigations.
ƒƒ Give chlorpheniramine PO (4 mg tablet; 2 mg/mL syrup), 3 times/day. See
table 5.1.1.1 for dosages.

Table 5.1.1.1. Chlorpheniramine Dosages by Weight and Approximate Age for the
Management of Allergic Conjunctivitis

Syrup
Weight (kg) Dose (mg) (2 mg/5 mL) Tablet (4 mg) Approximate Age
6–10 kg 0.8 2 mL — 6–12 months
10–18 kg 1 2.5 mL — 1–5 years
18–25 kg 2 — ½ tablet 5–8 years
25–50 kg 2–4 — ½–1 tablet 8–14 years
>50 kg 4 — 1 tablet >14 years
and adults

5.1.1.2 Infective Conjunctivitis

5.1.1.2.1 Bacterial Infective Conjunctivitis
Causes
ƒƒ Staphylococci
ƒƒ Streptococci
ƒƒ Gonococci
ƒƒ Chlamydia

Signs and symptoms

ƒƒ Usually bilateral
ƒƒ Itchy eyes and swollen lids
ƒƒ Stickiness of eyelids on awakening in the morning
ƒƒ Abundant and purulent discharge from one or both eyes

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Diagnosis
Based on clinical signs and symptoms

Management objectives
ƒƒ Identify the cause and treat
ƒƒ Prevent spread of infection to the other eye if the infection is presently in
one eye only
ƒƒ Prevent complications

Nonpharmacological management
ƒƒ Provide patient education on personal hygiene.
ƒƒ Advise the patient to clean his or her eyes 4–6 times/day with cooled boiled
water or 0.9% sodium chloride.
ƒƒ Counsel the patient on correct method for application of ophthalmic
ointment.
ƒƒ Advise the patient—
yy To wash his or her hands thoroughly before applying ophthalmic
ointment
yy Not to share ophthalmic ointments or drops
yy Not to rub the eyes

Pharmacological management
Adults and children—
ƒƒ Give chloramphenicol 1% eye ointment, applied every 6 hours in both eyes
for 7 days.
OR
ƒƒ Give tetracycline 1% eye ointment 2 times/day, in both eyes for 7 days.
ƒƒ Do not use corticosteroid drops or ointments.
ƒƒ For pain relief, give paracetamol PO (500 mg tablet; 120 mg/5 mL
suspension) every 4–6 hours, PRN, not to exceed 4 doses daily. See table
5.1.1.2.1 for dosages.

Referral
If the patient has no response to treatment after 3 days

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Table 5.1.1.2.1. Paracetamol Dosages by Age and Weight for the Management of
Pain Associated with Bacterial Infective Conjunctivitis

Age Weight Dose (mg) Quantity Frequency Duration

3–12 months 6–10 kg 60 2.5 mL 3 times/day 5–7 days
(½ tsp)
1–5 years 10–18 kg 120 5 mL (1 tsp) 3 times/day 5–7 days
5–8 years 18–25 kg 240 10 mL (2 tsp) 3 times/day 5–7 days
or ½ tablet
8–14 years 25–50 kg 500 1 tablet 3–4 times/day 5–7 days
>14 years >50 kg 1,000 2 tablets 3–4 times/day 5–7 days
and adults

5.1.1.2.2 Viral Infective Conjunctivitis

Signs and symptoms
ƒƒ Watery discharge
ƒƒ Feeling of grittiness or burning, which can be painful
ƒƒ Photophobia

Diagnosis
Based on clinical signs and symptoms

Management objectives
ƒƒ Prevent the spread of infection
ƒƒ Symptomatic relief

Nonpharmacological management
ƒƒ Educate the patient on the correct method for cleansing or rinsing the eye.
ƒƒ Advise the patient to clean his or her eyes 4–6 times/day with cooled boiled
water or 0.9% sodium chloride.
ƒƒ Suggest cold compresses for symptomatic relief.

Pharmacological management
Adults and children—
ƒƒ Recommend sodium chloride 0.9% eye washes or irrigations. If sodium
chloride 0.9% is not available, use cooled boiled water or sterile water.
ƒƒ For pain relief, give paracetamol PO (500 mg tablet; 120 mg/5 mL

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suspension) every 4–6 hours PRN,not to exceed4 doses daily. (See table
5.1.1.2.1 for dosages.)
ƒƒ If the conjunctivitis is associated with measles, treat systemically with
vitamin A to prevent keratitis.

5.1.1.3 Chemical Conjunctivitis

Caution: Chemical burns to the eye constitute an emergency. Treat immediately.
Alkaline chemicals are the most dangerous.

Management
ƒƒ Instil a topical anaesthetic drop immediately (if available).
ƒƒ Rinse the eye with cooled boiled water or sterile water for at least 30
minutes ensuring that all foreign matter has been removed. The length of
time is very important.
ƒƒ Give an antibiotic drop (chloramphenicol eye drops) 4 times/day.
ƒƒ For pain relief, use paracetamol PO (500 mg tablet; 120 mg/5 mL
suspension) every 4–6 hours PRN, not to exceed 4 doses daily. (See table
5.1.1.2.1 for dosages.)

Referral
ƒƒ If severe, refer the patient immediately after initial treatment.
ƒƒ If less severe but there is no improvement after 3 days, refer.
ƒƒ If the patient was wearing contact lenses at the time of the injury, refer.

5.1.1.4 Neonatal Conjunctivitis

Description
Neonatal conjunctivitis is an acute purulent conjunctivitis of the newborn in the
first 28 days of life.
Caution: Neonatal conjunctivitis is an ophthalmic emergency requiring urgent
treatment to save the infant’s eye(s).

Causes
ƒƒ Neisseria gonorrhoea
ƒƒ Chlamydia trachomatis
ƒƒ Streptococcus
ƒƒ Enterobacteriaceae

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Signs and symptoms

ƒƒ Purulent discharge from the eye
ƒƒ Swollen eyelids
ƒƒ Red conjunctivae
ƒƒ Corneal ulcers or opacities in severe cases (especially gonococcal infection)

Diagnosis
ƒƒ Base the diagnosis on clinical signs and symptoms.
ƒƒ Send pus from eyes for culture.

Management objectives
ƒƒ Prevent blindness
ƒƒ Relieve symptoms

Nonpharmacological management
Clean eyes regularly (every 10–30 minutes initially).

Pharmacological management
ƒƒ Give chloramphenicol eye drops 1% 4 times/day for 7 days.
ƒƒ For gonorrhoea, give ceftriaxone 50 mg/kg stat, not to exceed 125 mg.
PLUS
ƒƒ Give erythromycin syrup 10 mg/kg 4 times/day for 14 days.

Referral
No response to treatment after 3 days

References—1, 3, 8, 10, 76

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5.1.2 Keratitis (Corneal Ulcer)

Description
Keratitis is an inflammation of the cornea. There are two types: superficial,
which heals without permanent damage; and deep, which is a serious disease.
Deep keratitis causes corneal scarring with permanent visual loss and can
progress to cause perforation of the eyeball with loss of the eye.

Causes and risk factors

ƒƒ Infective
yy Viral—especially herpes simplex (most common)
yy Bacterial—from injury or wearing contact lenses. The bacteria involved
are Staphylococcus aureus and, for contact lens wearers, Pseudomonas
aeruginosa.
yy Chlamydia
yy Fungal (especially after injuries due to plant material)
yy Amoeba—the most serious corneal infection, usually affecting contact
lens wearers. Mainly due to acanthamoeba.
ƒƒ Vitamin A deficiency
ƒƒ Injury—foreign bodies from plant material, sand, and other substances
ƒƒ Arc eye—injuries from welding without protective glasses—also called
welder’s eye (see section 5.1.4, “Arc Eye”)

Signs and symptoms

ƒƒ Usually occurs in one eye only
ƒƒ History of injury (in some patients)
ƒƒ History of wearing contact lens
ƒƒ Redness of the eye
ƒƒ Excess tears or other discharge (pus) from the eye
ƒƒ Eye pain
ƒƒ Difficulty opening the eyelid because of pain or irritation
ƒƒ Blurred or decreased vision
ƒƒ Sensitivity to light (photophobia)
ƒƒ An itchy, burning or gritty feeling in the eye
ƒƒ Swelling around the eye
ƒƒ Cornea unclear, dull, grey

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Diagnosis
ƒƒ Based on signs and symptoms
ƒƒ Fluorescein test

Management objectives
Prevent blindness and injury to the eyeball

Management
Treatment is dependent on the cause.

Referral
All cases

References—3, 77

5.1.3 Foreign Body in the Eye

Management objective
Remove the object without doing damage to the eye

Nonpharmacological management
Caution: Don’t try to remove a large object or one that is deeply stuck in the eye.
Refer.

For small particles (e.g., sand or gravel) or something under the upper eyelid, in
the corner of the eye or under the lower lid—
ƒƒ Rinse the eye with saline solution.
ƒƒ Evert the eyelid, and remove the item with the corner of a damp cloth or
moistened cotton swab.
ƒƒ Do not attempt to remove an object that is stuck in cornea.

Pharmacological management
At the hospital level—
ƒƒ Before attempting removal, instil topical anaesthetic (tetracaine eye drops
0.5%) in eye.
ƒƒ After removal, instil 0.5% chloramphenicol ointment 3 times/day for 3 days.

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5.1.4 Arc Eye

Arc eye, also known as welder’s flash, occurs when the eyes are exposed to bright
ultraviolet light during welding.

Nonpharmacological management
Educate patient about prevention by wearing protective glasses

Pharmacological management
ƒƒ Use topical steroidal anti-inflammatory eye drops (dexamethasone).
ƒƒ For pain relief, give paracetamol PO (500 mg tablet; 120 mg/5 mL
suspension) every 4–6 hours PRN, not to exceed 4 doses daily.

Table 5.1.4. Paracetamol Dosages by Age and Weight for the Management of
Pain Associated with Arc Eye

Age Weight Dose (mg) Quantity Frequency Duration

3–12 months 6–10 kg 60 2.5 mL 3 times/day 5–7 days
(½ tsp)
1–5 years 10–18 kg 120 5 mL (1 tsp) 3 times/day 5–7 days
5–8 years 18–25 kg 240 10 mL (2 tsp) 3 times/day 5–7 days
or ½ tablet
8–14 years 25–50 kg 500 1 tablet 3–4 times/day 5–7 days
>14 years >50 kg 1,000 2 tablets 3–4 times/day 5–7 days
and adults

Referral
ƒƒ Severe infective keratitis
ƒƒ Foreign body sticking through eyelid
ƒƒ Severe vision loss (refer to specialist)
ƒƒ Condition has not improved in 2 days

Reference—3

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5.2 Eyelid Infection—Stye

Description
Stye is an acute infection of the secretory gland of the eyelid, which results from
a blocked gland. It can form a lump that is red and painful. It is found on the edge
of the eyelid with a hair follicle in the middle of the swelling. If infected, a stye
can cause redness of the eye and surrounding eyelid. The most common cause of
infection is staphylococcus.

Causes
ƒƒ Improper or incomplete removal of eye makeup
ƒƒ Use of outdated or infected cosmetics
ƒƒ Poor eyelid hygiene

Signs and symptoms

ƒƒ A lump on the top or bottom eyelid
ƒƒ Localised swelling of the eyelid
ƒƒ Pain
ƒƒ Redness
ƒƒ Tenderness to touch
ƒƒ Crusting of the eyelid margins
ƒƒ Burning in the eye
ƒƒ Droopiness of the eyelid
ƒƒ Scratchy sensation on the eyeball
ƒƒ Blurred vision
ƒƒ Mucous discharge in the eye

Management objectives
Prevent infection of the eye

Nonpharmacological management
ƒƒ Remove the eyelash.
ƒƒ Apply warm compresses to the eye 4–6 times/day for about 15 minutes at a
time to help the drainage. Advise the patient to keep his or her eyes closed
while using compresses.
ƒƒ Gently scrub the eyelid with tap water or with a mild, nonirritating soap, or
shampoo (such as baby shampoo).

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ƒƒ Instruct the patient to discontinue the use of eye makeup as well as eye
lotions and creams until the stye heals.
ƒƒ Do not squeeze or puncture the stye. A more serious infection may occur as
a result.
ƒƒ Advise the patient to discontinue use of contact lenses until the stye heals.

Pharmacological
ƒƒ Use chloramphenicol eye ointment 3 times/day for 1 week.

Referral
If the patient has no improvement after 1 week

References—3, 78

5.3 Xerophthalmia
Description
A disease of the eye characterized by pathological dryness of the conjunctiva
and cornea due to failure of the eye to produce tears. If untreated, it can lead to
corneal ulceration and ultimately blindness.

Cause
ƒƒ Severe vitamin A deficiency
ƒƒ Affects mainly children (particularly those suffering from malnutrition or
measles) and older people

Signs and symptoms

As the disease progresses—
ƒƒ Irritation in the eyes that may feel like the presence of a foreign body
ƒƒ Night blindness
ƒƒ Sensitivity to light
ƒƒ Conjunctiva dry and dull, thick and insensitive
ƒƒ Bitôt’s spots: grayish foamy patches on the conjunctiva
ƒƒ Corneal ulceration, which may develop secondary infection
ƒƒ Softening of the cornea with perforation of the eyeball

Diagnosis
ƒƒ Based on clinical history and physical findings
ƒƒ Tests of dark adaptation

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Management objective
Avoid the development of severe complications

Nonpharmacological management
ƒƒ Inform patients and parents that—
yy Vitamin A deficient children cannot see in the dark and have dry eyes.
yy Xerophthalmia leads to blindness.
ƒƒ Recommend a diet containing plenty of vitamin A rich foods—green leafy
vegetables, orange and yellow fruits (mango and paw paw), and vegetables
(pumpkin, carrots, sweet potato), fish, eggs, liver, and milk.

Pharmacological management
ƒƒ Give retinol (vitamin A) tablets 200,000 IU regardless of the clinical stage.
yy Children 6–11 months (or <8 kg): 100,000 IU once daily (cut tablet in
half ) on days 1, 2, and 8 of treatment
yy Children >1 year (or >8 kg): 200,000 IU once daily on days 1, 2, and 8 of
treatment
yy Adults (except pregnant women): 200,000 IU once daily on days 1, 2, and
8 of treatment.
ƒƒ Repeat 4 weeks later.

Referrral
No response after initial treatment

References—1, 3, 10

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6. Cardiovascular System

6.1 Angina Pectoris

Description
Angina pectoris is defined as a severe crushing pain behind the sternum and is
due to an insufficient supply of blood to the heart muscles. It can be intermittent
and relieved by rest. The pain typically lasts 2–5 minutes, and may radiate to the
left arm, base of the neck, jaw, epigastrium, or back. It tends to affect men >50
years of age and women >60 years.

Causes and risk factors

Angina pectoris is caused by any circumstance leading to the narrowing of the
coronary arteries resulting in insufficient blood supply to the heart muscle,
including—
ƒƒ Age (≥50 years for men, ≥60 for women)
ƒƒ Cigarette smoking
ƒƒ Hypertension
ƒƒ Diabetes mellitus
ƒƒ Hypercholesterolemia or a family history of hyperlipidaemia
ƒƒ Kidney disease (microalbuminuria or GFR <60 mL/minute)
ƒƒ Obesity (BMI ≥30 kg/m2)
ƒƒ Exertion (exercise, hurrying, or sexual activity)
ƒƒ Lack of exercise (sedentary lifestyle)
ƒƒ Stress, anger, fright
ƒƒ Family history of coronary artery disease

Signs and symptoms

ƒƒ Chest discomfort, which may be a tightness, crushing, squeezing, burning,
or choking sensation
ƒƒ Increases with exercise or emotional stress
ƒƒ Can occur while the patient is at rest (unstable angina pectoris)

Diagnosis
Based on the clinical history and signs and symptoms and response to rest and to
sublingual nitroglycerine

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Management objectives
Relieve the pain as soon as possible

Nonpharmacological management
ƒƒ Reassure patient.
ƒƒ Advise the patient to rest.
ƒƒ Determine existing risk factors and manage appropriately.

Pharmacological management
Give glyceryl trinitrate tablet (0.5 mg) sublingually stat and as needed.

Referral
Episodes occurring more than twice a week
Reference—1, 3

6.2 Congestive Heart Failure

Description
Congestive heart failure (HF) is the inability of the heart to pump sufficient
blood through the circulatory system to meet the needs of the body. Left-sided
HF (often secondary to coronary or valvular heart disease, arterial hypertension,
or both) is the most common form.

Causes
ƒƒ Causes—
yy Ischaemic heart disease
yy Hypertension (high BP)
yy Obesity
yy Valvular heart disease (especially in older populations)
yy Congenital heart disease
yy Severe anaemia
yy Lung disease
ƒƒ Precipitating factors—
yy Infection, especially pulmonary
yy Arrhythmias
yy Physical, dietary, fluid, and emotional excesses
yy Pulmonary embolism
yy Anaemia

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Classification
ƒƒ Left-sided HF compromises aortic flow to the body and brain.
ƒƒ Right-sided HF compromises pulmonic flow to the lungs.

Signs and symptoms

ƒƒ Left-sided HF
yy Dyspnoea on exertion, then progresses to dyspnoea at rest
yy Paroxysmal nocturnal dyspnoea (difficulty breathing at night when lying
down)
yy Orthopnoea (being able to breathe better when in an upright position)
yy Wheezing
yy Tachycardia
yy Tachypnoea (rapid breathing)
yy Anxiety, sweating, and nasal flare
yy On examination
ŠŠ Apex beat displaced
ŠŠ Crepitations over the lungs
ŠŠ Changes in heart sounds or rhythm
ƒƒ Right-sided HF
yy Oedema of lower limbs
yy Fatigue
yy Enlargement of the liver (hepatomegaly)
yy Distension of the jugular vein in the neck
yy Ascites in advanced stages
yy Cyanosis or pallor

Diagnosis
ƒƒ Based on clinical signs and symptoms
ƒƒ Chest x-ray
ƒƒ ECG

Management objectives
ƒƒ Reduce symptoms and improve cardiac symptoms
ƒƒ Correct underlying cause and aggravating factors
ƒƒ Prevent deterioration of cardiac function

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Nonpharmacological management
ƒƒ Reassure patient.
ƒƒ Place patient in an upright or semi-reclining position with legs lowered.
ƒƒ Administer oxygen.

Pharmacological management
Reduce pulmonary pressure with—
ƒƒ Furosemide injection (10 mg/mL) 40 mg IM or IV stat if patient severely
dyspnoeic; repeat every 2 hours according to response
ƒƒ HCTZ (50 mg tablet), 1 tablet daily
OR
ƒƒ Furosemide (40 mg tablet) 1 tablet daily in 1–2 divided doses
ƒƒ Digoxin (0.25 mg tablet)
ƒƒ If urgent: 2 tablets stat then 1 tablet every 8 hours for 3 doses
yy If less urgent: 1 tablet 2 times/day for 7 days
yy Maintenance: ½–1 tablet daily

Follow-up
ƒƒ See patient monthly.
ƒƒ Control BP.
ƒƒ Check for signs of heart failure.
ƒƒ Advise the patient to seek medical help immediately if signs and symptoms
recur.
ƒƒ Instruct the patient on dietary changes (i.e., reduction in salt intake)and
weight control.
ƒƒ Urge the patient to take his or her medication regularly as prescribed.
ƒƒ Advise on rest and low-grade exercise.

Referral
If no response to initial treatment

References—1, 3, 10

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6.3 Hypertension
Description
Hypertension is defined as a BP ≥140/90 mmHg at two or more consecutive
readings or on two or more visits after initial screening or the use of
antihypertensive medications. Hypertension may be primary/essential (the
most common), with no identifiable cause, or secondary. Secondary is more
likely related to hormonal or renal function, medications, neurological disorders,
or coarctation of the aorta. Hypertension may also occur during pregnancy. BP
must be assessed under the best conditions after the patient has been at rest for
at least 5 minutes.

Causes and risk factors

ƒƒ Age, race (e.g., African ancestry), and family history of hypertension or
diabetes are important contributory factors.
ƒƒ Obesity (especially a large waist circumference and abdominal obesity)
ƒƒ Excessive intake of salt
ƒƒ High fat (especially saturated fats) and calorie intake
ƒƒ Diabetes mellitus
ƒƒ Tobacco usage, particularly cigarettes
ƒƒ High alcohol consumption
ƒƒ Low potassium intake
ƒƒ Psychosocial stress
ƒƒ Sleep apnoea
ƒƒ Elevated LDL (or total) cholesterol or low HDL cholesterol
ƒƒ Inadequate physical activity

Classification
BP classifications for adults are given in table 6.3A.

Signs and symptoms

Most patients have no signs or symptoms referable to their BP elevation, and it is
discovered on general physical examination. Symptoms that may occur include—

ƒƒ Headache (mainly occipital) on awaking, subsiding after several hours

ƒƒ Dizziness
ƒƒ Palpitations

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ƒƒ Easy fatigability
ƒƒ Impotence
ƒƒ Other symptoms related to underlying disease or complications of
hypertension (see table 6.3B)

Diagnosis
The diagnosis must be established by a doctor or Medex.
ƒƒ Based on history and clinical findings
ƒƒ Urinalysis for protein, glucose, and blood
ƒƒ Check for underlying disease or complications (fasting blood glucose,
cholesterol, triglycerides)

Management objectives
ƒƒ Identify and manage modifiable risk factors
ƒƒ Achieve and maintain the target BP (<130/80)
ƒƒ Achieve target BP in special cases such as patients who have diabetes,
heart, or kidney problems (<120/75 mmHg)

Nonpharmacological management
The cornerstone of hypertension management is lifestyle modification. It is
indispensable both for the prevention and management of all stages of high BP,
and all persons undergoing assessment or treatment for hypertension should
be offered advice on lifestyle changes (diet and exercise) initially and then
periodically. (See table 6.3C.)

Nonpharmacological management of hypertension entails the following

approach.
ƒƒ Managing pre-hypertension (BP 120–139/80–90 mmHg)—
yy Emphasize lifestyle modifications. (See table 6.3C.)
yy Reassess at 6–12 months.
ƒƒ Managing stage 1 hypertension (BP 140–159/90–99 mmHg)—
yy Step 1. If the patient has no signs of complications, instruct him or her
to make the lifestyle modifications listed in table 6.3C for 6–9 months.
The target is to get the patient’s BP controlled to <130/80 mmHg within
3 months. If control cannot be achieved after 3 months (in patients with
or without major risk factors), then move to step 2 (pharmacological
management).

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Table 6.3A. Classification of BP for Adults

BP Classification Systolic BP (mmHg) Diastolic BP (mmHg)

Normal <120 <80
Pre-hypertension 120–139 80–89
Stage 1 hypertension 140–159 90–99
Stage 2 hypertension ≥160 ≥100
Stage 3 hypertension ≥180 ≥110
Note: The classifications in this table are based on the average of two or more readings taken at each of two or
more visits after initial screening.
Source: National Institutes of Health. 2004. Report of the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure. Washington, DC: US Department of Health and Human Services.

Table. 6.3B. Hypertension Danger Signs and Symptoms

Symptoms Signs
ƒƒ Severe headache ƒƒ Motor or sensory deficits
ƒƒ Vertigo ƒƒ Fundoscopic abnormalities
ƒƒ Confusion ƒƒ Murmurs over heart and neck
ƒƒ Drowsiness ƒƒ Arrhythmias
ƒƒ Coma ƒƒ Left ventricular hypertrophy
ƒƒ Impaired vision ƒƒ Rhonchi and crepitations
ƒƒ TIA ƒƒ Peripheral oedema (legs)
ƒƒ Sensory or motor deficit (paralysis) ƒƒ Proteinuria
ƒƒ Palpitations or chest pain ƒƒ Pulses absent or weak
ƒƒ Shortness of breath or difficult
breathing
ƒƒ Swollen ankles
ƒƒ Thirst, polyuria, and nocturia
ƒƒ Haematuria
ƒƒ Cold extremities
ƒƒ Intermittent claudication

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Pharmacological management
ƒƒ Managing uncontrolled stage 1 and higher hypertension—
yy Step 2. Start treatment with a thiazide diuretic (hydrochlorothiazide
25 mg tablet), 12.5–25 mg daily. Target: control BP to <130/80 mmHg in
1 month. Note: Diabetes is not a contraindication to the use of low-dose
thiazide.
Caution: Do not use a thiazide diuretic in gout or in severe kidney or liver
failure.
yy Step 3. If step 2 has failed after 1 month or if the patient’s hypertension
is stage 3, give the medications listed below. Target: control BP to
<130/80 mmHg in 1 month.
ŠŠ A diuretic
PLUS EITHER
ŠŠ A long-acting calcium channel blocker amlodipine tablet (5 mg and
10 mg) (first choice)
OR
ŠŠ An ACE inhibitor: captopril (25 mg tablet) 12.5–50 mg 2 times/day
ŠŠ Caution: Do not use captopril in pregnancy.
yy Step 4. If step 3 has failed after 3 months, then give the following. Target:
control BP to <130/80 mmHg in 1 month with no side effects.
ŠŠ A diuretic
PLUS
ŠŠ An ACE inhibitor
PLUS
ŠŠ A beta blocker (atenolol) (50 and 100 mg tablets)/calcium channel
blocker (amlodipine)
yy If step 4 fails, refer the patient for specialist evaluation.
ƒƒ Reviewing patients monthly—
yy Check and record BP.
yy Measure weight for BMI calculation, and urine for proteinuria.
yy Ask about symptoms and changes since the last visit, and any adverse
medicine effects.
yy Reinforce dietary measures and health education.

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Table 6.3C. Lifestyle Changes to Manage Hypertension

Lifestyle Change Comment

Lose weight, if overweight. Aim at a BMI of <25.
Get regular physical exercise, Walking is easiest for most people.
30–60 minutes at least5 times/week,
preferably daily.
Stop smoking. (See appendix D,
“Tobacco Cessation.”)
Restrict or eliminate alcohol intake. Do not consume more than 2 drinks per day
(for men) and 1 drink per day (for women).
See table 6.3D below

Restrict salt intake. Do not add salt in cooking or at the table;

avoid canned foods and salted meat.
Restrict fat intake.
Reduce the intake of coffee and other
caffeine-containing beverages.
Increase sources of folic acid and Legumes, whole grain cereals, eggs, fish, and
vitamins B12 and B6 in the diet. meat are all good sources of these vitamins.
Ensure an adequate dietary fibre Fruit, vegetables, and whole grains are all high
intake. in fibre.
Increase the intake of potassium by Bananas, tomatoes, oranges, and coconut
eating more fruits and vegetables. water contain potassium
If possible, see a dietician or Use the dietary approaches to stop
nutritionist for advice. hypertension (DASH) diet. (See appendix E.)
Use stress relief and relaxation Try, for example, meditation or biofeedback.
techniques.
Monitor BP frequently. Check at least monthly.

Table 6.3D. Size of Alcoholic Drinks

12 fl oz = 8–9 fl oz = 5 fl oz = 3–4 oz = 2–3 oz = 1.5 oz = 1.5 fl oz

of regular of malt of table of fortified of cordial, of brandy shot of
beer liquor wine wine liqueur, (a single 80-proof
(such as or aperitif jigger or spirits
sherry shot) (“hard
or port) liquor”)

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ƒƒ Conducting the annual visit—

yy Update the medical history.
yy Check BP, weight, and urine as with the monthly visits.
yy Do laboratory investigations for BUN, plasma creatinine, electrolytes,
fasting cholesterol and triglycerides, and blood sugar.
yy Do an electrocardiogram.

Referral
ƒƒ Refer hypertensive emergencies urgently.
yy Patients with BP >240/140 (repeated more than once, with correct size
cuff )
yy Patients with BP >210/120 and complications (e.g., hypertensive
encephalopathy, grade 3 or 4 retinopathy, or accelerated or malignant
hypertension)
yy Patients who have severe hypertensive complications.
ƒƒ Other referrals include—
yy Young adults <30 years
yy Older adults >55
yy Patients whose BP is not controlled by two medicines and who have no
doctor available
yy Pregnant patients
yy Patients who have signs of target organ damage, such as oedema,
dyspnoea, proteinuria, or angina
yy Patients who have developed severe side effects to their medications

References—1, 3, 79, 80, 81, 82

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6.4 Peripheral Vascular Disease

Description
Peripheral vascular disease (PVD) is a general term that covers all diseases of the
blood vessels outside the heart. PVD can affect both the arteries that carry blood
from the heart to the body (i.e., peripheral arterial disease) and veins that carry
blood from the body back to the heart (i.e., deep vein thrombosis).

6.4.1 Peripheral Arterial Disease

Description
Peripheral arterial disease (PAD) is a condition in which the arteries that
carry blood to the legs (and rarely the arms) become narrowed or obstructed,
interfering with normal blood flow.

Causes and risk factors

ƒƒ Atherosclerosis (fatty deposits in the artery wall)
ƒƒ Narrowing of the arteries
ƒƒ Smoking
ƒƒ Diabetes
ƒƒ Obesity (a body mass index >30)
ƒƒ High BP (≥140/90 mmHg)
ƒƒ High cholesterol (total blood cholesterol >240 mg/dL or 6.2 mmol/L)
ƒƒ Increasing age, especially after reaching 50 years of age; highest incidence
in the 60s and 70s.
ƒƒ A family history of peripheral artery disease, heart disease

Signs and symptoms

ƒƒ Most people have no symptoms
ƒƒ Absent pulses in the limbs
ƒƒ Leg pain (discomfort in the calves)
ƒƒ Intermittent claudication (pain after walking a certain distance) and
disappearing with rest
ƒƒ Tingling and numbness in feet

Diagnosis
ƒƒ Done at the primary health care level
ƒƒ Based on history and clinical findings

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Management objective
Slow the progress of the disease

Nonpharmacological management
Advise patient to—
ƒƒ Stop smoking (see appendix D)
ƒƒ Lose weight if overweight or obese
ƒƒ Eat a healthy, low-fat diet
ƒƒ Exercise regularly

Pharmacological management
ƒƒ Continue on antihypertensive, antidiabetic medications (as indicated), or
both.
ƒƒ Start treatment with a cholesterol-lowering agent: tablet of atorvastatin
(10 mg, 20 mg), 10 mg once daily.
ƒƒ Advise the patient to take an aspirin tablet daily: (300 mg), ½ –1 tablet once
a day.

Referral
For further investigation and indicated treatment

References—1, 3

6.4.2 Deep Vein Thrombosis

Description
Deep vein thrombosis (DVT) is due to the blockage of a deep vein by a clot. It
predominantly occurs in the legs. The risk of thrombosis is increased following
trauma. The most significant consequence is pulmonary embolism.

Causes and risk factors

ƒƒ Decreased blood flow
ƒƒ Damage to the blood vessel wall
ƒƒ Varicose veins
ƒƒ Prolonged immobility including during travel
ƒƒ Pregnancy, particularly during the third trimester and the first month
postpartum
ƒƒ Obesity

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ƒƒ Medicines (e.g., oestrogens, postmenopausal hormone replacement

therapy, and oral contraceptives)

Signs and symptoms

ƒƒ Pain in the lower leg
ƒƒ Unilateral swelling of the leg
ƒƒ Warmth, swelling, and redness of the leg

Diagnosis
ƒƒ Clinical signs and symptoms
ƒƒ Ultrasound
ƒƒ Blood tests—coagulation

Management objectives
ƒƒ Relieve pain
ƒƒ Slow or stop the coagulation process

Nonpharmacological management
ƒƒ Advise bed rest.
ƒƒ Elevate the limb above the level of the heart, until the oedema and
tenderness subside.

Pharmacological management
ƒƒ For pain give paracetamol (500 mg tablet) 2 tablets 3–4 times/day for
7 days
ƒƒ Start on anticoagulants.
yy Give heparin 5,000 IU stat, then IV infusion of 1,000–2,000 IU per hour
(Harrison’s suggest 7,500–10,000 stat).
OR
yy Give heparin 1 mg/kg body weight subcutaneously every 12 hours.
PLUS
yy Give warfarin 5–10 mg PO. Monitor prothrombin time.
ƒƒ Continue treatment for at least 6 weeks to as long as 6 months.

References—1, 3

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7. GastroIntestinal System

7.1 Anorectal Disorders

7.1.1 Anal Fissures

Description
An anal fissure is a small slit or tear in the mucosa lining the anus. Anal fissures
usually extend from the anal opening and are usually located posteriorly in the
midline. Fissure depth may range from superficial to deep—sometimes down to
the underlying sphincter muscle. Fissures tend to self-heal in a couple of weeks,
but if they become chronic and deep, they will not heal.

Causes and risk factors

ƒƒ Stretching of the anal mucosa beyond its capacity
ƒƒ Constipation, hard stools
ƒƒ Straining at defecation
ƒƒ Anal intercourse or insertion of a foreign body into the rectum

Signs and symptoms

ƒƒ Anal pain or itching
ƒƒ Pain on defecation
ƒƒ Spasm of the anal sphincter
ƒƒ Passing bright red blood per rectum

Diagnosis
ƒƒ Based on history and clinical findings
ƒƒ Visual and digital examination of anal area

Management objectives
ƒƒ Promote healing
ƒƒ Relieve symptoms

Nonpharmacological management
Advise the patient to—
ƒƒ Avoid straining during defecation
ƒƒ Increase his or her dietary fibre intake

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ƒƒ Use stool softeners (mineral oil preparations)

ƒƒ Take sitz baths (particularly after bowel movements)
ƒƒ Avoid chronic laxative use; use laxatives only when constipation is severe

Pharmacological management
Give a topical anaesthetic: lidocaine spray 10% and etidocaine/lidocaine cream
(2.5%/2.5%)

Referral
ƒƒ Severe pain or unusually tight anus
ƒƒ No response to medication

References—1, 3

7.1.2 Constipation
Description
Constipation refers to persistent, difficult, infrequent bowel movements or
a feeling of incomplete evacuation. Although normal bowel movements vary
widely, from 1–3 times/day to one every 2–5 days, constipation is usually defined
as bowel movements of fewer than 3 per week. Frequency alone, however, is not
enough to make a diagnosis since patients may have a normal frequency in the
presence of the other symptoms.

Causes and risk factors

Causes may be primary or dietary, related to medicines the patient is taking, or
occur for medical reasons.
ƒƒ Primary—not due to any underlying cause
ƒƒ Dietary
yy Insufficient fibre or roughage
yy Bottle feeding in babies
yy Inadequate fluid intake
ƒƒ Medications
yy Atropine
yy Codeine-containing medicines
yy Anti-inflammatory medicines
yy Morphine
yy Chronic laxative use

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ƒƒ Medical
yy Lack of exercise
yy Hypothyroidism
yy Pregnancy
yy Anal fissure
yy Perianal disease
yy Carcinoma of the rectum or sigmoid colon (especially in the elderly)
yy Pelvic mass (fibroid uterus)

Signs and symptoms

ƒƒ Stools too hard and passed out in small or large lumps
ƒƒ Infrequent defecation
ƒƒ Pain or straining on defecation
ƒƒ Feeling of incomplete evacuation

Diagnosis
ƒƒ Based on history and clinical findings
ƒƒ Digital rectal examination
ƒƒ Rule out anal fissure or haemorrhoids
ƒƒ Further examination may be needed in the presence of weight loss, rectal
bleeding, or anaemia.

Management objective
Restore normal, regular bowel movements

Nonpharmacological management
ƒƒ Advise the patient to—
yy Increase his or her intake of water to 6–8 glasses per day
yy Avoid coffee and black tea
yy Gradually increase the amount of fibre in his or her diet, especially by
eating more fruit, vegetables, oats, beans, lentils, whole-wheat cereals
and bread, and grains
yy Increase his or her physical activity (e.g., walking briskly every day)
ƒƒ Use manual disimpaction.
ƒƒ Give the patient an enema.

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Pharmacological management
Give bisacodyl suppository or tablets 10–20 mg nocte.

Referral
ƒƒ Unexplained rectal bleeding
ƒƒ Persistent abdominal problems
ƒƒ Weight loss

References—1, 3

7.1.3 Haemorrhoids (Piles)

Description
Haemorrhoids are varicose veins in the anorectal area, resulting from a
persistent increase in venous pressure. Haemorrhoids may be exposed outside
the rectum during defecation. They are often referred to as piles. They may be
internal or external.

Causes and risk factors

ƒƒ Constipation with straining during defecation
ƒƒ Increased intra-abdominal pressure
ƒƒ Low-fibre diet
ƒƒ Obesity
ƒƒ Pregnancy
ƒƒ Sitting for long periods
ƒƒ Straining during lifting of heavy weights

Signs and symptoms

ƒƒ Painless rectal bleeding (bright red blood, often found on toilet paper or
dripping into the toilet bowl)
ƒƒ Perianal itch
ƒƒ Severe anal pain if haemorrhoid is thrombosed or strangulated
ƒƒ Mucous discharge
ƒƒ Protrusion of the haemorrhoidal tissue
ƒƒ Occasional incontinence

Classification
See table 7.1.3.

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Table 7.1.3. Classification of Haemorrhoids

Mild Moderate Severe

Minimal pain Severe pain Severe pain
Minimal bleeding Moderate bleeding Severe bleeding
Minimal prolapse that can Prolapse that can be Prolapse that cannot be
easily be pushed back into pushed back only with pushed back into rectum
rectum effort Strangulation, thrombosis,
infection, or ulceration

Diagnosis
Based on physical examinations:
ƒƒ Visual examination of the anus and surrounding areas—may reveal a
prolapsed haemorrhoid
ƒƒ Rectal examination to rule out tumours or polyps

Investigation at the hospital level will include a proctoscopy.

Management objectives
ƒƒ Prevent progression
ƒƒ Reduce prolapse where present
ƒƒ Rule out colorectal cancer

Nonpharmacological management
ƒƒ Advise patient to avoid straining or prolonged sitting on the toilet.
ƒƒ Recommend a high-fibre diet.
ƒƒ Counsel against the chronic use of laxatives.
ƒƒ Encourage increased fluid intake to 6–8 glasses of water a day.
ƒƒ Recommend regular exercise, including walking.
ƒƒ In a mild case with prolapse, tell the patient how to reduce his or her own
haemorrhoids by first putting petroleum jelly on his or her finger and then
lightly pushing the haemorrhoid back into the rectum.
ƒƒ Recommend warm soaks (i.e., sitz baths).

Pharmacological management
ƒƒ Give fibre supplements to provide bulk.
ƒƒ Give bisacodyl (5 mg tablet), 2 tablets 2 times/day for 2 weeks then 2 tablets
nocte PRN to soften stool.

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OR
ƒƒ Give bisacodyl suppository (5 mg, 10 mg) PRN for pain relief.
ƒƒ Give ibuprofen tablet (200 mg) every 4–6 hours PRN for pain.

Referral
ƒƒ To a specialist to rule out colorectal cancer, in patients >40 years
ƒƒ For surgical intervention if—
yy The haemorrhoid cannot be reduced
yy The haemorrhoid is thrombosed

References—3, 8, 83, 84

7.2 Gastroenteritis (Diarrhoea)

Description
Gastroenteritis is an inflammation of the gastrointestinal tract, involving both
stomach and intestines and resulting in diarrhoea (i.e., the passing of loose—
liquid or unformed—stools >3 times/day). It may be accompanied by vomiting
and abdominal cramps. Gastroenteritis may be acute (i.e., lasting only a few
days), persistent (i.e., lasting for 2–4 weeks), or chronic (i.e., lasting >4 weeks). It
can be mild to severe leading to loss of electrolytes and dehydration.

Causes and risk factors

More than 90% of cases of acute diarrhoea are caused by infectious agents
through the faecal-oral route; the rest are caused by medications (e.g., senna,
cascara, castor oil), toxins, and other conditions.

There are two clinical types, each with its own causes—
ƒƒ Diarrhoea without blood (see section 7.2.1)
yy Viruses, particularly rotaviruses and enteroviruses in 60% of cases; most
common cause in children
yy Bacteria, especially E. coli and Salmonella
yy Parasites such as giardia
yy Contaminated water
yy Unhygienic conditions
yy Ingestion of foods contaminated by human or animal faeces

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ƒƒ Diarrhoea with blood (see section 7.2.2)

yy Bacteria—campylobacter, E. coli, Salmonella, Shigella
yy Parasites—amebiasis

Signs and symptoms

ƒƒ General—
yy Fever may or may not be present
yy Vomiting
yy Diarrhoea
yy Blood may be present
yy Dehydration may be present (see table 7.2)
yy Abdominal cramps (may or may not be present)
ƒƒ Signs of shock—
yy Tachycardia
yy Cold, pale extremities
yy Rapid, deep breathing
yy Floppy, lethargic, or comatose

Table 7.2. Assessing Dehydration

Signs and Symptoms Mild (<3%) Moderate (3–8%) Severe (>8%)

General condition Alert, responsive Restless, irritable Floppy, weak
Thirst Drinks normally Thirsty, drinks Drinks poorly or
eagerly not able to drink
Eyes Normal Sunken Deeply sunken
Mucus membranes Moist Dry Very dry
Skin pinch Retracts quickly Retracts slowly Retracts very
slowly
Skin turgor Normal Diminished Very diminished
Neurological state Normal Drowsiness, Lethargic,
altered comatose
neurological
status
Signs of shock (i.e., cold, None None Yes
clammy skin; profuse
sweating; tachycardia;
hypotension)
Note: Percentage of dehydration refers to the amount of fluid lost as a percentage of body weight.

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7.2.1 Diarrhoea without Blood

Diagnosis
Based on the patient’s history and the physical examination
ƒƒ If dehydration is present, do urea and electrolytes, Hb, WBC, and
differential.
ƒƒ If there is blood in the stool, send stool for culture and microscopy.

Management objectives
ƒƒ Stop the diarrhoea
ƒƒ Treat infection, if it is suspected to be bacterial
ƒƒ Prevent or treat dehydration and electrolyte imbalance

Pharmacological management
For no or mild dehydration in children (child can be treated at home)—
ƒƒ Tell the parent or caregiver—
yy To increase the child’s fluid intake (children ≤2 years: 50–100 mL after
every stool or vomit; children >2 years: 100–200 mL). Continue until
diarrhoea has stopped.
yy To increase number of breastfeedings for breastfed children
yy To continue regular feedings for older children, giving soft porridge,
pureed or liquid foods
yy To use boiled, cool water for drinking
yy How to mix and give ORS at home (provide at least 2 packs)
yy How to recognize that child is becoming dehydrated and need to be taken
to clinic or hospital
ƒƒ If ORS is not available, teach the parent or caregiver how to mix the
equivalent. (See table 7.2.1 for amounts to give.) To 1 L boiled, cooled water
add—
yy 30–40 mL (6–8 tsp) of sugar
yy 2.5 mL (½ tsp) of salt
OR
yy Coconut water
ƒƒ Avoid liquids that do not contain salt or that contain too much sugar (e.g.,
carbonated drinks or commercial fruit juices).
ƒƒ If diarrhoea persists or gets worse, advise parents to bring the child back to
the clinic.

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For moderate dehydration in adults or children—

ƒƒ Give ORS.
yy In the first 4 hours, give according to IMCI guidelines.
yy Give the amount of fluid (in mL) according to age and weight of child.
The amount is calculated by multiplying the child’s weight in kg by 75
(i.e., mL = weight in kg × 75).
yy Adolescents (<30 kg): 1–2 L
yy Adults: 2.2–4.0 L
ƒƒ Advise that ORS be taken slowly. If the patient vomits, wait 10 minutes and
try again.
ƒƒ Re-evaluate after 4 hours. If the patient is better, continue as for mild
dehydration.

For dehydration in adults—

ƒƒ Have patients drink frequent small amount of fluids.
ƒƒ Give ORS, 200–300 mL after every loose stool.
ƒƒ If no improvement, refer.

For severe dehydration in adults or children, see section 1.4, “Acute Diarrhoea
with Dehydration.”

Table 7.2.1. ORS Guide for Children

Amount of ORS Given Amount of ORS to Provide

Age after Each Loose Stool for Use at Home
≤24 months 50–100 mL 500 mL/day
2–10 years 100–200 mL 1 L/day
≥10 years As much as wanted 2 L/day

7.2.2 Diarrhoea with Blood

Diagnosis
Based on investigations: culture stool for bacteria, ova, and parasites.

Nonpharmacological management
Check for dehydration and treat as above.

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Pharmacological management
Start empirical treatment.
ƒƒ First-line treatment: co-trimoxazole (80 mg/400 mg tablet)
yy Adults and children ≥12 years:2 tablets 2 times/day for 3–5 days
yy Children<12 years
ŠŠ Children 6 weeks to 5 months: 120 mg 2 times/day
ŠŠ Children 6 months to 5 years: 240 mg 2 times/day
ŠŠ Children 6–11 years: 480 mg 2 times/day
ƒƒ Second-line treatment:
yy Ciprofloxacin (500 mg tablet)
ŠŠ Adults: 500 mg 2 times/day for 3–5days
ŠŠ Children >14 years: 30 mg/kg/day in 2 divided doses for 3–5 days
Caution: Ciprofloxacin is contraindicated in pregnant women. In
pregnant women, use ceftriaxone IM 1 g once daily for 3–5 days.
PLUS
yy Metronidazole (200 mg and 400 mg tablets)
ŠŠ Adults and children >12 years: 800 mg stat followed by 400 mg at
8-hour intervals
ŠŠ Children 8 weeks to 12 years: 20–30 mg/kg/day as a single dose or
divided into 7.5 mg/kg every 8 hours for 7 days

Note: In immunocompromised patients (i.e., HIV) or the elderly, antibiotic

coverage is indicated whether or not a causative organism is found.

References—1, 3, 8

7.3 Bacterial Food Poisoning

Description
Bacterial food poisoning is an illness resulting from the ingestion of food or
drink contaminated with bacteria, bacterial toxins, or both. The illness tends to
be self-limited.

Causes and risk factors

Several organisms can cause food poisoning, and the time of onset of the
symptoms after ingestion of the food and the duration of symptoms gives an idea
of which organism (table 7.3A).

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Table 7.3A. Bacterial Food Poisoning Indicators

Incubation Period Most Likely Bacterium Duration

1–6 hours Staphylococcus aureus or Less than 12 hours
Bacillus ceres
8–16 hours Clostridium acillus ceres Rarely lasting more than
24 hours
>16 hours E. coli, Salmonella, Shigella, Can last for several days
botulism

Sources of contamination:
ƒƒ Food usually becomes contaminated from poor sanitation or preparation.
ƒƒ Food handlers who do not wash their hands after using the bathroom or
who have infections themselves often cause contamination.
ƒƒ Improper packaging food or storing it at the wrong temperature also
promotes contamination.

Signs and symptoms

ƒƒ Fever
ƒƒ Chills
ƒƒ Nausea
ƒƒ Vomiting
ƒƒ Diarrhoea
ƒƒ Abdominal cramps

See section 7.2, “Gastroenteritis (Diarrhoea)” for signs and degree of dehydration
(table 7.2).

Diagnosis
Specific diagnosis is not necessary. Many food-borne infections are not
identified by routine laboratory procedures; they require specialized,
experimental, and expensive tests that are not generally available.

Management objectives
ƒƒ Maintain proper hydration
ƒƒ Prevent recurrence

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Nonpharmacological management
ƒƒ Advise patients to wash their hands thoroughly after going to the toilet and
before eating.
ƒƒ Remind patients that vegetables to be eaten raw must be thoroughly
washed.
ƒƒ Instruct patients on how to rehydrate as required (see section 7.2.1,
“Diarrhoea without Blood”).

Pharmacological management
Not indicated at the primary care level except in case of infection. If needed, see
table 7.3B.

Table 7.3B. Pharmacological Management of Infection Caused by Bacterial

Food Poisoning

Organism Medicine Dose Duration

Salmonella Ciprofloxacin Adults: 500 mg every 8 hours 14 days
Chloramphenicol Children: 50–100 mg/kg/day 14 days
Giardia Metronidazole Adults: 800 mg stat then 3–5 days
400 mg every 8 hours
Children: 250 mg every 8 hours 5 days
Other Co-trimoxazole Adults: 960 mg every 12 hours 5–10 days
Children: 30 mg/kg every 5 days
12 hours

Referral
ƒƒ Nonresponse to conservative treatment
ƒƒ Signs of severe dehydration

References—1, 3, 85, 86, 87

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7.4 Epigastric Disorders

7.4.1 Gastro-oesophageal Reflux Disease

Description
Gastro-oesophageal reflux disease is characterized primarily by heartburn
and caused by the regurgitation of stomach acid and other contents into the
oesophagus.

Causes and risk factors

ƒƒ Poor functioning of the lower oesophageal sphincter
ƒƒ Slow stomach emptying as in pyloric stenosis
ƒƒ Hiatus hernia
ƒƒ Abdominal distension or raised abdominal pressure

Signs and symptoms

ƒƒ Regurgitation of sour material into the mouth
ƒƒ Heartburn
ƒƒ Pain on swallowing (i.e., dysphagia)
ƒƒ Retrosternal chest pain
ƒƒ Vomiting
ƒƒ Reflux can occur into the respiratory tract causing a chronic cough and
signs of respiratory tract infection, especially laryngitis.
ƒƒ Difficulty in swallowing suggests the development of a stricture.

Diagnosis
ƒƒ Usually based on history alone
ƒƒ For patients >50 years and patients who are not responding to treatment or
who have developed complications (e.g., unexplained weight loss, painful
swallowing, bleeding, or anaemia), do the following investigations to rule
out underlying conditions:
yy Full blood count, ESR
yy Barium meal
yy H. pylori test
yy Oesophagoscopy (at a level 4 or 5 facility)

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Management objectives
ƒƒ Provide relief of symptoms
ƒƒ Heal the oesophagitis
ƒƒ Prevent complications

Nonpharmacological management
Advise the patient to make the following lifelong lifestyle changes:
ƒƒ Change eating habits to avoid foods that precipitate symptoms (e.g., citrus,
tomatoes and tomato-based products, caffeine, chocolate, peppermint,
carbonated soft drinks, and fatty foods).
ƒƒ Eat smaller more frequent meals.
ƒƒ Eat the last meal of the day 2–3 hours before going to bed.
ƒƒ Do not drink large quantities of fluids with meals.
ƒƒ Avoid medicines that exacerbate reflux (e.g., beta-blockers, calcium
channel blockers, alpha-adrenergic agonists, theophylline).
ƒƒ Avoid tobacco and alcohol. (See appendix D, “Tobacco Cessation.”)
ƒƒ Elevate the head of the bed 10–20 cm using blocks.
ƒƒ Lose weight (for overweight patients).
ƒƒ Avoid clothing that is tight around the waist.
ƒƒ Avoid pain pills such as aspirin and other NSAIDs.

Pharmacological management
ƒƒ First-line management. Give aluminium hydroxide plus magnesium
hydroxide antacid 1–2 tablets 4 times/day 20–60 minutes after eating.
Note: Although antacids may be useful for relief of mild symptoms, they are
generally ineffective in severe cases of reflux. Do this for 5–7 days.
ƒƒ Second-line management. Give H2 blockers.
yy Give either—
ŠŠ Ranitidine (150 mg tablet): 150–300 mg nightly
ŠŠ OR
ŠŠ Ranitidine (150 mg tablet): 150 mg 2 times/day for 4 weeks
yy Increase to 300 mg 2 times/day if necessary. Then reduce to a
maintenance dose of 150 mg nightly.
ƒƒ Third-line management. Add a pro-kinetic agent. If the patient has no
response to ranitidine after 10 days, change to metoclopramide 10 mg
2 times/day for 14 days.

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ƒƒ Fourth-line management. Add a PPI. If the patient has no response to

metoclopramide after 14 days, change to a PPI: omeprazole (10 mg and 20
mg tablets) 20 mg daily. This may be continued for several weeks.

Note: It may take 8–12 weeks for significant improvement of symptoms while on
treatment for gastro-oesophageal reflux disease.

Referral
Nonresponse to treatment

References—1, 3, 88, 89

7.4.2 Gastritis and Peptic Ulcer Disease

Description
Gastritis is the inflammation of the mucosa (lining) of the stomach and
duodenum resulting from excessive acid in the stomach, which eventually can
cause a peptic ulcer. Gastritis can be classified as acute or chronic.

Causes and risk factors

ƒƒ Excessive alcohol consumption
ƒƒ Stress
ƒƒ Prolonged consumption of NSAIDs (e.g., aspirin, ibuprofen, indomethacin,
and others)
ƒƒ Bacterial infection, primarily H. pylori

Signs and symptoms

See table 7.4.2.

Diagnosis
ƒƒ Base the diagnosis on clinical findings.
ƒƒ A definitive diagnosis can be made only by endoscopy at a level 5 facility or
diagnostic centre.
ƒƒ Test for H. pylori.
Management objectives
ƒƒ Relieve the symptoms
ƒƒ Remove the cause of the inflammation
ƒƒ Treat any underlying infection

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Table 7.4.2. Signs and Symptoms of Gastritis and Peptic Ulcer Disease

Condition Signs and Symptoms

Gastritis Nonspecific clinical signs and symptoms such as—
yy Abdominal tenderness
yy Bloating
yy Poor appetite
yy Nausea (with or without vomiting)
yy Epigastric and retrosternal pain
Gastric ulcer Pain immediately after eating
Duodenal ulcer Pain before eating, which is relieved by food
Nonbleeding ulcer ƒƒ Gastritis, usually after excessive alcohol intake
ƒƒ Epigastric abdominal pain 1–2 hours after eating (i.e., stomach
empty); pain alleviated by food, milk, or antacids
ƒƒ Nausea and vomiting
ƒƒ Discomfort on palpation of the upper abdomen
Bleeding ulcer ƒƒ Sudden weakness and dizziness
ƒƒ Cold and clammy skin
ƒƒ “Coffee grounds” vomitus
ƒƒ Shock (i.e., weak pulse, clammy skin, and low BP)

Nonpharmacological management
Advise the patient to—
ƒƒ Avoid substances that irritate the stomach mucosa, such as pepper, alcohol,
coffee, acidic substances, and NSAIDs
ƒƒ Make lifestyle modifications, including avoidance of tobacco (see appendix
4) and foods that might trigger the symptoms

Pharmacological management
ƒƒ First-line treatment: give an antacid.
yy Aluminium hydroxide and magnesium hydroxide (1–2 tablets or 10–20
mL liquid) 4 times/day, 20–60 minutes after eating and at bedtime.
yy If vomiting is present, give dimenhydrante (gravol) 50 mg 3 times/day
½ hour before meals. Do this for 3–5 days. If symptoms persist, move to
second-line treatment.

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ƒƒ Second-line treatment: give an antacid plus an H2 blocker. To the first-line

medication, add—
yy Ranitidine (150 mg tablets) 150 mg 2 times/day. Severe cases may need a
maximum of 600 mg (300 mg 2 times/day) for 2 weeks.
yy If symptoms improve, switch to maintenance therapy: ranitidine 150 mg
at night for 6–8 weeks.
yy If symptoms persist, move to third-line treatment.
ƒƒ Third-line treatment: give an antacid plus an H2 blocker plus a PPI.
ƒƒ To the second-line medications, add omeprazole tablets (10 mg and 20 mg)
in all patients who are chronic NSAID users.
yy Adults: 20–40 mg/day
yy Children:
ŠŠ >5 kg to <10 kg: 5 mg/day
ŠŠ 10 kg to ≤20 kg: 10 mg/day
ŠŠ >20 kg: 20 mg/day
ƒƒ Fourth-line treatment: give antibiotics to eradicate H. pylori bacteria.
(All patients with a history of peptic ulcer disease, active gastric ulcer, or
active duodenal ulcer associated with H. pylori infection should be treated.
Successful treatment of H. pylori can help the ulcer to heal, prevent ulcers
from coming back, and reduce the risk of complications such as bleeding.)
Use a combination of two antibiotics plus an H2 blocker or a PPI for 14 days.
yy Common antibiotic combinations are—
ŠŠ Metronidazole and amoxicillin
ŠŠ Metronidazole and tetracycline (for penicillin-allergic patients)
yy At the following dosages—
ŠŠ Metronidazole: Adults: 500 mg 2 times/day. Children: 250 mg 2
times/day.
ŠŠ Amoxicillin: Adults: 500 mg 2 times/day. Children: 125–250 mg 2
times/day.
ŠŠ Tetracycline: Adults: 500 mg 2 times/day. Do not use in pregnancy.
Children >8 years: 25–50 mg/kg/day divided in 4 equal doses.
OR
ŠŠ Doxycycline: Adults: 100 mg 2 times/day. Do not use in pregnancy.
Children >8 years: 100 mg 2 times/day.
PLUS

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ŠŠ H2 blocker (see above)

OR
ŠŠ If no response after 7 days, change to PPI (see above).

Referral
ƒƒ Failure to respond to treatment after 2 weeks
ƒƒ Suspicion of development of a peptic ulcer or cancer of the stomach

References—1, 3, 90, 91

7.4.3 Gastrointestinal Bleeding

Description
Gastrointestinal bleeding is defined as bleeding originating in any part of the GI
tract, from the mouth to the anus, although it occurs most often from the upper
GI tract (i.e., between the mouth and the upper small intestines). The amount of
bleeding can range from undetectable to acute, massive, and life threatening.

Causes and risk factors

ƒƒ Causes of upper GI tract bleeding—
yy Peptic ulcers (most common cause)
yy Varicose veins in the oesophagus
yy Tears across the gastroesophageal junction
yy Gastritis
yy Cancer
ƒƒ Causes of lower GI tract bleeding—
yy Haemorrhoids (most common cause)
yy Anal fissures, which contribute to minor bleeding
yy Diverticular disease
yy Colitis
yy Cancer

Signs and symptoms

Signs and symptoms are dependent on the site of the bleeding as well as the
severity and duration.
ƒƒ Bleeding from upper GI tract—
yy Vomiting of bright red or “coffee grounds” material (i.e., haematemesis)
yy Passage of black, tarry, foul-smelling stool (i.e., melena)

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ƒƒ Bleeding from lower GI tract—passage of bright red or maroon blood from

the rectum (i.e., haematochezia)
ƒƒ Other symptoms relate to the underlying disease.

Slow, chronic bleeding can lead to iron-deficiency anaemia with listlessness and
pale mucosa. Severe bleeding leads to increased heart rate and falling or low BP.

Caution: Severe bleeding is a medical emergency. Refer the patient immediately.

Set up IV infusion of normal saline or Ringer’s lactate.

Diagnosis
ƒƒ A careful history of onset and frequency of the bleeding and the patient’s
previous history will help to determine cause and possible site of bleeding.
ƒƒ Order an endoscopy to determine the site of the bleed (at the hospital level).
ƒƒ Test the stool for occult blood.

Management objectives
ƒƒ Replace blood loss
ƒƒ Stop the bleeding
ƒƒ Treat the underlying cause

Nonpharmacological management
In heavy drinkers, advise a reduction or cessation of alcohol intake.

Pharmacological management
ƒƒ For upper GI bleeding, give—
yy Injectable ranitidine (50 mg/mL) 50 mg dosage stat then 2 times/day for
7 days
yy Dimenhydrinate tablet (50 mg) 3 times/day, ½ hour before meals
yy If indicated, provide fluid replacement.
yy If patient is anaemic, see section 12.1, “Anaemia.”
ƒƒ For lower GI bleeding—
yy For anal fissure, give—
ŠŠ Bismuth subgallate compound, ointment, topical, applied 2 times/day
OR
ŠŠ Tetracaine 1%, cream, topical, applied after each bowel action
yy For haemorrhoids, use antihemorrhoidal suppositories (see section 7.1.3,
“Haemorrhoids”).

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Referral
ƒƒ Falling BP and increasing heart rate, for blood replacement and surgical or
other intervention
ƒƒ Vomiting blood or passing frank blood PR

At the district hospital level—

ƒƒ Rehydrate with an IV of Ringer’s lactate.
ƒƒ Give H2 blocker: ranitidine.
ƒƒ Refer the patient to the regional hospital.

References—1, 3, 92, 93

7.5 Liver Disease

7.5.1 Jaundice
Definition
Jaundice is the yellowish discoloration of the conjunctiva of the eyes, mucous
membranes, and skin due to deposition of bilirubin from an increased level in the
blood. It can be a symptom of either liver disease or a haemolytic disorder.

Causes
ƒƒ Prehepatic (increased breakdown of red blood cells)
yy Haemolytic anaemia
yy Incompatible blood transfusion
yy Hypersplenism
yy Infections (e.g., malaria)
yy Sickle cell disease
yy Thalassemia
ƒƒ Intrahepatic
yy Hepatitis (e.g., leptospirosis)
yy Cirrhosis
yy Hepatocellular cancer
yy Medicines (e.g., HAART, isoniazid)
yy Pregnancy
ƒƒ Extrahepatic (obstructive jaundice)
yy Gallstones in common bile duct
yy Pancreatic cancer

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yy Pancreatitis
yy Bile duct atresia

Diagnosis
ƒƒ Base on a careful medical history and clinical signs to identify possible
cause.
ƒƒ Pay particular attention to the abdomen.
ƒƒ Investigations
yy Liver function tests
yy Urine
Note: Rule out sickle cell disease. (See chapter 13, “Haemaglobinopathy—Sickle
Cell Disease.”)

Management objectives
ƒƒ Determine the underlying cause of the jaundice
ƒƒ Treat accordingly

Nonpharmacological and pharmacological management

ƒƒ At the health centre level, refer to the hospital.
ƒƒ In the hospital, treat according to the underlying cause.

7.5.2 Hepatitis
Description
Hepatitis is the acute inflammation of the liver cells.

Causes and risk factors

ƒƒ Viral infection. There are five main hepatitis viruses, referred to as types
A, B, C, D, and E. These five types are of greatest concern because of the
burden of illness and death they cause and the potential for outbreaks and
epidemic spread.
yy Hepatitis A and E can be transmitted by eating food or water
contaminated by faecal matter.
yy Hepatitis B and C and D can be transmitted through parenteral contact
with infected body fluids (e.g., transfusion with contaminated blood
or blood products or during invasive procedures using improperly
sterilized instruments).

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yy Hepatitis B can also be transmitted from mother to baby at birth and

through sexual contact. It is one of the world’s most common and serious
infectious diseases.
yy The clinical characteristics of all five diseases are similar enough to
make differential diagnosis difficult.
ƒƒ Nonviral infections (e.g., toxoplasmosis, leptospirosis)
ƒƒ Illicit drugs, poisons, and medicines
ƒƒ Alcohol
Signs and symptoms
Acute infection may occur with limited or no symptoms or may include
symptoms that are insidious or sudden in onset, with varying intensity, such as—
ƒƒ Fever
ƒƒ Weakness and malaise
ƒƒ Nausea, loss of appetite, and vomiting

Early symptoms are followed by—

ƒƒ Jaundice
ƒƒ Enlarged liver
ƒƒ Pain or tenderness over to right upper quadrant of the abdomen
ƒƒ Dark urine
ƒƒ Stool may be pale
ƒƒ Severe itching of the skin

Diagnosis
Use the same investigations as for jaundice. (See section 7.5.1, “Jaundice.”)

Management objective
Determine underlying cause and treat accordingly

Nonpharmacological management
ƒƒ Recommend—
yy Rest and hydration.
yy High sugar diet, best tolerated in the morning
ƒƒ Advise the patient to—
yy Avoid fatty foods
yy Avoid alcohol
yy Boil all drinking water

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yy Protect all food from flies

yy Wash hands with soap and water after using the toilet; all family
members must do the same
yy Not share items that go in the mouth (e.g., cutlery. crockery,
toothbrushes)

Pharmacological management
ƒƒ In the hospital, give symptomatic pharmaceutical therapy.
ƒƒ Analgesics, antipyretics, antidiarrhoeals, and antiemetics are
contraindicated during the acute phase because they may aggravate the
symptoms.

Referral
ƒƒ At the health centre level, refer to the hospital.
ƒƒ In the hospital—
yy Treat according to underlying cause.
yy In general, follow the nonpharmacological and pharmacological
management above.

References—1, 3, 10, 94

7.6 Parasitic Infestations

7.6.1 Giardiasis
Description
Giardiasis is the infestation of the small intestines by Giardia lamblia.

Causes and risk factors

ƒƒ Ingestion of infective cysts
ƒƒ Poor hygiene and sanitation, leading to person-to-person transmission
ƒƒ Can also be waterborne
Signs and symptoms
Onset of symptoms may be gradual or sudden and includes—

ƒƒ Loose, foul-smelling stools

ƒƒ Abdominal pain
ƒƒ Bloating
ƒƒ Nausea and vomiting

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ƒƒ Diarrhoea; when profuse, can lead to dehydration

ƒƒ Weight loss

Giardiasis can become chronic with symptoms recurring from time to time.

Diagnosis
Microscopic examination of the stool

Management objectives
ƒƒ Treat the infection
ƒƒ Prevent reinfection and spread to others

Nonpharmacological management
ƒƒ Assess for dehydration (see table 7.2, “Assessing Dehydration”). If the
patient is dehydrated, follow guidelines for rehydration in section 7.2.
ƒƒ If diarrhoea continues for more than 1 day in a child, but the child is not
dehydrated, give ORS as follows:
yy Adults: Refer to section 1.4 “Acute Diarrhoea with Dehydration.”
yy Children <2 years: 50–100 mL after each bout of diarrhoea, up to ~½ L/
day
yy Children 2–9 years: 100–200 mL after each bout of diarrhoea, up to 1 L/
day
yy Children >10 years: can have as much as wanted, up to ~2 L/day
ƒƒ Advise the patient on good hygiene practices.
yy Wash hands thoroughly with soap and water—
ŠŠ After using the toilet
ŠŠ Before any sort of food preparation
ŠŠ After handling raw meat and fish
ŠŠ Before eating
ŠŠ After gardening
ŠŠ Soak soiled clothing and bed linens in disinfectant before washing;
wash in hot water.
yy Clean toilet seats, flush handles, door handles, and taps frequently.
yy Use bottled or boiled water.
yy Wash fruit, salad, or vegetables thoroughly using water treated with
bleach.

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Pharmacological management
Give—
ƒƒ Adults: metronidazole (250 mg tablets), 1 tablet, 3 times/day for 5 days
ƒƒ Children: metronidazole (125 mg/5 mL suspension), 5 mL (1 tsp) 3 times/
day for 5 days

Note: Do not drink alcohol with metronidazole. In pregnant women, withhold

treatment until after delivery.

Referral
Cases not responding to oral treatment

References—1, 8, 95, 96

7.6.2 Helminthiasis
Description
Helminthiasis is infestation with one or more intestinal parasitic worms such
as roundworms (Ascaris lumbricoides), whipworms (Trichuris trichiura), or
hookworms (Necator americanus and Ancylostoma duodenale). In Guyana
pinworm (Enterobius vermicularis) is also a likely cause.

Causes and risk factors

ƒƒ Causes—
yy Ingestion of infective cysts
yy Poor hygiene and sanitation, leading to person-to-person transmission
yy Can also be waterborne
ƒƒ Risk factors—
yy Infected people excrete helminth eggs in their faeces, which then
contaminate the soil in areas with inadequate sanitation.
yy Other people can then be infected—
ŠŠ By ingesting eggs or larvae in contaminated food
ŠŠ Through penetration of the skin by infective larvae in the soil
(hookworms)
ŠŠ By person-to-person contact (pinworms)

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Signs and symptoms

Soil-transmitted worms produce a wide range of symptoms including—
ƒƒ Intestinal symptoms (e.g., diarrhoea, abdominal pain)
ƒƒ Vomiting (if present, suspect an intestinal obstruction)
ƒƒ General malaise and weakness
ƒƒ Anaemia (from chronic blood loss from the gut, especially with hookworm)
ƒƒ Irritating nonproductive cough or wheezing (during migration of larvae
through the lung)
ƒƒ Adult worms in the stool
ƒƒ Anal itching, worse at nights (with pinworms)
ƒƒ With severe infestation, rectal prolapse; pinworms visible in the area
ƒƒ Possible signs of undernutrition

Diagnosis
ƒƒ Based on history and clinical findings
ƒƒ Stool test for ova and parasites (can be carried out at level 3 facility)
ƒƒ Blood test for Hb and eosinophil count
ƒƒ Adhesive tape test (for pinworms)

Management objectives
ƒƒ Treat the worms
ƒƒ Prevent further infestation
ƒƒ Treat any anaemia or nutritional disorder

Nonpharmacological management
ƒƒ Provide patient counselling and education.
ƒƒ Advise the patient to practice good hygiene.
yy Wash hands with soap and water—
ŠŠ After passing a stool
ŠŠ Before working with food or eating
yy Keep fingernails short and clean
yy Wash fruit and vegetables well or cook
yy Keep toilet seats clean
yy Teach children to use toilets properly and wash hands
yy Dispose of faeces properly

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Pharmacological management
ƒƒ Give albendazole (200 mg and 400 mg tablets; oral suspension 200 mg/
5 mL) single dose. Repeat after 3–4 weeks if needed.
yy Adults: 400 mg
yy Children 1–2 years: 200 mg
yy Children >2 years: 400 mg
Caution: Do not use albendazole during the first trimester of pregnancy.

ƒƒ Give mebendazole (100 mg and 500 mg tablets; 100 mg/5 mL suspension).

yy For pinworms, give children and adults: 100 mg once. Repeat in 2 weeks
if not cleared.
yy For other worms, give children and adults: 100 mg morning and evening
for 3 days.
Caution: Do not use mebendazole during the first trimester of pregnancy
since it may cause congenital defects.

Referral
ƒƒ Abdominal tenderness
ƒƒ Pain
ƒƒ Vomiting
ƒƒ Pregnancy

References—1, 8, 97, 98

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8. Urogenital System

8.1 Urinary Tract Infection

Description
A urinary tract infection is caused by bacteria that spread upwards from the
urethra or via the blood stream from another septic focus.

Classification
There are two categories:
ƒƒ Lower tract infections—urethritis (infection of the urethra) and cystitis
(infection of the bladder
ƒƒ Upper tract infections—pyelonephritis (infection of the kidney)

Causes and risk factors

ƒƒ Females are more prone because of transfer of organisms from anus to
urethra
ƒƒ Organisms:
yy Enterobacteria (E. coli, Klebsiella, Proteus)
yy Anaerobic bacteria
yy STIs
yy Chlamydia
yy Trichomonas
yy Candida
ƒƒ Catheterization
ƒƒ Incomplete emptying of bladder leading to vesicoureteral reflux
ƒƒ Obstruction (e.g., kidney, ureteric or bladder stones)
ƒƒ Use of spermicidal compounds with diaphragm, cervical cap, or condom
ƒƒ Diabetes
ƒƒ Menopause
ƒƒ Pregnancy
ƒƒ Chronically ill, debilitated patients

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Signs and symptoms

ƒƒ General—
yy Dysuria, abnormal smell, cloudy urine
yy Frequency
yy Occasionally, fever
yy Occasionally, lower back pain
yy Suprapubic tenderness
ƒƒ In neonates—
yy Fever
yy Poor feeding
yy Vomiting
yy Prolonged jaundice
yy Failure to thrive
ƒƒ In infants and young children—
yy Vomiting and poor appetite (may be the only symptoms)
yy Failure to thrive
yy Persistent fever
yy Abdominal pain
yy Frequency and dysuria

Diagnosis
ƒƒ Based on history, clinical signs, and symptoms
ƒƒ Urine analysis (blood, WBC, and proteins) and culture

Management objectives
ƒƒ Identify factors predisposing to infection
ƒƒ Determine the cause of infection and treat

8.1.1 Urethritis
Signs and symptoms
ƒƒ Dysuria and frequency
ƒƒ Pain at the start of urination
ƒƒ Mucopurulent urethral discharge in men is suggestive of gonococcus or
chlamydia

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Nonpharmacological management
Advise the patient to—
ƒƒ Increase fluid intake to at least 1.5 L/day
ƒƒ Refer his or her partner for treatment if an STI is suspected

Pharmacological management
ƒƒ Give—
yy Doxycycline (100 mg tablet) 1 tablet PO 2 times/day for 7 days
Caution: Doxycycline is contraindicated in pregnancy.
OR
yy Erythromycin (250 mg, 500 mg tablets) 500 mg PO 4 times/day for 7
days
OR
yy Cefixime 400 mg PO in a single dose
PLUS
yy Azithromycin 1 g PO in a single dose
ƒƒ For male child <9 years, give—
yy Cefixime (400 mg tablet) 8mg/kg PO in a single dose, not to exceed
400 mg
PLUS
yy Azithromycin (500 mg tablet; 125 mg/5 mL suspension), 10–15 mg/kg
PO in a single dose, not to exceed 1 g
ƒƒ For persistent urethritis, give metronidazole (250 mg tablet; 125 mg/5 mL
suspension), adults: 2 g PO in a single dose.
ƒƒ Follow-up
yy Patients should be instructed to return for evaluation if symptoms
persist or recur after completion of therapy.
yy Repeat testing of all men diagnosed with chlamydia or gonorrhoea
is recommended 3–6 months after treatment, regardless of whether
patients believe that their sex partners were treated.

Referral
ƒƒ No improvement after 48 hours
ƒƒ Children <9 years

References—1, 3, 99, 100

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8.1.2 Cystitis
Cystitis is more common in women than men, especially in the reproductive
years, basically because of the closeness of the urethra to the vagina and anus.

Signs and symptoms

ƒƒ Dysuria and frequency and urgency
ƒƒ Nocturia
ƒƒ Cloudy, foul-smelling urine, sometimes haematuria (30% of cases)
ƒƒ Suprapubic pain
ƒƒ Tenderness over lower abdomen
ƒƒ Pain at the end of urination

Management objective
Determine the cause and treat appropriately

Nonpharmacological management
Increase fluid intake to at least 1.5 L/day

Pharmacological management
ƒƒ For uncomplicated cystitis in nonpregnant women—
yy Give ciprofloxacin (500 mg tablet) 500 mg PO as a single dose
yy If no relief after 48 hours, give ciprofloxacin (500 mg tablet) 500 mg PO 2
times/day for 5 days
ƒƒ For cystitis in men, give ciprofloxacin (500 mg tablet) 500 mg PO 2 times/
day for 10 days
ƒƒ In pregnant and lactating women, refer to a doctor or the hospital.

References—1, 3, 101

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8.1.3 Pyelonephritis
Description
Pyelonephritis is an infection of the kidneys that generally starts in the urethra
and travels up to the kidneys.

Causes
ƒƒ Uropathogenic E. coli
ƒƒ The following microorganisms are also commonly isolated:
yy Staphylococcus saprophyticus
yy Klebsiella pneumoniae
yy Proteus mirabilis
yy Enterococci
yy S. aureus
yy Pseudomonas aeruginosa
yy Enterobacter species

Risk factors
ƒƒ Female anatomy (i.e., urethra closer to anus)
ƒƒ Obstruction in the urinary tract—anything that impedes the flow of urine or
complete emptying of bladder
ƒƒ Weakened immune system
ƒƒ Prolonged use of a urinary catheter

Signs and symptoms

Acute pyelonephritis is complex, and there is no consistent set of signs and
symptoms that is both sensitive and specific for the diagnosis. Therefore,
clinicians must maintain a high index of suspicion.

In infants and young children, the only sign may be high fever. In older children
and adults, the classic signs are—
ƒƒ Fever sometimes >39.4°C (>103°F)
ƒƒ Costovertebral (i.e., flank) or groin pain
yy Mild, moderate, or severe
yy Flank pain—unilateral but sometimes bilateral
ƒƒ Nausea, vomiting, or both

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Other signs that may be present are—

ƒƒ Abdominal pain
ƒƒ Frequent urination
ƒƒ Strong, persistent urge to urinate
ƒƒ Burning sensation or pain when urinating
ƒƒ Pus or blood in the urine

Nonpharmacological management
Provide patient education—
ƒƒ Advise females to wipe to the back after defecation to reduce risk of anal-
urethral transfer of microorganisms.
ƒƒ Advise all patients to drink plenty of fluids, at least 1.5 L/day to help to flush
bacteria from the urinary tract, but not coffee or alcohol. Coffee and alcohol
should be avoided until the infection has cleared.
ƒƒ Advise all patients to take antibiotics as directed and complete the course
as prescribed, since doing so minimizes the risk of recurrence and the
development of resistant organisms.

Referral
ƒƒ All cases
ƒƒ If there is a delay in transfer, start on an antibiotic (ampicillin)—
yy Adults (except pregnant and lactating women): ampicillin (powder for
injection 500 mg, 1 g) 8 g IV daily in 3 divided doses
yy Children: ampicillin (powder for injection 500 mg, 1 g) 200 mg/kg/day
IV, in 3 divided doses, every 8 hours
OR
ƒƒ For penicillin-allergic adults and children, give—
yy Ceftriaxone: 1 g IV every 24 hours
OR
yy Cefotaxime: 1–2 g IV every 8 hours
Note: Only a doctor can administer IV medication.
OR
yy For pregnant or lactating women, refer.
ƒƒ Give ciprofloxacin 500 mg 2 times/day while waiting for transfer.

References—1, 3, 102, 103

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8.2 Renal Disorders

8.2.1 Nephrotic Syndrome

Description
Nephrotic syndrome is a clinical syndrome characterized by a number of renal
and extrarenal features, the most prominent of which is massive proteinuria due
to increased permeability of the glomerular basement membrane.

Classification
Nephrotic syndrome can be either—
ƒƒ Primary, being a disease specific to the kidneys
ƒƒ Secondary, being a renal manifestation of a systemic general illness

In all cases, injury to glomeruli is an essential feature.

Causes and risk factors

ƒƒ Primary causes of nephrotic syndrome include the following, in
approximate order of frequency:
yy Minimal-change nephropathy
yy Focal glomerulosclerosis
yy Membranous nephropathy
yy Hereditary nephropathies
ƒƒ Secondary causes include the following, again in order of approximate
frequency:
yy Diabetes mellitus
yy Lupus erythematosus
yy Amyloidosis and paraproteinemias
yy Viral infections (e.g., hepatitis B, hepatitis C, HIV)
yy Preeclampsia

Signs and symptoms

ƒƒ In children, swelling of the face followed by swelling of the entire body
ƒƒ In adults, dependent oedema
ƒƒ Proteinuria of >50 mg/kg in 24 hours in children and>3 g/day in adults
ƒƒ Single test: 2 g protein to 1 g urine creatinine
ƒƒ Hypoalbuminaemia <25 g/L
ƒƒ Hyperlipidaemia

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Management objectives
ƒƒ Treat underlying causative disease
ƒƒ Control proteinuria
ƒƒ Control nephritic complications

Nonpharmacological management
All patients should be referred to the hospital, but while awaiting transfer if
delayed, begin treatment.

Assess hydration status

ƒƒ If not dehydrated—
yy Restrict salt intake
yy Impose no fluid restrictions
ƒƒ If dehydrated (often preceded by diarrhoea and vomiting)—
yy Check urine, sodium, potassium, and creatine
yy Give IV fluid, sodium chloride 0.9%, 20 mL/kg over 10 minutes

Pharmacological management
Begin symptomatic treatment of oedema.
ƒƒ For severe oedema, give furosemide injection IV2 mg/kg, slow IV infusion
over 5 hours.
ƒƒ For mild to moderate oedema, give furosemide tablets (40 mg)
PLUS
ƒƒ hydrochlorothiazide tablets 1 mg/kg once daily, not to exceed 25 mg/day.
ƒƒ For children, give furosemide syrup (20 mg/mL) 1 mg/kg/day.

Referral
Refer all patients to the hospital.

References—1, 8, 10, 104

8.2.2 Glomerulonephritis
Description
Acute glomerulonephritis refers to the inflammation and proliferation of
glomerular tissue, triggered by an immunologic mechanism that can result in
damage to the basement membrane, mesangium, or capillary endothelium. It is
most common in children >3 years and in young adults.

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Causes and risk factors

Previous streptococcal infection (most common)

Signs and symptoms

ƒƒ Fluid retention
ƒƒ Hypertension
ƒƒ Haematuria
ƒƒ Oliguria with concentrated urine
ƒƒ Significant proteinuria
ƒƒ In mild glomerulonephritis—
yy Oedema around the eyelids
yy Pitting oedema of the lower limbs
ƒƒ In severe glomerulonephritis—
yy Acute pulmonary oedema
yy Cerebral oedema with seizures

Management objectives
ƒƒ Give highest priority to patients who present with hypertension or with
pulmonary or CNS symptoms
ƒƒ Eradicate streptococcal causes by oral antibiotic therapy
ƒƒ Treat complications

Nonpharmacological management
All patients should be referred to the hospital, but while awaiting transfer if
delayed, begin treatment.
ƒƒ With mild oedema, the most effective treatment is sodium and fluid
restriction.
ƒƒ Advise bed rest.

Pharmacological management
ƒƒ For severe oedema, give furosemide PO (40 mg tablets; 20 mg/mL syrup)
yy Adults: 40–60 mg/day in 1–2 divided doses
yy Children: 1–2 mg/kg/day in 1–2 divided doses
ƒƒ Give penicillin (250 mg 4 times/day for 7–10 days) is indicated for non-
allergic patients. For penicillin-allergic patients, give erythromycin (500
mg 4 times/day for 7 days)
Note: Early antibiotic therapy does not affect the development of post
streptococcal glomerulonephritis.

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ƒƒ For complications, see—

yy Section 6.3, “Hypertension”
yy Section 1.13 “Seizures and Convulsions”

Referral
ƒƒ Refer all patients to the hospital.
ƒƒ Watch especially for the presence of following—
yy Oliguria and renal failure
yy Immunosuppression
yy Anuria
yy Nephritic syndrome
yy Massive proteinuria
yy Significant hypertension
yy Pulmonary symptoms

References—1, 10, 105

8.2.3 Haematuria
Description
Haematuria is blood in the urine, which may be either visible or microscopic.
Microscopic haematuria is defined as 2–5 RBCs per high power field and can be
detected by dipstick.

Classification
ƒƒ Gross haematuria
ƒƒ Microscopic haematuria

Causes and risk factors

ƒƒ Causes
yy Urinary tract infections
yy Kidney infections
yy A bladder or kidney stone
yy Enlarged prostate or prostatitis
yy Kidney disease (i.e., glomerulonephritis)
yy Cancer
yy Inherited disorders (e.g., sickle cell anaemia)

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yy Kidney injury
yy Medications (e.g., aspirin, penicillin, heparin, and cyclophosphamide)
ƒƒ Risk factors
yy Age (men >50 years)
yy A recent infection
yy Family history
yy Strenuous exercise (particularly long-distance running)
yy Certain medications (e.g., aspirin, NSAIDs, and antibiotics such as
penicillin)

Signs and symptoms

ƒƒ Pink, red, or cola-coloured urine
ƒƒ Usually no other signs or symptoms

Diagnosis
Use the following to determine the underlying cause.
ƒƒ History and physical findings
ƒƒ Urinalysis to indicate presence of infection or stones
ƒƒ In the hospital—
yy Ultrasound
yy Cystoscopy

Management objective
Determine underlying cause and treat

Management
The nonpharmacological and pharmacological management required depends
on the underlying cause. See figure 8.2.3.

Referral
See figure 8.2.3.

References—1, 106

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Figure 8.2.3. Algorithmic approach to microscopic haematuria in adults

Microscopic evaluation of urine to confirm presence of RBCs

Signs or symptoms of infection (e.g., dysuria, frequency, flank/CVA

pain, leukocyte esterase, nitrites, white blood cells, bacteria)?

YES NO
Treat infection; confirm resolution Findings in support of glomerular cause
of microscopic hematuria with (e.g., proteinuria, elevated creatinine
follow-up urinalysis six weeks level, red cell casts, dysmorphic RBCs)?
after completion of therapy.

YES NO
Refer to nephrology Other etiology probable (e.g.,
subspecialist. vigorous exercise, trauma to urethra,
menstruation, offending medication)?

YES NO
Stop and retest urine after possible Proceed with upper urinary
contributing factor stopped. tract radiographic evaluation.

Note: High risk = smoking, history of urothelial neoplasm, age older than 40 years, occupational exposure to
benzenes or aromatic amines.

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8.3 Sexually Transmitted Infections

Description
Sexually transmitted infections (STIs) are infections that are spread primarily
through person-to-person sexual contact. There are more than 30 different
sexually transmissible bacteria, viruses, and parasites.

Causes and risk factors

The most common causes of STIs in Guyana are listed below:
ƒƒ Neisseria gonorrhea (gonorrhoea)
ƒƒ Chlamydia trachomatis (genital chlamydia and Lymphogranuloma
venereum)
ƒƒ Trichomonas vaginalis (trichomoniasis)
ƒƒ Candida albicans (vulvo-vaginal candidiasis)
ƒƒ Treponema pallidum (syphilis)
ƒƒ Herpes simplex (genital herpes)
ƒƒ Haemophilus ducreyi (chancroid)
ƒƒ Klebsiella granulomatis (granuloma inguinale/donovanosis)

Risk factors include the following:

ƒƒ Sexual contact with someone who has a known STI
ƒƒ Age <30 years with multiple partners
ƒƒ Homelessness, dwelling on the street
ƒƒ Unprotected intercourse with a new partner in the preceding 2 months
ƒƒ >2 partners in the previous 12 months
ƒƒ Men who have sex with men
ƒƒ Commercial sex workers

Signs and symptoms

See individual disease entities.

Diagnosis
ƒƒ Based on history, physical examination
ƒƒ Laboratory examination and culture—discharge, swab from ulcers, or both
ƒƒ Screening questions
yy Is the patient currently sexually active?
yy Has he or she had a new sex partner in the previous 2 months?

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yy Has he or she had multiple partners in the past 12 months?

yy Does the patient have any history of past STI?

Management
Management should include—
ƒƒ Partner notification
ƒƒ Partner treatment
ƒƒ Counselling, to help prevent repeat infection
ƒƒ Syphilis and HIV testing
ƒƒ Promotion of condom use (offer condoms)

8.3.1 Gonorrhoea
Signs and symptoms
In men—
ƒƒ Burning on micturition
ƒƒ White, yellow, or green discharge from penis
ƒƒ Occasionally, painful or swollen testicles

In women, usually asymptomatic, but may present with—

ƒƒ Pain or burning sensation on micturition
ƒƒ Increased vaginal discharge
ƒƒ Vaginal bleeding between periods

Diagnosis
Signs and symptoms are similar to those of a chlamydial infection except that
the latter tends to be milder. Sometimes coinfection exists. Perform gram stain
of the discharge.

Management objective
Prevent the spread of the infection to adjacent structures
ƒƒ In men, prevent epididymitis
ƒƒ In women, prevent pelvic inflammatory disease

Nonpharmacological management
Advise the patient on the consistent use of condoms if he or she is not in a
mutually monogamous relationship.

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Pharmacological management
ƒƒ Uncomplicated anogenital infection in males—
yy For first-line treatment, give cefixime (200 mg tablet) 400 mg PO as a
single dose
yy For second-line treatment, give—
ŠŠ Ceftriaxone, 125 mg by IM injection as a single dose
OR
ŠŠ Spectinomycin, 2 g by IM injection as a single dose
ŠŠ If second-line treatment fails, refer patient.
ƒƒ Uncomplicated anogenital infection in females, give—
yy Cefixime (200 mg tablet) 400 mg stat
OR
yy Ceftriaxone (500 mg, 1 g injections) 250 mg IM stat
PLUS
yy Fluconazole (150 mg) PO stat
PLUS
yy Metronidazole (500 mg tablet) PO 2 times/day for 7 days
ƒƒ Disseminated infection, give ceftriaxone (500 mg injection) 1 g IM or IV,
once daily for 7 days

Reference—107

8.3.2 Chlamydial Infections

8.3.2.1 Genital Chlamydia
Signs and symptoms
Similar to that of gonorrhoea. Often coinfection exists. There may be few or no
symptoms.

8.3.2.2 Lymphogranuloma Venereum

Signs and symptoms
ƒƒ Ulcerative genital lesions (see table 8.3.9)
ƒƒ Marked swelling of the lymph nodes in the groin
ƒƒ Headache
ƒƒ Fever and malaise

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Diagnosis
Blood or urine tests or cultures

Pharmacological management
ƒƒ For first-line treatment, give—
yy Doxycycline, (100 mg tablet) PO 2 times/day for 7 days.
Caution: Doxycycline is contraindicated in pregnancy. See below for
alternative.
OR
yy Azithromycin (250 mg tablet) 1 g PO in a single dose
ƒƒ For second-line treatment, give—
yy Amoxicillin (250 mg, 500 mg tablets) 500 mg PO 3 times/day for 7 days
OR
yy Erythromycin (250 mg, 500 mg tablets) 500 mg 4 times/day for 7 days
OR
yy Ofloxacin (200 mg tablet) 300 mg 2 times/day for 7 days
Note: Authorized at the region hospital level only.
OR
yy Tetracycline (500 mg tablet) PO 4 times/day for 7 days
Caution: Tetracycline is contraindicated in pregnancy. See below for
alternative.
ƒƒ In pregnancy, give—
yy Erythromycin (250 mg, 500 mg tablet) 500 mg 4 times/day for 7 days
OR
yy Amoxicillin (250 mg, 500 mg tablet) 500 mg PO 3 times/day for 7 days

8.3.3 Trichomoniasis
Cause and risk factors
ƒƒ Infection with T. vagialis
ƒƒ Multiple sex partners
ƒƒ Other STIs

Signs and symptoms

Symptoms of the disease vary, and most patients are asymptomatic. Women are
more likely to have symptoms than men, however.

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ƒƒ Symptoms in men are related to—

yy Burning on urination or ejaculation
yy Itching or irritation inside the penis
yy Penile discharge
ƒƒ Symptoms in women—
yy Malodorous vaginal discharge (often yellow or green)
yy Vulvar erythema and itching
yy Dysuria or urinary frequency
yy Dyspareunia

Diagnosis
Microscopic examination of vaginal or prostatic secretions

Management objective
Effect early cure especially in pregnancy, since infection can result in adverse
pregnancy outcomes

Pharmacological management
ƒƒ In men and nonpregnant women, give—
yy Metronidazole (250 mg tablet) 2 tablets (500 mg) 2 times/day for 7 days
OR
yy Metronidazole (2 g tablet) PO in a single dose
ƒƒ During pregnancy, give metronidazole (250 mg tablet) 2 g PO as a single
dose
Caution: Not recommended during the first trimester.

8.3.4 Vulvo-vaginal Candidiasis

Cause
Mainly C. albicans

Signs and symptoms

ƒƒ Vulvar itching and soreness
ƒƒ Inoffensive vaginal discharge
ƒƒ Vulvar erythema or excoriations from scratching
ƒƒ Vulvar oedema
ƒƒ Pain on urination and sexual intercourse

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Diagnosis
Microscopy of wet smear

Management objective
ƒƒ Remove any predisposing factors
ƒƒ Treat the infection

Pharmacological management
Give—
ƒƒ Miconazole cream or suppository 200 mg intravaginally daily for 3 days
OR
ƒƒ Clotrimazole pessary 200 mg intravaginally daily for 3 days
OR
ƒƒ Fluconazole (150 mg tablet) 1 tablet PO as a single dose
OR
ƒƒ Nystatin suppository (100,000 IU) intravaginally daily for 14 days

8.3.5 Syphilis
Characterized by episodes of active disease interspersed with periods of latency

Classification
ƒƒ Congenital (i.e., transmitted from mother to child in utero). Not a problem
in Guyana.
ƒƒ Acquired through sexual intercourse or blood transfusion. Acquired
syphilis may be primary, secondary, or latent.

Signs and symptoms

ƒƒ For primary syphilis—
yy Usually the appearance of a single sore at the site of inoculation, but
multiple sores are possible (for characteristics of the sore, see table
8.3.9). The locations are—
ŠŠ In heterosexual men, usually on the penis
ŠŠ In homosexual men, the anus, rectum, penis, or mouth
ŠŠ In women, the cervix and labia
yy Sore lasts 3–6 weeks whether treated or not.
yy Regional lymphadenopathy is present.
yy Primary syphilis may go on to become secondary syphilis.

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ƒƒ For secondary syphilis—

yy Generalized skin rash
yy Symmetric mucocutaneous lesions
yy Generalized, nontender lymphadenopathy
yy Condylomata lata (in 10% of patients) in warm moist body areas
ƒƒ For latent syphilis, there are no clinical manifestations.
ƒƒ Late latent syphilis is an infection of >2 years without evidence of
treponemal infection.

Diagnosis
VDRL, RPR
Management objectives
Prevent the progression of the disease to the secondary and latent phases
Nonpharmacological management
Advise patient on—
ƒƒ Consistent use of condoms during sexual intercourse, if not in a mutually
monogamous relationship
ƒƒ Need for treatment for partner(s)

Pharmacological management
ƒƒ For early syphilis
yy Give first-line treatment—
ŠŠ Benzathine benzylpenicillin injection (2.4 MIU) IM as a single dose
(divide between 2 sites)
OR
ŠŠ Procaine benzylpenicillin injection (1.2 MIU) IM daily for 10 days.
yy For penicillin-allergic, nonpregnant patients, give—
ŠŠ Doxycycline (100 mg tablet) PO 2 times/day for 14 days
OR
ŠŠ Tetracycline (500 mg tablet) PO 4 times/day for 14 days
yy For penicillin-allergic or pregnant patients, give erythromycin (250 mg,
500 mg tablets) 500 mg 4 times/day for 14 days
yy Follow-up
ŠŠ Re-evaluate clinically and serologically 3 months after treatment
ŠŠ Do a second evaluation 6 months later if indicated by results and a
third 12 months later.

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ŠŠ Check for possible reinfection.

ŠŠ Consider repeat treatment if—
–– Clinical signs or symptoms of active syphilis persist or recur
–– There is confirmed increase in the titre of a non-treponemal test
ƒƒ For late latent syphilis
yy Give first-line treatment—
ŠŠ Benzathine benzylpenicillin injection (2.4 MIU) IM once weekly for
3 weeks
OR
ŠŠ Procaine benzylpenicillin injection (1.2 MIU) IM daily for 20 days
yy For penicillin-allergic nonpregnant patients, give—
ŠŠ Doxycycline (100 mg tablet) PO 2 times/day for 30 days
OR
ŠŠ Tetracycline (500 mg tablet) PO 4 times/day for 30 days
yy For penicillin-allergic or pregnant patients, give erythromycin (250 mg,
500 mg tablets) 500 mg 4 times/day for 30 days.

8.3.6 Genital Herpes

Cause
Herpes simplex virus type 2 (HSV-2)

Signs and symptoms

Most individuals infected with HSV-1 or HSV-2 experience either no symptoms
or have very mild symptoms that go unnoticed. Because of this, most people
infected with HSV-2 are not aware of their infection. When symptoms do occur,
they typically appear as—
ƒƒ One or more vesicles, pustules, or ulcers on or around the genitals, rectum,
or mouth that may take 2–4 weeks to heal (see table 8.3.9)
ƒƒ Tender and swollen inguinal glands
ƒƒ Dysuria
ƒƒ Vaginal and urethral discharge in women
ƒƒ During a first outbreak, the patient may have flu-like symptoms such as—
yy Fever
yy Headache
yy Body aches and muscle pain

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Repeat outbreaks of genital herpes are common, in particular during the first
year of infection. Symptoms of repeat outbreaks are typically shorter in duration
and less severe than the first outbreak of genital herpes.

Diagnosis
ƒƒ By visual inspection if the outbreak is typical
ƒƒ Swab and culture
ƒƒ Blood test (ELISA)

Management objectives
There is no cure for herpes so the aim is to shorten the episode and prevent
transmission to the patient’s partner(s).

Nonpharmacological management
Advise the patient on the correct and consistent use of latex condoms.

Pharmacological management
ƒƒ For the first clinical episode, give—
yy Acyclovir (200 mg tablets) 2 tablets PO 3 times/day for 7days
OR
yy Valaciclovir (500 mg tablets) 1 g PO twice/day for 7 days
OR
yy Famciclovir (125 mg, 500 mg tablet) 250 mg 3times/day for 7 days
ƒƒ For recurrent infection, give—
yy Acyclovir (200 mg tablet) 400 mg PO 3 times/day for 5 days
OR
yy Acyclovir (200 mg tablet) 800 mg PO 2 times/day for 5 days
Note: For patients who have recurrent infections, provide a prescription
for the medication so that the patient can start treatment at the first sign
of the disease.
Note: Patients who have ≥6 recurrences during the year should go on
suppressive therapy.
ƒƒ Recommended regimen for suppressive therapy: give acyclovir (200 mg
tablet) 400 mg PO 2 times/day continuously for up to 1 year

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8.3.7 Chancroid
Cause
H. ducreyi

Signs and symptoms

ƒƒ Genital ulcers (see table 8.3.9)
ƒƒ Inguinal adenitis

Diagnosis
The combination of one or more painful genital ulcers and tender, suppurative
inguinal adenopathy suggests the diagnosis of chancroid.

Management objective
Promote early healing of the ulcers

Nonpharmacological management
Advise patient to keep ulcerative lesions clean.

Pharmacological management
ƒƒ For first-line treatment, give—
yy Ciprofloxacin (500 mg tablet) 1 tablet PO 2 times/day for 3 days.
Caution: Ciprofloxacin is contraindicated in pregnant women.
OR
yy Erythromycin (250 mg, 500 mg tablets) 500 mg 4 times/day for 7 days
OR
yy Azithromycin (250 mg tablet) 1 g PO as a single dose
ƒƒ For second-line treatment, give ceftriaxone (500 mg, 1 g injection) 250 mg
as a single dose.
ƒƒ Follow-up weekly until there is clear evidence of improvement.

8.3.8 Granuloma Inguinale/Donovanosis

Cause
K. granulomatis

Signs and symptoms

ƒƒ Subcutaneous nodules progress to painless ulcerative lesions (see table
8.3.9) that bleed readily on contact.
ƒƒ Genital swelling (particularly the labia) may be present.

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Diagnosis
Microscopy of smear or biopsy from lesion

Management objective
Early resolution of signs and symptoms

Pharmacological management
ƒƒ Give first-line treatment until lesions are healed—
yy Azithromycin (250 mg tablet) 1 g PO on the first day, then 500 mg
once daily
OR
yy Doxycycline (100 mg tablet) 1 tablet 2 times/day
Caution: Doxycycline is contraindicated in pregnancy.
ƒƒ If lesions are unhealed after 2 weeks, use alternative therapy—
yy Erythromycin (250 mg, 500 mg tablets) 500 mg PO 4 times/day
OR
yy Trimethoprim (80 mg/sulfamethoxazole 400 mg) 2 tablets PO 2 times/
day for a minimum of 14 days
ƒƒ Follow-up—
yy Reassess weekly
yy Continue therapy until lesions have healed (usually 3–5 weeks)

8.3.9 Genital Ulcers

Description
A genital ulcer is an ulcer located on the genital area. It reflects the presence
of an important set of STIs. It sharply increases the risk of the acquisition and
shedding of HIV.

Causes
ƒƒ Syphilis
ƒƒ Genital herpes (this is a chronic lifelong infection)
ƒƒ Chancroid

Diagnosis
ƒƒ Isolation of HSV in cell culture is the preferred virologic test.
ƒƒ Serological test (ELISA)

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196
Lymphogranuloma
Feature Syphilis Herpes Chancroid venereum Donovanosis
Incubation period 9–90 days 2–7 days 1–14 days 3 days to 6 weeks 1–4 weeks
(up to 4 months)
Early primary Papule Vesicle Pustule Papule, pustule, or Papule
8 . U rogenita l S ystem

lesions vesicle
Number of lesions Usually one Multiple, may Usually multiple, Usually one Variable
coalesce may coalesce
Diameter edges 5–15 mm sharp, 1–2 mm Variable, 2–10 mm elevated, Variable, elevated,
demarcated, elevated, erythematous undetermined, round or oval irregular
round or oval ragged, irregular
Depth base Superficial or deep; Superficial, serous, Necrotic, purulent; Superficial or Elevated, red, and
smooth, nonpurulent; erythematous, bleeds easily deep; variable, velvety; bleeds
relatively nonvascular nonvascular nonvascular readily
Induration Firm None Soft Occasionally firm Firm
Pain Uncommon Frequently tender Usually very tender Variable Uncommon
Lymphadenopathy Nontender, bilateral Firm, tender, often Tender, may Tender, may None,
bilateral with initial suppurate, suppurate, pseudobuboes
episode loculated, usually loculated, usually
unilateral unilateral

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Pharmacological management
ƒƒ For syphilis, give benzylbenzatine penicillin (injection 1.2 IU) 2.4 IU once
weekly for 3 weeks.
ƒƒ For herpes, give—
yy Acyclovir (200 mg tablet) 400 mg PO 3 times/day for 7–10 days
OR
yy Acyclovir (200 mg tablet) 200 mg PO 5 times/day for 7–10 days
ƒƒ For chancaroid give—
yy Azithromycin (250 mg tablet) 1 g PO in a single dose
OR
yy Ceftriaxone (500 mg and 1 g injections) 250 mg IM in a single dose
OR
yy Ciprofloxacin (500 mg tablet) 500 mg PO 2 times/day for 3 days.
Caution: Ciprofloxacin is contraindicated for pregnant and lactating
women.
OR
yy Erythromycin base (250 mg and 500 mg tablets) 500 mg PO 3 times/day
for 7 days

8.3.10 Urethral Discharge

Description
Urethral discharge is defined as discharge from the urethra and may be creamy or
yellow. See figure 8.3.10.

Causes and risk factors

N. gonococcus, C. trachomatis, or both

Pharmacological management
ƒƒ Treat for both organisms, using—
yy Cefixime (200 mg tablet) 400 mg PO as a single dose/day for 7 days
OR
yy Ceftriaxone (500 mg, 1 g injections), 125 mg IM as a single dose/day for
7 days
PLUS
yy Doxycycline (100 mg tablet) 1 tablet 2 times/day for 7 days

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Figure 8.3.10. Urethral discharge algorithm

Patient complains of urethral discharge

or burning when passing urine

Milk Urethra to confirm discharge

NO NO
Discharge confirmed Ulcer(s) present

YES YES

ƒƒ Treat for gonorrhea and See Table 8.3.9 ƒƒ Counsel about genital
Clamydia infections
ƒƒ Counsel about genital ƒƒ Advise to get HIV test
infections ƒƒ Refer if symptoms
ƒƒ Offer or refer for HIV persist beyond 1 week
testing
ƒƒ Promote the use of
condoms and provide
ƒƒ Advise partner testing
ƒƒ Return if symptoms
persist after 7 days of
treatment

ƒƒ Patients should be advised to return if symptoms persist 7 days after start

of therapy.

References—1, 107

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8.4 Testicular Disorders

8.4.1. Scrotal Swelling

Description
Scrotal swelling is the abnormal enlargement of the scrotum. It can occur in
males at any age. The swelling can be on one or both sides and vary in size. The
testicles and penis may or may not be involved. It can be with or without pain,
acute or long-standing.

Causes
ƒƒ Infection—STIs, coliform bacteria, mumps, or TB
ƒƒ Fluid collection around the testes (i.e., hydrocele)
ƒƒ Testicular cancer (common in young men, often a painless lump)
ƒƒ Inguinal hernia
ƒƒ Trauma
ƒƒ Epididymo-orchitis (ascending or haematogenous)
ƒƒ Urogenital TB
ƒƒ Varicocele

Signs and symptoms

ƒƒ Scrotum feels cystic or rubbery on palpation
ƒƒ If reducible and nontransilluminating by torchlight, a hernia is indicated.
ƒƒ If nonreducible and transilluminating, a hydrocele is indicated.
ƒƒ Occasional urethral discharge
ƒƒ Occasional dysuria

Diagnosis
ƒƒ A careful history and physical examination should suggest the cause.
ƒƒ Take blood for RPR/VDRL, and check for gonococcus if indicated

Management objectives
ƒƒ Determine the cause of the condition, particularly torsion of the testis;
because the latter may lead to gangrene in 6–12 hours, immediate referral
for surgery is indicated.
ƒƒ Treat infection if present
ƒƒ Refer to next level if due to causes other than infection

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Nonpharmacological management
ƒƒ Counsel on compliance with treatment and risk reduction.
ƒƒ Provide and promote use of male and female condoms (in the case of a
suspected STI).
ƒƒ Apply cold compresses and provide support for the testes in the case of
mumps orchitis.

Pharmacological management
ƒƒ If due to an STI and no diagnostic tests are available to rule out gonococcus,
give—
yy Cefixime (200 mg tablet) 400 mg PO as a single dose/day for 7 days
OR
yy Ceftriaxone (500 mg, 1 g injection), 125 mg IM as a single dose/day for
7 days
PLUS
yy Doxycycline (100 mg tablet) 1 tablet 2 times/day for 7 days
ƒƒ Have the patient return after 1 week.
ƒƒ Notify partner and treat.

Referral
ƒƒ Immediate—
yy Suspected torsion of the testis
yy Cause unknown
ƒƒ Subsequent—
yy Person who is not sexually active
yy Sudden onset of pain
yy History of trauma
yy History of serious non-STI disease

References—1, 3, 108, 109

8.4.2. Torsion of the Testis

Description
Testicular torsion, although it can occur at any age, is primarily a disease of
adolescents and neonates. It is caused by the spontaneous twisting of the
spermatic cord and the blood supply to the testicle, thus cutting off its own blood
supply.

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Cause
The cause is probably anatomical attributable to the failure of proper fixation of
the testes posteriorly.

Signs and symptoms

ƒƒ Testicular torsion is characterized by—
yy Excruciating one-sided testicular pain, with sudden swelling
yy Nausea or vomiting
yy High position of the testicle
yy Absent cremasteric reflex
ƒƒ Consequences of torsion
yy Infarction of testicle
yy Loss of testicle
yy Infection
yy Infertility secondary to loss of testes

Diagnosis
Differentiate from other causes of testicular pain because a delay in diagnosis
and management can lead to the above consequences.

Management objective
ƒƒ Save the testes
ƒƒ Maintain its integrity

Management
Caution: Torsion of the testis is an emergency.
Refer the patient immediately to the next level where surgery can be performed
because a delay in diagnosis and management can lead to the loss of the testicle.
The time elapsed between onset of pain and performance of detorsion, and the
corresponding salvage rate, is as follows:
ƒƒ <6 hours: 90–100% salvage rate
ƒƒ 12–24 hours: 20–50%
ƒƒ >24 hours: 0–10%

If transfer cannot take place ≤6 hours, attempt manual detorsion.

ƒƒ The procedure for manual detorsion of the testis is analogous to the
opening of a book when the physician is standing at the patient’s feet.

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yy Most torsions twist inward and toward the midline; thus, manual
detorsion of the testicle involves twisting outward and laterally.
Note: Lateral rotation has been described in up to a third of testicular
torsions, however, and in such cases, further lateral rotation will worsen
the condition.
yy For suspected torsion of the right testicle—
ŠŠ Position yourself in front of the standing or supine patient.
ŠŠ Hold the patient’s right testicle with your left thumb and forefinger.
ŠŠ Rotate the right testicle outward 180° in a medial-to-lateral direction.
yy For suspected torsion of the left testicle—
ŠŠ Position yourself in front of the standing or supine patient.
ŠŠ Hold the patient’s left testicle with your right thumb and forefinger.
ŠŠ Rotate the patient’s left testicle in an outward direction 180° from
medial to lateral.
ƒƒ Rotation of the testicle may need to be repeated 2–3 times for complete
detorsion.
ƒƒ Pain relief serves as a guide to successful detorsion, but restoration of blood
flow must be confirmed following the maneuver.
ƒƒ Subsequent elective orchiopexy is recommended to prevent recurrent
torsion.
ƒƒ In the literature, the success rate of manual detorsion has varied widely.
Success rates have ranged from 26.5% to more than 80%.

References—3, 110

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9. Musculoskeletal System

9.1 Lower Back Pain

Description
Lower back pain is a common presenting symptom especially in the elderly,
but it can present in a young person as well. The pain can be local in origin or
referred and can be acute or chronic.

Causes
Pain in the low back can relate to the bony lumbar spine, discs between the
vertebrae, ligaments around the spine and discs, spinal cord and nerves, muscles
of the low back, internal organs of the pelvis and abdomen, and the skin covering
the lumbar area. It can be inflammatory, mechanical, neurological, traumatic, or
due to other disease.
ƒƒ Mechanical
yy Lumbar strain (acute, chronic)
yy Carrying heavy objects
yy Pregnancy
yy Physical training
yy Bending down; dragging or pulling heavy objects
yy Lesions to the muscles or ligaments (sprains or trauma)
yy Posture
ƒƒ Neurological
yy Nerve irritation
yy Mechanical pressure (e.g., pinching in sciatica) by bone or other tissues
yy Lumbar radiculopathy—nerve irritation caused by damage to the discs
between the vertebrae
yy Slipping of the vertebrae or spondylolisthesis
ƒƒ Bone and joint conditions
yy Congenital or developmental
yy Degenerative
yy Injury (fractures)
yy Inflammation of the joints (arthritis)

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yy Infections (abscesses, TB, HIV and AIDS)

yy Malignancies (primary or metastatic)

Signs and symptoms

ƒƒ Pain and tenderness in the lumbosacral area (i.e., the lower part of the back)
is the primary symptom.
ƒƒ The pain may radiate down the front, side, or back of the leg, or it may be
localised to one area of the backbone.
ƒƒ The pain may increase with—
yy Activity
yy Lifting or carrying heavy loads
yy Bending down
yy Sitting for long periods
ƒƒ Neurological changes or disorders may occur, such as—
yy Weakness or loss of sensitivity in the legs
yy Inability to plantar flex the foot
yy Inability to stand on the toes
yy Pain with straight leg raising test

Diagnosis
Based on the history of the illness and a physical examination. It is essential
that the history include injury history, aggravating, and alleviating conditions,
associated symptoms (e.g., fever, numbness, tingling, incontinence), as well as
the duration and progression of symptoms.

Management objectives
ƒƒ Determine the cause of the pain
ƒƒ Treat the condition
ƒƒ Relieve the pain

Management
Management depends greatly on the precise cause of the low back pain.

Nonpharmacological management
ƒƒ Application of ice and heat on affected area provides relief for some people
and should be tried.
ƒƒ Recommend that the patient rest as much as possible.
ƒƒ Instruct the patient not to lift or pull heavy objects.

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ƒƒ Advise the patient to—

yy Apply warm compresses on the affected area 3 times/day
yy Bend at the knee, keeping the back straight, when lifting objects
yy Avoid turning or rotating the back too much
yy Sleep on a firm mattress
yy Sleep with pillow between the knees while lying in the side
yy Use correct posture (e.g., adjust chair, height of desk, position of
computer)

Pharmacological management
ƒƒ Give—
yy Paracetamol (500 mg tablet) 1 g PO 3 times/day for 4 days
OR
yy Aspirin (300 mg tablet) 600 mg 4 times/day (adults only)
Caution: Acetylsalicylic acid (aspirin) is not recommended for children
<12 years old because of the risk of Reye’s syndrome.
ƒƒ If pain persists, give—
yy Diclofenac injection (25 mg/mL) 50 mg stat then every 12 hours for 3
days
OR
yy Ibuprofen (200 mg, 400 mg tablets) 200–400 mg 3 times/day for 5 days

Referral
ƒƒ No improvement after 2–4 weeks
ƒƒ Any neurological or nerve involvement
ƒƒ Severe continuous neurological pain
ƒƒ Weakness of limb
ƒƒ Localised vertebra involvement
ƒƒ Bladder or bowel incontinence

References—1, 3, 111

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9.2 Joint Pain

9.2.1 Osteoarthritis
Description
Arthritis is a group of conditions involving damage to the joints of the body. There
are different forms of arthritis and each has a different cause. The most common
form of arthritis is osteoarthritis (i.e., degenerative joint disease), with damage
to articular cartilage. It may be primary or secondary to systemic disease.

Causes and risk factors

ƒƒ Injury to the joint
ƒƒ Infection of the joint
ƒƒ Obesity and overweight
ƒƒ Age

Signs and symptoms

ƒƒ Pain in the joint(s):limbs, neck, hips, knees, and fingers; usually
asymmetrical
ƒƒ Joint pain with swelling, warmth, and redness
ƒƒ Stiffness of joints (usually in the morning)
ƒƒ Decreased joint movement
ƒƒ Joint deformation
ƒƒ Deterioration with physical activity
ƒƒ Improvement with rest
ƒƒ Nodular thickening of the finger joints, especially the end joints

Diagnosis
Diagnosis is guided by the history. Important features are—
ƒƒ Speed and time of onset
ƒƒ Pattern of joint involvement
ƒƒ Symmetry of symptoms
ƒƒ Early morning stiffness
ƒƒ Tenderness, gelling, or locking with inactivity
ƒƒ Aggravating and relieving factors

In children, rule out rheumatic fever especially if several joints are affected in
succession.

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Run the following—

ƒƒ Blood tests
ƒƒ ESR and full blood count
ƒƒ x-ray of affected joints

Management objectives
ƒƒ Identify the nature of the underlying process
ƒƒ Relieve symptoms
ƒƒ Maintain the integrity of the joint

Nonpharmacological management
ƒƒ Apply heat to the affected joint, making sure not to burn the patient.
ƒƒ Provide physical and occupational therapy.
ƒƒ Encourage the patient to make lifestyle changes including exercise and
weight control.
ƒƒ Recommend dietary supplements (symptomatic or targeted at the disease
process causing the arthritis) such as glucosamine, chondroitin, and
turmeric.
ƒƒ Arthroplasty ( joint replacement surgery) may be required in eroding forms
of arthritis.

Pharmacological management
For pain relief, give—
ƒƒ Ibuprofen (200 mg, 400 mg, 600 mg tablets; 100 mg/5 mL suspension)
yy Adults: 200–600 mg 4 times/day depending on severity
yy Children: 20–40 mg/kg/day in 4 divided doses
PLUS
ƒƒ Aluminium hydroxide + magnesium hydroxide tablet, 1 tablet 4 times/day
after meals,
OR
ƒƒ Paracetamol (500 mg tablet; 120 mg/5 mL suspension). See table 9.2.1 for
dosages.
OR
ƒƒ Acetylsalicylic acid (300 mg, 500 mg tablets) 1–2 tablets 4 times/day
Caution: Acetylsalicylic acid (aspirin) is not recommended for children
<12 years old because of the risk of Reye’s syndrome.

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Table 9.2.1. Paracetamol Dosages by Age and Weight for the Management
of Pain Associated with Osteoarthritis

Age Weight Dose (mg) Quantity Frequency Duration

3–12 months 6–10 kg 60 2.5 mL (½ 3 times/day 5–7 days
tsp)
1–5 years 10–18 kg 120 5 mL (1 tsp) 3 times/day 5–7 days
5–8 years 18–25 kg 240 10 mL (2 tsp) 3 times/day 5–7 days
or ½ tablet
8–14 years 25–50 kg 500 1 tablet 3–4 times/day 5–7 days
>14 years >50 kg 1,000 2 tablets 3–4 times/day 5–7 days
and adults

Referral
ƒƒ Swelling, warmth, redness, and tenderness on exerting pressure
ƒƒ Suspicion of a systemic disease
ƒƒ Failure to respond to NSAIDs
ƒƒ Chronic pain for 1 week in children or >2 weeks in adults
ƒƒ Incapacitating pain
ƒƒ Fever

References—1, 3, 8

9.2.2 Rheumatoid Arthritis

Description
Rheumatoid arthritis (RA) is a chronic, systemic inflammatory disorder of the
connective tissue. It can affect the whole body, but it principally attacks the
peripheral joints, in a symmetric fashion, producing an inflammatory synovitis
that often progresses to destruction of the articular cartilage and bone erosion
leading to ankylosis of the joints. The joints most often affected are those of the
hands, wrist, feet, ankles, neck, knees, and shoulders. Although RA primarily
affects the joints, problems affecting other parts of the body—such as the
heart, lungs, and spleen—can occur. People who have RA are more prone to
atherosclerosis, and the risk of myocardial infarction (heart attack) and stroke is
markedly increased.

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Cause
The cause is unknown but autoimmunity plays a part in making it chronic and in
its progression.

Signs and symptoms

Increased stiffness of ≥3 joints, usually worse in the morning and lasting for at
least an hour (for >6 weeks)
ƒƒ Joints red, swollen, and painful
ƒƒ Fingers most affected with spindle-shaped metacarpal-phalangeal, or
proximal interphalangeal joint swelling
ƒƒ Arthritis of hand joints, present for at least 6 weeks
ƒƒ Symmetric arthritis (i.e., involvement of the same join areas on both sides)
present for at least 6 weeks
ƒƒ Subcutaneous nodules over bony prominences
ƒƒ Abnormal amounts of serum rheumatoid factor
ƒƒ Radiographic changes

The following may also be present—

ƒƒ Limitation of movement progressing to loss of movement and joint
deformity
ƒƒ Constitutional symptoms including—
yy Fatigue
yy Low-grade fever
yy Malaise
yy Loss of appetite
yy Loss of weight

Diagnosis
ƒƒ At least four of the first eight signs and symptoms listed above must be
present for the diagnosis to be made.
ƒƒ x-ray of the hands and feet
ƒƒ Blood test for rheumatoid factor, ESR, uric acid

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Management objectives
There is no known cure for RA, but many different types of treatment can
alleviate symptoms, modify the disease process, or both. Management therefore
aims to—
ƒƒ Relieve pain
ƒƒ Reduce inflammation
ƒƒ Protect the joints
ƒƒ Maintain function
ƒƒ Prevent further destruction of the joints
ƒƒ Control systemic involvement

Nonpharmacological management
Advise the following:
ƒƒ Daily rest, but not all day because of risk of permanent stiffening of joints
ƒƒ Splinting of joints, when inflamed and swollen, to reduce movement
ƒƒ Exercise to maintain muscle strength and joint movement
ƒƒ Lifestyle changes to minimize stress on joints
ƒƒ An adequate intake of omega-3 fatty acids (i.e., eat more fish and less meat)
ƒƒ Use of soya, canola, and olive oil in preference to others
ƒƒ Losing weight (if the patient is overweight or obese)

Pharmacological management
Treat pain and inflammation with—
ƒƒ Ibuprofen (first choice) (200 mg, 400 mg tablet) 200–400 mg 4 times/day
OR
ƒƒ Paracetamol (500 mg tablet) (See table 9.2.1 for dosages.)
OR
ƒƒ NSAIDs
OR
ƒƒ Acetylsalicylic acid (300 mg tablets) 2 tablets 4 times/day for pain
Caution: Acetylsalicylic acid (aspirin) is not recommended for children
<12 years old because of the risk of Reye’s syndrome.

OR
ƒƒ Diclofenac sodium (25 mg, 75 mg tablets) 2 (25 mg) tablets 3 times/day or 1
(75 mg) tablet 2 times/day (injection not authorized for use at the HC level)

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Reassess the patient in 2 weeks and continue on therapy if response is

acceptable.

Referral
Refer to level 4 or 5 for additional treatment if—
ƒƒ The patient is not responding to NSAIDs alone
ƒƒ The patient shows progressive disability and joint damage

In the hospital, confirm the diagnosis and take the following steps—
ƒƒ Provide pain relief (see above)
ƒƒ Give corticosteroids
ƒƒ Give prednisolone (5 mg tablet) 1 tablet 3 times/day

References—1, 3, 8, 34, 112, 113

9.2.3 Gout
Description
Gout is a metabolic disease, most often affecting middle-age to elderly men and
postmenopausal women. It is typically associated with an elevated level of uric
acid in the blood (i.e., hyperuricaemia), that results in the deposit of uric acid
crystals in tissues. Recurrent bouts of acute gout can lead to a degenerative
form of chronic arthritis called gouty arthritis. Gout is also associated with an
increased risk of kidney stones.

Stages and classification

ƒƒ Asymptomatic tissue deposition. Gout has no overt symptoms, but
hyperuricaemia and the asymptomatic deposition of crystals in tissues are
present.
ƒƒ Acute gout occurs when urate crystals in the joint(s) cause acute
inflammation. A flare is characterized by pain, redness, swelling, and
warmth lasting days to weeks.
ƒƒ Chronic/recurrent gout is characterized by chronic arthritis, with
soreness and aching of joints. People who have gout may also get tophi (i.e.,
lumps of urate crystals deposited in soft tissue), usually in cooler areas of
the body (e.g., elbows, ears, distal finger joints).

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Causes and risk factors

Hyperuricaemia is caused by an imbalance in the production and excretion of
urate (i.e., overproduction, underexcretion, or both).

Risk factors for gout include the following:

ƒƒ Being overweight or obese; weight loss lowers the risk for gout
ƒƒ Having hypertension
ƒƒ Consuming alcohol (beer and spirits more than wine)
ƒƒ Using diuretics
ƒƒ Eating a diet rich in meat and seafood

Signs and symptoms

ƒƒ Acute gout will typically manifest itself as an acutely red, hot, and swollen
joint (usually large toe, knee, or ankle) with excruciating pain and restricted
movement.
ƒƒ An attack is often preceded by a history of alcohol intake or binge eating.
ƒƒ Most initial attacks occur in the lower extremities.

Management objectives
ƒƒ Relieve pain and restore movement to the joint
ƒƒ Prevent future attacks through lowering uric acid levels in blood

Nonpharmacological management
For acute gout, advise patient to—
ƒƒ Rest the joint
ƒƒ Apply an ice pack to the affected joint (for no more than 20 minutes at a
time)
ƒƒ Drink 2–3 litres of water and other fluids (e.g., low-fat or skimmed milk,
much-diluted fruit juices)
ƒƒ Avoid alcohol intake
ƒƒ Avoid or strictly restrict the intake of foods such as kidney, liver, offal,
sardines, foods with high yeast content, pork crackling, and the skin of fish
ƒƒ Eat less fat
ƒƒ Lose weight if overweight or obese, but do not fast

For chronic, recurrent gout—

ƒƒ Emphasise dietary adherence
ƒƒ Urge the patient to exercise regularly but not intensively

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Pharmacological management
Acute gout. The mainstay of treatment during an acute attack is the
administration of anti-inflammatory medicines.
ƒƒ Diclofenac 50–100 mg IM stat
OR
ƒƒ Indomethacin 25–50 mg TID
OR
ƒƒ Ibuprofen 400–800 mg TID
OR
ƒƒ If the patient has no response to anti-inflammatory medicines, give
prednisone 40 mg PO daily for 3–5 days

Chronic gout
ƒƒ First-line treatment—
yy Allopurinol (100 mg, 300 mg tablets) 150 mg once daily initially
yy Increase by 150 mg each week according to response, not to exceed
900 mg daily
yy If dose is >300 mg give in 2–3 divided doses
ƒƒ If no response, move to second-line treatment—
yy Probenecid tablet 250 mg 2 times/day for 1 week
yy Then 500 mg 2 times/day
ƒƒ Give an NSAID or colchicine as a prophylactic and continue until at least
1 month after the hyperuricaemia has been corrected.
yy Indomethacin 25–50 mg 3 times/day
yy Ibuprofen 200–400 mg 3 times/day
yy Colchicine 0.5 mg 1–2 times/day

Referral
Failure to respond to treatment

References—1, 3, 114

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9.2.4 Osteoporosis
Description
Osteoporosis is defined as a reduction of bone mass (or density), which causes
deterioration in the architecture of the skeleton. This deterioration leads to a
marked increase in the risk of fracture. It is prevalent among postmenopausal
women but also occurs in women and men with underlying conditions
associated with demineralization of bone.

Causes and risk factors

ƒƒ Imbalance between new bone formation and old bone resorption.
ƒƒ Inadequate calcium intake or absorption
ƒƒ Vitamin D deficiency (vitamin D facilitates the absorption of calcium)
ƒƒ Reduction in oestrogen levels in women and androgens in men
ƒƒ Inactivity—prolonged bed rest
ƒƒ Lack of weight-bearing exercise
ƒƒ Cigarette smoking over a long period
ƒƒ Excessive alcohol use
ƒƒ Certain medications:
yy Corticosteroids
yy Cytotoxic medicines
yy Anticonvulsants

Signs and symptoms

ƒƒ Early in the disease, the patient may have no symptoms.
ƒƒ Later, it may cause dull pain in the bones or muscles, particularly in the low
back or neck.
ƒƒ Later still, the patient has sudden sharp pains, made worse by activity that
puts weight on the area.
ƒƒ The patient experiences loss of height and a stooped posture.
ƒƒ The patient may report a fall that may result in a spine or foot fracture.

Diagnosis
ƒƒ X-ray the affected area.
ƒƒ Test for serum calcium level.
ƒƒ Test for bone density.

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Management objectives
ƒƒ Slow down or stop the mineral loss
ƒƒ Increase bone density
ƒƒ Prevent bone fractures
ƒƒ Control the pain associated with the disease

Nonpharmacological management
Advise the patient to—
ƒƒ Eat a diet rich in calcium (1,000 mg daily); drink milk or calcium-fortified
orange juice and eat foods high in calcium. (See appendix F.)
ƒƒ Get exposure to direct sunlight at least 20 minutes a day
ƒƒ Restrict salt and caffeine intake
ƒƒ Perform weight-bearing exercise such as walking, dancing, or aerobics at
least 3 times/week
ƒƒ Maintain normal body weight
ƒƒ Stop smoking (see appendix D)
ƒƒ Restrict alcohol intake (1 drink per day for women and 2 for men) (See table
6.3D for size of alcoholic drinks)

Pharmacological management
ƒƒ Give calcium supplementation, not to exceed 600 mg at a time.
ƒƒ Give vitamin D supplementation—
yy Adults <50 years: 200 IU
yy 50–70 years: 400 IU
yy >70 years: 600 IU
ƒƒ Give oestrogen replacement for postmenopausal women.

Follow-up
If the patient is on oestrogens, do routine mammograms, pelvic examinations,
and visual inspection of the cervix with acetic acid.

Referral
ƒƒ Suspected fracture
ƒƒ To physiotherapist to advise on exercise

References—1, 3, 115

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9.3 Muscular Disorders—Myalgia

Description
Myalgia, or muscle pain, is a symptom of many diseases and disorders. Muscle
aches and pains are common and can involve more than one muscle. Ligaments,
tendons, and fascia, the soft tissues that connect muscles, bones, and organs can
also be involved. The pain can be temporary or chronic.

Causes and risk factors

The most common causes of myalgia are—
ƒƒ Injury or trauma, including sprains, hematoma from exercise or physically
demanding work
ƒƒ Overuse: using a muscle too much or too often, including protecting a
separate injury
ƒƒ Chronic tension

Myalgia without a traumatic history is often due to viral infections:

ƒƒ Influenza
ƒƒ Dengue

Myalgia can also be caused by—

ƒƒ Diseases affecting the whole body:
yy Malaria
yy Metabolic disorders
ƒƒ Disorders:
yy Severe potassium deficiency
yy Muscle abscess
ƒƒ Medications, especially fibrates and statins; occasionally ACE inhibitors;
cocaine; some antiretroviral medicines
ƒƒ Autoimmune diseases:
yy Systemic lupus erythematosus
yy Polymyalgia rheumatica
yy Polymyositis
yy Dermatomyositis
yy Multiple sclerosis (i.e., neurologic pain localised to a myotome)

Longer term myalgias may be indicative of a metabolic myopathy, some

nutritional deficiencies, or chronic fatigue syndrome.

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Signs and symptoms

ƒƒ In patients for whom the pain is related to injury or overuse, the pain tends
to involve specific muscles and starts during or just after the activity. In
these situations, it is usually obvious which activity is causing the pain.
ƒƒ Pain is most noticeable when muscles are being used, particularly with
repetitive activities.
ƒƒ Accompanying symptoms may be weakness, tenderness to palpation, and
swelling.

Diagnosis and management

See figure 17.4, “Algorithm for myalgia.”

9.4 Tendon Disorders

9.4.1 Carpal Tunnel Syndrome

Description
Carpal tunnel syndrome is the result of the compression of the median nerve at
the wrist, which results in neurological symptoms in the affected hand.

Cause and risk factors

ƒƒ Pressure on the median nerve at the wrist
ƒƒ Excessive use of the wrist in repetitive actions such as uninterrupted typing
ƒƒ Tenosynovitis
ƒƒ Underlying systemic disease
yy Hypothyroidism
yy Diabetes mellitus
yy Rheumatoid arthritis

Signs and symptoms

ƒƒ Early signs and symptoms include—
yy Nocturnal paresthesias of thumb, index, and middle fingers
yy Pain, numbness, and tingling in the hand and fingers
ƒƒ As the disease progresses, patients can develop—
yy A burning sensation
yy Cramping and weakness of the hand
yy Decreased grip strength, which can lead to frequent dropping of objects
from the hand

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yy Occasionally, sharp shooting pains in the forearm

yy Chronic carpal tunnel syndrome can also lead to wasting (atrophy) of the
hand muscles, particularly those near the base of the thumb in the palm
of the hand.
Diagnosis
ƒƒ Based on the symptoms and the distribution of the hand numbness
ƒƒ Swelling, warmth, tenderness, deformity of wrist

Management objectives
ƒƒ Relieve pain
ƒƒ Prevent muscle deterioration
ƒƒ Return the hand to normal functioning

Nonpharmacological management
Advise the patient to—
ƒƒ Do stretching exercises of the wrist
ƒƒ Wear a wrist splint at night

Pharmacological management
ƒƒ Give paracetamol: PO (100 or 500 mg tablet; 120 mg/5 mL oral suspension).
See table 9.4.1 for dosages.

Table 9.4.1. Paracetamol Dosages by Age and Weight for the Management of
Pain Associated with Carpal Tunnel Syndrome

Age Weight Dose (mg) Quantity Frequency Duration

8–14 years 25–50 kg 500 1 tablet 3–4 times/day 5–7 days
>14 years >50 kg 1,000 2 tablets 3–4 times/day 5–7days
and adults

OR
ƒƒ Ibuprofen (600 mg tablet) dosage 600 mg 4 times/day for 5–7 days
OR
ƒƒ Corticosteroids can be given by mouth or injected directly into the involved
wrist joint by the appropriate, skilled professional, not to exceed 2–3 times/
year.

References—1, 116

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9.4.2 Tennis Elbow

Description
Tennis elbow is a condition caused by the inflammation of the tendons on the
outer bony prominence (i.e., lateral epicondyle) of the elbow. Tennis elbow can
occur in anyone who strains the tendons of the forearm and is not limited to
tennis players.

Causes
Any repetitive motion of the wrist, including tennis, hedge clipping, excessive
use of a hammer or screwdriver, painting, or any activity that requires excessive
constant gripping or squeezing can cause tennis elbow.

Signs and symptoms

ƒƒ Tenderness on the outer bony part of the elbow
ƒƒ Morning stiffness of the elbow with persistent aching
ƒƒ Soreness in the forearm
ƒƒ Pain worse when grasping or holding an object

Diagnosis
ƒƒ Based on medical history and physical examination
ƒƒ x-ray of elbow to rule out other causes

Nonpharmacological management
ƒƒ Advise the patient to—
yy Apply a cold pack to the elbow for 20 minutes twice/day
yy Rest the area to prevent further injury
ƒƒ An elbow strap or splint may help take the pressure off the inflamed tendon.
ƒƒ Physical therapy involves different exercises to increase flexibility and
strength. These exercises are usually performed at home. Refer the patient
to a physiotherapist.

Pharmacological management
ƒƒ Steroid injections can be made into the inflamed area by the appropriate,
skilled professional, not to exceed 2–3 times/year.

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10. Dermatology

10.1 Acne
Definition
Acne is a common skin disease characterized by pimples on the face, chest, and
back. It occurs when the pores of the skin become clogged with oil, dead skin
cells, and bacteria, caused by changes in skin structures consisting of a hair
follicle and its associated sebaceous gland. It can present in inflammatory or
noninflammatory forms. Acne lesions are commonly referred to as pimples,
blemishes, spots, zits, or acne.

Acne is most common during adolescence but may continue into adulthood.
For most people, acne improves over time and tends to disappear in the early
twenties. The most common sites for acne vulgaris are the forehead, cheeks,
nose, and chin; the chest and back may sometimes be involved.

Causes and aggravating factors

ƒƒ Sebum overproduction during puberty
ƒƒ Altered hormonal status in adolescence with increased androgens in males
ƒƒ Increased androgenic properties of progesterone in premenstrual females
or those taking progesterone-containing contraceptives
ƒƒ Some medicines (e.g., steroids) and cosmetics
ƒƒ Family history
ƒƒ Infection by propionibacterium, mainly P. acnes

Signs and symptoms

Acne can be categorised as mild, moderate, and severe (table 10.1A). It may
worsen during menstruation. Psychological problems (i.e., depression) may
occur in persistent acne.

Diagnosis
Diagnosis is based on clinical findings: the presence of a combination of papules,
pustules, blackheads and whiteheads nodules, and scarring on the forehead,
cheeks, nose, chin, chest, and back. Two types are recognized (table 10.1B).

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Table 10.1A. Categories of Acne

Degree Signs and Symptoms

Mild ƒƒ Open and closed comedones (i.e., whiteheads and blackheads)
ƒƒ Some papules and pustules (pimples), commonly on face, chest,
back, and shoulders
Moderate ƒƒ More frequent papules and pustules
ƒƒ Mild scarring
Severe ƒƒ All of the above plus nodular abscesses
ƒƒ Leads to more extensive scarring that may be keloidal in some cases

Table 10.1B. Diagnosing the Two Types of Acne

Acne vulgaris Acne

Peak prevalence in mid to late teens Peak prevalence in patients ages 40–70
Papules, pustules,comedones, and Papules, pustules, redness, and bleparhitis
nodules
Scarring Soft tissue overgrowth in the form of
rhinophyma
Improves in sunshine Can be exacerbated by sunshine
Can affect chest and back Usually limited to the head

Management objectives
ƒƒ Alleviate symptoms by reducing the number and severity of lesions
ƒƒ Limit duration and recurrence
ƒƒ Decrease sebaceous gland activity
ƒƒ Decrease bacterial infection and inflammation
ƒƒ Minimise cosmetic disfigurement and psychological suffering

Nonpharmacological management
Advise patients to—
ƒƒ Avoid squeezing pimples because doing so may increase the risk of scarring
ƒƒ Avoid excessive use of cosmetics and use only water-based products
ƒƒ Wash face with mild soap and water 3 times/day; minimise scrubbing
ƒƒ Get some sun (sunshine is helpful), but avoid sunburn
ƒƒ Shave as lightly and as infrequently as possible (male patients). Strokes
should be in the direction of hair growth, shaving each area only once.

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ƒƒ Discontinue or avoid any aggravating factors

ƒƒ Maintain a balanced diet
ƒƒ Control stress

Pharmacological management
ƒƒ For mild acne—
yy Start with topical benzoylperoxide cream or lotion 5%, once daily (use
overnight).
yy Treatment should be assessed after 4 weeks and, if beneficial, should be
continued for at least 4–6 months.
yy If the patient has no satisfactory response with benzoylperoxide,
progress to topical antibiotics or a combined preparation:
ŠŠ Erythromycin lotion or solution 1.5% or 2% applied 2 times/day to the
affected area
OR
ŠŠ Benzoyl peroxide 5%/erythromycin 3% gel applied 2 times/day to the
affected area.
ƒƒ For moderate acne—
yy Use topical treatment as for mild acne.
yy For patients who fail to respond to topical treatment, give oral
antibiotics for at least 3 months:
ŠŠ Erythromycin (250 mg tablet) 1 tablet 2 times/day for 4 weeks
OR
ŠŠ Doxycycline (100 mg tablet) 1 tablet once daily; can be taken with
food or milk
Caution: Doxycycline is contraindicated in pregnancy.
yy If necessary, supplement with a topical non-antibiotic.
yy Consider an oral contraceptive in women. Use a product that does not
contain norethisterone.
ƒƒ Severe acne
yy Use the topical treatment as for mild acne.
yy Give also—
ŠŠ Tetracycline (250 mg tablet) 250–1,000 mg/day
Caution: Tetracycline is contraindicated in pregnancy.
OR

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ŠŠ Erythromycin (250 mg, 500 mg tablets) 250–1,000 mg/day

yy Duration of treatment depends on response. It may require 6 months to
a year.

Referral
Patients should be referred to a dermatologist for specialist treatment if they
have—
ƒƒ Severe acne or painful, deep nodules or cysts (i.e., nodulocystic acne)
ƒƒ No improvement after 3 months of primary care treatment, which should
include several courses of topical and systemic treatment. Failure should be
based upon a subjective assessment by the patient.
ƒƒ Severe social or psychological problems, including a morbid fear of
deformity
ƒƒ A risk of (or are developing) scarring, despite treatment in primary care

References—1, 3, 34, 118, 119

10.2 Candidiasis
Description
Candidiasis is an infection caused by the fungus Candida albicans. It occurs
more often in infants, malnourished children, and persons with AIDS. It may
also be caused by prolonged broad-spectrum antibiotic use. Candidiasis is
usually a very localised infection of the skin or mucosal membranes, including
the oral cavity (thrush), the back of the throat or oesophagus, the gastrointestinal
tract, the urinary bladder, or the genitalia (vagina, penis). Candida can also infect
areas that are chronically damp, such as the inner aspects of the thighs, under
the breasts, the underarms, groin, and nails.

Causes and risk factors

ƒƒ Unhygienic preparation of bottle feedings
ƒƒ Poor oral hygiene
ƒƒ Malnutrition
ƒƒ Alcohol abuse
ƒƒ HIV and AIDS, leukaemia, and other cancers
ƒƒ Prolonged use of antibiotic
ƒƒ Diabetes mellitus

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Signs and symptoms

The signs and symptoms are site specific (table 10.2A).

Table 10.2A. Signs and symptoms of candidiasis

Site Signs and Symptoms

Oral ƒƒ White patches on the gums, tongue, and other areas of the oral
cavity
ƒƒ Burning sensation of the tongue and sore throat
ƒƒ Swollen lymph glands in neck
ƒƒ Fever (possibly)
Oesophageal ƒƒ Recent onset of retrosternal pain
ƒƒ Difficulty swallowing
ƒƒ Presence of oral candidiasis
Skin ƒƒ Well-demarcated, red patches of various size and shape with
itching
ƒƒ Redness that may be difficult to see on skin
Nails ƒƒ Thickened, brittle, crumbly, or ragged; distorted in shape, loosening
or lifting up of the nail; dull with no shine; white or yellow streaks on
the side of the nail; build up of debris under the nail
Vagina ƒƒ Smelly, thick, white-yellow discharge that might be accompanied by
itching, burning, and swelling.
ƒƒ Walking, urinating, or sex painful

Diagnosis
Based on microscopy and culture

Management objectives
ƒƒ Remove any predisposing factors
ƒƒ Treat the infection
ƒƒ Maintain proper hydration and nutrition

Management
Both nonpharmacological and pharmacological management are site specific
(table 10.2B).

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Table 10.2B. Nonpharmacological and Pharmacological Management of

Candidiasis

Nonpharmacological
Site Management Pharmacological Management
Oral ƒƒ Instruct the patient on good Give nystatin suspension (100,000
oral hygiene. IU/mL) 4–5 times/day for 5 days at
ƒƒ Advise the patient to— the following dosages—
yy Clean the mouth with ƒƒ If the patient has had symptoms
a sodium bicarbonate for <2 weeks: 100,000 IU
solution (½ teaspoon—or 4 times/day for 5 days
2.5 mL—in 250 mL of ƒƒ If the patient has had symptoms
boiled and cooled water), for >2 weeks: 200,000–500,000
4 times/day IU 4times/day for 5–10 days
yy Apply gentian violet 2
When oral candidiasis is an
times/day for 10 days
opportunistic infection of HIV and
yy Keep affected area clean
AIDS use—
to prevent secondary
infection ƒƒ Fluconazole (150 mg tablet;
yy Drink plenty of water 50 mg/5 mL suspension) 100 mg
(or 3–6 mg/kg for children) once
ƒƒ Continue feeding. Use
daily for 7 days
nasogastric tube in infants if
necessary. ƒƒ If response is slow, continue for
another 7 days
Oesophageal None ƒƒ Adults: Fluconazole (150 mg
tablet) 1 tablet once daily for
14–21 days.
ƒƒ Children: Fluconazole (50 mg/
5 mL suspension) 6 mg/kg once
then 3 mg/kg once daily for 14–21
days
Skin None Use topical nystatin ointment
100,000 IU/g 3 times/day for
14 days
Nails Advise patient to soak the nails Give clotrimazole 1% +
in a solution of Epsom salts for beclometasone 0.025% ointment
about 15 minutes every day 3 times/day for 14 days
until it clears
Vagina None See section 8.3.4, “Vulvo-Vaginal
Candidiasis.”

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Referral
ƒƒ Patients who are nonresponsive to topical treatment
ƒƒ Patients who have frequent recurrences
ƒƒ HIV-positive patients

References—1, 3, 8, 10

10.3 Contact Dermatitis

Description
Contact dermatitis is a term for a skin reaction resulting from exposure to
allergens (i.e., allergic contact dermatitis) or irritants (i.e., irritant contact
dermatitis). Chronic contact dermatitis can develop when the removal of the
offending agent no longer provides expected relief.

Causes
ƒƒ The most common causes of allergic contact dermatitis are the following:
yy Certain plants
yy Metals such as gold and nickel in jewellery, particularly costume
jewellery
yy Fragranced in cosmetics and perfumes
yy Topical antibiotics (e.g., neomycin, bacitracin)
yy Preservatives in polishes, paints, and waxes
ƒƒ Irritant contact dermatitis can result from the following:
yy Highly alkaline soaps, detergents, and cleaning agents
yy Latex
ƒƒ Aggravating factors include the following:
yy Dry skin
yy Emotional tension
yy Sweating, exudation
yy Excessive exposure to sun

Signs and symptoms

Allergic dermatitis usually appears on the area where the offending substance
actually touched the skin. Irritant dermatitis, however, may be more widespread
on the skin. Particularly affected are the flexures of the elbows and knees, but
also the neck, chest, feet, and hands.

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Symptoms of both allergic and irritant dermatitis include the following:

ƒƒ Red rash. The rash appears immediately in irritant contact dermatitis. In
allergic contact dermatitis, however, the rash sometimes does not appear
until 24–72 hours after exposure to the allergen.
ƒƒ Blisters or wheals and urticaria (hives) often form where the skin was
directly exposed to the allergen or irritant.
ƒƒ Itchy, burning skin. Irritant contact dermatitis tends to be more painful
than itchy. Allergic contact dermatitis tends to be more itchy.

Although either form of contact dermatitis can affect any part of the body,
irritant contact dermatitis often affects the hands, which have been exposed by
resting in or dipping into a container (e.g., sink, pail, tub, swimming pools with
high chlorine) containing the irritant.

Diagnosis
Based on skin appearance and history of exposure to an irritant or allergen

Management objectives
ƒƒ Identify and remove or avoid further contact with the irritant or allergen
ƒƒ Treat the underlying cause
ƒƒ Relieve the itching

Nonpharmacological management
Advise the patient to—
ƒƒ Avoid known allergens and irritants
ƒƒ Use a weak acid solution (e.g., lemon juice, vinegar) to counteract the
effects of irritants
ƒƒ Cut a cucumber and rub it over the itchy area as a good home remedy
ƒƒ If blistering develops, apply cold moist compresses for 30 minutes
3 times/day
ƒƒ Avoid scratching because it can cause secondary infections
ƒƒ Use bath oil, and pat skin dry after a bath with a soft towel
ƒƒ Apply body oil or cream after bathing
ƒƒ Use soothing lotions or creams such as calamine lotion

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Food handlers and kitchen workers should wear gloves when handling products
that can cause contact dermatitis. Immediately after exposure to a known
allergen or irritant, they should wash with mild soap and tap water to remove or
inactivate most of the offending substance.

Pharmacological management
ƒƒ For mild cases that cover a relatively small area, give—
yy Hydrocortisone cream 1% 3–4 times/day as needed
OR
yy Betamethasone ointment or cream 0.1% 3 times/day for 7 days
ƒƒ For relief of itching, give oral antihistamines such as chlorpheniramine
maleate (4 mg tablets; 2 mg/5 mL suspension) PRN.
yy Adults: 4 mg tablet 3 times/day, not to exceed 24 mg/day
yy Children: 2 mg/5 mL (suspension)
ŠŠ <1 year: Do not administer
ŠŠ 1–2 years: 1 mg (¼ tablet) or 2.5 mL (½ tsp) 2 times/day
ŠŠ 2–5 years: 1 mg (¼ tablet) or 2.5 mL (½ tsp) 3 times/day, not to exceed
6 mg/day
ŠŠ 6–12 years: 2 mg (½ tablet) or 5 mL (1 tsp) 3 times/day, not to exceed
12 mg/day

If the patient has a secondary infection, use a topical antiseptic (e.g., Lugol’s
solution)

Referral
ƒƒ Very severe cases
ƒƒ Cases not responding to treatment

References—1, 3, 120, 121

10.4 Eczema
Description
Eczema (i.e., atopic dermatitis) is a long-term (i.e., chronic) skin disorder that
involves scaly and itchy rashes. It presents with variable clinical findings and
varies with age. It could be acute or become chronic. Most cases present by the
age of 5 years.

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Causes
ƒƒ Eczema is the end result of a number of disorders including contact
dermatitis and seborrheic dermatitis (i.e., dandruff ). The latter is usually
allergy related, and the patient may have a family history of dermatitis,
asthma, or hay fever.
ƒƒ Secondary infection with staphylococcus may occur with any form of
eczema.

Signs and symptoms

Eczema may present with erythematous macules, papules, and vesicles that can
come together to form patches and plaques that are poorly demarcated. Itching
is predominant.
ƒƒ In acute eczema, there is oozing.
ƒƒ In chronic eczema, the area is dry and scaly.
ƒƒ In childhood and adolescence, lesions appear on the inner surfaces of the
elbows and knees and in the creases of the neck.

Diagnosis
Based on clinical history and physical findings

Management objectives
ƒƒ Look for and treat any pre-existing skin disease
ƒƒ Control the itching to prevent scratching

Nonpharmacological management
Advise patient to—
ƒƒ Wear clothing made of cotton, linens, and other natural fabrics that
“breathe” to prevent overheating
ƒƒ Cut his or her nails short
ƒƒ Avoid scratching
ƒƒ Expose affected areas to sunlight
ƒƒ Avoid soap because it dries the skin; use a moisturizing body wash instead
ƒƒ Keep baths short and use skin moisturizer immediately after

Pharmacological management
ƒƒ For acute eczema, use calamine ointment 2 times/day.
ƒƒ For chronic eczema, use zinc oxide ointment—
yy Emulsifying ointment (UE), (e.g., paraffin oils) to wash or bathe

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yy Aqueous cream (UEA), applied to dry areas as a moisturizer

ƒƒ If the patient has no response to the zinc ointment within 3 days or for more
severe eczema, give hydrocortisone 1% cream, applied 2 times/day for 7
days. Apply it sparingly to the face; do not apply around the eyes.
yy If there is a response, reduce the use of the hydrocortisone cream over a
few days and maintain treatment with aqueous cream (UEA)
yy If there is no response to the hydrocortisone cream within 7 days or for
more severe eczema, give betamethasone 0.1% ointment applied 2 times/
day for 7 days.
Note: Not authorized for use at health post level.
yy Do not apply to the face, neck, and flexures.
yy If there is a response, reduce the use of betamethasone ointment over a
few days and maintain treatment with calamine ointment.
ƒƒ For severe itching, give chlorpheniramine PO (4 mg tablets; 2 mg/5 mL
suspension)—
yy Adults: 4 mg (1 tablet) 3 times/day, but not to exceed 16 mg/day
yy Children: 2–5 years: 1 mg (2.5 mL or ½ tsp) 3 times/day, but not to exceed
4 mg/day
yy Children: 6–12 years: 2 mg (5 mL or 1 tsp) 3 times/day, but not to exceed
8 mg/day

Referral
If no improvement in 2 weeks

References—1, 3, 10

10.5 Hansen’s Disease (Leprosy)

Description
Hansen’s disease, also known as leprosy, is a curable, chronic infectious disease
involving mainly the skin and peripheral nerves. It is a chronic granulomatous
disease of the skin, mucous membranes, nerves, lymph nodes, eyes, and internal
organs such as the liver, spleen, and testicles. The main mode of transmission
is considered to be airborne, through droplets discharged from the respiratory
tract of untreated infectious cases. Transmission may also occur through skin-
to-skin contact with entry through broken skin.

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Cause and risk factors

ƒƒ Infection with Mycobacterium leprae
ƒƒ Close contacts with patients who have untreated, active, predominantly
multibacillary disease

Classification
The disease is classified as paucibacillary or multibacillary depending on
bacillary load:
ƒƒ Paucibacillary Hansen’s disease is milder and characterized by one or more
(up to 5) hypopigmented or reddish skin macules.
ƒƒ Multibacillary Hansen’s disease is associated with multiple symmetric skin
lesions, nodules, plaques, thickened dermis, and frequent involvement of
the nasal mucosa resulting in nasal congestion and epistaxis.

Signs and symptoms

Leprosy mainly affects the skin and peripheral nerves. It is characterized by the
following:
ƒƒ Hypopigmented skin patch with some sensory loss
ƒƒ An enlarged or painful peripheral nerve (preferably with some evidence of
nerve function loss)
ƒƒ Nodules found mainly on nose, ears, face, limbs but can occur at any site
ƒƒ Painless wounds, especially on the sole of the foot, palm of hand, and fingers
ƒƒ Loss of sensation on hands, feet, or both
ƒƒ Dryness of hands, feet, or both due to loss of sweating, accompanied by loss
of feeling

If left untreated, leprosy can lead to progressive and permanent damage of

nerves, leading to loss of sensation and sweating in the extremities and paralysis
of muscles in the hands, feet, and face.

Management objectives
ƒƒ Cure the patient
ƒƒ Interrupt transmission
ƒƒ Prevent disabilities

Diagnosis
Diagnosis can be made on clinical signs alone.

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Nonpharmacological management
Household contacts should be checked for the disease. Contacts are defined
as anyone who has lived with the patient for at least 1 month since the onset of
symptoms.

Pharmacological management
Multidrug therapy is the cornerstone of the leprosy elimination strategy because
it cures patients, reduces the reservoir of infection, and thereby interrupts its
transmission. Multidrug therapy also prevents disabilities through early cure.

For purposes of treatment, leprosy is divided into two types:

ƒƒ Paucibacillary leprosy (i.e., 1–5 skin lesions) is treated with a regimen of
two medicines—rifampicin and dapsone—for 6 months.
ƒƒ Multibacillary leprosy (i.e., >5 skin lesions) is treated with a regimen of
three drugs—rifampicin, clofazimine, and dapsone—for 24 months.

Multidrug therapy is provided in blister packs, each containing 4 weeks’

worth of treatment. Specific blister packs are available for multibacillary and
paucibacillary leprosy as well as adults and children (table 10.5).

Table 10.5. Dosages of Medicines for Management of Hansen’s Disease

Multibacillary Paucibacillary Multibacillary Paucibacillary

Regimen (Adults) (Adults) (Children) (Children)
Rifampicin 600 mg once 600 mg once 450 mg once 450 mg once
a month a month a month a month
Clofazimine 300 mg once — 150 mg once —
a month, and a month, and
50 mg daily 50 mg every
other day
Dapsone 100 mg daily 100 mg daily 50 mg daily 50 mg daily
Duration 24 months 6 months 24 months 6 months

Referral
All level 1 facilities should refer patients to level 2 facilities or the district
hospital.

References—122, 123

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10.6 Napkin Rash

Description
A diffuse, reddish eruption in the napkin (i.e., diaper) area of infants. The area
may become infected with candida.

Causes
ƒƒ Generally napkin rash is caused by persistent moisture from diarrhoeal
stools or urine being left in contact with the skin for prolonged periods.
ƒƒ Sometimes the rash may be caused by underlying skin conditions due to
improper rinsing of napkins to remove soap or detergent.

Signs and symptoms

Red rash in napkin area

Diagnosis
Based on clinical signs and symptoms

Management objectives
ƒƒ Relieve the symptoms
ƒƒ Prevent recurrence

Nonpharmacological management
ƒƒ Advise the use of cloth napkins.
ƒƒ Advise against the use of waterproof pants to cover cloth napkins.
ƒƒ Instruct the caregiver to expose napkin area to air and sunlight if possible
especially with severe napkin rash.
ƒƒ Educate caregiver and give advice on—
yy Washing and drying of the napkin area when soiled with urine or stool
yy Regular napkin changes
yy Proper washing and rinsing of napkins

Pharmacological management
ƒƒ Use silver sulfadiazine cream 1%, applied at each napkin change until rash
clears.
ƒƒ If there is no improvement within 3 days, suspect candida:
yy Treat with nystatin ointment 100,000 IU/g, applied after each napkin
change.
yy Continue to use for 2 weeks after rash clears.

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Referral
If no further improvement after 7 days

References—8, 124, 125

10.7 Psoriasis
Description
Psoriasis is a chronic, noncontagious autoimmune disease. It is commonly an
inherited condition that affects the skin and joints. It commonly causes red scaly
patches to appear on the skin. The scaly patches are areas of inflammation and
excessive skin production. Skin rapidly accumulates at these sites and takes on a
silvery-white appearance. In the most common form of psoriasis, plaques occur
on the skin of the elbows and knees and the trunk, but they can affect any area
including the scalp and genitals. In another variation of the disease, plaques can
occur under the arms, in the groin, under the breasts, and around the navel. Over
half of patients report a family history of psoriasis.

The areas affected tend to be the same on both sides. Unlike with eczema,
psoriasis is more likely to be found on the outer aspect of the joint.

The disorder varies in severity from minor localised patches to complete

body coverage. Fingernails and toenails are frequently affected (psoriatic nail
dystrophy) and can occur alone. The joints can also become inflamed causing
psoriatic arthritis.

Signs and symptoms

ƒƒ Slowly enlarging red, well-demarcated plaques covered by silvery scale in
the affected area
ƒƒ Itching possible

Diagnosis
A diagnosis of psoriasis is usually based on the appearance of the skin.

Management objective
Control the severity of the disease

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Nonpharmacological management
Advise the patient to—
ƒƒ Use bath solutions and shampoos that contain cold tar or oats
ƒƒ Avoid excess drying or irritation of skin
ƒƒ Limit periods of exposure to sunlight

Pharmacological management
Cold tar ointment 2 times/day, forever

Referral
Failure to respond to treatment

References—1, 3, 126, 127, 128, 129

10.8 Scabies
Description
Scabies is a contagious skin condition caused by a tiny mite (Sarcoptes scabei)
that burrows into the outer layer of the skin and deposits its eggs there. It
spreads easily through person-to-person contact. It is particularly problematic
in areas of poor sanitation and overcrowding.

Signs and symptoms

There may be no symptoms for the first 2–3 weeks after catching scabies. It will
develop into an allergic type rash on several parts of the body, particularly—
ƒƒ In the webs between the fingers
ƒƒ On wrists and elbows
ƒƒ Around the waist
ƒƒ Under the breasts in females
ƒƒ On male genitalia and on the buttocks
ƒƒ In infants, on the face, scalp, neck, palms of the hands, and soles of the feet

Other symptoms will appear—

ƒƒ Intense itching, particularly at night, develops
ƒƒ Crusting due to secondary bacterial infection can occur, due to bruising of
the skin from scratching.
ƒƒ Often tunnels (burrows) made by mites may be seen.
ƒƒ Often more than one member of the family is affected.

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Diagnosis
Diagnosis is mainly by clinical history and physical examination. The history,
particularly itching of recent onset, and careful scrutiny of hands and wrists will
usually establish the diagnosis. Scabies can be confirmed with skin scrapings.

Management objectives
ƒƒ Prevent re-infection or further spread of the disease
ƒƒ Relieve the itching

Nonpharmacological management
ƒƒ All close family and skin-to-skin contacts must be treated at the same time
to prevent re-infection, even if symptoms are not evident.
ƒƒ The patient should be advised to wash, boil, dry in the sun, and iron
(concentrating on the seams) all clothing, bedding, and bed linens after
each use.
ƒƒ The mattress, pillows, and chair cushions must be placed in the sun for at
least 3 consecutive days.
ƒƒ Advise the patient to keep his or her nails short and clean.
ƒƒ Instruct the patient to dry his or her skin thoroughly after bathing and to
put on clean clothes.
ƒƒ The whole house should be cleaned and disinfected with a disinfectant
spray.

Pharmacological management
ƒƒ Use benzyl benzoate lotion 25%.
yy Adults and children >6: full strength 25% solution
yy Children <6 years: 12% solution (dilute 25% solution 1 part solution:
1 part water or baby oil
yy Infants: 1:3 dilution
ƒƒ Apply benzyl benzoate lotion to the entire body, excluding the face and
nipple area of breastfeeding women, for 3 consecutive evenings. Leave on
overnight and wash off the next day. Attention should be paid to the toes,
fingers, genital area and areas where the rash is seen.
ƒƒ A scrub bath must be taken before and after the 3 days of application.
ƒƒ Repeat the treatment after 10 days.
ƒƒ Itching may persist for some weeks after completing the treatment. This
can be relieved by applying calamine lotion BID or taking chlorpheniramine

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maleate. Give chloreniramine (4 mg tablets; 2 mg/5 ml syrup) PO every

4–6 hours daily.
yy Adults: One 4 mg tablet 4–6 times/day, not to exceed 24 mg/day
yy Children
ŠŠ 2–5 years: 1 mg (½ teaspoon) syrup 4–6 times/day, not to exceed 6 mg/
day
ŠŠ 6–12 years: 2 mg (½ tablet or 5 mL—1 teaspoon—syrup) 4–6 times/
day, not to exceed 12 mg/day

Note: Itching usually starts to abate after 1 week and the rash after 3 weeks.

Referral
If there are signs of treatment resistance, refer the patient to the specialist.

References—3, 8, 130, 131, 132, 133

10.9 Tinea (Pityriasis) Versicolor (Lata)

Description
This condition is caused by a fungus that is a normal inhabitant of the skin. On
dark skin, it is characterized by pale brown or hypopigmented spots; on light
skin, the spots are pink or hyperpigmented. They appear mainly on the trunk and
upper arms but may also be present on the face. The spots scale with scraping
(whitish fine scales). Infection is promoted by heat and humidity. The condition
never occurs in children. Onset is usually around puberty.

Treatment is effective, but recurrence is common. It may take months for the
skin coloration to return to normal. In some people, discoloration is permanent.
Since it is not known why some people develop tinea versicolor and others do
not, it cannot be totally prevented.

Signs and symptoms

ƒƒ Presence of pale brown, pink, or hypopigmented spots, mainly on the trunk
ƒƒ Mild itching
ƒƒ Spots can be dry and scaly
ƒƒ Skin may itch where the spots appear
ƒƒ Spots grow slowly
ƒƒ As the yeast grows, the spots can combine and form patches of lighter
(or darker) skin

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Diagnosis
Diagnosis made on clinical appearance

Management objectives
ƒƒ Get rid of the spots
ƒƒ Rule out leprosy

Nonpharmacological management
ƒƒ Advise the patient to use antifungal shampoos, such as—
yy Selenium sulfide (1%)
yy Extra-medicated selsun 2.5%
yy Ketoconazole 2%
ƒƒ Shampoo is left on the skin for 10 minutes then rinsed off. Do this for 7 days.
ƒƒ The shampoo is also used weekly as a soap substitute when bathing to
prevent recurrences.

Pharmacological management
ƒƒ Try topical antifungal creams, or lotions (i.e., clotrimazole or miconazole).
These medicines are applied directly to the affected areas of the skin. They
are used 2–3 times/day over 2 months to be effective.
ƒƒ If topical treatments do not work, use oral antifungal medications.
yy Persistent cases that do not respond to other types of treatment are
sometimes treated with ketoconazole 200 mg tablets once daily for
5 days.
yy Do not use for patients <14 years or for pregnant women.

Note: Griseofulvin is not recommended for the treatment of tinea versicolor.

Referral
Not necessary

References—1, 134, 135, 136

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10.10 Tineas
Description
Tinea or ringworm is a highly contagious fungal infection of the skin. It can
affect different areas of the skin from which it derives its specific names: skin
on the trunk (tinea corporis), scalp (tinea capitis), groin area (tinea cruris, also
called jock itch), nails (tinea ungunum), beard (tinea barbae), face (tinea facei),
hands (tinea manus), or feet (tinea pedis, also called athlete’s foot). Tinea capitis
should be considered in all adults with a patchy inflammatory scalp disorder.
In infants, tinea capitis, also called cradle cap, is the most common pediatric
dermatophyte infection worldwide.

Signs and symptoms

Tineas have the appearance of itchy, ringlike patches with raised borders.
ƒƒ The patches slowly grow bigger.
ƒƒ As a patch extends, a clear area develops in the center and becomes
pigmented in dark skin.

Tinea corporis may be acute (i.e., sudden onset and rapid spreading) or chronic
(i.e., a slow extension of a mild, barely inflamed rash). It usually occurs on
hairless parts of the body. It can occur on the face and arms and is possible
anywhere from lower jaw to knees. Itching is present.

Tinea capitis. In this tinea, the patient may have alopecia areata, infection of
the area, or both. Tinea capitis is often found in children.
ƒƒ Itchy scalp
ƒƒ Hair breaks off; bald patches appear
ƒƒ Dry flaky areas

Tinea cruris involves lesions specific to the groin and is sometimes pustular.
ƒƒ It causes itching in the groin, thigh skin folds, or anus
ƒƒ Red, raised, scaly patches that may blister and ooze form.
ƒƒ It gets worse because of the moisture in the groin area especially when the
patient sweats.

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Tinea unguium, a fungal infection of the nails, often present in adult diabetics,
presents with—
ƒƒ Thin, discoloured, and brittle nail
ƒƒ Swelling of the cuticle areas

Tinea pedis, which is also often present in diabetics, is characterized by—

ƒƒ Itching, burning, and stinging between the toes spreading to the sole
ƒƒ Vesicles, cracks, and bursts
ƒƒ Frequent reinfection
ƒƒ Secondary bacterial infection

Diagnosis
Diagnosis is based on clinical history and physical examination.

Management objectives
ƒƒ Get rid of the fungus
ƒƒ Resolve lesions and symptoms
ƒƒ Prevent the spread of the infection to others

Nonpharmacological management
ƒƒ General measures—
yy Advise the patient not to share clothes, towels, or toiletries, especially
combs and hair brushes.
yy Instruct the patient to wash his or her skin well and to dry it before
applying treatment.
yy Heat kills fungus, so all pieces of clothing, especially underwear, must be
boiled when possible, dried in the sun, and then ironed. This measure is
a critical part of management of fungal infections.
ƒƒ With tinea pedis (athlete’s foot), advise the patient to—
yy Keep his or her feet dry
yy Dry between toes carefully after wearing closed shoes for long periods,
washing, or walking in water
yy Wear cotton socks; avoid socks made of synthetic materials
ƒƒ With tinea cruris, advise the patient to—
yy Wear boxer shorts or no underwear
yy Wear loose sleepwear or no sleepwear
yy Sleep near a fan if possible
ƒƒ With tinea capitis, hats must be treated.

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Pharmacological management
Combination therapy is necessary. The duration depends on the area affected
and the type of infection.
ƒƒ With tinea corporis—
yy Use topical antifungal creams, lotions, or ointments (clotrimazole 1%,
miconazole 2%, or Whitfield’s ointment). To be effective, apply directly
to the affected areas of the skin, 2–3 times/day for 2 months.
yy If topical treatment has failed, use griseofulvin tablets 10 mg/kg/day in
single or divided doses for 3 weeks.
Caution: Do not use griseofulvin in pregnant women and women of
childbearing age unless the patient is using a contraceptive.
ƒƒ With tinea capitis—
yy For infected scalp ringworm, treat both infections concurrently. Use an
antibiotic ointment plus antifungal cream amoxil PLUS griseofulvin.
yy Shave the area around the affected area before applying ointment.
yy Recommend that the patient use selineum sulphide or ketoconozole
shampoo.
yy Use oral antifungal medications: griseofulvin tablets (125 mg, 500 mg)
daily for 4–6 weeks at the following dosages.
ŠŠ Adults (>17 years): 500 mg
ŠŠ Children <6 years: 62.5 mg
ŠŠ Children 6–11 years: 125 mg
ŠŠ Children 12–17 years: 250 mg
Caution: Do not use griseofulvin in pregnant women and women of
childbearing age unless the patient is using a contraceptive.
ƒƒ With tinea unguium—
yy Prescribe griseofulvin (125 mg, 500 mg tablets), 125–500 mg daily for
4–6 weeks at the following dosages.
ŠŠ Adults (>17 years): 500 mg
ŠŠ Children <6 years: 62.5 mg
ŠŠ Children 6–11 years: 125 mg
ŠŠ Children 12–17 years: 250 mg
Caution: Do not use griseofulvin in pregnant women and women of
childbearing age unless the patient is using a contraceptive.

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ƒƒ With tinea cruris—

yy Use topical antifungal creams, lotions, or ointments (clotrimazole 1%,
miconazole 2%, or Whitfield’s ointment), 2–3 times/day for 3 months.
yy If the patient has discomfort and itching, add 1% hydrocortisone
ointment.
yy If secondary bacterial infection is present, treat with
ŠŠ Amoxicillin 250 mg tablet 3 times/day for 5 days
OR
ŠŠ In penicillin-allergic patients, erythromycin 250 mg every 6 hours for
5 days

Referral
Refer for specialist management—
ƒƒ Patients who have no response to treatment after 4 weeks
ƒƒ Patients who have persistent recurrence or are immuno-compromised

References—3, 8, 10, 137, 138, 139, 140

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11. Endocrine System

11.1 Diabetes Mellitus

Description
Diabetes mellitus (DM) is a metabolic disorder of multiple aetiologies
characterized by persistent abnormally high blood glucose with disturbances
of carbohydrate, fat, and protein metabolism. It results from defects in insulin
secretion, insulin action, or both. If uncontrolled, DM will eventually negatively
affect the eyes, blood vessels, kidneys, and nerves and will lead to infections,
especially of the skin. DM affects a large number of Guyanese, both children and
adults.

Complications from DM include the following:

ƒƒ Hypoglycaemia
ƒƒ Hyperglycaemic ketoacidosis (i.e., nausea and vomiting, thirst, abdominal
pain, shortness of breath)
ƒƒ Eye problems: retinopathy with visual impairment, blindness, cataracts
ƒƒ Skin problems: infections, ulcers
ƒƒ Vascular problems: gangrene of toes or fingers, stroke, myocardial
infarction
ƒƒ Kidney problems: proteinuria, renal failure, kidney infections
(pyelonephritis)
ƒƒ Nerve damage or neuropathy: loss of sensation in the hands and feet
ƒƒ Diabetic foot leading to leg amputations

Classification
There are two main types of diabetes:
ƒƒ Type 1 diabetes (formerly called juvenile diabetes)
yy Type 1 DM affects mainly children and young adults (occurring most
often before the age of 30 years), but it can affect adults as well.
yy It is a disease in which the body does not produce insulin and therefore
is often referred to as insulin dependent.
yy Patients with type 1 DM must take insulin to stay alive.
yy Type 1 DM patients are prone to the development of ketosis.

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ƒƒ Type 2 diabetes is a chronic debilitating disease.

yy It typically develops with increasing age (≥45 years),but it can occur in
children, especially obese adolescents.
yy Either the body does not produce enough insulin or is insulin resistant.
Type 2 DM is often called non–insulin dependent.
yy It is associated with overweight and lack of physical activity.
yy It is the most common type accounting for nearly 95% of cases of DM.
yy If not properly controlled, it will lead to serious acute and chronic
complications.

A third type of DM may also occur: type 3, gestational diabetes, is glucose

intolerance that develops during pregnancy.

Causes and risk factors

ƒƒ Family history (both types 1 and 2)
ƒƒ Autoimmunity (auto-antibodies to islets of Langerhans in the pancreas) in
children
ƒƒ Overweight or obesity (BMI ≥25 kg/m2)
ƒƒ Poor nutrition and lifestyle
ƒƒ Insulin resistance
ƒƒ Deficient insulin secretion
ƒƒ Race or ethnicity (e.g., persons of Asian and African descent)

Signs and symptoms

Type 1—
ƒƒ Weight loss despite good appetite
ƒƒ Frequent urination (polyuria)
ƒƒ Frequent drinking of water (polydipsia)
ƒƒ Glucose in urine
ƒƒ Sweet-smelling breath
ƒƒ Tiredness
ƒƒ Blurred vision

Type 2—
ƒƒ Polyuria, polydipsia, and unexplained weight loss
ƒƒ Polyphagia (increase hunger)
ƒƒ Delayed healing of wounds and sores

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ƒƒ Numbness and tingling of feet

ƒƒ Pruritus (itching)
ƒƒ Glucose in urine
ƒƒ Blurred vision

Diagnosis
ƒƒ Fasting or blood glucose levels (very high blood sugar levels)
ƒƒ Glucose tolerance test—glucose intolerance (see table 11.1A)
ƒƒ Sugar in the urine

Table 11.1A. Blood Glucose Levels for Diagnosis of Diabetes

Diagnostic Test Normal Pre-diabetes Diabetes

Fasting blood glucose <100 mg/dL 100–126 mg/dL >126 mg/dL
Random blood glucose <140 mg/dL 140–199 mg/dL ≥200 mg/dL
Oral glucose tolerance <140 mg/dL 140–199 mg/dL ≥200 mg/dL
(2-hour postprandial)

In patients who exhibit symptoms of hyperglycaemia (i.e., thirst, polyuria,

weight loss, or itching), a single blood glucose in the diabetic range confirms the
diagnosis. In asymptomatic patients, blood glucose in the diabetic range must be
recorded at least twice for diagnosis.

Note: Detection of glucose in the urine is not sufficient for diagnosis of diabetes.

Management objectives
ƒƒ Maintain blood sugar level within acceptable limits
ƒƒ Obtain optimal weight for height
ƒƒ Prevent complications both acute (e.g., ketoacidosis, hypoglycaemia, and
hyperglycaemia) and chronic (e.g., ischaemic heart disease, peripheral
artery disease, poor circulation to the extremities, stroke, deteriorating eye
sight, foot ulcers)
ƒƒ Improve and maintain quality of life
ƒƒ Manage co-morbid conditions
ƒƒ Educate and counsel client and relatives on self-management

Note: Advise the patient that he or she must be followed up regularly for the rest
of his or her life.

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Table 11.1A. Targets for Control in Diabetes and Associated Conditions for Adults

Measurement Good Result

Blood glucose
yy Fasting 90–130 mg/dL (5.0–7.2 mmol/L)
yy Postprandial <180 mg/dL (<10 mmol/L)
HbA1c (glycated Hb) <6.5%
Total cholesterol <200 mg/dL (5.2 mmol/L)
HDL cholesterol >40 mg/dL (>1 mmol/L)
LDL cholesterol <70 mg/dL (<1.8 mmol/L
Fasting triglycerides <150 mg/dL (<1.7 mmol/L)
BP ≤130/80 mmHg
BMI 18.7–25 kg/m2
Waist circumference
yy Women <80 cm (<32 inches)
yy Men <94 cm (<37 inches)

Management of type 1 DM
Step 1. Use nonpharmacological management.
ƒƒ Advise the patient to establish a meal plan with a regular meal pattern.
Consult the dietary guidelines in appendix E.
ƒƒ Advise the patient to exercise at least for 30 minutes, 3 times/week.
ƒƒ Educate the patient on self-management.
ƒƒ Instruct the patient on how to self-monitor blood glucose. Monitoring
should be done at least 4 times/day, depending on level of control.
ƒƒ Advise the patient to eat something sweet in case of hypoglycaemia (i.e.,
palpitations, headache, hunger, nervousness or confusion). The following
are appropriate choices:
yy ½ cup orange juice or other fruit juice
yy Soft drink (not a sugar-free drink)
yy 1 tablespoon of honey or syrup
yy 1 tablespoon of sugar, candy, or chocolate

Step 2. Use pharmacological management: give insulin. Table 11.1B provides the
amounts.

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Cautions:
• Type 1 DM patients require insulin to survive.
• Do not give oral diabetic medications.
• D
 o not use oral hypoglycaemic medicines in children. They are dangerous
and ineffective.

Table 11.1B. Insulin Amounts for Type 1 DM Management

Sugar Levels Insulin

250–300 mg/dL 20/10
300–400 mg/dL 25/15
400–500 mg/dL 35/15 and titrate up to 70/30
Note: If glucometer is in mmol, multiply by 18 to convert to mg/dL.

Management of type 2 DM
Step 1. Use nonpharmacological management.
ƒƒ Advise the patient to establish a meal plan with a regular meal pattern.
Consult the dietary guidelines in appendix G.
ƒƒ Encourage patients to maintain a healthy body weight (BMI 18–24.9).
ƒƒ Encourage the patient to—
yy Have regular meals but smaller portions
yy Eat foods that are rich in fibre, such as whole grains, vegetables, whole
wheat flour, ground provision (potatoes, eddoes, cassava, yams, tannia)
yy Avoid added sugar in juices
ƒƒ Encourage regular exercise (e.g., brisk walking, jogging, swimming, cycling)
for at least 30 minutes 3 times/week
ƒƒ Assess the smoking status if patient is smoking, then advise to stop
(appendix D). If the patient does not smoke, then congratulate him or her
and encourage not to start smoking.
ƒƒ Advise on moderation of alcohol (i.e., 2 oz/day for males and 1 oz/day for
females). It should be 2 drinks per day for men and 1 for women. (See table
6.3D for drink equivalent.)
ƒƒ Advise self-monitoring of blood glucose (at least once a day).

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Step 2. Use oral pharmacological management.

ƒƒ Give metformin (500 mg tablets).
yy Recommended for obese patients
yy Adults: Start at 500 mg daily and increase if blood glucose not controlled,
not to exceed 2,500 mg daily. (See table 11.1C.)
yy Increase to 500 mg 3 times/day OR 1,000 mg in the morning and 500 mg
at night, then to maximum of 1,000 mg 2 times/day

Table 11.1C. Suggested Regimen of Metformin

Blood Glucose Level Dosage

150-200 mg/dL 500 mg (1 tablet) daily in the morning
>225 mg/dL 500 mg (1 tablet) twice/day, morning and afternoon

Caution: Metformin is contraindicated in pregnancy, cardiovascular diseases,

renal diseases, and liver diseases.

OR
ƒƒ Give gliclazide (30 mg, 80 mg tablets).
yy Recommended for non-obese patients.
yy Start at 80 mg/day and increase to 80 mg 2 times/day, then 160 mg in
morning and 80 mg at night, and finally to 160 mg 2 times/day, not to
exceed 320 mg/day.
OR
ƒƒ Give glibenclamide (5 mg tablet) 2.5–15.0 mg (½–3 tablets) daily in 1–3
divided doses. Increase to 10 mg in the morning or 5 mg 2 times/day, and
then to a maximum of 10 mg in the morning and 5 mg at night.

Step 3. If patient does not respond to the regimen in step 2, try a combination of
metformin and gliclazide (same dosage as above).

Step 4. If the patient does not respond to the regimen in step 3, start him or her
on insulin injections (table 11.1D). Total daily dose is usually based on weight.
Give ⅔ of the total dose in the morning and ⅓ in the evening. Starting doses are—
ƒƒ Slim adults: 0.35–0.5 units/kg of body weight
ƒƒ Obese adults: approximately 1 unit/kg of body weight
ƒƒ Children: 0.25 unit/kg of body weight

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Table 11.1D. Guidelines for Insulin Regimen

Starting Dose Incremental Increase Maximum Daily Dose

See above for amounts. Two units daily— yy 40 units
yy Inject 2⁄3 daily dose yy First increment is added to yy Refer the patient
30 minutes before the morning dose for specialist care
breakfast yy Second increment is added if >40 units are
yy Inject 1⁄3 daily dose 30 to the afternoon dose needed.
minutes before dinner yy Following increments to
follow same pattern

Management of insulin for type 2 DM in children

For insulin treatment in children, follow these steps:
ƒƒ In severe DM—
yy Give short-acting insulin 20% before each meal (breakfast, lunch,
dinner).
yy Give intermediate-acting insulin (lente) 40% at 9:00 or 10:00 p.m.
ƒƒ In controlled DM, give ⅔ in morning (30 minutes before breakfast) and ⅓ in
evening (30 minutes before dinner).
ƒƒ Educate the patient and the parent or caregiver on insulin treatment.
Education should include the following:
yy Types of insulin
yy Injection techniques and sites
yy Insulin storage
yy Glucose monitoring
yy Meal frequency and amount
yy Recognition and treatment of complications
yy Screen for and manage complications, associated conditions, or both
(table 11.1A).

Monitoring and investigations

ƒƒ Tests at every clinic visit—
yy Weight, BMI, and BP
yy Urine testing: glucose, protein, blood, ketone
yy Random blood glucose
yy Always check feet (pulses and sensation)
ƒƒ Advise on—
yy Diet

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yy Exercise
yy Smoking and alcohol
yy Adherence with treatment
ƒƒ Every 3–6 months, check glycated haemoglobin (HbA1c).
ƒƒ Annual tests—
yy Cholesterol and blood lipids
yy Blood urea and creatinine
yy ECG
yy Eye examination—visual acuity and fundoscopy
yy Waist circumference
yy Oral health

Referral
ƒƒ All patients who have suspected or confirmed type 1 DM, for confirmation
of diagnosis, initiation and stabilization of therapy, and long-term control
ƒƒ Symptoms of hypoglycaemia—nervousness, sweating, confusion,
palpitations, tremor. Give something sweet before transferring.
ƒƒ Signs of hyperglycaemia, excessive thirst and passage of urine
ƒƒ Weight loss
ƒƒ Serious infection
ƒƒ Sudden deterioration of vision

References—1, 3, 141, 142, 143

11.2 Thyroid Gland Disorders

11.2.1 Goitre
Description
Goitre refers to an enlarged thyroid gland. Nodules may be present.

Causes and risk factors

ƒƒ Iodine deficiency affects thyroid hormone synthesis, which stimulates
thyroid growth.
ƒƒ Autoimmune disease may be present.
yy Hyperthyroidism (overproduction of thyroid hormone)—Grave’s disease
yy Hypothyroidism (inadequate production of thyroid hormone)—
Hashimoto’s disease

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ƒƒ In thyroid cancer the swelling is usually confined to one side.

ƒƒ Thyroiditis—inflammation of the gland—may cause a goitre.
ƒƒ Women are more prone to develop goitres.
ƒƒ Goitres are more likely to occur during pregnancy and menopause.
ƒƒ Chances of developing a goitre increase with age.

Classification
ƒƒ Simple goitre—diffuse swelling with no nodules
ƒƒ Colloid goitre—presence of uniform follicles filled with colloid

Signs and symptoms

Not all goitres cause signs and symptoms. When present they may include the
following:
ƒƒ Visible neck swelling on both sides of the midline. Swelling may—
yy Be smooth or nodular
yy Move upward on swallowing
yy Be painless and not pulsate
ƒƒ Difficulty with swallowing
ƒƒ Difficulty with breathing; snoring

Diagnosis
ƒƒ Made on physical examination
ƒƒ Thyroid function test

Nonpharmacological management
At the health centre—
ƒƒ Ensure that the patient has an adequate intake of iodine.
ƒƒ Advise on diet. Diet should include iodised salt. Advise the patient to eat
seafood (especially shrimp and other shellfish) about twice a week.

Referral
ƒƒ Swelling nodular
ƒƒ Trouble breathing
ƒƒ Size of thyroid gland suddenly increases
ƒƒ Eye becomes more prominent and pulse rate increases
ƒƒ Hyperthyroidism

References—1, 3, 148

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11.2.2 Hypothyroidism
Hypothyroidism, or underactive thyroid, can be managed at the health centre
level if a doctor is available.

Signs and symptoms

Signs and symptoms vary, depending on the severity of the hormone deficiency,
but in general, they include the following:
ƒƒ Tiredness and weakness
ƒƒ Increased sensitivity to cold
ƒƒ Constipation
ƒƒ Weight gain with poor appetite
ƒƒ Hoarseness
ƒƒ Dyspnoea
ƒƒ Menorrhagia (later oligomenorrhoea or amenorrhoea)
ƒƒ Muscle weakness
ƒƒ Muscle aches, tenderness, and stiffness
ƒƒ Pain, stiffness, or swelling of joints
ƒƒ Depression
ƒƒ Difficulty concentrating and impaired memory
ƒƒ Dry, coarse skin
ƒƒ Thinning hair
ƒƒ Puffy face, hands, and feet
ƒƒ Slowed heart rate (i.e., bradycardia)

Diagnosis
ƒƒ Based on signs and symptoms
ƒƒ Based on blood test—elevated thyroid stimulating hormone (TSH)

Pharmacological management
Hormone replacement with levothyroxine (0.5 mg tablet) 100–150 mcg daily

References—1, 3

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12. Nutritional Disorders

12.1 Anaemia
Definition
Anaemia may be defined as a haemoglobin level below that of the reference
ranges for the age and gender of the individual, as shown in table 12.1.

Table 12.1. Haemoglobin Reference Ranges

Age or Gender Haemoglobin (g/dL)

Adults (>13 years)
Males 14.3–18.3
Females 12.1–16.3
Infants and children
Birth 18.0–27.0
1 day to 1 week 16.0–25.5
1 week to 1 month 12.0–21.8
1 month to 6 months 10.0–15.0
6 months to 2 years 10.5–13.7
2 to 3 years 10.8–12.2
3 to 5 years 11.1–14.7
5 to 8 years 10.7–15.1
8 to 13 years 10.3–15.5

Causes
ƒƒ Increased loss of red blood cells from—
yy Acute blood loss: trauma, surgery, or obstetric blood loss
yy Chronic blood loss: usually from gastrointestinal (e.g., parasitic
infestation, malignancy), urinary (e.g., malignancy), or reproductive
tract (e.g., malignancy, menorrhagia)
ƒƒ Decreased production of normal red blood cells from—
yy Nutritional deficiencies: iron, vitamin B12, folate
yy Bone marrow failure: leukaemia, malignant metastases to bone marrow
yy Chronic illness (e.g., cancer, HIV, TB)

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ƒƒ Increased destruction of red blood cells from—

yy Infections: viral, parasitic (e.g., malaria)
yy Medicines: sulphonamides, methyldopa, chemotherapy, antiretrovirals
yy Genetic: sickle cell disease (see chapter 13)

Signs and symptoms

ƒƒ Tiredness, weakness especially after exercising
ƒƒ Pale palms of hands and mucous membranes
ƒƒ Dizziness, faintness, headaches

Diagnosis
Investigations include the following:
ƒƒ Red cell morphology: MCV (high MCV indicates enlarged RBC, which may
be due to a vitamin B12 deficiency), MCH
ƒƒ Malaria smear
ƒƒ Stool for occult blood
Management objectives
ƒƒ Determine the cause of the anaemia
ƒƒ Treat as appropriate

12.1.1 Iron-Deficiency Anaemia

Description
As the name implies, iron-deficiency anaemia is due to insufficient iron to make
haemoglobin. Anaemia occurs when the haemoglobin (Hb) concentration in the
blood falls below normal values, as defined by healthy populations, resulting in
the reduction of the oxygen-carrying capacity of red blood cells. (See table 12.1.1
for the accepted levels in Guyana.) Iron-deficiency anaemia is common among
young children, pregnant women, and the elderly.

In Guyana, anaemia is often a reflection of iron deficiency, although there are

other causes as indicated in section 12.1. Iron is necessary for the formation of
haemoglobin, and a deficiency of iron in the diet or poor absorption of the iron
in the diet can result in reduced intake of iron into the body. Anaemia may also
result from other nutritional deficiencies as well as malaria, worm infestation,
and sickle cell disease. Other nutrients that are implicated in anaemia include
folic acid and vitamin B12, which are needed for the normal production of red
blood cells.

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Table 12.1.1. Classification of Anaemia in Infants, Children, Adults, and

Pregnant Women

Anaemia Measured by Haemoglobin (g/dL) Anaemia

Measured by
Haematocrit
All Mild Moderate Severe (%)—
Age or Gender Anaemia Anaemia Anaemia Anaemia All Anaemia
Children <11.0 10.0–10.9 1.0–9.9 <7.0 <33
6 months to
4 years
Children 11.5 10.0–11.4 7.0–9.9 <7.0 <34
5–11 years
Children 12.0 10.0–11.9 7.0–9.9 <7.0 <36
12–14 years
Nonpregnant 12.0 10.0-11.9 7.0–9.9 <7.0 <36
women
>15 years
Pregnant 11.0 10.0–10.9 7.0–9.9 <7.0 <33
women
Men >15 years 13.0 12.0–12.9 9.0–11.9 <9.0 <39
Source: Guyana Ministry of Health. 2004. Protocol for the Detection, Prevention and Treatment of Iron Deficiency
Anaemia for Use in Maternal and Child Health Clinics in Guyana. Georgetown: CFNI/MOH.

Signs and symptoms

ƒƒ Signs of anaemia include pallor of the conjunctivae, tongue, palms, and nail
beds
ƒƒ In severe anaemia, the patient may present with—
yy A feeling of listlessness or fatigue
yy Breathlessness
yy Increased heart rate
yy Low BP and urine output
yy Hepatosplenomegaly
yy Swelling of the lower limbs

Diagnosis
ƒƒ Clinical examination can sometimes indicate if anaemia might be present.
ƒƒ Test Hb level, peripheral blood smear, and microcytosis.

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ƒƒ During pregnancy, test the haemoglobin level of all women at the first visit.
Testing should be repeated every 4 weeks or at least at weeks 28, 32, and 36.
ƒƒ Check for worm infestation.
ƒƒ Do a sickle cell test if warranted by family history.
ƒƒ Check for malaria in malaria endemic areas (i.e., regions 1, 7, 8, 9, and parts
of regions 2 and 10).

Management objectives
ƒƒ Identify and treat the cause
ƒƒ Replace the iron

Nonpharmacological management
Advise the patient to eat foods that are rich in iron, for example—
ƒƒ Meats—beef, pork, liver, and other organ meats
ƒƒ Poultry—chicken, duck, turkey (especially dark meat)
ƒƒ Fish—shellfish, sardines
ƒƒ Leafy greens of the cabbage family—callaloo, pak choi, spinach
ƒƒ Legumes—green peas, dry beans and peas, black-eyed peas, and canned
baked beans

See appendix H, “Guidelines for Iron Supplementation.” For more details, see
also Appendix D in Protocol for the Detection, Prevention and Treatment of Iron
Deficiency Anaemia for Use in Maternal and Child Health Clinics in Guyana.

Pharmacological management
ƒƒ Give iron supplementation (elemental iron)
yy Children: (ferrous gluconate syrup mg 40 mg/5 mL) iron, oral, 2 mg/kg
elemental iron per dose 3 times/day with meals
ŠŠ 3–6 kg (0–3 months): 1.5 mL
ŠŠ 6–10 kg (3–12 months): 2.5 mL
ŠŠ 10–18 kg (1–5 years): 5 mL
ŠŠ 18–25 kg (5–8 years): 7.5 mL
ŠŠ 25–50 kg 8–14years: 10 mL
yy Adults: ferrous sulphate, oral, 200 mg 3 times/day
Note: Advise the patient that iron supplementation should be taken
between meals preferably with fruit juice (e.g., lime, orange, cherry,
guava). Do not take with milk or other dairy products, tea (including
bush tea), coffee, or antacids.

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ƒƒ Follow up at monthly intervals.

ƒƒ Continue supplementation for 3–4 months after Hb is normal to replenish
body iron stores.
ƒƒ Treat or manage the underlying cause. Check for—
yy Worm infestation (see section 7.6, “Parasitic Infestations”)
yy Malaria (see section 14.6, “Malaria”)
yy Sickle cell disease (see chapter 13, “Haemaglobinopathy—Sickle Cell
Disease”)

Referral
Signs of severe anaemia; patient may need a blood transfusion

References—3, 8, 145, 146

12.1.2 Iron Deficiency in Pregnancy

Description
Iron deficiency in pregnancy is defined as a haemoglobin count <10 g/dL. It is a
common problem and can be prevented.

Nonpharmacological management
ƒƒ Educate the patient on what constitutes a proper diet. Recommended
dietary changes should be practical, and consideration should be given to
cultural, religious, and philosophical circumstances.
ƒƒ Instruct the patient to use medications as prescribed.
ƒƒ Inform the patient about the side effects of medication (e.g., constipation
and black stools with iron medication).
ƒƒ Advise the patient that the following alterations in meal patterns can
enhance iron absorption. Ask the patient to—
yy Increase the amount of iron-rich foods in her diet. (See appendix D of
Protocol for the Detection, Prevention and Treatment of Iron Deficiency
Anaemia for Use in Maternal and Child Health Clinics in Guyana.)
yy Abstain from drinking green tea, bush tea, or coffee; from using milk,
cheese, or dairy products; or from taking antacids in combination with
iron-rich foods because doing so can inhibit iron absorption.
yy Include foods or juices rich in vitamin C in each meal (e.g., oranges,
grapefruit, garden cherries, carrots, sweet peppers, pak choi).

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Pharmacological management
ƒƒ Educate the patient on the correct use of iron supplements and how to
reduce their side effects. Instruct her to take the supplements, preferably
with fruit juice, between meals or before going to bed.
ƒƒ Add sprinkles to the woman’s food. Sprinkles are an iron supplement that
can be added to the food of pregnant women who have mild to moderate
iron-deficiency anaemia. Mix one sachet of sprinkles with an amount of
food that the woman can consume at a single meal.
ƒƒ Instruct the patient on the correct use of sprinkles. Tell her to—
yy Tear open the top of the package.
yy Pour the entire contents of the package into any semi-liquid food after
the food has been cooked and is at a temperature acceptable to eat.
yy Mix sprinkles with an amount of food that she can consume at a single
meal.
yy Mix the food well after adding the package of sprinkles.
yy Use no more than one full package per day at any mealtime.
yy Refrain from sharing the food to which sprinkles were added with other
household members since the amount of minerals and vitamins in a single
package of sprinkles is just the right amount for the pregnant woman.
yy Eat the food mixed with sprinkles within 30 minutes because the
vitamins and minerals in the sprinkles will cause the food to noticeably
darken.
Caution: Sprinkles must not be used in combination with other iron
supplements.
ƒƒ Pregnant women who have mild to moderate iron-deficiency anaemia can
be treated with either iron tablets and folic tablets or with sprinkles but
not with both. If the choice of treatment is to use iron and folic acid tablets,
then the dosage guidelines in table 12.1.2 should be followed.
ƒƒ Pregnant women who have severe anaemia should be managed with iron
and folic acid tablets (table 12.1.2).

Referral
ƒƒ Nonresponse of Hb to oral iron supplementation
ƒƒ Hb <7.0 g/dL

References—145, 146, 147, 148

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Table12.1.2. Guidelines for Iron and Folic Acid Supplementation of

Pregnant Women

Category Other Criteria Dosage

Normal: None Standard supplementation:
Hb ≥11.0 g/dL Ferrous sulphate/folic acid
tablets (60 mg elemental
iron/250 mcg folic acid daily)
Mild to moderate None Standard supplementation:
anaemia: Ferrous sulphate/folic acid
Hb 7.0–10.9 g/dL tablets
(60 mg elemental iron/
250 mcg folic acid daily)
Severe anaemia: Less than 28 weeks pregnant 120 mg iron daily (ferrous
Hb <7.0 g/dL and asymptomatic sulphate tablets, 2/day)
28–34 weeks pregnant and 120 mg iron daily (ferrous
asymptomatic sulphate tablets, 2/day)
OR
IM iron (dextran iron
50 mg/mL)
>34 weeks pregnant IM or IV iron (at the district
hospital level or higher)
Hb 4.0–6.9 g/dL Symptomatic Admit to hospital
Hb<4.0 g/dL Symptomatic Admit to hospital

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12.1.3 Iron Deficiency in Children 6–24 Months

Diagnosis
Clinical examination can sometimes indicate if anaemia might be present.

ƒƒ Look for signs of anaemia: pallor of the conjunctivae, tongue, palms, and
nail beds.
ƒƒ Check Hb level and do a blood film.
ƒƒ Check for worm infestation.
ƒƒ Do a sickle cell test if warranted by family history.
ƒƒ Check for malaria in malaria endemic areas (i.e., regions 1, 7, 8, 9, and parts
of regions 2 and 10).

Nonpharmacological management
Advise parents or caregivers on the use of iron-rich foods (see appendix D
Protocol for the Detection, Prevention and Treatment of Iron Deficiency Anaemia
for Use in Maternal and Child Health Clinics in Guyana) and foods fortified with
iron in the child’s diet.

Pharmacological management
ƒƒ Advise the parents or caregivers to add sprinkles, an iron supplement, to
the child’s food. Mix one sachet of sprinkles with an amount of food that the
child can consume at a single meal.
ƒƒ Educate the parents or caregivers on the correct use of sprinkles. Tell
them to—
yy Tear open the top of the package.
yy Pour the entire contents of the package into any semi-liquid food after
the food has been cooked and is at a temperature acceptable to eat.
yy Mix sprinkles with an amount of food that the child can consume at a
single meal.
yy Mix the food well after adding the package of sprinkles.
yy Give no more than one full package per day at any mealtime.
yy Do not share the food to which sprinkles were added with other
household members since the amount of minerals and vitamins in a
single package of sprinkles is just right amount for one child.
yy The food mixed with sprinkles should be eaten within 30 minutes
because the vitamins and minerals in the sprinkles will cause the food to
noticeably darken.

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Caution: Sprinkles must not be used in combination with other iron

supplements.
ƒƒ Children who have mild to moderate iron-deficiency anaemia can be
treated with either iron and folic tablets or with sprinkles but not with
both. If the choice of treatment is to use iron and folic acid tablets, then the
dosage guidelines in table 12.1.3 should be followed.
ƒƒ For children who have severe anaemia, use iron and folic acid tablets (table
12.1.3).

Table 12.1.3. Guidelines for Iron and Folic Acid Supplementation to Treat Iron-
Deficiency Anaemia in Children 6 Months to 5 Years

Category of Anaemia Age Dosage

Mild to moderate 6–24 months Standard supplementation:
anaemia 12.5 mg iron daily
50 mcg folic and daily
2–5 years Standard supplementation:
25 mg iron daily
200 mcg folic acid daily
Severe anaemia 6–12 months 25 mg iron daily
100 mcg folic acid daily
2–5 years 60 mg iron daily
400 mcg folic acid daily
Source: Guyana Ministry of Health. 2004. Protocol for the Detection, Prevention and Treatment of Iron Deficiency
Anaemia for Use in Maternal and Child Health Clinics in Guyana. Georgetown: CFNI/MOH.

Referral
ƒƒ Nonresponse of Hb to oral iron supplementation
ƒƒ Hb <7.0 g/dL

Reference—146, 148

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12.2 Malnutrition

12.2.1 Undernutrition
Description
Undernutrition is a condition in which the patient’s physical state is impaired
to the point that his or her body can no longer maintain adequate bodily
performance. It is manifested by weight loss and occurs when there is a
significant imbalance between nutritional intake and individual needs or
inability to absorb and use nutrients. It can also be the result of excessive
energy expenditure due to a disease processes such as TB, AIDS, cancer,
trypanosomiasis, or visceral leishmaniasis.

Signs and symptoms

ƒƒ Growth retardation in children
ƒƒ Sudden unintentional weight loss
ƒƒ Muscle wasting
ƒƒ Pallor of the conjunctiva (anaemia)
ƒƒ Bilateral lower limb oedema
ƒƒ Dry, flaky skin of the lower extremities
ƒƒ Hyperpigmentation of exposed skin
ƒƒ Diarrhoea in children
ƒƒ Angular stomatitis
ƒƒ Smooth red tongue

Diagnosis
Based on history and physical examination
ƒƒ Loss of subcutaneous fat
ƒƒ Abnormal anthropometric measurements
yy In children, weight-for-height measurements will establish the severity
of the malnutrition. In children ≤5 years, use the MOH Child Health
Record Card (weight/height).
yy In adolescents and adults, use BMI [weight (kg) divided by height (m2)]
<19.9 OR for adults, use mid upper arm circumference (MUAC) <16 cm
irrespective of clinical status or MUAC<18.5 PLUS one of the clinical
signs for the elderly.

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yy In the elderly, use MUAC <15 cm or MUAC <17.5 cm PLUS one of the
following clinical signs:
ŠŠ Oedema of lower limbs
ŠŠ Inability to stay standing
ŠŠ Visible dehydration
ƒƒ Check for underlying or associated problems
yy Hb and serum albumin
yy Stool test for ova cysts and parasites
yy Blood smear for malaria in malaria endemic areas
yy TB (in patients who have a history of chronic cough)
yy HIV

Management objectives
ƒƒ Treat underlying and associated disease(s)
ƒƒ Restore metabolic function
ƒƒ Restore normal weight

Nonpharmacological management
ƒƒ Restore metabolic function. (This should be done in a hospital setting.)
yy Recovery of normal nutritional status is progressive and not aggressive.
yy Give the patient many small meals over 24 hours to reduce the risk of
hypoglycaemia, hypothermia, diarrhoea, vomiting, and heart failure
linked with electrolyte imbalance.
ŠŠ Adults including the elderly: 40 kcal/kg/day
ŠŠ Adolescents: 55 kcal/kg/day (e.g., high-energy milk)
yy The patient can be discharged and followed up as an outpatient, when
50% of weight/height2 (BMI) has been achieved. (See Table 12.2.2.)
ƒƒ Provide nutritional rehabilitation. The objective is to recover normal
weight by eating an enriched diet high in energy and balanced in protein.
yy Adults including the elderly: 80 kcal/kg/day
yy Adolescents: 100 kcal/kg/day

Pharmacological management
ƒƒ For intestinal parasites, on the seventh day, treat the patient with an
anthelminthic: albendazole PO 400 mg as a single dose.
Caution: Albendazole is contraindicated in the first trimester of pregnancy.

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ƒƒ Give elemental iron only from the 14th day for all patients, with or without
anaemia.
yy Adults: 120 mg/day in 2 divided doses for about 2 weeks (2 tablets of 200
mg of ferrous sulphate/day). Then follow protocol for iron-deficiency
anaemia, in anaemic patients (see section 12.1.1).
yy Adolescents: 3 mg/kg once daily for about 2 weeks

Referral
ƒƒ Patients who have severe malnutrition
ƒƒ Patients who are unable to eat or retain food given orally
ƒƒ Patients who have underlying conditions needing specialist attention

References—1, 10, 146, 148, 149, 150

12.2.2 Overweight and Obesity

Description
Obesity is excess fat (i.e., adipose tissue) that is deposited in the body and
presents a risk to health. Although not a direct measure of adiposity, the most
widely use measure of obesity is the BMI, which is equal to weight/height2 (in
kg/m2). (See table 12.2.2.) The consequences of obesity include the following:
ƒƒ Hypertension
ƒƒ Type 2 DM
ƒƒ Hyperlipidaemia
ƒƒ MI
ƒƒ Increased risk of osteoarthritis and gout
ƒƒ Gallstones
ƒƒ Cancer
ƒƒ Reproductive disorders
ƒƒ Sleep apnoea
ƒƒ Increased mortality

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Table 12.2.2. Classifying BMIs

Classification Criteria
Underweight BMI <18 (Guyana uses 19.9)
Healthy body BMI 18–25 (Guyana uses 20–24.9)
weight Waist circumference <80 cm (females) and <94 (males)
Overweight BMI 25–30
OR
Waist circumference >88 cm (females) and >102 (males)
Obese BMI 31–39
OR
Waist circumference >88 cm (females) or >102 (males)
Morbidly obese BMI >40

Causes
ƒƒ Genetic
ƒƒ First-degree relative—families tend to share diets and lifestyles
ƒƒ Excessive calorie intake—eating too much and eating a lot of fatty foods
ƒƒ Emotional—overeating because of depression, hopelessness, anger,
boredom, and many other reasons that have nothing to do with hunger
ƒƒ Sedentary lifestyle—no exercise or limited activity
ƒƒ Gender—obesity is more prevalent in females

Signs and symptoms

ƒƒ BMI >25
ƒƒ Difficult breathing and history of sleep apnoea
ƒƒ Joint damage
ƒƒ Low fertility
ƒƒ Depression possible

Management objectives
Management should be guided by the health risks in any given individual.
ƒƒ Rule out diseases associated with obesity (e.g., Cushing’s syndrome,
hypothyroidism)
ƒƒ Reduce BMI to within normal limits
ƒƒ Treat associated conditions (e.g., hypertension, diabetes)

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Nonpharmacological management
ƒƒ Advise the patient to reduce his or her caloric intake. To reach this goal, the
patient can—
yy Limit intake from total fats and shift fat consumption away from
saturated fats to unsaturated fats
yy Increase consumption of fruit and vegetables, as well as legumes, whole
grains, and nuts
yy Limit intake of sugars
ƒƒ Advise the patient to increase calories burnt by gradually increasing his or
her physical activity to at least 30 minutes of regular, moderate-intensity
activity 3–5 days/week.
ƒƒ Provide health education.
yy Explain the consequences of obesity (e.g., hypertension, diabetes, MI,
joint problems) to the patient.
yy Advise the patient to set a goal (e.g., 10% weight loss per year).
ƒƒ Follow up.
yy Do monthly checks of weight and BP.
yy Do annual checks of blood glucose level.

Pharmacological management
ƒƒ Not advised for obesity at health centre and district hospital levels
ƒƒ Treat associated conditions (e.g., hypertension).

Referral
ƒƒ Uncontrolled hypertension, DM
ƒƒ Other conditions needing higher level care (e.g., hypothyroidism)
ƒƒ To rule out Cushing’s syndrome

References—151, 152

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 1 3 . H aemog l obinopathies — S ic k l e C e l l disease

13. Haemoglobinopathies—
Sickle Cell disease
Description
Sickle cell disease is a hereditary blood disorder that encompasses all genotypes
containing at least one sickle gene in which HbS makes up at least half the
haemoglobin present. In addition to sickle cell anaemia (HbSS), there are other
compound heterozygous conditions: haemoglobin SC, haemoglobin SDPunjab,
haemoglobin SE, haemoglobin S/ß thalassaemia (ß+, ß0, δß, and Lepore), and
haemoglobin SOArab.

HbSS is the most common condition in Guyana. It is characterized by red blood

cells that assume an abnormal, rigid, sickle shape, which decreases the cells’
flexibility and affects its ability to go through small capillaries resulting in vase-
occlusion leading to various complications.

Sickle-cell disease occurs more commonly among people whose ancestors

lived in tropical, subtropical, and sub-Saharan regions where malaria is or was
common. Where malaria is common, persons carrying a single sickle-cell gene,
HbAS (sickle cell trait) show less severe symptoms when infected with malaria.

Life expectancy has improved considerably over the last decades due to
improved recognition and better management of acute episodes. Introduction
of neonatal screening programmes in parts of the United States dramatically
improved health care and childhood mortality; it is a program about to be
introduced in Guyana.

Complications of HbSS include the following:

ƒƒ Loss of the functioning of the spleen by 1½–3 years of age
ƒƒ Damage to the kidney leading to renal failure in adults
ƒƒ Aseptic necrosis, particularly of the heads of the femur and humerus
ƒƒ Chronic arthropathy
ƒƒ Susceptibility to osteoarthritis
ƒƒ Infarcts of the digits and dactylitis (i.e., hand-foot syndrome)
ƒƒ Acute chest syndrome (i.e., sickling within the lung)
ƒƒ Severe reduction in red blood cell production (i.e., aplastic crisis)

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ƒƒ Priapism—affecting mainly adolescents and adults. Priapism may be

classified as—
yy Stuttering (occurring for <3 hours’ duration but several times/week)
yy Minor (isolated or infrequent episodes of <3 hours’ duration)
yy Major (events usually lasting >3 hours)
yy Delayed onset of sexual maturation
ƒƒ Oligomenorrhoea or amenorrhoea
ƒƒ Leg ulcers

Signs and symptoms

Most patients with sickling syndromes suffer from—
ƒƒ Severe anaemia (haemolytic or aplastic)
ƒƒ Pallor
yy Fatigue
yy Breathlessness
yy Tachycardia
yy Jaundice
ƒƒ Acute pain and tenderness almost anywhere in the body (painful crises)
lasting from a few hours to months
ƒƒ Inflammation of an entire finger or toe
ƒƒ Acute, painful enlargement of the spleen

Diagnosis
ƒƒ Full blood count revealing Hb level of 6–8 g/dL with high reticulocyte count
ƒƒ An acute sickle-cell crisis is often precipitated by infection; check for
infection
ƒƒ Cell morphology and haemoglobin electrophoresis

Management objectives
ƒƒ Treat the anaemia
ƒƒ Relieve pain
ƒƒ Prevent or treat intercurrent infection

Nonpharmacological management
Educate parents or caregivers on—
ƒƒ What to expect and how to identify various crises
ƒƒ Diet and nutrition

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ƒƒ Using lots of fluids. If child is unwell and needs extra fluids, give the
following minimum amounts. For children weighing—
yy <10 kg, give 150 mL for every kg body weight in 24 hours
yy 10–20 kg, give 80 mL for every kg body weight in 24 hours
yy >20 kg, give 40 mL for every kg body weight in 24 hours
ƒƒ The importance of—
yy Immunising against H. influenza, pneumococcus, and hepatitis B
yy Avoiding infections
yy Avoiding extremes of heat and cold
ƒƒ How to manage illnesses at home

Pharmacological management
ƒƒ Give folic acid.
ƒƒ Give malaria chemoprophylaxis in malaria endemic areas.
ƒƒ Give analgesics for pain.
yy Give paracetamol (500 mg tablets; 120 mg/5 mL suspension) at the
following dosages, not to exceed 4 doses in 24 hours.
ŠŠ 6–12 months: 60 mg (2.5 mL or ½ tsp) 3–4 times/day
ŠŠ 1–5 years: 120 mg (5 mL or 1 tsp) 3–4 times/day
ŠŠ 5–8 years: 250 mg (10 mL or 2 tsp or ½ tablet) 3 times/day
ŠŠ 8–14 years: 500 mg (1 tablet) 3–4 times/day
ŠŠ >14 years: 1,000 mg (2 tablets) 3–4 times/day
OR
yy Give ibuprofen.
ŠŠ 8–12 years: 200 mg every 6–8 hours
ŠŠ >12 years: 400 mg every 6–8 hours
ƒƒ Give prophylactic antibiotics.
yy Amoxicillin (250 mg and 500 mg tablets; 125 mg/5 mL suspension)
ŠŠ Adults: 500 mg 3 times/day
ŠŠ Children: 100 mg/kg/day in 3 divided doses
OR
yy For penicillin-allergic patients, give erythromycin (250 mg and 500 mg
tablets; 125 mg/5 mL suspension) at the same dosages as for amoxicillin.
ƒƒ Manage priapism. Minor attacks of priapism may be aborted by emptying
the bladder, taking a warm bath, and using oral analgesics.

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Referral
ƒƒ Acute painful crises
ƒƒ Severe anaemia requiring transfusion
ƒƒ Respiratory distress
ƒƒ Protracted pain in hips or thighs
ƒƒ Priapism lasting ≥2 hours

References—1, 153, 154, 155

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14. Infectious Diseases

14.1 Chickenpox
Description
Chickenpox is a mild but extremely contagious viral infection caused by
Varicella zoster, occurring mainly during childhood. It is spread by droplet
infection. The incubation period is about 2–3 weeks after exposure. Patients are
infectious from about 2 days before the appearance of the rash, during the period
of formation of the rash (about 6 days), and until all the lesions have crusted. The
infection is self-limiting with duration of about 1 week.

Signs and symptoms

ƒƒ Fever preceding the rash
ƒƒ Loss of appetite
ƒƒ Weakness
ƒƒ Lesions beginning on the trunk and face, later spreading to the arms and
legs
ƒƒ Small, red, itchy spots that turn into blisters and burst to form scabs. These
lesions may all be present at the same time. The severity of the lesions
varies from person to person.
ƒƒ Secondary bacterial infection of the skin may appear, a result of bruising of
the skin from scratching
ƒƒ Complications of encephalitis and pneumonia occur rarely and are more
likely in adults

Diagnosis
Basically clinical

Management objectives
ƒƒ Provide symptomatic treatment
ƒƒ Prevent and manage avoidable complications

Nonpharmacological management
ƒƒ Isolate the patient from immunocompromised people and pregnant women
until all lesions have crusted.

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ƒƒ Ensure adequate hydration.

ƒƒ Cut the patient’s fingernails very short and discourage the patient from
scratching.
ƒƒ Maintain good hygiene and daily cleansing of the skin to prevent secondary
infection.
ƒƒ Use wet compresses on the skin to relieve itching.

Pharmacological management
ƒƒ For itch, give calamine lotion, applied as needed.
ƒƒ For pain and fever, give paracetamol (500 mg tablets; 120 mg/5 mL
suspension) PO, every 4–6 hours, when required not to exceed 4 doses daily.
See table 14.1 for dosages.
Caution: Acetylsalicylic acid (aspirin) is not recommended for children
<12 years old because of the risk of Reye’s syndrome.

Table 14.1. Paracetamol Dosages by Age and Weight for the Management of
Chicken Pox

Age Weight Dose(mg) Quantity Frequency Duration

3–12 months 6–10 kg 60 2.5 mL (½ tsp) 3 times/day 5–7 days
1–5 years 10–18 kg 120 5 mL (1 tsp) 3 times/day 5–7 days
5–8 years 18–25 kg 240 10 mL (2 tsp) 3 times/day 5–7 days
or ½ tablet
8–14 years 25–50 kg 500 1 tablet 3–4 times/day 5–7 days
>14 years >50 kg 1,000 2 tablets 3–4 times/day 5–7 days
and adults

ƒƒ If a skin infection is present due to scratching, treat as for bacterial skin

infection.

Referral
ƒƒ If the patient—
yy Seems extremely ill
yy Is difficult to wake up or appears confused
yy Has difficulty walking
yy Has a stiff neck
yy Is vomiting repeatedly

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yy Has difficulty breathing

yy Has a severe cough
ƒƒ These are suggestive of complications such as—
yy Meningitis
yy Pneumonia
yy Encephalitis
ƒƒ Also refer—
yy Babies <6 months
yy HIV-infected patients
yy Severely ill adults
yy Pregnant women
yy Recurrent chickenpox

References—1, 34, 156, 157

14.2 Dengue
Description
Dengue is a viral, self-limited, mosquito-borne (Aedes aegypti) infection
caused by the dengue virus of the family Flaviviridae. Four serotypes are
responsible for three disease conditions, which vary in severity: dengue fever,
dengue hemorrhagic fever, and dengue shock syndrome in humans. The first
infection with the virus may be asymptomatic or may result in classic dengue
fever. Dengue haemorrhagic fever occurs when a person catches a different
type dengue virus after being infected by another one sometime before. Prior
immunity to a different dengue virus type plays an important role in this severe
disease, which may go on to dengue shock. In Guyana, most of the cases are from
the coastal areas of regions 1, 3, and 4 with some cases in the interior region 9.

Signs and symptoms

Signs and symptoms may vary from asymptomatic to complicated.
ƒƒ Dengue fever
yy Early symptoms include—
ŠŠ A feeling of listlessness
ŠŠ Headache for about 2 days

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yy Followed by—
ŠŠ Fever (so-call break bone)
ŠŠ Severe backache
ŠŠ Generalized muscle and joint pains
ŠŠ Painful red eyes
ŠŠ Palpable lymph nodes
ŠŠ Poor appetite
ŠŠ Nausea and vomiting
ŠŠ Slow heart rate
ŠŠ Prostration and depression
ŠŠ A continuous high fever that breaks on the fourth or fifth day
ŠŠ In some cases, a rash developing gradually on the dorsum of the hands
and feet and spreading upwards
ƒƒ Dengue haemorrhagic fever
yy High fever (39–41ºC) of sudden onset lasting about 2–7 days
yy Signs of haemorrhage in the skin (positive tourniquet test)
yy Mucous membranes (bleeding from the nose and gums)
yy Gastrointestinal tract (vomiting blood, dark black stools)
yy Enlarged liver
ƒƒ Dengue shock syndrome
yy Signs preceding shock are—
ŠŠ Persistent vomiting
ŠŠ Intense abdominal pain
ŠŠ Sudden drop in body temperature
yy Signs of shock are—
ŠŠ Rapid, weak pulse
ŠŠ Cold extremities and profuse sweating
ŠŠ Drop in BP

Diagnosis
ƒƒ CBC including haematocrit and platelet count
ƒƒ Serological tests for dengue antibodies—
yy Within 5 days of onset—viral culture
yy After day 7—serology test with both IgM and IgG
yy Repeat tests after day 14 (IgM significantly increased)

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Management objectives
ƒƒ Reduce fever and pain
ƒƒ Prevent or treat moderate dehydration
ƒƒ Refer at any sign of developing complication

Nonpharmacological management
ƒƒ Sponge patient with wet cloths to reduce fever.
ƒƒ Encourage patient to drink plenty of fluids; give ORS if necessary.

Pharmacological management
For dengue fever, give paracetamol (500 mg tablets; 120 mg/5 mL suspension).
See table 14.2 for dosages.
Caution: Do not give acetylsalicylic acid (aspirin). It can aggravate
haemorrhaging.

Table 14.2.Paracetamol Dosages for the Management of Dengue Fever

Age Weight Dose(mg) Quantity Frequency Duration

3–12 months 6–10 kg 60 2.5 mL (½ tsp) 3 times/day 5–7 days
1–5 years 10–18 kg 120 5 mL (1 tsp) 3 times/day 5–7 days
5–8 years 18–25 kg 240 10 mL (2 tsp) 3 times/day 5–7 days
or ½ tablet
8–14 years 25–50 kg 500 1 tablet 3–4 times/day 5–7 days
>14 years >50 kg 1,000 2 tablets 3–4 times/day 5–7days
and adults

Referral
All cases of dengue haemorrhagic fever and developing shock syndrome. Set up
infusion of Ringer’s lactate before transferring the patient to the hospital.

References—10, 158, 159, 160

14.3 Filaria (Lymphatic Filariasis)

Description
Filaria is an infection of the subcutaneous tissue, lymphatic channels, or lymph
nodes by the threadlike adult parasite (Wuchereria bancrofti). The adult worms
cause permanent damage to the lymphatic system. Transmission occurs by
insect vector (mosquitoes).

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Signs and symptoms

ƒƒ Acute
yy Recurrent attacks of fever lasting 7–10 days
yy Localised lymphangitis of the limbs and scrotum
ƒƒ Chronic
yy Hydrocele
yy Epididymo-orchitis
yy Elephantiasis (particularly of the legs)

Diagnosis
Detection of microfilariae in blood collected between 10:00 p.m. and midnight

Management objectives
Treat current infection and prevent possible transmission of the causative agent
of lymphatic filariasis (W. bancrofti) to others, through—
ƒƒ Antiparasitic pharmacological therapy
ƒƒ Supportive clinical and surgical care
ƒƒ Patient education and counselling

Nonpharmacological management
ƒƒ Advise the patient to—
yy Wash the affected parts 2 times/day with soap and clean, cool water; dry
carefully
yy Raise the affected limb at night
yy Exercise the limb regularly
yy Keep the nails and spaces between the toes clean
yy Wear comfortable shoes
ƒƒ Provide patient education and counselling. Psychological counselling is
essential to support patients who have filaria-induced disability because
they can suffer from acute shame, isolation, sexual dysfunction, and intense
chronic pain and suffering.

Pharmacological management
Give—
ƒƒ Diethylcarbamazine citrate (50 mg, 100 mg tablets) 6 mg/kg in 3 divided
doses for 21 days

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Caution: Do not use diethylcarbamazine in pregnant or breastfeeding

women.

OR
ƒƒ Albendazole (200 mg, 400 mg tablets) 400 mg 2 times/day for 21 days.
Caution: Albendazole is contraindicated in the first trimester of pregnancy.

Referral
Patients with hydroceles for drainage or corrective surgery

References—1, 10, 161

14.4 Leishmaniasis
Description
The term leishmaniasis refers collectively to various clinical syndromes caused
by parasites of the genus Leishmania, which affects both humans and animals
and is transmitted by sand flies. In humans, leishmaniasis can be classified as
cutaneous, mucosal, or visceral.

Causes and risk factors

ƒƒ Leishmania chagasi
ƒƒ Malnutrition
ƒƒ Children are at greater risk than adults in endemic areas.
ƒƒ Persons with AIDS are at 100–1,000 times greater risk of developing
visceral leishmaniasis in certain areas.
ƒƒ Incomplete therapy of initial disease is a risk factor for recurrence of
leishmaniasis.

Signs and symptoms

ƒƒ Cutaneous (incubation period weeks to months)
yy Development of a small red papule at the site of the sand-fly bite,
evolving to nodular to ulcerative
yy The ulcers can be moist, open with seropurulent exudate, or dry with a
crusted scab.
yy Sores usually are found on exposed areas of skin (face and extremities).
yy Regional lymphadenopathy

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ƒƒ Mucocutaneous (incubation period 1–3 months)

yy Similar to cutaneous with spread of lesions to—
ŠŠ Mouth (gingival oedema and periodontitis)
ŠŠ Nose (nasal obstruction and bleeding)
ŠŠ Conjunctiva
yy Lesions gradually become painful and can become infected leading to
sepsis.
ƒƒ Visceral (mainly remains subclinical but can become symptomatic)
yy Fever of any type—persistent, undulating, in peaks
yy Hepatosplenomegaly
yy Weight loss and weakness
yy Darkening of the skin (thus, the name kala azar or black fever).
yy Lymphadenopathies
yy Epistaxis
yy Diarrhoea possible

Patients may die of haemorrhage (secondary to infiltration of the haematopoietic

system), severe anaemia, secondary bacterial infections of mucous membranes,
bacterial pneumonia, septicaemia, TB, or dysentery.

Diagnosis
Skin scrape for gyms staining and microscopic examination

Management objective
Prevent reinfection

Nonpharmacological management
Practice prevention using—
ƒƒ Insecticide-treated bed nets
ƒƒ Vector control and elimination of animal reservoir hosts

Referral
Refer all cases to skin clinic for treatment.

References—1, 10, 162

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14.5 Leptospirosis
Description
Leptospirosis is an infectious disease that affects both humans and animals,
domestic and wild (principally rats), characterized by a broad spectrum of
clinical manifestations varying from mild, which usually has a favourable
outcome, to severe, which has a fatal outcome.

Cause and risk factors

ƒƒ Spirochetes of the genus Leptospira
ƒƒ Persons at risk include—
yy Farmers
yy Sewer workers
yy Veterinarians and animal caretakers
yy People in flooded areas
ƒƒ Mode of transmission
yy Contact of skin or mucous membranes with urine from infected animals
yy Contact with water, soil, or food contaminated with the urine of infected
animals

Signs and symptoms

ƒƒ The incubation period is about 1–3 weeks.
ƒƒ The mild form has the following signs and symptoms:
yy Influenza-like illness—fever, chills, headaches (frontal or retro-orbital),
nausea, vomiting, and myalgias (especially calf, back, and abdomen)
yy Possible pulmonary signs (e.g., cough and chest pain)
yy Mild jaundice
yy Conjunctival haemorrhage
yy Rash
ƒƒ The severe form has the following signs and symptoms:
yy Fever and jaundice
yy Oligoanuric renal failure during the second week of illness
yy Diffuse haemorrhagic syndrome (e.g., epistaxis, petechiae, purpura)
yy Cough, dyspnoea, chest pain, and haemoptysis
yy Cardiac signs (i.e., myocarditis, pericarditis)

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Diagnosis
Investigations—
ƒƒ Culture of leptospira from blood or CSF (during first 10 days of illness) or
from urine beginning at about 1 week.
ƒƒ Urinalysis: proteinuria, leucocytes, possible haematuria

Management objectives
ƒƒ Reduce fever
ƒƒ Kill the bacteria
ƒƒ Treat complications

Nonpharmacological management
Advise rest.

Pharmacological management
ƒƒ Give paracetamol (500 mg tablet; 120 mg/5 mL suspension) for pain and
fever. See table 14.5 for dosages.

Table 14.5. Paracetamol Dosages for the Management of Leptospirosis

Dose
Age Weight (mg) Quantity Frequency Duration
3–12 months 6–10 kg 60 2.5 mL (½ tsp) 3 times/day 5–7 days
1–5 years 10–18 kg 120 5 mL (1 tsp) 3 times/day 5–7 days
5–8 years 18–25 kg 240 10 mL (2 tsp) 3 times/day 5–7 days
or ½ tablet
8–14 years 25–50 kg 500 1 tablet 3–4 times/day 5–7 days
>14 years >50 kg 1,000 2 tablets 3–4 times/day 5–7days
and adults

Caution: Do not use acetylsalicylic acid (aspirin) to treat pain and fever
because of the risk of haemorrhage.

ƒƒ Give an antibiotic.
yy For mild leptospirosis, give doxycycline 100 mg PO bid for 7 days.
Caution: Do not give doxycycline to pregnant or breastfeeding women or
to children <8 years.

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yy For moderate leptospirosis, give—

ŠŠ Amoxicillin PO (250 mg, 500 mg tablets; 125 mg/5 mL suspension)
–– Adults: 500 mg PO QID for 7 days
–– Children: 50 mg/kg/day in 2–3 divided doses for 7 days
OR
ŠŠ Doxycycline PO (100 mg tablet)
–– Adults: 100 mg 2 times/day for 7 days
–– Children >8 years: 100 mg/day in 2 divided doses for 7 days
Caution: Do not give doxycycline to pregnant or breastfeeding women or
to children <8years.
OR
ŠŠ Erythromycin PO (250 mg, 500 mg tablets; 125 mg/5 mL suspension)
–– Adults: 1 g 2–3 times/day for 7 days
–– Children: 50 mg/kg/day in 2–3 divided doses for 7 days
yy For severe leptospirosis, give—
ŠŠ Ampicillin IV (powder for injection500 mg, 1 g)
–– Adults: 4–6 g/day in 3–4 divided doses for 7 days
–– Children: 100 mg/kg/day in 3 divided doses
ŠŠ Switch to the oral route as soon as possible with amoxicillin to
complete the 7 days
yy For penicillin allergic patients, give—
ŠŠ Erythromycin (250 mg and 500 mg tablets, 125 mg /5 ml susp)
–– Adults: 500 mg 4 times/day for 7 days
–– Children:
‚‚ <1 year: 125 mg (5 mL or 1 tsp) 2 times/day for 7 days
‚‚ 1–5 years: 250 mg (10 mL or 2 tsp) 2 times/day for 7 days
‚‚ 6–12 years: 250 mg tab 4 times/day for 7 days

Referral
Patients—
ƒƒ Who are not responding to treatment
ƒƒ Who have severe leptospirosis
ƒƒ Who are penicillin-allergic

References—1, 10, 163

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14.6 Malaria
Description
Malaria is a protozoan disease transmitted by an infected female anopheles
mosquito. Anopheles darlingi, a primary vector, is both effective and efficient
in malaria transmission. Malaria is a major public health problem in Guyana,
notably in regions 1, 7, 8, 9, and parts of regions 2 and 10.

Cause and risk factors

Four species of protozoa of the genus Plasmodium cause nearly all malarial
infections in humans:
ƒƒ P. falciparum (the most common and the cause of almost all deaths)
ƒƒ P. vivax (the next most common)
ƒƒ P. malariae
ƒƒ P. ovale (This species is not a problem in Guyana.)

The incubation period is 7–12 days for falciparum and >15 days for the others.

The following groups are at the highest risk of contracting malaria:

ƒƒ The elderly
ƒƒ Severely malnourished individuals
ƒƒ Immunocompromised people
ƒƒ People who have uncontrolled DM

Signs and symptoms

For uncomplicated malaria, the symptoms are nonspecific:
ƒƒ Fever (usually high)
ƒƒ Chills
ƒƒ Sweating
ƒƒ Headache
ƒƒ Muscle ache
ƒƒ Arthralgia (i.e., joint pain)
ƒƒ Anorexia irregular at first, but may occur every 2–3 days
ƒƒ Nausea and vomiting
ƒƒ Anaemia common among children living in endemic areas

Classically, symptoms are cyclical with occurrence of sudden coldness followed

by rigor and then fever and sweating lasting 4–6 hours, occurring every 2 days

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in P. vivax and P. ovale infections and every 3 days in P. malariae. P. falciparum

can have recurrent fever every 1½–2 days or a less pronounced and almost
continuous fever.

Diagnosis
The diagnosis of malaria is based on—
ƒƒ Clinical suspicion. Always consider malaria in a febrile patient living in or
returning from an area where the disease is endemic.
ƒƒ Detection of parasites in the peripheral blood (confirmed case)

Investigations (at health centre level) include—

ƒƒ Rapid malaria diagnostic test (RDT)
ƒƒ Thin and thick blood films (microscopy)
ƒƒ FBC and white cell differential
ƒƒ Blood glucose especially in unconscious patients

Management objectives
ƒƒ Reduce fever
ƒƒ Kill the infectious agent
ƒƒ Treat complications
ƒƒ Reduce transmission of the infection to others

Management
The treatment policy recommendation in Guyana requires parasitological
confirmation of the diagnosis of malaria before administration of antimalarial
medicine. It is also vital to differentiate between the different species of
Plasmodia to allow for the correct treatment. Parasitological confirmation
should be provided by microscopy or, where not available, RDTs.

Note: A negative RDT or a negative blood smear does not exclude malaria, and
treatment can be initiated on clinical grounds.

Nonpharmacological management
ƒƒ Exclude other causes of fever.
ƒƒ Give the patient plenty of fluids to drink.
ƒƒ Advise the patient on the use of insecticide-treated bed nets and mosquito
repellents and coils.

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ƒƒ Advise the patient to wear appropriate clothing (e.g., long sleeves especially
in the evenings and night).
ƒƒ Advise the patient to cover exposed skin with insect repellent.

Pharmacological management
Pharmacological management depends on the type of malaria and patient. Each
is discussed in detail in the following sections.

14.6.1 Falciparum Infections

14.6.1.1 Mild to Moderate Falciparum Infection
ƒƒ For first-line treatment, give—
yy Artemether-lumefantrine (Coartem®) (20 mg/120 mg tablet). See table
14.6.1A for dosages.
PLUS
yy Primaquine as a single dose. See table 14.6.1B for dosages.
ƒƒ Consider second-line treatment under these conditions:
yy The patient experiences treatment failure or has a reoccurrence of
symptoms, parasites, or both at rechecks within 28 days of the onset of
first-line treatment.
yy The patient is allergic to or has an inability to tolerate first-line
medicines.
yy The first line treatment is unavailable.
ƒƒ For second-line treatment, give—
yy Artesunate for 3 days. See table 14.6.1C for dosages.
PLUS
yy Mefloquine for 2 days. See table 14.6.1C for dosages.
PLUS
yy Primaquine as a single dose. See table 14.6.1B for dosages.

ƒƒ For second-line treatment (alternative A), give—

yy Quinine sulphate (300 mg tablet) for 7 days. See table 14.6.1D for
dosages.
PLUS
yy Tetracycline 4 mg/kg 4 times/day for 7 days
OR

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Table 14.6.1.1A. Artemether-Lumefantrine Dosage for Falciparum Cases

(First Line)

Age Number of Tablets at Approximate Timing of Dosing Body

(in Years) 0h 8h 24 h 36 h 48 h 60 h Weight (kg)
<3 1 1 1 1 1 1 5–14
3–8 2 2 2 2 2 2 14–24
9–14 3 3 3 3 3 3 25–34
>14 4 4 4 4 4 4 >34

Table 14.6.1.1B. Primaquine (7.5 mg and 15 mg) Dosage for Falciparum Cases
(First and Second Line)

Daily Dose Daily Dose

(15 mg Tablets) (7.5 mg Tablets)
Age Number of Tablets Weight (kg)
<6 months 0 0 6–10
6–11 months ½ 1 11–14
1–2 years ½ 1 15–24
3–6 years 1 2 25–34
7–11 years 2 4 35–49
12–14 years 3 4 35–49
≥15 years 3 6 >50

Table 14.6.1.1C. Artesunate and Mefloquine Dosage for Falciparum Cases

(Second Line)

Dose (in mg) (Number of Tablets)

Artesunate (50 mg tablets) Mefloquine (250 mg tablet)
Age Day 1 Day 2 Day 3 Day 1 Day 2 Day 3
≥5–11 months 25 (½) 25 (½) 25 (½) — 125 (½) —

≥1–6 years 50 (1) 50 (1) 50 (1) — 250 (1) —

≥7–13 years 100 (2) 100 (2) 100 (2) — 500 (2) 250 (1)
>13 years 200 (4) 200 200 — 1,000 (4) 500 (2)

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yy Doxycycline 3.5 mg/kg once a day for 7 days

OR
yy Clindamycin 10 mg/kg 3 times/day for 7 days
PLUS
yy Stat dose of primaquine (0.75/kg body weight) as a single dose on day 1.
See table 14.6.1E for dosages.
ƒƒ For second-line treatment (alternative B), give—
yy Artesunate (50 mg tablet). See table 14.6.1.1F for dosages.
PLUS
yy Clindamycin 10 mg/kg 3 times/day.

Table 14.6.1.1D. Quinine Sulphate Dosage for Falciparum Cases (Second Line,
Alternative A)

Age Morning Midday Afternoon

<1 year ¼ tablet (75 mg) ¼ tablet (75 mg) ¼ tablet (75 mg)
1–2 years ½ tablet (150 mg) ½ tablet (150 mg) ½ tablet (150 mg)
3–6 years ½ tablet (150 mg) 1 tablet (300 mg) ½ tablet (150 mg)
7–11 years 1 tablet (300 mg) 1 tablet (300 mg) 1 tablet (300 mg)
10–14 years 1 tablet (300 mg) 2 tablets (600 mg) 1 tablet (300 mg)
>15 years 2 tablets (600 mg) 2 tablets (600 mg) 2 tablets (600 mg)

Table 14.6.1E. Stat Dose of Primaquine for Falciparum Cases (Second Line,
Alternative A)

Age Dose Weight

<6 months 0 6–10 kg
6–11 months ½ tablet (7.5 mg) 11–14 kg
1–2 years ½ tablet (7.5 mg) 15–24 kg
3–6 years 1 tablet (15 mg) 25–34 kg
7–11 years 2 tablets (30 mg) 35–49 kg
12–14 years 3 tablets (45 mg) 35–49 kg
≥15 years 3 tablets (45 mg) ≥50 kg

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Table 14.6.1.1F. Artesunate Dosage for Falciparum Cases (Second Line,

Alternative B)

Dose (in mg) (Number of Tablets)

Age Day 1 Day 2 Day 3
≥5–11 months 25 (½) 25 (½) 25 (½)
≥1–6 years 50 (1) 50 (1) 50 (1)
≥7–13 years 100 (2) 100 (2) 100 (2)
>13 years 200 (4) 200 (4) 200 (4)

14.6.1.2 Severe Falciparum Malaria

Description
Severe falciparum malaria is acute falciparum malaria with signs of severity,
evidence of vital organ dysfunction, or both. It usually occurs as a result of delay
in treating an uncomplicated attack of falciparum malaria. Sometimes, however,
especially in children, severe malaria may occur very rapidly. Recognizing and
promptly treating uncomplicated P. falciparum malaria is therefore of vital
importance. If severe falciparum malaria is left untreated, mortality is 100%.

For severe malaria (caused only by falciparum), the symptoms are—

ƒƒ High fever
ƒƒ Neurological signs (indicating cerebral malaria)
ƒƒ Impaired consciousness (prostration, drowsiness, delirium, disorientation,
coma)
ƒƒ Seizures
ƒƒ Abnormal posturing and cognitive impairment in children
ƒƒ Severe anaemia (especially in children)
ƒƒ Renal dysfunction (rare in children): oliguria, anuria, in the absence of
signs of dehydration or after adequate rehydration
ƒƒ Hypoglycaemia (frequent in children and pregnant women)
ƒƒ Pulmonary oedema (particularly in adults)
ƒƒ Respiratory distress: dyspnoea (i.e., slow, deep breathing)
ƒƒ Haematuria or very dark red urine
ƒƒ Jaundice (check mucosa of mouth, conjunctiva, and palms)
ƒƒ Circulatory collapse: cold extremities, weak pulse, slow skin recolouration
time, cyanosis

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Diagnosis
Diagnosis of severe falciparum malaria is based on the following clinical and
laboratory findings.

Clinical findings—
ƒƒ Impaired consciousness or coma; hallucinations with disorientation in
time, place, or person
ƒƒ Prostration (i.e., unable to stand, walk, or sit without assistance)
ƒƒ Unable to swallow
ƒƒ Convulsions, >2 episodes in 24 hours
ƒƒ Respiratory distress (acidotic breathing)
ƒƒ Circulatory collapse (systolic BP <70 mmHg in adults; <50 mmHg in
children)
ƒƒ Clinical jaundice plus evidence of other vital organ dysfunction
ƒƒ Haemaglobinuria (as distinct from haematuria)
ƒƒ Blood-shot eyes or subcutaneous bleeding
ƒƒ Pulmonary oedema
Laboratory findings (in addition to identification of the parasite)—
ƒƒ Hypoglycaemia (blood glucose <40 mg/dL)
ƒƒ Severe normocytic anaemia (Hb<7 g/dL, PCV <15%)
ƒƒ Haemaglobinuria
ƒƒ Serum creatinine >265 µmol/L

Referral
ƒƒ Refer any patient with severe falciparum malaria to the hospital
immediately.
ƒƒ Give the patient the first dose of one of the following before referral (unless
the referral time is <6 hours):
yy Quinine IM
OR
yy Artemether IM
ƒƒ In young children (<5 years), the use of rectal artesunate (10 mg/kg) has
been shown to reduce the risk of death and permanent disability.
ƒƒ For more detailed information, consult National Treatment Guidelines for
Malaria (Guyana Ministry of Health 2013).

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14.6.2 P. vivax Infection

ƒƒ For first-line treatment, give—
yy Chloroquine (150 mg base/tablet) at a dose of 25 mg/kg (base) for 3 days.
See table 14.6.2A for dosages.
PLUS
yy Primaquine at a dose of 0.25 mg/kg daily for 14 days. See table 14.6.2B
for dosages.

Table 14.6.2A. Dosage Regimen for Chloroquine for P. vivax Infection (First Line)

Number of Tablets
Age Weight (in kg) Day 1 Day 2 Day 3
<6 months <6 ¼ ¼ ¼
6–11 months 6–10 ½ ½ ½
1–2 years 11–14 1 ½ ½
3–6 years 15–24 1 1 1
7–11 years 25–34 2 1½ 1½
12–14 years 35–49 3 2 2
>15 >50 4 3 3

Table14.6.2B. Daily Dosing for Primaquine for P. vivax Infection (First and
Second Line)

Age Daily Dose (15 mg tablets) Daily Dose (7.5 mg tablets)

<6 months 0 0
6–11 months ¼ 1
⁄3
1–2 years ¼ 1
⁄3
3–6 years ½ 2
⁄3
7–11 years 1 1 ⁄3
1

12–14 years 1 1½
≥15 years 1 2

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ƒƒ For second-line treatment, give—

yy Artemether-lumefantrine for 3 days. See table 14.6.2C for dosages.
PLUS
yy Primaquine for 14 days as per prescribed guidelines only.

Table 14.6.2C. Artemether-Lumefantrine Dosage for P. vivax Infection

(Second Line)

Number of Tablets at Approximate Timing of Dosing Body

Age Weight
(in years) 0h 8h 24 h 36 h 48 h 60 h (kg)
<3 1 1 1 1 1 1 5–14
≥3–8 2 2 2 2 2 2 15–24
≥9–14 3 3 3 3 3 3 25–34
>14 4 4 4 4 4 4 >34

14.6.3 P. malariae Infection

The recommended treatment for P. malariae is—
ƒƒ The standard regimen of chloroquine at 25 mg/kg (base) divided over
3 days. See table 14.6.2A for dosages.
PLUS
ƒƒ Primaquine for 7 days as per the prescribed guidelines only.

14.6.4 Mixed Infections

Table14.6.4. Treatment of Mixed Infections

To review the doses of each medicine used for the treat-

ment of mixed infections, see tables above Table Number
Falciparum + malariae: artemether-lumefantrine + 14.6.1.1A, 14.6.2A, 14.6.2B
chloroquine (3 days) + primaquine (7 days)
Vivax + malariae: chloroquine (3 days) + primaquine 14.6.2A, 14.6.2B
(14 days)
Falciparum + vivax + malariae: artemether-lumefantrine + 14.1.1A, 14.6.2A, 14.6.2B
chloroquine (3 days)+ primaquine (14 days)
Falciparum + vivax: artemether-lumefantrine + 14.6.1.1A, 14.6.2A, 14.6.2B
chloroquine (3 days) + primaquine (14 days)

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13.6.5 Malaria in Pregnancy

Description
Malaria in pregnancy is associated with low birth weight, foetal death,
premature labour, anaemia, and increased risk of severe malaria. Therefore,
all pregnant women living in malaria endemic areas should have a malaria
smear at each prenatal check-up and, if positive, should start treatment with
antimalarials promptly. Monitor with smears on days 1, 3, 6, and 14.

In addition, all pregnant women who present with a fever or who are from or
have visited a malaria endemic area require a malaria smear and treatment if the
smear is positive.

If the woman first presents at a health post, the community health worker should
commence oral therapy immediately and refer her to the health centre where
she can be seen by a Medex or doctor. After assessment, and recommended
observation, the doctor or Medex can seek expert obstetric advice. If severe
malaria is suspected, the pregnant woman should start treatment with
parenteral antimalarials and be transferred to Georgetown Public Hospital
immediately.

Pharmacological management of uncomplicated P. falciparum malaria

ƒƒ If the woman is in the first trimester of her pregnancy, give—
yy Quinine (300 mg tablet) 600 mg PO, 3 times/day (or 450 mg if the patient
weighs <50 kg)
PLUS
yy Clindamycin (150 mg, 300 mg tablet) 450 mg PO3 times/day (or 300 mg
if the patient weighs <50 kg) for 7 days
ƒƒ If the woman is in the second or third trimester of her pregnancy, give
Coartem (20 mg artemether + 120 mg lumefantrine) as shown in table
14.6.5.

Table 14.6.5. Coartem Dosage in Pregnancy

Number of Tablets and Approximate Timing of Dosing Body

Age weight
(years) 0h 8h 24 h 36 h 48 h 60 h (kg)
9–14 3 3 3 3 3 3 25–34
≥15 4 4 4 4 4 4 >34

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Referral
ƒƒ Persons with HIV stage 3 or 4
ƒƒ Patient with excessive vomiting
ƒƒ Patients showing no improvement
ƒƒ All cases of severe malaria

References—1, 164
See also—information on malaria in Guyana at http://www2.paho.org/hq/
dmdocuments/2011/PAHO_ENG_Malaria_LR.pdf (pg 156-166)

14.7 Mumps
Description
Mumps is an acute viral infection that usually spreads through saliva and can
infect many parts of the body, especially the parotid salivary glands. Involvement
of other salivary glands and the gonads is also common. Patient is infectious
from 3 days before parotid swelling to 7 days after it started.

Signs and symptoms

The signs and symptoms of mumps appear 2–3 weeks after exposure and
include—
ƒƒ Fever
ƒƒ Pain on opening the mouth, swallowing, or eating
ƒƒ Loss of appetite
ƒƒ Body aches

Both the left and right parotid glands may be affected, with one side swelling
a few days before the other, or only one side may swell. The tender swelling
appears below the ears at the angle of the jaw and starts about 2 days after the
onset of the initial symptoms. The swelling disappears in about 7–10 days.

Among post-pubertal males, the testes may become infected. Usually one testicle
becomes swollen and painful about 7–10 days after the parotids swell and is
accompanied by—
ƒƒ A high fever
ƒƒ Shaking chills
ƒƒ Headache

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ƒƒ Nausea and vomiting

ƒƒ Abdominal pain that can sometimes be mistaken for appendicitis if the
right testicle is affected

The testes may become enlarged to several times its normal size (orchitis).

Encephalitis and meningitis are rare complications of mumps.

Management objective
Provide symptomatic treatment

Nonpharmacological management
ƒƒ Advise bed rest during febrile period.
ƒƒ Isolate the patient until swelling subsides; application of warm or cold
compresses to the swelling may be helpful.
ƒƒ Advise the patient, parent, or caregiver on oral hygiene.
ƒƒ Recommend plenty of fluids and soft food during the acute stage.
ƒƒ For testicular pain, suggest cold compresses and support to the scrotum.
ƒƒ Children may return to school 1 week after initial swelling.

Pharmacological management
Give paracetamol (500 mg tablets; 120 mg/5 mL suspension) to relieve pain and
fever. See table 14.7 for dosages. Do not give aspirin.

Table 14.7. Paracetamol Dosages by Age and Weight for the Management of
Mumps

Age Weight Dose (mg) Quantity Frequency Duration

3–12 months 6–10 kg 60 2.5 mL (½ tsp) 3 times/day 5–7 days
1–5 years 10–18 kg 120 5 mL (1 tsp) 3 times/day 5–7 days
5–8 years 18–25 kg 240 10 mL (2 tsp) 3 times/day 5–7 days
or ½ tablet
8–14 years 25–50 kg 500 1 tablet 3–4 times/day 5–7 days
>14 years >50 kg 1,000 2 tablets 3–4 times/day 5–7days
and adults

Caution: Acetylsalicylic acid (aspirin) is not recommended for children <12 years
old because of the risk of Reye’s syndrome.

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Referral
ƒƒ High fever
ƒƒ Severe headache, stiff neck, and drowsiness (suspect meningitis)
ƒƒ Abdominal pain (suspect pancreatitis)
ƒƒ Painful testes or orchitis
ƒƒ Suspected encephalitis

References—1, 8, 165, 166

14.8 Tuberculosis
Description
TB is a potentially fatal contagious disease that can affect almost any part
of the body but is mainly an infection of the lungs. Caused by a bacterial
microorganism, the tubercle bacillus or Mycobacterium tuberculosis, TB is
spread by droplet infection from a patient with infectious pulmonary TB through
coughing, sneezing, spitting, singing, or speaking. TB can be treated, cured, and
prevented if persons at risk take certain medicines. Few diseases have caused so
much distressing illness for centuries and claimed so many lives.

Risk factors
The following groups are at risk to contract TB.
ƒƒ Persons in close, frequent, or prolonged contact with an infected person
ƒƒ Persons who live or spend time in certain congregated or institutionalized
settings such as—
yy Prisons, jails, and correctional facilities
yy Group homes or facilities for the elderly
yy Shelters for homeless persons
yy Acute inpatient and outpatient care facilities
yy Overcrowded habitations
ƒƒ Persons who live or work in a country that has a high prevalence of TB
ƒƒ The elderly
ƒƒ Children <5 years
ƒƒ HIV-infected persons (21–34 times more likely to become infected)
ƒƒ Alcoholics
ƒƒ Intravenous drug abusers

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ƒƒ Smokers
ƒƒ Persons who have certain medical conditions such as—
yy Silicosis
yy Diabetes mellitus
yy Chronic renal failure or on haemodialysis
ƒƒ Persons who are underweight or malnourished

Signs and symptoms

ƒƒ The general symptoms of TB disease (pulmonary or extrapulmonary)
include—
yy Fever and night sweats
yy Listlessness, weakness, malaise
yy Loss of appetite
yy Weight loss
ƒƒ Pulmonary TB in a child presents with—
yy Enlarged painless lymph nodes (especially in the neck)
yy Unexplained fever for >2 weeks
yy Unexplained weight loss or failure to thrive
yy Hepatosplenomegaly or ascites
yy Chronic unremitting cough for >14 days
ƒƒ Pulmonary TB in an adult presents with a persistent, productive cough for
≥2 weeks and sometimes—
yy Haemoptysis (coughing up blood)
yy Chest pains when coughing or breathing
yy Shortness of breath
yy Enlarged lymph nodes in neck for >3 weeks
yy Clubbing of the fingers
ƒƒ The signs and symptoms of extrapulmonary TB depend on the site or organ
affected and include—
yy Lymphadenopathy
yy Pleural effusion (difficulty in breathing and dullness to percussion)
yy Pericarditis (fever and dull retrosternal pain)
yy Dry cough and hepatosplenomegaly (miliary TB)
yy Headache, meningismus, impaired consciousness (TB meningitis)
yy Deformity, bone pain, abscess, osteomyelitis (TB of the spine and bones)

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Diagnosis
ƒƒ Comprehensive history (very important), which should include the
patient’s—
yy Contacts
yy Medical history
yy Occupation
yy Living environment
ƒƒ Physical examination
ƒƒ Tuberculin skin test (TST or Mantoux) (see table 14.8A)
ƒƒ Chest x-ray
ƒƒ Sputum microscopy (3 tests: immediate sample, overnight sample, and spot
test at return visit). At least one positive sputum smear by microscopy is
sufficient to establish the diagnosis of TB and initiate treatment.
ƒƒ Smear-negative plus clinical evidence, radiological evidence, or both. (CXR
is indicated only when there are ≥2 AFB, severe haemoptysis, severe illness,
or exposure.)
ƒƒ Sputum culture in cases of—
yy Sputum smear-negative for TB
yy TB defaulters
yy TB treatment failures or relapse
yy Persons exposed to MDR/XDR TB cases
yy Patients who have DM and are HIV positive
yy Medicine sensitivity (in suspected multidrug resistance)
ƒƒ CXR (pleural effusion may be present)

Management objectives
ƒƒ Start treatment as soon as possible and effect cure
Note: Treatment can be ambulatory or hospital based depending on the
patient’s condition.
ƒƒ Ensure compliance with treatment
ƒƒ Prevent relapse of TB
ƒƒ Decrease risk of transmission to others
ƒƒ Prevent the development of acquired resistance to anti-TB medicines
ƒƒ Organize DOTS for all patients on treatment
ƒƒ Identify and treat the source or index case

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Table 14.8A. Interpretation of the Tuberculin Skin Tests

Size of Induration Interpretation

0 mm Uninfected
Anergy
≥5 mm Positive in—
yy HIV-infected individuals
yy Persons with fibrotic changes on chest x-rays consistent
with prior TB
yy Recipients of organ transplants and those on chronic
immunosuppressive therapy
≥10 mm Positive in—
yy Residents and workers of high-risk settings including
health care workers, laboratory personnel, and inmates of
detention facilities
yy Illicit drug users
yy Children <5 years of age
yy Children, adolescents, and adults exposed to an infectious
adult TB case
≥15 mm Positive in a person with no history of contact
Note: Reactivity in adults due to BCG given in infancy is often <10 mm (ATS/CDC).

Nonpharmacological management
ƒƒ Screen all contacts for tuberculosis infection.
ƒƒ Advise patient on rest and diet.
ƒƒ Provide HIV counselling and testing.

Pharmacological management
Start patient on anti-TB medicines (table 14.8B).

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Table 14.8B. Essential Anti-TB Medicines

Recommended Doses (mg/kg)

Medicines Mode of Action Daily 3 Times/Week
Isoniazid (H) Bactericidal 5 (4–6) 10 (8–12)
Rifampicin (R) Bactericidal 10 (8–12) 10 (8–12)
Pyrazinamide (Z) Bactericidal 25 (20–30) 35 (30–40)
Ethambutol (E) Bacteriostatic 15 (15–20) 30 (20–35)
Streptomycin (S) Bactericidal 15 (12–18) 15 (12–18)
New patient: —
ƒƒ New smear PTB 2 HRZE 4 HR
ƒƒ New smear with extensive 4 H3R3
lung involvement
ƒƒ Severe extrapulmonary TB 6HE

ƒƒ For new smear–positive and new smear-negative pulmonary TB give—

yy Isoniazid (100 mg, 300 mg tablets) 5 mg/kg daily for 2 months
PLUS
yy Rifampicin (150 mg, 300 mg tablets or capsules) 10 mg/kg daily for 2
months
PLUS
yy Pyrazinamide (500 mg tablet) 25 mg/kg daily for 2 months
PLUS
yy Ethambutol (400 mg tablet) 15 mg/kg daily for 2 months
ƒƒ If the patient is in a DOTS programme, the following regimen may be used
instead (summarized in table 14.8C)—
yy Isoniazid (100 mg, 300 mg tablets) 10 mg/kg 3 times/week for 2 months
PLUS
yy Rifampicin (150 mg, 300 mg tablets or capsules) 20 mg/kg 3 times/week
for 2 months
PLUS
yy Pyrazinamide (500 mg tablet) 50 mg/kg 3 times/week for 2 months
PLUS
yy Ethambutol (400 mg tablet) 30 mg/kg 3 times/week for 2 months
FOLLOWED BY

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yy Isoniazid (100 mg, 300 mg tablets) 5 mg/kg daily for 4 months

OR
yy Isoniazid (100 mg, 300 mg tablets) 10 mg/kg 3 times/week for 4 months
PLUS
yy Rifampicin (150 mg, 300 mg tablets or capsules) 10 mg/kg daily for 4
months
OR
yy Rifampicin (150 mg, 300 mg tablets or capsules) 20 mg/kg 3 times/week
for 4 months
Note: A 3 times/week regimen must be used with patients in a DOTS
programme only.
ƒƒ Patients with HIV co-infection (see below) must be put on a daily regimen.

Table 14.8C. Fixed-Dose Combinations for Patients on DOTS

Strength for Use on

Medicine Strength for Daily Use the 3 Times/Week Regime
HRZE 75 + 150 + 400 + 275 —
HRE 75 + 150 + 400 150 + 150 + 400
30 + 60 + 150
HR 75 +150 150 + 150
150 + 300 60 + 60
30 + 60
HE 150 + 400 —

ƒƒ Obtain sputum for AFB at the end of the second month.

yy If the sputum is smear-negative and the patient is clinically better,
change to the continuation phase.
yy If the sputum is still smear-positive, send the sputum for culture as well
as DST, and initiate the continuation phase.
yy Obtain sputum for AFB at the end of the fifth month.
yy If the sputum is smear-negative, continue the second or continuation
phase of therapy.
yy If the sputum is smear-positive, stop treatment, start re-treatment
therapy, and label as treatment failure. Obtain sputum for AFB culture
and DST.

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ƒƒ Prophylaxis.TB infection prophylaxis is used in three types of cases:

yy Persons, especially children <5 years, who have close contact with a
recently diagnosed smear-positive patient
yy HIV-positive patients (children and adults)
yy Persons who have a positive TST or a positive blood assay for
mycobacterium TB.
ƒƒ Medicines to treat TB infection. Isoniazid combined with vitamin B6 is
the regimen of choice to treat TB infection (table 14.8D). The vitamin B6
is used to prevent peripheral neuropathy. If INH is not tolerated or if the
index case is INH-resistant, rifampicin daily for 4 months is the regimen
of choice. INH and rifampicin are both recommended and tolerated during
pregnancy and breastfeeding. Some experts recommend, however, delaying
INH for pregnant women with a low risk of progression to active TB until
after delivery.

Table 14.8D. Treatment of TB Infection

Dosage
Medicine Adults Children Duration
Isoniazid (INH) 300 mg daily 5 mg/kg HIV-negative: 6 months
HIV-positive: 9 months
Vitamin B6 25–50 mg daily 10 mg/kg (not to HIV-negative: 6 months
exceed 300 mg) HIV-positive: 9 months
Rifampicin (R) 600 mg daily 15 mg/kg daily Adults: 4 months
(if INH not (not to exceed Children and
tolerated) 600 mg) immunosuppressed
persons: 6 months

ƒƒ Coinfection. Guidelines for TB-HIV coinfection are addressed in the

National Guidelines for the Management of HIV-Infected and HIV-Exposed
Adults and Children (pp. 82–3).
ƒƒ Follow up.
yy Educate the patient on the following—
ŠŠ What TB is
ŠŠ How TB is spread
ŠŠ What can be done to limit the spread of TB

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ŠŠ Curability of TB
ŠŠ What medications are used and for how long
ŠŠ How treatment is to be followed
ŠŠ Expected side effects of medications
yy Monitor the nutritional status of the patient, especially children.
yy Enroll the patient in a DOTS programme to ensure adherence to
treatment regimen.
yy Stress the need for regular clinic attendance.
yy Report all missed appointments to the DOTS supervisor.
ƒƒ Monthly case monitoring
yy At each monthly follow-up visit, measure the patient’s vital signs (i.e.,
temperature, respiratory rate, BP, yearly weight and height for adults,
and monthly weight and height for children and adolescents).
yy Assess the patient’s response to treatment (i.e., signs and symptoms,
appetite and weight changes), and document them at each visit.
yy Determine the patient’s adherence to treatment.
yy Assess the patient for any adverse effects of the medication.

Referral
ƒƒ At the health centre level, all persons newly diagnosed with TB, for
confirmation
ƒƒ All HIV-positive patients, to an HIV care centre
ƒƒ All smear-negative cases with severe pulmonary involvement or suspected
extrapulmonary TB

References—1, 3, 10, 167, 168

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14.9 Typhoid (Enteric Fever) and Salmonella Infections

Description
Typhoid is an acute life-threatening systemic disease characterized by
persistent high-grade fever (>38°C) and abdominal pain.

Causes and risk factors

ƒƒ Salmonella typhi causes typhoid. The bacteria survives only in humans.
ƒƒ More than 95% of all transmission occurs through food, especially eggs.
ƒƒ Water contaminated by faeces from an infected person carries the disease.
ƒƒ Symptoms are most severe in the elderly, infants, and those who have an
existing illness.
ƒƒ AIDS patients are frequently affected and have recurrences.

Signs and symptoms

ƒƒ Initial signs and symptoms:
yy Prolonged or high fever (38.8–40.5ºC), with profuse sweating, in a
previously healthy individual, lasting>1 week; the person may become
delirious
yy A slower pulse rate than expected with the level of fever
yy Headache and possible convulsions
yy Malaise and anorexia
yy Abdominal pain possible
yy In the first week, constipation
yy Diarrhoea possible later in the illness; may be accompanied by frank
bleeding
ƒƒ Signs of complications
yy Intestinal perforation—abdominal tenderness, with sudden increase in
pulse rate and hypotension
yy Altered mental status
yy Deafness

Diagnosis
Confirmation is only by stool culture or blood tests (Widal). Repeat the test 4–6
weeks after the start of treatment to certify that the patient is S. typhi free.

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Management objectives
ƒƒ Reduce the fever
ƒƒ Prevent dehydration
ƒƒ Prevent the spread of the disease in the community

Nonpharmacological management
ƒƒ Encourage the use of fluids. Give ORS, if necessary, or initiate IV infusion.
ƒƒ Ensure appropriate nutrition.
ƒƒ Bathe the patient with tepid water, or sponge him or her with a cool cloth to
reduce the fever.
ƒƒ Discuss the importance of good personal hygiene with the patient. Advise
the patient to wash his or her hands thoroughly—
yy After using the toilet
yy Before eating
ƒƒ Keep the patient isolated for the duration of the illness.
ƒƒ Disinfect the patient’s clothing.
ƒƒ Institute the following control measures:
yy Educate the patient and the family on hand washing, safe sewage
disposal, safe drinking water, and food safety.
yy Urge the patient and the family to control flies by reducing and
eliminating breeding sites and to protect food or food utensils from
contact with flies.
yy Identify and treat all carriers

Pharmacological management
ƒƒ For fever and pain, give paracetamol (500 mg tablets; 120 mg/5 mL
suspension). See table 14.9 for dosages. Do not give aspirin.
Caution: Acetylsalicylic acid (aspirin) is not recommended for children
<12 years old because of the risk of Reye’s syndrome.

ƒƒ Give an antibiotic: ciprofloxacin (200 mg, 500 mg tablets; 2 mg/5 mL

injection)
yy Adults: PO (500 mg tablets) one tablet 2 times/day for 3 weeks
yy Children: 30 mg/kg/day in 2 divided doses for 5–7 days
Caution: Do not use ciprofloxacin in pregnant or lactating women.

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Table 14.9. Paracetamol Dosages by Age and Weight for the Management of
Fever and Pain in Typhoid

Age Weight Dose (mg) Quantity Frequency Duration

3–12 6–10 kg 60 2.5 mL (½ tsp) 3 times/day 5–7 days
months
1–5 years 10–18 kg 120 5 mL (1 tsp) 3 times/day 5–7 days
5–8 years 18–25 kg 240 10 mL (2 tsp) 3 times/day 5–7 days
or ½ tablet
8–14 years 25–50 kg 500 1 tablet 3–4 times/day 5–7 days
>14 years >50 kg 1,000 2 tablets 3–4 times/day 5–7days
and adults

Referral
ƒƒ All known or suspected cases. Initiate treatment in remote areas while
waiting to arrange transfer.
ƒƒ Patients who have a high fever and altered state of consciousness
ƒƒ Patients who have signs of intestinal bleeding or perforation

References—1, 10, 169, 170, 171

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15. Gynaecology

15.1 Dysmenorrhoea
Description
Dysmenorrhoea is severe or incapacitating uterine cramping just before or
during menstruation. It typically occurs in the first few years after menarche.

Classification
ƒƒ Primary—in the absence of disorders of the pelvis
ƒƒ Secondary—if associated with diseases of the pelvis

Causes and risk factors

Causes of secondary dysmenorrhoea
ƒƒ Infections of the pelvic organs (e.g., PID, see section 15.4)
ƒƒ Intrauterine contraceptive device (IUD)
ƒƒ Endometriosis
ƒƒ Fibroids
ƒƒ Malignancy
ƒƒ Malnutrition and anaemia

Risk factors
ƒƒ Early age at menarche
ƒƒ Long menstrual periods
ƒƒ Heavy menstrual flow
ƒƒ Smoking
ƒƒ Positive family history

Signs and symptoms

Primary dysmenorrhoea
ƒƒ Cramping or labour-like pain (lower abdominal pain)
ƒƒ Usual duration of 48–72 hours (often starting several hours before or just
after the menstrual flow)
ƒƒ Sometimes abdominal distention
ƒƒ Nausea and vomiting

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ƒƒ Diarrhoea
ƒƒ Headache
Suspect secondary dysmenorrhoea if—
ƒƒ Dysmenorrhea began after the age of 25.
ƒƒ Pelvic abnormality is found with physical examination. Consider
endometriosis, pelvic inflammatory disease, pelvic adhesions, and
adenomyosis.
ƒƒ The patient has little or no response to therapy with NSAIDs, oral
contraceptives, or both

Management objective
Provide symptomatic relief

Nonpharmacological management
Explain to the patient—
ƒƒ Dysmenorrhoea will occur with every period but could disappear with time
and age.
ƒƒ She will need to use medicines as prescribed.

Pharmacological management
ƒƒ Give NSAIDs: diclofenac OR ibuprofen.
ƒƒ Consider oral contraceptives if these fail.

References—1, 3, 10, 178

15.2 Abnormal Vaginal Discharge

Description
Normal vaginal discharge is clear, odourless, and related to normal cycle
changes. When the patient reports a change in the amount, consistency,
colour, and odour of the discharge, it is considered to be abnormal. It may be
accompanied by pain, itching, or burning.

Causes
ƒƒ Trichomonas vaginalis (an STI)
ƒƒ Candida albicans (a fungal infection)
ƒƒ Bacterial vaginosis

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ƒƒ Neisseria gonorrhoea (an STI)

ƒƒ Chlamydia trachomatis (an STI)

Signs and symptoms

ƒƒ Often asymptomatic
ƒƒ Vaginal discharge
ƒƒ Itching
ƒƒ Dysuria
ƒƒ Thick white plaques

Diagnosis
See table 15.2 for diagnostic information.

Table 15.2. Diagnosing Abnormal Vaginal Discharge

Vulvo-Vaginal
Feature Candidiasis T. vaginitis Bacterial Vaginosis
Aetiology C. albicans T. vaginalis Associated
with Gardnerella
vaginalis, various
anaerobic bacteria,
and mycoplasmas
Typical symptoms Vulvar itching, Profuse purulent Malodorous,
irritation, or both discharge; vulvular slightly increased
itching discharge
Inflammation of Erythema of Erythema of None
vulvar or vaginal vaginal epithelium, vaginal and vulvar
epithelium introitus; vulvar epithelium; colpitis
dermatitis common macularis
Discharge
Amount Scant Often profuse Moderate
Colour White White or yellow White or grey
Consistency Clumped; adherent Homogeneous Homogeneous, low
plaques viscosity; uniformly
coats vaginal wall

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Nonpharmacological management
Advise the patient:
ƒƒ Do not douche.
ƒƒ Use mild soap and water to cleanse vaginal area.
ƒƒ Do not use talcum powder and vaginal deodorants.
ƒƒ Use cotton underwear rather than synthetics.

Pharmacological management
All women who have abnormal vaginal discharge should receive systemic
treatment with metronidazole to cover T. vaginalis and bacterial vaginosis.
ƒƒ For T. vaginitis, give—
yy Metronidazole (250 mg tablet) 2 g as a single dose
yy In the event of treatment failure, give metronidazole 500 mg BID for 7
days.
ƒƒ For bacterial vaginosis, give metronidazole (250 mg tablet) 500 mg BID for
7 days.
ƒƒ For C. albicans, give clotrimazole pessaries (100 mg) once daily for 7 days
(per Harrison’s).

References—1, 3, 172

15.3 Abnormal Vaginal Bleeding

Description
Abnormal vaginal bleeding is any vaginal bleeding unrelated to normal
menstruation. It is characterized by increased vaginal blood flow in volume,
duration, or frequency. This type of bleeding may range from spotting of small
amounts of blood between periods—often seen on toilet tissue after wiping—to
heavy periods enough to soak a pad an hour for several hours. Bleeding that lasts
for weeks at a time is also considered abnormal. The blood loss typically arises
from the lining of the uterus but may arise from uterine or cervical lesions, the
vagina, or rarely from the fallopian tube.

Causes
Bleeding before the expected time of menarche could be a sign of precocious
puberty.

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ƒƒ Other possible causes include—

yy The presence of a foreign body in the vagina
yy Molestation
yy Vaginal infection and vaginitis
yy Rarely, a tumour
ƒƒ During pregnancy, it is usually, but not always, related to the pregnancy
itself. Abnormal vaginal bleeding can signal gynaecologic conditions and
other medical problems.
ƒƒ In premenopausal women, it may be due to disorders of menstruation,
hormonal imbalance, fibroids, infection, or cancer of cervix or uterus.
ƒƒ Postmenopausal bleeding may result from—
yy Replacement hormonal treatment
yy Endometritis
yy Polyps
yy Uterine or cervical cancer

Signs and symptoms

ƒƒ Bleeding from the vagina at an unexpected time or in an abnormal quantity
ƒƒ Lower abdominal pain possible

Diagnosis
The diagnosis can often be made on the basis of the patient’s time of life, her
bleeding history, a physical examination, and other medical tests as appropriate,
typically—
ƒƒ A pregnancy test and additional hormonal tests
ƒƒ VIA—should be offered to all women >30 years
ƒƒ Transvaginal ultrasound
ƒƒ CBC to check for anaemia—if bleeding was excessive or prolonged
ƒƒ Hysteroscopy with a biopsy or a dilation and curettage to investigate
abnormal endometrium

Management objectives
ƒƒ Determine and treat the cause
ƒƒ Treat anaemia if present
ƒƒ Replace blood if indicated

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Management
Management is dependent on the cause, most of which cannot be handled at the
primary health care level.

Nonpharmacological management
For premenopausal bleeding—
ƒƒ Assess current contraceptives used
ƒƒ Exclude pregnancy complication or an organic disease (e.g., fibroids)

Pharmacological management
ƒƒ Give a combined oral contraceptive pill. A fixed-ratio oestrogen plus
progesterone is available.
ƒƒ Give ibuprofen PO 200–400 mg every 8 hours with or after food PRN for
2–3 days. Ibuprofen may reduce blood loss in menorrhagia associated
with—
yy An intrauterine contraceptive device (IUD)
yy Menstruation following puberty when no ova are produced (i.e.,
anovulatory cycles)
If blood loss has been severe or the patient has signs of anaemia, give
ferrous sulphate PO 200 mg 3 times/day after food for 1 month.

Referral
ƒƒ Girls <12 years who have vaginal bleeding before the development of their
secondary sexual characteristics for investigation of other causes such as—
yy Sexual abuse
yy Foreign bodies
yy Tumours of the genital tract
ƒƒ Severe anaemia
ƒƒ Bleeding during pregnancy
ƒƒ Any postmenopausal bleeding

References—8, 174, 175

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15.4 Pelvic Inflammatory Disease

Description
Pelvic inflammatory disease (PID) refers to infection that ascends from the
cervix or vagina to involve the endometrium, the fallopian tubes, the ovaries,
or any combination of the three. It can lead to pelvic peritonitis, generalized
peritonitis, and pelvic abscess. Intrauterine infection can be primary (usually
sexually transmitted, usually chlamydia or gonorrhoea) or secondary to invasive
intrauterine surgical procedures, postpartum, or postabortion.

Signs and symptoms

Symptoms may be minimal to nonexistent. Symptoms suggestive of PID are—
ƒƒ Lower abdominal and pelvic pain
ƒƒ Fever
ƒƒ Painful intercourse
ƒƒ Vaginal discharge
ƒƒ Sometimes painful urination
ƒƒ Painful menstrual periods and abnormal vaginal bleeding
ƒƒ Sometimes nausea and vomiting

Diagnosis
Based on history and physical findings—
ƒƒ History of recent intercourse or of recent delivery, miscarriage, or abortion
ƒƒ Tenderness in adnexa
ƒƒ Abdominal rebound tenderness
ƒƒ Pain on movement of the cervix

Management objectives
ƒƒ Rule out conditions needing surgical intervention such as appendicitis,
ectopic pregnancy, or ovarian cyst
ƒƒ Start treatment as early as possible

Nonpharmacological management
ƒƒ Advise the patient to—
yy Get bed rest
yy Avoid sexual intercourse
ƒƒ Treat partner if sexual transmission suspected.

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Pharmacological management
Give—
ƒƒ Ceftriaxone IM (125 mg) 125 mg as a single dose (to be dispensed on the
advice of a physician)
PLUS
ƒƒ Doxycycline PO (100 mg tablet) 1 tablet, 2 times/day for 14 days
PLUS
ƒƒ Metronidazole PO (500 mg) 1 tablet, 2 times/day for 14 days

Referral
ƒƒ Patient who has fever and chills, foul-smelling vaginal discharge, or history
of recent delivery, miscarriage, or abortion (suggestive of puerperal sepsis)
ƒƒ Very ill patient
ƒƒ Patient who has a history of immunodeficiency
ƒƒ Pregnant patient
ƒƒ Surgical emergency
ƒƒ Uncertain diagnosis
ƒƒ Patient who is unable to follow outpatient treatment or unable to tolerate
oral medication
ƒƒ Patient who fails to respond after 72 hours of outpatient treatment

References—1, 10, 176

15.5 Vulvo-Vaginal Candidiasis

Description
Vulvo-vaginal candidiasis is an infection of the vulvo-vaginal mucous membrane
with C. albicans. It causes a smelly, thick, white-yellow discharge that might
be accompanied by itching, burning, and swelling. It can also make walking,
urinating or sex very painful. Women with uncontrolled DM, immuno-
compromised, pregnant or debilitated are more prone to contract the disease.
See section 8.3.4 for details and management.

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16. Neuropsychiatric Disorders

Mental disorders are common in medical practice and may present as a primary
disorder or as a co-morbid condition. Changes in health care delivery underscore
the need for primary care physicians and other health workers at the primary
care level to be able to recognize mental disorders and assume responsibility
for the initial diagnosis and treatment of the most common of these disorders.
Prompt diagnosis is essential to ensure that patients have access to appropriate
medical services and to maximize clinical outcome.

Patients should be referred on suspicion of diagnosis, and treatment should be

continued at primary level, if appropriate, after a definitive diagnosis has been
made and a treatment regimen has been instituted.

16.1 Anxiety Disorders

Description
Anxiety disorder is the most prevalent psychiatric illness in the general
population. The average age of onset is 12 years. It can indicate a primary
psychiatric condition or can be a component of, or reaction to, a primary medical
disease. It is associated with an increased risk of suicide, with rates of attempts
being 10 times higher than that in the general population.

Although it is normal to feel anxious from time to time, especially in stressful

situations, severe ongoing anxiety that interferes with day-to-day activities
may be a sign of generalised anxiety disorder. It may develop in childhood
or adulthood and needs to be distinguished from panic disorder, obsessive
compulsive disorder, and other anxiety disorders.

Classification
Anxiety disorders are classified according to their duration and course and to the
existence and nature of the things that precipitate the attack:
ƒƒ Generalised anxiety disorder
ƒƒ Obsessive-compulsive disorder
ƒƒ Panic disorder
ƒƒ Phobias

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ƒƒ Post-traumatic stress disorder

ƒƒ Separation anxiety
ƒƒ Childhood anxiety disorder

Causes and risk factors

Causes are not fully understood but may involve naturally occurring brain
chemicals (i.e., neurotransmitters), such as serotonin, dopamine, and
norepinephrine. It is likely that the condition has several causes that may
include genetics, life experiences, and stress.

Risk factors include—

ƒƒ Being female. More than twice as many women as men are diagnosed with
generalized anxiety disorder.
ƒƒ Experiencing a stressful life event. Children who endured abuse or
trauma, including witnessing traumatic events, are at higher risk of
developing generalized anxiety disorder at some point in life.
ƒƒ Illness. Having a chronic health condition or serious illness, such as cancer,
can lead to constant worry about the future.
ƒƒ Stress. A big event or a number of smaller stressful life situations may
trigger excessive anxiety.
ƒƒ Personality. People who have some personality types (e.g., extreme
shyness) are more prone to anxiety disorders than are others.
ƒƒ Genetics. Family history of anxiety or mental illness may be a risk factor.
ƒƒ Substance abuse. Drug or alcohol abuse can worsen generalised anxiety
disorder. Caffeine and nicotine also may increase anxiety.

16.1.1 Generalised Anxiety Disorder

Signs and symptoms
Generalised anxiety disorder is a persistent, excessive, or unrealistic worry
about small or large concerns, occurring more days than not for at least 6
months, associated with three or more of the following:
ƒƒ Muscle tension or muscle aches
ƒƒ Difficulty controlling the worry
ƒƒ Difficulty concentrating or mind going blank
ƒƒ Restlessness or feeling keyed up or on edge
ƒƒ Being easily fatigued

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ƒƒ Irritability
ƒƒ Difficulty falling or staying asleep or having restless or unsatisfying sleep,
leading to significant distress or impairment in social, occupational, or
other important areas of functioning

Diagnosis
Based on clinical grounds. Use the following screening questions:
ƒƒ Do you find yourself worrying a lot about several things in all areas of your
life?
ƒƒ Has anyone ever told you that you worry too much?
ƒƒ Do you have difficulty controlling worry?
yy Does it keep you from sleeping?
yy Does it keep you from working?
yy Does it cause any physical symptoms, such as headache, sweating,
increased heart rate, or muscle spasm?

Management objective
Prevent anxiety where possible

Nonpharmacological management
ƒƒ Advise the patient to seek cognitive behavioural therapy.
ƒƒ Recommend elimination of caffeine from diet.

Referral
All patients

References—177, 178

16.1.2 Obsessive-Compulsive Disorder

Description
Obsessive-compulsive disorder (OCD) is an anxiety disorder characterized by
persistent intrusive ideas, thoughts, impulses, or images (obsessions) that often
result in compulsive behaviour or performing rituals over and over again and
that impair everyday functioning. Typical compulsions are hand washing (fear
of germs), checking (e.g., lock checking), arranging things, and counting. These
actions give individuals with OCD, only temporary relief from their anxiety.
Even though many persons with OCD know that their compulsions are excessive

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they feel compelled to complete them. With early diagnosis and the right
treatment, people can avoid the suffering that comes with OCD.

OCD is equally likely to occur in both males and females, and the median age of
onset is 19 years. (According to Harrison’s Principles of Internal Medicine, it is
more common in males and first-born children.)There are four types of OCD:
ƒƒ Obsessions that are aggressive, sexual, religious, or harm-related combined
with checking compulsions
ƒƒ Obsessions about symmetry that are accompanied by arranging or
repeating compulsions
ƒƒ Obsessions of contamination that are associated with cleaning
compulsions
ƒƒ Symptoms of hoarding

Causes
The cause of OCD is thought to be genetic and is often associated with
depression, other anxiety disorders, and eating disorders.

Diagnosis
Based on clinical findings. Use the following screening questions:
ƒƒ Do you experience recurrent disturbing thoughts, images, or urges?
ƒƒ Do you ever have to perform a behaviour or repeat an action that you don’t
want to do in order to feel less anxious (e.g., washing hands over and over)?

Management objective
Reduce the compulsive behaviour

Nonpharmacological management
Cognitive behaviour therapy is used to treat OCD.
ƒƒ Gradual exposure to stressful situations
ƒƒ Maintenance of a diary to clarify stressors
ƒƒ Substitution of new activities for compulsive behaviours

Referral
Refer all patients with suspected disorder.

References—1, 177, 179, 180

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16.1.3 Panic Disorder

Description
Panic disorder is an anxiety disorder characterized by recurrent and
unpredictable panic attacks—episodes of intense fear and discomfort associated
with a variety of physical symptoms.

Causes and risk factors

The causes are unknown, but appear to involve—
ƒƒ Genetic predisposition
ƒƒ Social learning
ƒƒ Major stress
ƒƒ Temperament that is more susceptible to stress
ƒƒ Body’s natural fight-or-flight response to danger, in the absence of obvious
danger

Symptoms of panic disorder often start in the late teens or early adulthood and
affect more women than men. Factors that may increase the risk of developing
panic attacks or panic disorder include—
ƒƒ Family history of panic attacks or panic disorder
ƒƒ Significant stress
ƒƒ Death or serious illness of a loved one
ƒƒ Major changes in life, such as the addition of a baby
ƒƒ History of childhood physical or sexual abuse
ƒƒ Experiencing a traumatic event, such as an accident or sexual assault

Signs and symptoms

A panic attack is a period of intense fear or discomfort in which at least four of
the following develop and reach a peak within 10 minutes.
ƒƒ Palpitations, pounding heart, or increased heart rate
ƒƒ Sweating
ƒƒ Trembling or shaking
ƒƒ Shortness of breath
ƒƒ Feeling of choking
ƒƒ Chest pain or discomfort
ƒƒ Nausea or abdominal distress
ƒƒ Feeling dizzy, unsteady, light-headed, or faint
ƒƒ Fear of losing control or going crazy

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ƒƒ Fear of impending death

ƒƒ Numbness or tingling sensations
ƒƒ Chills or hot flashes

Diagnosis
Based on—
ƒƒ Recurrent unexpected panic attacks that are sudden, develop within 10
minutes, and resolve over the period of 1 hour
ƒƒ Worry about the occurrence of these symptoms for at least 1 month after
the attack and—
yy Persistent concern of having additional attacks
yy Worry about the implications of the attack or its consequences
yy A significant change in behaviour related to them

The frequency and severity of the panic attacks vary, ranging from once a week
to clusters of attacks separated by months of well-being.

Use the following screening questions:

ƒƒ Are there times when you experience a sudden rush of physical feelings
such as racing heart, feeling dizzy, or sick to your stomach?
ƒƒ If so, do you feel panicked or scared during these times?
ƒƒ Do the feelings come out of the blue, or are they related to something?
ƒƒ Do you avoid places or situations in which a panic attack might occur?

Check for and rule out cardiovascular, respiratory, endocrine, and neurological
conditions.

Management objective
Eliminate all panic attack symptoms

Nonpharmacological management
ƒƒ Cognitive behavioural therapy
ƒƒ Participation in a support group
ƒƒ Avoidance of caffeine, alcohol, and illegal drugs
ƒƒ Practicing stress management and relaxation exercises
ƒƒ Participating in regular physical activity
ƒƒ Getting sufficient sleep so as not to feel drowsy next day

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Referral
ƒƒ All patients with suspected diagnosis
ƒƒ Treatment must be continued until avoidance behaviour is overcome.
Typically therapy should be continued 8–12 months.

References—1, 177, 181, 182

16.1.4 Phobias
Description
A phobia is a marked and persistent irrational fear of an object, activity, or
situation, exposure to which results in an immediate anxiety reaction. Panic
attacks may be triggered by the phobia. Unlike with other anxiety disorders,
individuals with phobias usually experience anxiety only in specific situations.
If left untreated, a phobia may worsen until the person’s life is seriously affected,
both by the phobia itself and by the attempts to avoid or conceal it.

Types of phobias include—

ƒƒ Social anxiety disorder—for example, fear of public speaking or performing,
of meeting new people, or of other social situations
ƒƒ Agoraphobia—being in situations in which escape may be difficult (e.g.,
being in elevators, tunnels, public transport, or going to a restaurant)
ƒƒ Specific phobias—fear of particular items or situations such as—
yy Insects or animals
yy Heights
yy Flying
yy Enclosed spaces (claustrophobia)
yy Blood or needles

Causes and risk factors

Causes are unknown but are thought to be—
ƒƒ Familial
ƒƒ Cultural (i.e., type of upbringing [overly protected])

Risk factors include the following—

ƒƒ Women are four times more likely to suffer from agoraphobia than men.
ƒƒ Persons with a family history of a phobia are three times more likely to have
a phobia.

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ƒƒ Alcoholics can be up to 10 times more likely to suffer from a phobia than

those who are not alcoholics.

Signs and symptoms

Similar to that of having a panic attack

Diagnosis
Based on clinical history. Attack occurs in relation to a specific activity or
situation or in the presence of a particular object. Use the following screening
questions:
ƒƒ Are there specific objects or situations that make you fearful and trigger an
attack?
ƒƒ What are those objects or situations?
ƒƒ Do you try to avoid these objects or situations?
ƒƒ Does having to avoid these objects or situations cause interference with
your normal functioning?

Management objective
Control the response to the phobia

Nonpharmacological management
ƒƒ Cognitive behavioural therapy
ƒƒ Desensitisation to the triggering factors

Referral
All suspected cases

References—1, 177, 182

16.1.5 Post-Traumatic Stress Disorder

Description
A stress disorder is one in which a person may develop anxiety after exposure
to extreme traumatic events such as the threat of personal death or injury,
witnessing someone else’s life being put in danger, the death of a loved one, or
sexual or physical abuse. The reaction may occur shortly after the trauma (acute
stress disorder) or be delayed and become recurrent (post-traumatic stress
disorder [PTSD]).

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Causes and risk factors

The causes are unknown but may be associated with—
ƒƒ Inherited mental health risks, such as an increased risk of anxiety and
depression
ƒƒ Life experiences, including the amount and severity of trauma experienced
since early childhood
ƒƒ The inherited aspects of personality (i.e., temperament)

Risk factors include—

ƒƒ Past psychiatric history
ƒƒ Personality characteristics of high neuroticism and extroversion
ƒƒ Genetics (i.e., having a first-degree relative who has mental health problems
or depression)
ƒƒ Experiencing intense or long-lasting trauma such as combat exposure or
residence in a conflict area
ƒƒ History of sexual molestation or rape

Signs and symptoms

PTSD symptoms typically start within 3 months of a traumatic event and may
include—
ƒƒ Intrusive memory
yy Reliving the experience for minutes or even days at a time
yy Upsetting dreams about the traumatic event
ƒƒ Avoidance and emotional numbing
yy Trying to avoid thinking or talking about the traumatic event
yy Feeling emotionally numb
yy Avoiding activities once enjoyed
yy Hopelessness about the future
yy Memory problems
yy Trouble concentrating
yy Difficulty maintaining close relationships
ƒƒ Anxiety and increased emotional arousal
yy Irritability or anger
yy Overwhelming guilt or shame
yy Self-destructive behaviour, such as drinking too much
yy Trouble sleeping

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yy Being easily startled or frightened

yy Hearing or seeing things that are not there

Diagnosis
ƒƒ The person has been exposed to a traumatic event in which both of the
following were present:
yy The person felt that his or her life was in danger or witnessed someone
else’s life put in danger
yy The person experienced extreme fear, helplessness, and horror
ƒƒ The traumatic event is persistently re-experienced in ≥1 of the following
ways
yy Recurrent, intrusive, and distressing recollections of the event
yy Recurrent, distressing dreams or nightmares
yy Reliving the event, which causes psychological distress
ƒƒ Avoidance of things associated with the event, including ≥3 of the following:
yy Efforts to avoid thoughts, feelings, or conversations associated with the
trauma
yy Efforts to avoid activities, places, or people that cause recollection of the
trauma
yy Inability to recall aspects of the trauma
yy Decreased interest or participation in significant activities
yy Feeling detached or estranged from others
yy Restricted range of affect (e.g., unable to have loving feelings)
yy Sense of aforeshortened future (e.g., does not expect to have a career,
marriage, children, or a normal life span)
ƒƒ Persistent symptoms of increased arousal (not present before the trauma)
including ≥2 of the following:
yy Difficulty falling or staying asleep
yy Irritability or outbursts of anger
yy Difficulty concentrating
yy Hypervigilance
yy Exaggerated startle response
ƒƒ Duration of symptoms >1 month
ƒƒ The severity of the symptoms causes marked distress and impairment in
daily functioning

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Screening question: Are you bothered by memories or thoughts of a very

upsetting event that happened to you?

Management objectives
ƒƒ Help the patient gain control over his or her life
ƒƒ Help the patient feel better about him- or herself
ƒƒ Teach the patient ways to cope if symptoms arise

Nonpharmacological management
Cognitive behavioural therapy, including education, exposure, and cognitive
approaches

Referral
All suspected cases

References—1, 177

16.1.6 Childhood Anxiety Disorders

The same range of anxiety disorders experienced in adulthood can be
experienced during childhood and adolescence.

16.1.6.1 Generalized Anxiety Disorder

In addition to the general symptoms (see section 16.1.1), children and
adolescents may have excessive worries about—
ƒƒ Performance at school or sporting events
ƒƒ Being on time (punctuality)

A child with the disorder may also—

ƒƒ Feel overly anxious to fit in and worry about his or her relationship with
peers
ƒƒ Be a perfectionist
ƒƒ Lack confidence
ƒƒ Strive for approval
ƒƒ Require a lot of assurance and reassurance from others about performance

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16.1.6.2 Obsessive-Compulsive Disorder

Most children with OCD are diagnosed around age 10, although the disorder can
strike children as young as 2 or 3 years of age. Boys are more likely to develop
OCD before puberty; girls tend to develop it during adolescence.

OCD in children is characterized by—

ƒƒ Unwanted and intrusive thoughts (obsessions)
ƒƒ Feeling compelled to repeatedly perform rituals and routines
(compulsions)
ƒƒ Feeling compelled to redo tasks because they aren’t perfect the first time

16.1.6.3 Panic Disorder

Panic disorder is diagnosed if the child suffers at least two unexpected panic
or anxiety attacks followed by at least 1 month of concern over having another
attack and losing control or a sense of “going crazy.”

16.1.6.4 Post-traumatic Stress Disorder

Children most at risk for PTSD are those who—
ƒƒ Directly witnessed a traumatic or life-threatening event
ƒƒ Suffered directly (such as injury or the death of a parent)
ƒƒ Had mental health problems before the event
ƒƒ Lack a strong support network
ƒƒ Live with violence in the home

Children with PTSD may—

ƒƒ Have intense fear and anxiety
ƒƒ Become emotionally numb or easily irritable
ƒƒ Avoid places, people, or activities

Not every child who experiences or hears about a traumatic event will develop
PTSD. It is normal to be fearful, sad, or apprehensive after such events, and many
children will recover from these feelings in a short time.

16.1.6.5 Separation Anxiety

Description
Many children experience separation anxiety between 18 months and 3 years,
when it is normal to feel some anxiety when a parent leaves the room or goes

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out of sight. Separation anxiety disorder, however, is a mental health disorder

occurring during childhood and is characterized by worrying that is out of
proportion to the situation of temporarily leaving home or otherwise separating
from loved ones. Approximately 4%–5% of children and adolescents suffer from
separation anxiety disorder, which is most common in children ages 7–9. Usually
children can be distracted from these feelings.

Causes and risk factors

Separation anxiety disorder (as with most mental health conditions) is likely
caused by a combination of genetic and environmental vulnerabilities rather
than by any one thing. Risk factors include:
ƒƒ Family histories of anxiety
ƒƒ Mothers who were stressed during pregnancy
ƒƒ Overprotective or intrusive parenting behaviours

Signs and symptoms

ƒƒ Has inability to leave parent or another family member
ƒƒ Takes longer to calm down than other children in these circumstances
ƒƒ Cries when first being left at day-care or preschool
ƒƒ Refuses to go to school, camp, or a sleepover
ƒƒ Has extreme homesickness and feelings of misery at not being with loved
ones
ƒƒ Demands that someone stay with him or her at bedtime
ƒƒ Worries about bad things happening to his or her parents or caregivers
ƒƒ May have a vague sense of something terrible occurring while they are
apart

Diagnosis
Based on clinical history and observed behaviour of the child

Management objective
Start treatment early to avoid risk of developing depression and anxiety
problems, as well as personality disorders in later life.

Nonpharmacological management
Counselling, rather than medication, is the treatment of choice for separation
anxiety disorder that is mild in severity.

Reference—184

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16.2 Depression
Description
Depression is a medical illness resulting from a reduction in vitality and spirits
that affects the way one feels, thinks, and acts on a daily basis. It may occur in
association with, or part of, the presentation of many medical conditions such as
hormonal disease, autoimmune disorders, serious infections, and cancers, and it
may reflect the psychological stress of coping with the disease. It may be caused
by the disease process itself or by the medications used to treat it. According to
WHO, it is one of the top five major causes of disability in the world.

Classification
ƒƒ Major depressive disorder
ƒƒ Dysthymic disorder
ƒƒ Depressive disorder not otherwise specified

Causes and risk factors

The causes are not fully understood, but several factors are known to play a role
in its development.
ƒƒ Genetics—it can run in families and can be associated with a family history
of depression, alcohol abuse, or sociopathy
ƒƒ Gender—women are twice as likely to be affected
ƒƒ Age—Although depression is seen in children and adolescents, in the
Caribbean the age of onset is often in the late 20s.Biochemistry—related to
abnormalities of serotonin and norepinephrine in the brain
ƒƒ Personality—persons who have decreased self-esteem or who are
pessimistic or overwhelmed by stress
ƒƒ Environment—living in poverty, violence, neglect, abuse
ƒƒ Experience of childhood trauma—abuse or abandonment
ƒƒ Living with a chronic medical condition
ƒƒ Recent stressors—financial, legal, conflicts, death of a loved one, problems
at work, loss of employment, retirement, isolation, chronic illness
ƒƒ Medical conditions—acute physical illness or chronic issues (e.g., brain
tumour, vitamin deficiency)
ƒƒ Bereavement
ƒƒ Separation from family
ƒƒ Threats to life both of self and associates

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16.2.1 Major Depressive Disorder

Description
Depression is considered to be major when the mood persists for a minimum
duration of 2 weeks and five or more of the following signs and symptoms
(including one of the first two) are present most of the day or nearly every day.

Signs and symptoms

ƒƒ Depressed mood (i.e., feels sad or empty or is tearful)
ƒƒ Markedly diminished interest or pleasure in all or almost all activities
ƒƒ Sleep changes (i.e., insomnia or hypersomnia)
ƒƒ Significant weight loss or gain and appetite changes
ƒƒ Having little energy or feeling of fatigue
ƒƒ Feeling guilty or worthless
ƒƒ Emotional numbness or emptiness
ƒƒ Difficulty concentrating or indecisiveness
ƒƒ Moving or speaking slower than usual
ƒƒ Thinking that life is not worth living or having suicidal thoughts
ƒƒ Decreased ability to cope with stressful situations
ƒƒ Increased negative thought patterns

16.2.2 Dysthymic Disorder

Description
Dysthymic disorder is a depressed mood for most of the day, for more days than
not, for at least 2 years. In children and adolescents, mood can be irritable and
duration must be at least 1 year. The symptoms must never have been absent
for more than 2 months, and no major depressive episode occurred within the
first 2-year period. Two or more of the following signs and symptoms must be
present.

Signs and symptoms

ƒƒ Poor appetite or overeating
ƒƒ Insomnia or hypersomnia
ƒƒ Low energy or fatigue
ƒƒ Low self-esteem
ƒƒ Poor concentration or indecisiveness
ƒƒ Feeling of hopelessness.

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16.2.3 Depressive Disorders not Otherwise Specified

Diagnosis
Based on clinical findings—
ƒƒ The feelings start to interfere with the activities of daily living such as work
and family relationships.
ƒƒ Rule out general medical illness or drug abuse

Use the following screening questions:

ƒƒ In the past month, have you lost interest in the things you normally like to
do?
ƒƒ In the past month, have you felt sad, low, down, depressed, or hopeless?

If the patient answers yes to either of these questions, proceed with further
assessment.

Assess the patient’s suicide risk by asking the following questions:

ƒƒ Do you have feelings of hopelessness or feel that life is not worth living?
ƒƒ Do you have thoughts of committing suicide? If the answer is yes, follow up
by asking—
yy How much thought have you put into this?
yy Have you thought about the method you would use?
yy Do you have access to the materials required to commit suicide?
yy Have you said goodbyes, written a note, or started giving things away?
yy What is stopping you from following through with suicide?
ƒƒ Have you ever attempted suicide?

The patient should be monitored closely and treated if—

ƒƒ Suicidal thoughts are persistent.
ƒƒ The patient has a prior history of a suicide attempt or has a current plan.
ƒƒ The patient has several risk factors for suicide.

Management objectives
ƒƒ Improve the patient’s ability to function normally
ƒƒ Reduce the risk of suicide, self-neglect, and homicide
ƒƒ Eliminate all depressive symptoms
ƒƒ Manage any coexisting or co-morbid medical conditions
ƒƒ Eventual full remission
ƒƒ Prevention of recurrence

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Nonpharmacological management
ƒƒ Offer psychotherapy—supportive, cognitive, problem-solving, marital,
family, and group.
ƒƒ Provide education about the condition, and discuss self-management and
its goals.
ƒƒ Include family and friends in management.
ƒƒ Advise on regular meals and prevention or management of obesity.
ƒƒ Encourage the consumption of foods rich in tryptophan (e.g., bananas,
dates, raisins, and prunes).
ƒƒ Follow up.
yy See the patient monthly after he or she has started therapy and has been
referred back to the health centre.
yy Monitor the patient’s response, side effects, and compliance with
pharmacological management.

Referral
All patients for confirmation and diagnosis

References—1, 185, 186

16.3 Dementia
Description
Dementia is not a specific disease. It is a descriptive term for a collection of
symptoms that can be caused by a number of disorders that affect the brain. It is
defined as an acquired decline of cognitive function, presenting initially as loss
of memory and a failing of intellect that impairs the successful performance
of activities of daily living. Other mental faculties that may be affected are
language, visuospatial ability, calculation, judgment, and problem solving. The
common forms of dementia are progressive, but some illnesses are static or
fluctuate dramatically from day to day.

Causes and risk factors

The most common causes are—
ƒƒ Unknown (Alzheimer’s disease)
ƒƒ Vascular dementia (small or larger strokes)
ƒƒ Alcoholism (particularly in association with malnutrition)

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ƒƒ Vascular calcification (DM, high BP, high cholesterol, obesity)

ƒƒ Parkinson’s disease
ƒƒ HIV and AIDS

Risk factors include—

ƒƒ Aging—risk increases with each decade >50 (most significant risk factor)
ƒƒ Family history
ƒƒ Smoking
ƒƒ Arteriosclerosis
ƒƒ Hypertension
ƒƒ Alcoholism
ƒƒ Diabetes

Signs and symptoms

ƒƒ Memory loss (short and long term)
ƒƒ Decreased concentration
ƒƒ Loss of orientation to time and place
ƒƒ Depression, tearfulness
ƒƒ Withdrawal
ƒƒ Hallucinations
ƒƒ Delusion
ƒƒ Agitation, phobias
ƒƒ Insomnia or sleep rhythm disturbances
ƒƒ Purposeless behaviour

Diagnosis
ƒƒ Based on history, focusing on onset, duration, and rate of progression
yy Persons with two or more of the signs and symptoms above
yy Elderly person with slowly progressive memory loss (likely Alzheimer’s
disease)
ƒƒ A physical examination can help rule out treatable causes of dementia and
identify signs of stroke or other disorders that can contribute to dementia.
Rule out neurological and vascular problems.
ƒƒ Check for HIV.

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Management objectives
ƒƒ Determine whether the condition is reversible or irreversible
ƒƒ Treat reversible causes
ƒƒ Help alleviate burden on caregivers

Nonpharmacological management
ƒƒ Suggest intellectually stimulating activities such as crossword puzzles,
reading, or Sudoku.
ƒƒ Advise regular exercise.
ƒƒ Encourage the patient to avoid alcohol and stop smoking (see appendix 4).
ƒƒ Recommend following a healthy diet.

Pharmacological management
Continue medications for DM, hypertension, hypercholesterolemia, and HIV.

Referral
Refer all patients to the hospital for definitive diagnosis.

References—1, 3, 187, 188

16.4 Nonpsychiatric Disorders

16.4.1 Migraine
Description
A migraine is a benign and recurring syndrome of headache of varying severity,
with sudden onset that lasts 4–72 hours, is often unilateral, and is accompanied
by nausea and vomiting. Some migraines are preceded or accompanied by
sensory warning symptoms (aura), such as visual disturbance (e.g., flashing light
or brief loss of vision). Often the patient wants to be in a dark quiet room.

Causes and risk factors

ƒƒ Genetic
ƒƒ Family history (in 99% of cases)
ƒƒ Age (usually starts in adolescence but before age 40)

Precipitated by—
ƒƒ Foods—red wine and beer, aged cheeses, chocolate, monosodium glutamate
ƒƒ Hormonal changes in women—menses, pregnancy, menopause

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ƒƒ Hunger
ƒƒ Lack of sleep or excessive sleep
ƒƒ Severe exertion
ƒƒ Glare

Signs and symptoms

ƒƒ Unilateral headache, worse with physical activity
ƒƒ Severe, pulsating
ƒƒ Photophobia and phonophobia

Management objective
Relieve the headache

Nonpharmacological management
ƒƒ Order bed rest in a dark quiet area.
ƒƒ Advise the patient to determine then avoid trigger factors.

Pharmacological management
ƒƒ For a mild attack (take early in the attack), give—
yy Paracetamol (500 mg tablet), not to exceed 2 tablets per dose and 8
tablets in 24 hours
OR
yy Paracetamol + codeine (500 mg + 30 mg), not to exceed 2 tablets per dose
and 8 tablets in 24 hours
ƒƒ In moderate attack, give ergotamine + caffeine combination—
yy Take 1 tablet stat (when aura appears or first sign)
PLUS
yy ½–1 tablet every 2 hours, not to exceed 4 in 24 hours

Referral
Patients with severe and recurrent attacks

References—1, 3, 189

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16.4.2 Meningitis
Description
Meningitis is a disease caused by the inflammation of the protective membranes
covering the brain and spinal cord (i.e., the meninges). The inflammation is
usually caused by an infection of the fluid surrounding the brain and spinal cord.

Causes and risk factors

The causes of meningitis are—
ƒƒ Bacteria
yy Streptococcus pneumonia
yy Neisseria meningitides
yy Haemophilus influenza
yy Staphylococcus aureus
yy Gram-negative bacilli (E. coli)
yy TB, especially in HIV infection
ƒƒ Viruses
yy Enterovirus—Coxsackie
yy Herpes simplex
ƒƒ Fungi
yy Cryptococcus neoformans
yy Candida
yy Histoplasma

The risk factors for meningitis are—

ƒƒ Ear disease, especially in children
ƒƒ Upper respiratory tract infection
ƒƒ Skull base fracture
ƒƒ HIV and AIDS, particularly for Cryptococcus

Signs and symptoms

ƒƒ Children <1 year
yy Classic signs
yy Neck stiffness (Brudzinski’s and Kernig’s signs)
yy Bulging fontanel
yy Irritability
yy Weak cry

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yy Hypotonic (i.e., floppy)

yy Occasionally convulsions
ƒƒ Classic signs are often absent. Consider meningitis if the following signs
are present.
yy Poor sucking and refusal to eat
yy Fever
yy Diarrhoea and vomiting
yy Drowsiness
yy High-pitched cry
yy Unusual behaviour
yy Gaze turned upwards
yy Limp neck and bulging fontanel when not crying
ƒƒ Children >1 year and adults
yy Severe headache
yy Neck stiffness (Brudzinski’s and Kernig’s signs)
yy High fever (>38ºC) of sudden onset
yy Nausea and vomiting
yy General weakness and malaise
yy Loss of appetite
yy Photophobia
yy Change in behaviour
yy Altered level of consciousness or delirium
ƒƒ Severe form
yy Convulsions
yy Coma

Diagnosis
ƒƒ Based on history and clinical findings
ƒƒ LP-CSF for gram stain, culture, and sensitivity
ƒƒ If the patient is HIV positive, cryptococcal antigen test of CSF
ƒƒ In malaria areas, check for malaria.

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Management
Prompt treatment will improve the prognosis. If the diagnosis of meningitis
is suspected, refer the patient to hospital immediately. If immediate referral
is not possible, start presumptive treatment. Treatment will depend on the
most common causes. If a doctor is available at a health centre, an LP should be
performed before starting treatment. Do not do an LP in children if the patient
has—
ƒƒ Prolonged seizures
ƒƒ Papillary dilatation
ƒƒ Abnormal posture or movement
ƒƒ Papilloedema
ƒƒ Low pulse, elevated BP, and irregular respiration (i.e., signs of impending
brain herniation)

Pharmacological management
ƒƒ Start on treatment before transfer.
ƒƒ Give chloramphenicol (250 mg capsules; 125 mg/5 mL suspension)
yy Adults and teenagers: 12.5 mg/kg every 6 hours
yy Children:
ŠŠ <2 weeks old: 6.25 mg/kg every 6 hours
ŠŠ >2 weeks old: 12.5 mg/kg every 6 hours
ƒƒ Give ceftriaxone injection (500 mg, 1 g)
yy Adults: 2 g IV stat
yy Neonates, infants, and children: 100 mg/kg stat
ƒƒ In HIV-positive patients, give— fluconozole 400 mg PO twice daily

References—1, 3, 8, 190, 191

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1 7. S igns and S ymptoms

17. Signs and Symptoms

17.1 Abdominal Pain

Description
Abdominal pain can be defined as pain occurring anywhere in the abdomen.
Because of the many organs in the abdomen the pain can originate in different
anatomical systems. It can be acute, dull, or colicky. Any abdominal pain or
discomfort must be assessed according to its location, duration, severity, and
type. Abdominal pain is a common problem, and usually, the cause is minor, self-
limited, or both. More serious causes, however, may require urgent intervention.

Signs and symptoms

Accompanying clinical features include—
ƒƒ Nausea
ƒƒ Vomiting
ƒƒ Constipation
ƒƒ Diarrhoea
ƒƒ Tenderness
ƒƒ Fever
ƒƒ Tachycardia
ƒƒ Distension

References—1, 10, 192, 193

17.1.1 Acute Abdominal Pain

Figure 17.1.1 is an algorithm for the management of acute abdominal pain.

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 1 7. S igns and S ymptoms

Figure 17.1.1. Algorithm for acute abdominal pain

Symptoms Diagnosis Management

Begin here
1. Abdominal pain that Go to #7.
is severe, constant, NO
and dull; severe and
knife-like; or severe
cramping
YES
2. If female, is In pregnant women, Emergency
she pregnant, or YES lower abdominal or
Set up an IV line and
believes she might be pelvic pain along with administer normal
pregnant? vaginal bleeding may saline. Refer to
be a sign of a serious hospital immediately.
condition such as Monitor continuously.
ectopic pregnancy or
miscarriage.
NO
3. Is there— These may be signs of Emergency
YES a serious problem such
ƒƒ Bloody diarrhoea or Refer to hospital
as one of the following: immediately.
stools that are black
or tarry? ƒƒ Infectious diarrhoea Do not give any
ƒƒ History of vomiting ƒƒ Gastrointestinal medication.
blood? bleeding NPO
ƒƒ Abdominal ƒƒ Appendicitis or Monitor vital
tenderness with perforated appendix signs continuously
guarding? ƒƒ Diverticulitis or while awaiting
ƒƒ Rebound ulcer transportation.
tenderness? ƒƒ Pancreatitis
ƒƒ Fever? ƒƒ Intestinal
obstruction
NO
4. Is the pain in the Possibly gallstones Refer to hospital.
RUQ and does it get YES or if fever is present
worse after eating cholecystitis (i.e.,
fatty or greasy food? infection of the
gallbladder)
NO
continues

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1 7. S igns and S ymptoms

Figure 17.1.1. Algorithm for acute abdominal pain (continued)

Symptoms Diagnosis Management

5. Is the pain or Urinary tract infection Encourage the use of

discomfort in the YES lots of fruit juices.
supra pubic area with See chapter 8.1.
frequency and burning
on passing urine?
NO
6. Does the pain Renal calculi (i.e., Refer for investigation
radiate from loin to YES kidney stones) and treatment.
groin?
NO
7. Is there a history Possibly For children, see IMCI
of diarrhoea, fever, YES gastroenteritis, guidelines.
muscle aches, chills, which can lead to For adults, see GI
nausea, or vomiting? dehydration in infants diseases (chapter 7).
and young children.
NO
8. Has patient had no Constipation. Check Advise high-fibre diet
bowel movement for YES for history suggestive and lots of fluids and
a few days or longer? of haemorrhoid or fruits (e.g., mango,
Does patient have to anal fissure. pawpaw).
strain to have a bowel In the elderly, there Recommend a
movement? may be faecal laxative–bisacodyl
impaction, which may (5 mg tablet).
need manual removal.
NO
9. Has the patient Urinary obstruction Apply a warm pack
failed to pass urine for YES to the abdomen,
>1 day with distended catheterize if possible,
and painful bladder? and refer.
NO
continues

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 1 7. S igns and S ymptoms

Figure 17.1.1. Algorithm for acute abdominal pain (continued)

Symptoms Diagnosis Management

10. Does the patient May be gastritis or an See section 7.4.

have pain or a burning YES ulcer
sensation in the upper
abdomen that is either
relieved or gets worse
with food?
NO
11. Is the patient These may be signs of See section 15.4.
a female who has YES pelvic inflammatory
constant pain in the disease.
lower abdomen and
rebound tenderness
along with a vaginal
discharge?
NO
12. Does the patient Diabetic ketoacidosis Emergency
have a history of DM YES
If blood sugar is >250
and is presenting give 5 units insulin SC,
with breathlessness, and refer to hospital
nausea and vomiting, immediately.
extreme thirst, and
sweet-smelling
breath?
NO
13. Does the patient Consider myocardial Complete rest. Give
have epigastric pain? YES infarction aspirin + glyceryl
trinitrate, and refer.
NO
Cause unknown. Refer for investigation.
Source and adapted from: American Academy of Family Physicians. 1996. Family Health and Medical Guide. Dallas:
Word Publishing.

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1 7. S igns and S ymptoms

17.1.2 Chronic Abdominal Pain

Description
Ongoing or recurrent abdominal pain, also called chronic pain, may be difficult
to diagnose, causing frustration for both patient and doctor. Accompanying
symptoms may include constipation, abdominal distension, dyspepsia, and
tenderness. Figure 17.1.2 is an algorithm for the management of chronic
abdominal pain.

Figure 17.1.2. Algorithm for chronic abdominal pain

Symptoms Diagnosis Management

Begin here
1. Does the pain get May be a hiatal Advise eating smaller
worse after eating a YES hernia. meals, especially at
big meal, with pressure night. Advise against
in the upper abdomen lying down right after
that gets worse when eating. Suggest using 2
bending over or lying or 3 pillows, or raising
down at night? the head of the bed to
prevent discomfort. If
no relief, refer. Patient
may need surgery.
NO
2. Is the pain relieved Possibly gastritis, an Advise eating smaller
by antacids or milk? YES ulcer, or heartburn. meals. See section
Rule out myocardial 7.4.2. If no response in
infarction. 5 days,refer.
NO
3. Does the pain start May be gallstones Refer to hospital.
in the upper middle or YES
upper right abdomen,
and is it brought on by
eating greasy or fatty
foods?
NO
continues

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 1 7. S igns and S ymptoms

Figure 17.1.2. Algorithm for chronic abdominal pain (continued)

Symptoms Diagnosis Management

4. Does the pain get Irritable bowel Advise eating a diet

worse under stress, or YES syndrome high in soluble fibre
do the stools alternate and cutting out foods
between loose and containing gluten for
hard? 2 weeks. Counsel on
stress relief and advise
to exercise regularly.
If no relief in 1 week,
refer to hospital.
NO
5. Are the stools Possibly ulcerative Refer to hospital.
frequent, soft, or YES colitis or amoebic
diarrhoea-like? Do dysentery
they contain mucus
or blood? Have these
symptoms been
occurring over a period
of weeks or months?
NO
6. Has the patient had Diverticulitis Start on metronidazole
recurrent bouts of pain YES (250 mg tablets;
in the lower left side 125 mg/5 mL
of the abdomen along suspension) and
with fever? paracetamol for pain.
Refer to hospital as
soon as possible.
NO
7. Is there bright red Haemorrhoid, a Refer to hospital.
blood in or coating YES bleeding polyp, or
stools? cancer of the colon
NO
continues

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1 7. S igns and S ymptoms

Figure 17.1.2. Algorithm for chronic abdominal pain (continued)

Symptoms Diagnosis Management

8. Does the patient Unintentional weight Refer to specialist.

have decreased YES loss can be a sign
appetite, with weight cancer or HIV.
loss of 4.5–7 kg over
the past few months?
NO
9. Are the patient’s Hepatitis, gallbladder See sections 7.5.2,
eyes yellow? Is his or YES disease, sickle cell 14.5, or 14.6; or
her urine dark? disease, malaria, or chapter 13.
leptospirosis If gallbladder disease
suspected, refer for
investigation.

10. Does the patient Lactose intolerance, Advise patient to

have abdominal YES wheat intolerance, or avoid foods and
bloating? Is the celiac disease beverages that cause
discomfort made the symptoms. Refer
worse by milk or for celiac.
wheat products?
NO
11. Does the patient Possibly pancreatic Advise patient to
have yellow, greasy YES insufficiency avoid fatty foods
stools that float in the and alcohol. Refer to
toilet? specialist.
NO
12. Does the patient Giardiasis or other See section 7.6.1
produce excess gas YES bowel infection or for management
that is very foul- malabsorption of giardiasis. If no
smelling? Does improvement, refer for
the patient have investigation
occasional loose bowel
movements?
NO
Diagnosis unknown Refer for investigation.
Source: American Academy of Family Physicians. 1996. Family Health and Medical Guide. Dallas: Word Publishing.
Copyright 2009 American Academy of Family Physicians

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17.2 Fever/PUO
Description
Fever is an increase in the internal body temperature above the normal limits
of oral 37.5°C and axillary 38°C. Fever can be a symptom of many underlying
medical conditions. Minor infections may cause mild or short-term temperature
elevations. Temperatures of ≥39.5°C are considered high and can signal a
potentially dangerous infection.

Persistent fever that cannot be explained after repeated routine clinical inquiries
is called pyrexia (or fever) of unknown origin (PUO). Figure 17.2 is an algorithm
for the management of PUO.

References—1, 10, 192, 194

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 Figure 17.2. Algorithm for PUO

344
Symptoms Diagnosis Management
Begin here
1. Is the fever mild with no other Nonpharmacological management: Liberal fluids,
symptoms? YES continue feeding and breast feeding in child. Tepid
sponging. Light and cool clothes.
1 7. S igns and S ymptoms

Pharmacological management: First line, give

paracetamol or aspirin (in adults only). Adults: PO
(500 mg tablet) 1 g every 6–8 hours, not to exceed
4 g/24 hours. Alternative, give ibuprofen.
NO
2. Is this an infant or child? YES See relevant
page in IMCI.

NO
3. Is the fever intermittent and staying NO Go to #9.
below 38.8°C?

YES
continues

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 Figure 17.2. Algorithm for PUO (continued)

Symptoms Diagnosis Management

4. Is there a history of sore throat, Common cold or Nonpharmacological management: Advise getting
runny nose, a dry cough, tiredness, mild YES influenza plenty of rest and drinking lots of fluids. Tepid
headaches, or muscle aches? sponging. Light and cool clothes
Pharmacological management: First line, give
paracetamol. Adults: PO (500 mg tablet) 1 g every
6–8 hours, not to exceed 4 g/24 hours. Children:
PO (100 mg tablet) (60 mg/kg/day in 3–4 divided
doses) and give chlorpheniramine. Alternative, give

g u ya n a sta n da r d t r e atm ent gu i del i nes 

ibuprofen.
NO
5.Is there a history of aches, chills, nausea, Gastroenteritis Give small, frequent sips of water or clear liquids to
vomiting, cramps, or watery diarrhoea? YES avoid dehydration. See section 1.4.
Dysentery,
Is there blood in stools? ulcerative Start on co-trimoxazole. If the patient has been
colitis, or vomiting for >2 days or vomiting blood, refer to
amebiasis district or regional hospital.
NO
6. Does the patient have shortness of Bronchitis Advise getting plenty of rest and drinking lots of
breath or a productive cough of yellow, YES fluids. Treat fever. (See section 3.1.) Bronchitis
green, or brown mucus? usually clears on its own in a few days. If fever
unresolved for >3 days or patient is coughing up
blood, suspect pneumonia. See section 3.6.
NO
continues

345
1 7. S igns and S ymptoms
 Figure 17.2. Algorithm for PUO (continued)

346
Symptoms Diagnosis Management

7. Does the patient have a sore throat with Pharyngitis Advise getting plenty of rest and drinking lots
exudates, tender anterior cervical lymph YES of fluids and treat for fever and sore throat. (See
Probably
nodes, and headache? streptococcal section 4.3.2.)
pharyngitis If no improvement in 48 hours, start on penicillin,
1 7. S igns and S ymptoms

(see Chapter 4.3.2.) and refer if the patient is a child.

NO
8. Does the patient have an intermittent Malaria or Refer to a level 4 or 5 facility for definitive diagnosis
fever and night sweats, headache, yellow YES TB and specialist treatment.
tinge to eyes?
Does the patient have weight loss with
swollen lymph nodes in the neck?
NO
9. Is the fever between 38.3°C and NO Go to #14.
39.4°C?

YES
10. Is there stomach pain and tenderness Appendicitis, Emergency
on palpation? Is there nausea, vomiting, or YES diverticulitis,
Refer to level 4 hospital.
both? pancreatitis,
hepatitis, or
colitis
NO

s ect i on i i . di s eas es and di s orde rs acco rding to bo dy system

continues
 Figure 17.2. Algorithm for PUO (continued)

Symptoms Diagnosis Management

11. Does the patient have an earache with YES Otitis, media or Treat for fever and pain and give antibiotics.
or without discharge? external (See sections 4.1.3 and 4.1.4.)
NO
12. Does the patient have a red rash and YES Chickenpox or See sections 14.1 and 14.2.
petechiae? dengue
NO
13. Is the patient female with a history of YES PID or puerperal Start antibiotic treatment immediately.

g u ya n a sta n da r d t r e atm ent gu i del i nes 

abortion or childbirth, lower abdominal sepsis (See Chapter 15.4.). Refer.
pain, and foul-smelling discharge?
NO
14. Is the patient’s temperature Pneumonia Refer to level 4 or 5 hospital.
consistently >39.4°C with shortness of YES or pulmonary
breath and coughing up mucus or blood? embolism. Rule
out TB.
NO

15. Is there frequency and pain or burning YES Urinary tract Treat with co-trimoxazole. See Chapter 8.1.
when passing urine, or back pain? infection
NO
continues

347
1 7. S igns and S ymptoms
 Figure 17.2. Algorithm for PUO (continued)

348
Symptoms Diagnosis Management

16. Is there severe headache, neck YES Meningitis Emergency

stiffness, drowsiness and vomiting? Refer to level 4 or 5 hospital.
Sensitivity to light?
NO
1 7. S igns and S ymptoms

17. Is the patient’s fever between 38.8°C Salmonellosis, See chapters 14.2, 14.4, and 14.9.
and 40°C, and does the patient have chills, YES dengue, or
headache, anorexia, weakness and muscle leptospirosis
pains, toxic confusional state, periumbilical
pain, and pea soup stools?
NO
Diagnosis unknown PUO Refer to higher level for diagnosis and treatment.
Source and adapted from: American Academy of Family Physicians. 1996. Family Health and Medical Guide. Dallas: Word Publishing.

s ect i on i i . di s eas es and di s orde rs acco rding to bo dy system

 1 7. S igns and S ymptoms

17.3 Headache
Description
Headache is defined as a pain in the head or upper neck. It is among the most
common pain complaints. It is a symptom of a number of different conditions of
the head and sometimes neck. Some of the causes are benign; others are medical
emergencies.

Headaches can be classified into three categories:

ƒƒ Primary
ƒƒ Secondary
ƒƒ Cranial neuralgias, facial pain, and other headaches

Primary headaches include migraines, tension, or hunger-related headaches.

Secondary headaches may result from an underlying condition such as head
injury; intracranial haemorrhage or tumour; infection; problems with the eyes,
ears, or nose; medication withdrawal; or hangovers. Headaches are, however,
most likely to be primary, harmless, and self-limited.

Signs and symptoms

The following signs and symptoms may accompany a headache:
ƒƒ Fever
ƒƒ Stiff neck
ƒƒ Change in behaviour
ƒƒ Vomiting
ƒƒ Weakness
ƒƒ Change in sensation

Figure 17.3 is an algorithm for the management of headache.

References—1, 191

g u ya n a sta n da r d t r e atm ent gu i del i nes  349

 Figure 17.3. Algorithm for headache

350
Symptoms Diagnosis Management
Take a history and begin here.
1. Does the patient have a fever and Influenza or a Give paracetamol (500 mg tablet; 120 mg/5 mL
cold symptoms, or nausea, vomiting or YES cold suspension) PO. Adults:1 g PO every 6–8 hours, not
diarrhoea? to exceed 4 g/24 hours. Children: PO 100 mg tablet
(60 mg/kg/day in 3–4 divided doses)to relieve cold
1 7. S igns and S ymptoms

or and influenza symptoms. Alternative: give ibuprofen.

gastroenteritis Advise drink plenty of oral rehydration fluids. See
section 7.2.
NO
2. Does the patient have a severe Possibly Emergency
headache with stiff neck, vomiting, and YES meningitis or
Refer to hospital immediately.
sensitivity to light? intracranial
haemorrhage
NO
3. Is there a history of recent head injury? Possibly Emergency
YES concussion
Refer to hospital for diagnostic tests.
or a subdural
haematoma
NO
4. Does the patient have numbness, YES Stroke or Emergency
tingling, or weakness in the arms, legs, or transient Check BP. If diastolic is >110, start on treatment, and
both? Is he or she slurring speech? ischemic attack refer to hospital immediately.
NO

s ect i on i i . di s eas es and di s orde rs acco rding to bo dy system

continues
 Figure 17.3. Algorithm for headache (continued)

Symptoms Diagnosis Management

5. Is there pressure around the eyes, Sinusitis Treat fever, headache, and sore throat. (See chapter
tenderness over sinus area, or nasal YES 4.2.1.2.)
discharge with pus, with a sore throat and
a fever?
NO
6. Is the pain like a band of tightness Tension Give paracetamol (500 mg tablet). Adults: PO (500
around the head? Does it occur during YES headache mg tablet) 1 g every 6–8 hours, not to exceed 4 g/24
times of emotional or physical stress (e.g. hours. Children: PO (100 mg tablet) 60 mg/kg/day

g u ya n a sta n da r d t r e atm ent gu i del i nes 

Worries at home or work)? in 3–4 divided doses. Alternative: Give ibuprofen.
Ice packs to the head may also be helpful. Refer if
headaches keeps recurring
NO
7. Is the pain intense and throbbing, Migraine Nonpharmacological management: Advise the
with nausea or vomiting? Is the pain is YES patient to avoid things that trigger an attack (e.g.,
sometimes preceded by seeing flashing red wine, cheese, chocolate, MSG). Advise the
lights or spots? patient to rest in a dark room and apply ice packs
and gentle pressure to painful areas.
Pharmacological management: First line, give
paracetamol or ibuprofen + dimenhydrinate. Second
line, give ergotamine + caffeine combination. Take 1
tablet stat (when aura appears or first sign) and ½–1
tablet every 2 hours, not to exceed 4 in 24 hours.
Refer if no response to treatment after 1 day.

351
1 7. S igns and S ymptoms

NO continues
 Figure 17.3. Algorithm for headache (continued)

352
Symptoms Diagnosis Management

8. Are the headaches recurring every 3–4 YES Suspect cluster Give paracetamol or ibuprofen, and refer for
weeks? headaches investigation.
NO
9. Are the headaches is related to Vision problems Refer for vision testing.
1 7. S igns and S ymptoms

prolonged reading, watching TV, or using YES

a computer? Do they get progressively
worse as the day goes on, especially in
children?
NO
10. Are the headaches related to hunger? YES Hypoglycaemia Check blood sugar. Give the patient something
Are they accompanied by severe sweating, sweet to eat. Advise the patient to eat regularly and
confusion, disturbed vision? on time.
NO
11. Is there a history of cutting down on YES Withdrawal Advise patient to not restart habit.
caffeine, alcohol, or some other drug? symptoms
NO
Cause unknown Refer for investigation.
Source and adapted from: American Academy of Family Physicians 1996. Headache. Family Health and Medical Guide. Dallas: Word Publishing.

s ect i on i i . di s eas es and di s orde rs acco rding to bo dy system

 1 7. S igns and S ymptoms

17.4 Myalgia (Muscle Pain)

Description
Muscle aches and pains are common and can involve more than one muscle.
Muscle pain can also involve ligaments, tendons, and fascia, the soft tissues
that connect muscles, bones, and organs. The pain can be temporary or chronic.
Muscle pain is most frequently related to tension, overuse, or muscle injury from
exercise or physically demanding work. In these situations, the pain tends to
involve specific muscles and starts during or just after the activity. It is usually
obvious which activity is causing the pain.

Myalgia without a traumatic history is often due to viral infections. Muscle pain
also can be a sign of conditions affecting the whole body, such as some disorders
that affect connective tissues throughout the body (e.g., lupus and metabolic
disorders).

Accompanying symptoms may be weakness, tenderness to palpation, and

swelling.

Figure 17.4 is an algorithm for the management of myalgia.

References—195, 196

Figure 17.4. Algorithm for myalgia

Symptoms Diagnosis Management

1. Is the pain confined Muscle injury ƒƒ Rest the affected muscle.

to specific muscles YES
ƒƒ Use paracetamol (500
and related to mg tablet) 2 tablets 3–4
strenuous activity? times a day or ibuprofen
(200 mg, 400 mg, 600
mg tablets) 400 mg 3–4
times/day, for pain.
ƒƒ Place ice packs on the
injured area for 24–48
hours. If no response, try
heat.
NO
continues

g u ya n a sta n da r d t r e atm ent gu i del i nes  353

1 7. S igns and S ymptoms

Figure 17.4. Algorithm for myalgia (continued)

Symptoms Diagnosis Management

2. Does the patient Fibromyalgia ƒƒ Advise rest followed

have severe muscle YES by massage or gentle
pain and tenderness, stretching.
sleep disturbance, and ƒƒ Suggest aerobic exercises
easy fatigability? (e.g., walking, cycling,
swimming).
ƒƒ Refer to physiotherapist
for advice on stress
reduction (e.g., yoga and
meditation).
NO
3. Is the patient >50 Polymyalgia Refer.
years old, and does he YES rheumatica
or she have stiffness
and pain in shoulders,
lower back, hips and
thighs?
NO
4. Is there a high Abscess Refer immediately for
fever? Redness, pain, YES (probably drainage and IV antibiotic
and swelling? S. aureus) treatment.
NO
5. Does the patient Viral infection Refer to the appropriate
have fever that YES dengue, section of this STG for
spikes, runny influenza, management.
nose, prostration, meningitis,
depression, headache, pneumonia,
abdominal discomfort, leptospirosis or
and chills? malaria
NO
6. Condition uncertain Refer for investigation.

354 s ect i on i i . di s eas es and di s orde rs acco rding to bo dy system

 A ppendix A . E ssentia l M edicine C oncept

Appendix A. Essential Medicine Concept

WHO describes essential medicines as those that satisfy the priority health
care needs of the population. Essential medicines are intended to be available
within the health systems at all times in adequate quantities, in the appropriate
dosage forms, with assured quality and adequate information, and at a price the
individual and the community can afford.

Thus, access to quality medicines and rational use of these medicines remain
critical issues of the health sector as it pursues its goal to ensure equity,
efficiency, quality, and sustainable financing in achieving its goal of healthy lives
for all Guyanese. Meeting this goal involves ensuring the following:
ƒƒ The availability and accessibility of essential medicines to all citizens
ƒƒ The safety, efficacy, and quality of medicines
ƒƒ Good prescribing and dispensing practices
ƒƒ The rational use of medicines by prescribers, dispensers, and patients

All stakeholders must receive the necessary training, education, and information
if Guyana is to meet its health care goals.

The second edition of the Essential Drug List, published 2007, is still being
used until the publication of the third edition. Apart from aiming at quality care
and rational medicines use, the list serves as a basis for the monitoring of the
availability of and correct use of medicines and for planning at the national and
peripheral level for procurement and distribution of the essential medicines.
(Note: The third edition is available only in draft.)

The list presents medicines that meet the needs of Guyana’s priority health
conditions in agreement with the Package of Publically Guaranteed Services.
Although prepared with the public sector in mind, the private sector is
encouraged to use these guidelines and medicines list wherever appropriate.

The criteria for the selection of essential medicines for primary health care in
Guyana were based on the WHO guidelines for drawing up a national EML. They
include the following:
ƒƒ Any medicine included must meet the needs of the majority of the
population.
ƒƒ Sufficient proven scientific data regarding effectiveness must be available.

g u ya n a sta n da r d t r e atm ent gu i del i nes  355

A ppendix A . E ssentia l M edicine C oncept

ƒƒ Any medicine included in the EML should have a substantial safety and
risk/benefit ratio.
ƒƒ All products must be of an acceptable quality and must be tested on a
continuous basis.
ƒƒ The aim, as a rule, is to include only products containing single
pharmacologically active ingredients.
ƒƒ Combination products, as an exception, will be included when patient
compliance becomes an important factor, or two pharmacologically active
ingredients are synergistically active in a product.

356a ppe ndixes

 A ppendix B . T he H eim l ich M anoeu v re

Appendix B. The Heimlich Manoeuvre

Choking because of an obstructed airway is a medical emergency. If a choking
person is not coughing or is unable to speak, that’s your cue to perform the
Heimlich manoeuvre immediately.

1. The manoeuvre is best done in a standing position although it can be

done with the patient in a sitting position if the patient is too heavy or in a
confined space

2. Stand behind the patient with your legs apart, which will help to stabilize the
patient should he or she become unconscious.

3. Place your arms around the patient’s waist.

4. Make a fist with one hand with the thumb facing

inside the fist and place just above his or her navel
and under the breast bone.

5. Wrap your other hand around this fist.

6. Deliver five upward squeeze-thrusts into the

abdomen. Pull inward and upward, pressing into
the patient’s abdomen with quick upward thrusts,
using good force. Make the motion similar to the
letter “J”–in, then up.

7. Make the thrusts quick and forceful, as if you’re trying to lift the victim off
his or her feet from this position. Repeat until the object is dislodged and
expelled. Use less force on a child.

8. Keep a firm grip on the victim, since he or she can lose consciousness and fall
to the ground if the Heimlich manoeuvre is not effective.

9. Check to see if normal breathing has returned.

g u ya n a sta n da r d t r e atm ent gu i del i nes  357

A ppendix C . C ommon A sthma T riggers and Av oidance S trategies

Appendix C. Common Asthma Triggers and Avoidance

Strategies
Common
Asthma Triggers Avoidance Strategies
Domestic dust mite Wash bed linens and blankets once a week in hot water and
allergens dry in a hot dryer or sunlight. Encase pillows and mattresses in
airtight covers. Remove carpets, especially in sleeping areas.
Use vinyl, leather, or plain wooden furniture instead of fabric-
covered furniture.
Tobacco smoke Patients and persons in the home should not smoke. Stay away
from tobacco smoke.
Allergens from Remove animals from the home or at least from the sleeping
animals with fur area.
Cockroach allergen Clean the home thoroughly and often. Make every effort to
reduce the availability of food. Use a pesticide spray, but
make sure the patient is not at home when spraying occurs.
Restrict potential havens by caulking and sealing cracks in the
plasterwork and flooring.
Outdoor pollens Close windows and doors, and remain indoors when pollen and
and mould mould counts are high.
Physical activity Do not avoid physical activity. Symptoms can be prevented
by taking a short- or long-acting beta 2 antagonist before
strenuous exercise.
Medication Avoid—or use with caution—aspirin, NSAIDs, beta blockers
(oral or intra ocular). Close supervision is essential.
Viral upper For the child who has recurrent severe asthma exacerbations
respiratory tract related to viral URTIs, consider limiting exposure to viral
infections infections. Advise influenza vaccines for children who have
persistent asthma and who are not allergic to eggs.
Occupational— Avoid exposure to isocyanates,a allergens from grain, and
farming, factory, smoke from wood.
municipal
Emotions Avoid emotional and psychological stress.
Foods Avoid foods known to trigger allergies (e.g., peanuts, eggs, food
additives such as MSG, metabisulphites).
a I socyanates are a family of highly reactive, low-molecular-weight chemicals. They are widely used in the
manufacture of flexible and rigid foams, fibres, coatings such as paints and varnishes, and elastomers, and are
increasingly used in the automobile industry, autobody repair, and building insulation materials.

358a ppe ndixes

 A ppendix D . T obacco C essation

Appendix D. Tobacco Cessation

Ask all patients about their tobacco (e.g., “Have you used any form of tobacco in
the past 6 months?”). Document tobacco use status (e.g., non-smoker, smoker,
ex-smoker).

How to help patients stop smoking

ƒƒ The most important step in addressing tobacco use and dependence
is screening for tobacco use and offering minimal smoking cessation
intervention messages to all persons who smoke, at every opportunity.
ƒƒ Use of a cueing system for the chart (e.g., labelling each client’s smoking
status clearly and visibly with stickers, stamps or on a flow sheet) prompts
health care providers to constantly and effectively integrate smoking
cessation into their care.
ƒƒ Provide information and support for the use of pharmacological and
nonpharmacological aids for persons who smoke and who want to quit.

Nonpharmacological management
Use the minimal smoking cessation intervention (lasting 1–3 minutes)—
ƒƒ Advise every tobacco user of the importance of quitting, in a nonjudgmental
and unambiguous manner.
ƒƒ Assist by providing minimal intervention.
ƒƒ Offer support and self-help resources, such as brochures.
ƒƒ Inform the patient about, or refer him or her to, a community stop-smoking
clinic or service.
ƒƒ Refer the patient to another health care provider.
ƒƒ Arrange follow up or referral.

g u ya n a sta n da r d t r e atm ent gu i del i nes  359

A ppendix E . T he D A S H ( D ietary A pproaches to S top H ypertension ) P l an

Appendix E. The DASH (Dietary Approaches to

Stop Hypertension) Plan
Table E.1. The DASH Eating Plan

Food Group Servings Examples Significance

Whole grain 7–8/day Whole wheat bread, Major source of fibre
products cereals, oatmeal
Vegetables 4–5/day Tomatoes, carrots, Rich in potassium,
beans, spinach, cabbage, magnesium, and fibre
broccoli
Fruits 4–5/day Bananas, oranges, Rich in potassium,
melons, apples magnesium, and fibre
Low-fat and 2–3/day Skimmed milk, low-fat Major source of calcium
nonfat dairy yogurt, nonfat cheese and protein
foods
Meats, poultry, ≤2/day Chicken or fish instead of Major source of protein
and fish red meat or at least lean and magnesium
cuts of red meat. Avoid
frying.
Nuts, seeds, and 4–5/week Almonds, peanuts, Major source of protein,
legumes sunflower seeds, kidney magnesium, and fibre
beans, lentils

360a ppe ndixes

 A ppendix E . T he D A S H ( D ietary A pproaches to S top H ypertension ) P l an

Table E.2. The DASH Eating Plan—Serving Sizes, Examples, and Significance

Significance of Each
Food Group to the DASH
Food Group Serving Sizesb Examples and Notes Eating Plan
Grains a
1 slice bread Whole-wheat bread and Major sources of energy
1 oz dry cereal rolls, whole-wheat pasta, and fibre
bagel, cereals, oatmeal,
½ cup cooked
brown rice, unsalted
rice, pasta, or
pretzels, and popcorn
cereal
Vegetables 1 cup raw leafy Broccoli, carrots, green Rich sources of
vegetable beans, green peas, kale, potassium, magnesium,
½ cup cut-up lima beans, potatoes, and fibre
raw or cooked spinach, squash, sweet
vegetable potatoes, tomatoes
½ cup
vegetable juice
Fruits 1 medium fruit Apples, apricots, Important sources of
¼ cup dried bananas, dates, grapes, potassium, magnesium,
fruit oranges, grapefruit, and fibre
grapefruit juice,
½ cup fresh,
mangoes, melons,
frozen, or
peaches, pineapples,
canned fruit
raisins, strawberries,
½ cup fruit tangerines
juice
Fat-free or 1 cup milk or Fat-free milk or Major sources of calcium
low-fat dairy yogurt buttermilk; fat-free, and protein
productsc 1½ oz cheese low-fat, or reduced-fat
cheese; fat-free/low-fat
regular or frozen yogurt
Lean meats, 1 oz cooked Select only lean; trim Rich sources of protein
poultry, and meats, poultry, away visible fats; broil, and magnesium
fish or fish roast, or poach; remove
1 egg skin from poultry

continues

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A ppendix E . T he D A S H ( D ietary A pproaches to S top H ypertension ) P l an

Table E.2. The DASH Eating Plan—Serving Sizes, Examples, and Significance
(continued)

Significance of Each
Food Group to the DASH
Food Group Serving Sizesb Examples and Notes Eating Plan
Nuts, seeds, ⁄3 cup or 1½ oz Almonds, mixed nuts,
1
Rich sources of energy,
and legumes nuts peanuts, walnuts, magnesium, protein, and
2 tbsp peanut sunflower seeds, peanut fibre
butter butter, kidney beans,
lentils, split peas
2 tbsp or ½ oz
seeds
½ cup cooked
legumes (dried
beans, peas)
Fats and oilsd 1 tsp soft Soft margarine, vegetable The DASH study had
margarine oil (canola, corn, olive, 27% of calories as fat,
1 tsp vegetable safflower), low-fat including fat in or added
oil mayonnaise, light salad to foods
dressing
1 tbsp
mayonnaise
2 tbsp salad
dressing
Sweets and 1 tbsp sugar Fruit-flavored gelatin, Sweets should be low
added sugars 1 tbsp jelly or fruit punch, hard candy, in fat
jam jelly, maple syrup, sorbet
and ices, sugar
½ cup sorbet,
gelatin dessert
1 cup
lemonade
a Whole grains are recommended for most grain servings as a good source of fibre and nutrients.
b S
 erving sizes vary between ½ cup and 1¼ cups, depending on cereal type. Check the product’s nutrition facts
label.
c F or lactose intolerance, try either lactase enzyme pills with dairy products or lactose-free or lactose-reduced
milk.
d F at content changes the serving amount for fats and oils. For example, 1 tbsp regular salad dressing = one
serving; 1 tbsp low-fat dressing = one-half serving; 1 tbsp fat-free dressing = zero servings.

362a ppe ndixes

 A ppendix F. G uide l ines f or C a l cium S upp l ementation

Appendix F. Guidelines for Calcium Supplementation

The US National Institutes of Health Consensus Conference on Osteoporosis
recommends the calcium intake amounts shown in table F.1 for all people, with
or without osteoporosis.

Table F.1. Recommended Calcium Intake

Population Category Amount of Calcium

Children 1–10 years of age 800 mg/day
Men, premenopausal women, and postmenopausal 1,000 mg/day
women also taking oestrogen
Teenagers and young adults 11–24 years of age 1,200 mg/day
Postmenopausal women not taking oestrogen 1,500 mg/day
Pregnant and nursing mothers 1,200–1,500 mg/day
Note: The total daily intake of calcium should not exceed 2,000 mg.

Daily dietary calcium intake can be calculated using the food values shown in
table F.2.

Table F.2. Calcium Content of Foods

Food Amount of Calcium (mg)

8-ounce glass of milk 300
8 ounces of plain yogurt 450
1 cup of cottage cheese 130
1 ounce of cheddar cheese 200
½ cup of vanilla ice cream 90
8 ounces of calcium-fortified orange juice 300

Nonmilk sources of calcium include beans (white, baked, black-eyed), tofu,

pak choi, peas, and okra. Sardines and salmon, canned with the bone, are also
extremely high in calcium.

Source: Shiel, W. 2014.“Osteoporosis, Treatment, Medications, Symptoms,

Prevention.” Accessed atwww.medicinenet.com/osteoporosis/article.htm. Last
updated August 29, 2014.

g u ya n a sta n da r d t r e atm ent gu i del i nes  363

A ppendix G . D ietary G uide l ines f or D iabetes

Appendix G. Dietary Guidelines for Diabetes

All foods and drinks contain calories but some have more than others.

All fats are high in calories, even so-called good fats

ƒƒ 1 tsp of fat (4 grams) = 36 calories
ƒƒ 1 tsp of starch or sugar = 16 calories
ƒƒ 1 tsp of protein = 16 calories

About half of the day’s food should consist of fruits and vegetables. Restrict the
use of fats and oils. Always choose low-fat products.

364a ppe ndixes

 A ppendix H . G uide l ines f or I ron S upp l ementation

Appendix H. Guidelines for Iron Supplementation

Iron supplementation for pregnant women
Table H.1. Guidelines for Iron Supplementation to Pregnant Women

Prevalence of
Anaemia in Pregnancy Dose Duration
<40% 60 mg elemental iron + 6 months in pregnancy
400 mcg folic acid daily
>40% 60 mg elemental iron + 6 months in pregnancy and
400 mcg folic acid daily continuing to 3 months
postpartum
Note: If 6 months duration cannot be achieved in pregnancy, continue to supplement during the postpartum
period for 6 months or increase the dose to 120 mg iron during pregnancy. If iron supplements containing
400 mcg of folic acid are not available, an iron supplement with less folic acid may be used. Supplementation with
less folic acid should be used only if supplements containing 400 mcg are not available.

Children 6–24 months

Infants need a relatively high iron intake because they are growing rapidly.
Infants are normally born with plenty of iron. Beyond 6 months of age, however,
iron content of milk is not sufficient to meet many infants’ requirements,
and complementary foods are usually low in iron. Low-birth-weight infants
(<2,500 g) are born with fewer iron stores and are at high risk of deficiency after
2months. If iron-fortified complementary foods are not widely and regularly
consumed by young children, infants should routinely receive iron supplements
in the first year of life (see table H.2). When the prevalence of anemia in young
children (6–24 months) is ≥40%, supplementation should continue through the
second year of life.

Table H.2. Guidelines for Iron Supplementation for Children 6–24 Months

Prevalence
of Anaemia Dosage Birth Weight Category Duration
<40% 12.5 mg iron +50 mcg Normal 6–12 months
folic acid daily Low birth weight (<2,500 g) 2–24 months
>40% 12.5 mg iron + 50 mcg Normal 6–24 months
folic acid daily Low birth weight (<2,500 g) 2–24 months
Note: If the prevalence of anaemia in children 6–24 months is not known, assume it is similar to the prevalence
of anemia in pregnant women in the same population. Iron dosage is based on 2 mg elemental iron/kg body
weight/day.

g u ya n a sta n da r d t r e atm ent gu i del i nes  365

A ppendix H . G uide l ines f or I ron S upp l ementation

Other population groups

Although pregnant women and young children are at the greatest risk of iron-
deficiency anaemia, other population groups frequently suffer its consequences
and may benefit from iron supplementation programs. In some contexts, it may
be feasible and cost effective to distribute iron supplements to other groups if
the prevalence of anaemia is high (table H.3). Complementary parasite control
measures for other population groups are given below the table.

Table H.3. Guidelines for Iron Supplementation to Other Population Groups

Group Dosage
Children 2–5 years 20–30 mg iron
Children 6–11 years 30–60 mg iron
Adolescents and adults 60 mg iron (see notes)
Notes: For children 2–5 years, iron dosage is based on 2 mg elemental iron/kg body weight/day. If the population
group includes girls or women of reproductive age, 400 mcg folic acid should be included with the iron
supplementation for the prevention of birth defects in those who become pregnant.

Complementary parasite control measures for other population groups

If hookworms are endemic (prevalence ≥20–30%), combining iron
supplementation with anthelminthic treatment to adults and children >5 years
is most effective. Universal anthelminthic treatment, irrespective of infection
status, is recommended at least annually. High-risk groups, women, and children
should be treated more intensively (2–3 times per year).

The following single-dose treatments are recommended:

ƒƒ Albendazole 400 mg single dose
ƒƒ Mebendazole 500 mg single dose
ƒƒ Levamisole 2.5 mg/kg single dose
ƒƒ Pyrantel 10 mg/kg single dose

Caution: Anthelminthic treatment can be given to pregnant and lactating women.

As a general rule, however, no medicine should be given in the first trimester.

If urinary schistosomiasis is endemic, provide annual treatment for urinary

schistosomiasis to school-age children who report having blood in their urine.
Give the following treatment: praziquantel 40 mg/kg, single dose.

366 a ppe ndixes

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382
 I ndex o f D iseases and C onditions

Index of Diseases and Conditions

Abdominal injuries, 46 Chickenpox, 271, 347
Abnormal vaginal bleeding, 308, 311 Childhood anxiety disorders, 323
Abnormal vaginal discharge, 306, 308 Chronic abdominal pain, 340
Acid and other corrosive poisoning, 39, 40 Chronic otitis media, 94, 98, 99, 100
Acne, 220, 221 Congestive heart failure, 75, 134
Acute abdomen, 1 Conjunctivitis, 107, 111, 114, 121, 122, 124, 125
Acute abdominal pain, 336 Constipation, 146, 147, 149, 252, 257, 302,
Acute airway obstruction, 4 336, 338, 340
Acute bronchitis, 62, 63 Contact dermatitis, 226
Acute diarrhoea with dehydration, 14, 154, Corneal ulcer, 126, 127
169 Coryza, 70, 73
Acute epiglottitis, 4, 9, 119 Cystitis, 173, 176
Acute laryngotracheobronchitis, 6
Acute sinusitis, 83 Deep vein thrombosis, 143, 144
Acute urinary retention, 16 Dementia, 329, 330
Allergic conjunctivitis, 121, 122 dengue, 274, 275, 347, 348, 354
Allergic reaction (severe), 17, 20 Dengue, 273
Allergic rhinitis, 73, 105, 106 Depression, 220, 265, 274, 316, 321, 325, 326,
Anaemia, 64, 134, 148, 158, 164, 165, 171, 182, 354
253, 254, 255, 257, 258, 259, 260, 261, 262, Diabetes mellitus, 75, 91, 133, 137, 179, 217,
264, 267, 268, 270, 278, 287, 288, 291, 305, 223, 243, 295
309, 310, 365, 366 Diabetic emergencies, 28
Anal fissures, 146, 163 Donovanosis, 185, 194, 196
Anaphylactic shock, 17, 20, 27 Dysmenorrhoea, 305, 306
Angina pectoris, 133 Dysthymic disorder, 326, 327
Anxiety disorders, 313, 314, 316, 319
Arc eye, 127, 129 Eczema, 17, 91, 228, 229, 230, 234
Aspirin or salicylate poisoning, 40 Epigastric disorders, 158
Asthma, 12, 63, 65, 66, 67, 75, 358 Epistaxis, 107, 278
Eye injuries, 53, 54
Bacterial food poisoning, 155, 156 Eyelid infection, 130
Bites by cats, dog, and wild animals, 24
Bronchiolitis, 63, 66, 71 Falciparum malaria, 287, 288, 291
Febrile convulsions, 32, 35, 43
Candidiasis, 223, 224, 225 Fever/PUO, 343
Candidiasis oral, 224, 225 Filaria, 275
Cardiopulmonary arrest, 27 Flail chest, 48, 50
Carpal tunnel syndrome, 217, 218 Foreign body aspiration, 4
Centipede bites, 22 Foreign body in the ear, 87, 91, 100
Chancroid, 185, 194 Foreign body in the eye, 128
Chemical conjunctivitis, 125 Foreign body in the nose, 102
Chest injuries, 48 Fractured clavicle, 50
Chicken pox, 272

g u ya n a sta n da r d t r e atm ent gu i del i nes  383

I ndex o f D iseases and C onditions

Gastritis and peptic ulcer disease, 160, 161 Influenza, 9, 62, 73, 75, 77, 78, 83, 94, 104, 105,
Gastroenteritis, 33, 151, 156, 338, 345, 350 111, 216, 269, 279, 333, 345, 350, 354, 358
Gastrointestinal bleeding, 163, 337 Insect Stings, 20
Gastro-oesophageal reflux disease, 158, 160 Iron-deficiency anaemia, 164, 254, 258, 261,
Generalised anxiety disorder, 313, 314 264, 366
Generalized anxiety disorder, 323 Iron deficiency in children 6–24 Months, 260
Genital chlamydia, 185, 187 Iron deficiency in pregnancy, 257
Genital herpes, 185, 192, 193, 195
Genital ulcers, 194, 195, 196 Jaundice, 165, 166, 167, 174, 279, 288
Giardiasis, 168, 169, 342 Joint pain, 206, 274, 282
Glomerulonephritis, 111, 113, 114, 180, 181,
182 Keratitis, 125, 127, 129
Goitre, 250, 251
Gonorrhoea, 16, 125, 126, 175, 185, 186, 187, Laryngitis, 116, 117, 119, 158
307, 311 Leishmaniasis, 262, 277
Gout, 140, 211, 212, 213, 264 Leptospirosis, 279, 280, 281, 342, 348, 354
Granuloma inguinale/donovanosis, 185, 194 Lower back pain, 203
Lymphogranuloma venereum, 185, 187, 196
Haematuria, 16, 139, 176, 181, 182, 184, 280,
287, 288 Malaria, 254, 256, 257, 260, 263, 267, 269,
Haemorrhoids, 148, 149, 150, 163, 164 282, 283, 284, 287, 288, 291, 292, 334, 346
haemothorax, 48 Malaria in Pregnancy, 291
Haemothorax, 51, 52 Malnutrition, 59, 64, 78, 131, 223, 262, 264,
Hansen’s disease, 230, 231, 232 277, 305, 329
Headache, 29, 36, 56, 73, 75, 76, 94, 254, 273, Meningitis, 32, 33, 43, 97, 100, 273, 293, 294,
279, 282, 292, 294, 295, 302, 306, 315, 331, 295, 333, 334, 335, 348, 350, 354
332, 334, 349, 350 Migraine, 331, 351
Head injuries, 27, 43, 56, 58 Mumps, 199, 200, 292, 293
Hearing loss, 87, 92, 95, 98, 100, 101 Muscle pain, 192, 216, 353, 354
Helminthiasis, 170 Myalgia, 216, 353, 354
Hepatitis, 2, 165, 166, 167, 179, 269, 342, 346
Hoarseness, 111, 114, 116, 117, 119, 120, 252 Napkin rash, 233
Human bites, 26, 59 Nasal and sinus infections, 104
Hyperglycaemia, 31, 32, 245, 250 Nasal obstruction, 84, 102, 278
Hypertension, 36, 43, 108, 110, 133, 134, 137, Neonatal conjunctivitis, 125
138, 139, 140, 141, 142 Nephrotic syndrome, 179
Hypertensive crisis, 36, 37
Hypoglycaemia, 28, 29, 30, 43, 243, 245, 246, Obesity, 133, 134, 137, 143, 144, 149, 206, 244,
250, 263, 287, 288, 352 264, 265, 266, 329, 330
Hypothyroidism, 119, 148, 217, 250, 252, 265, Obsessive-compulsive disorder, 313, 315, 324
266 Osteoarthritis, 206, 208, 264, 267
Osteoporosis, 214, 363
Impacted wax in the ear, 89, 100 Otitis externa, 90, 91, 93, 100
Infective conjunctivitis, 122, 124 Otitis media, 90, 91, 94, 97, 98, 99, 100, 105

384
 I ndex o f D iseases and C onditions

Panic disorder, 313, 317, 324 Undernutrition, 171, 262

Pelvic inflammatory disease, 186, 306, 311, Urethral discharge, 174, 192, 197, 198, 199
339 Urethritis, 173, 174, 175
Peripheral arterial disease, 143 Urinary tract infection, 33, 173, 182, 338, 347
Peripheral vascular disease, 59, 143
Pharyngitis, 114, 115, 346 Vaginal bleeding, 186, 308, 309, 310, 311, 337
Phobias, 313, 319, 330 Vulvo-vaginal candidiasis, 185, 189, 225, 307,
Pneumo-haemothorax, 48, 49, 51, 52 312
Pneumonia, 62, 63, 72, 78, 79, 81, 271, 273,
278, 333, 345, 347, 354 Wounds, 24, 46, 48, 56, 59, 60, 61, 231, 244
Pneumothorax, 48, 49, 51, 52
Poisoning, 38, 39, 40, 155, 156, 157 Xerophthalmia, 131, 132
Post-traumatic stress disorder, 314, 320
Psoriasis, 234
Pyelonephritis, 1, 2, 173, 177, 243

Rheumatoid arthritis, 208, 217

Rhinitis and rhinopharyngitis, 104, 106
Rib fractures, 48, 49, 52

Scabies, 235, 236

Scorpions, 21
Scrotal swelling, 199
Seizures and convulsions, 42, 182
Separation anxiety, 314, 324, 325
Sexually transmitted infections, 185
Sickle cell disease, 75, 78, 165, 166, 254, 257,
267, 342
Snake bites, 22
Status asthmaticus, 12, 13
Stye, 130, 131
Syphilis, 185, 186, 190, 191, 192, 195, 196, 197

Tennis elbow, 219

Tension pneumothorax, 51, 52
Testicular disorders, 199
Tinea (pityriasis) versicolor, 237, 238
Tineas, 239
Tonsillitis, 33, 111, 112, 113
Torsion of the testis, 199, 200
Trichomoniasis, 185, 188
Tuberculosis, 81, 294, 297
Typhoid, 302, 304

g u ya n a sta n da r d t r e atm ent gu i del i nes  385