DUMKA DIOCESE MEDICAL MANUAL
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- Title
- DUMKA DIOCESE MEDICAL MANUAL
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PUMA'S
Med®"1 M
June 1997
Dr Peter O’Brien
DUMKA DIOCESE CLINIC MANUAL
MEDICINES.....................................................................................................
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ANAEMIA & WEAKNESS
ASTHMA
ABDOMINAL PAIN
RAISED BLOOD PRESSURE
COUGH
DIARRHOEA
EPILEPSY
EYES
FILARIA
INFECTIONS
ITCHINT
LEPROSY
MALARIA
OEDEMA
PAIN
“TONICS
RECTAL PROLAPSE
SKIN DISEASES
TUBERCULOSIS
VAGINAL DISCHARGE
WORMS
SYPHILIS
GONORRHOEA
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CHEST TUBERCULOSIS................................................................................
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DIAGNOSIS OF TB
TREATMENT FOR PARTIALLY TREATED TB OR SPUTUM NEGATIVE TB
CHEST TB FOLLOW-UP
TB LYMPH NODES
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NON-CHEST TB...............................................................................................
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BONETB
TB MENINGITIS
CHILDREN WITH TB.......................................................................................
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TREATING A CHILD WITH A COUGH
TREATING AN ILL CHILD WITH NO COUGH
MALARIA..........................................................................................................
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CEREBRAL MALARIA
MALARIA IN PREGNANCY
CHLOROQUINE PHOSPHATE THERAPY
POSSIBLE REASONS FOR FEVER CONTINUING AFTER CHLOROQUINE
page 1 - 18/06/97
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FEVERS AND RIGORS...................................................................................
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MALARIA
MENINGITIS
PNEUMONIA
RENAL (URINE) INFECTION
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DIARRHOEA.......................................................................................................
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“SIMPLE DIARRHOEA
PROLONGED DIARRHOEA
BLOODY DIARRHOEA “DYSENTERY
1. Amoebic Dysentery
2. Shigella Dysentery
CHOLERA
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TYPHOID..........................................................................................................
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KALA-AZAR......................................................................................................
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TREATMENT OF KALA-AZAR
DOING THE K-A BLOOD TEST, THE “ALDEHYDE TEST
SKIN DISEASES..............................................................................................
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SCABIES
FUNGAL INFECTIONS
IMPETIGO
ECZEMA
CORNS AND CALLOUSES
ROUTINE ANTE-NATAL TREATMENTS
SPECIFIC TREATMENTS WHEN PREGNANT FOR PROBLEMS
IMMUNISATIONS...............................................................................................
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ANTE-NATAL CLINICS...................................................................................
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INFANTS UNDER AGE 2
CHILDREN AGE 2-10
ADULTS
ESSENTIAL DRUGS.......................................................................................
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DIAGNOSING SICK CHILDREN USING WEIGHT CHARTS.........................
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UNDER 5S CLINICS
We would both like to thank all the people who worked with us while
we in the Dumka diocese. Thank you especially to Marcette and to ail the
nurses and health workers for their hard work and their willingness to
learn.
peter and Elaine O'Brien
page 2-18/06/97
MEDICINES
ANAEMIA & WEAKNESS
IRON tablets (injections no better than tablets)
VITAMIN tablets (injections no better than tablets)
FOLIC ACID tablets
N.B. Give B vitamins for numbness tingling and burning.
ASTHMA
AMINOPHYLLINE 10Omg
“DERIPHYLLIN”
1 or 2
1 or 2
x3
x3
ABDOMINAL PAIN
ANTACIDS
(aluminium hydroxide and magnesium trisilicate are the cheapest)
+ ask about diarrhoea, see notes below.
In children indigestion is less common, but it may be worth trying treatment
for worms
SPASMOLYTICS
e.g.Buscopan, Spasmindol may be useful in some cases.
DIGESTIVE ENZYMES
e.g.Pancreazyme, are only useful in those with pancreatic failure, which is
very rare.
RAISED BLOOD PRESSURE
"ESSIDREX" (Hydrochlorthiazide)
“NEPRESOL” (Dihydrallazine)
25mg
25mg
1 or 2
1 or 2
morning
x3
Low blood pressure on a routine BP check is a sign of health not illness. To
give medicines like Decadurabilon is stupid, dangerous and expensive. Low
blood pressure in a patient with diarrhoea and vomiting needs fluid giving
(oral or i/v) but NOT Mephentine or Coramine.
COUGH
”Cough suppressants” such as codeine can be effective, but need such high
doses that they often give troublesome side effects. It is harmful to try to
suppress a cough caused by chronic bronchitis or pnemonia. "Cough
expectorants” have never been shown to be effective. For those patients
who are kept awake at night with a dry cough there can be some benefit
from antihistamines. Give one tablet of “Avil” or “Piriton”.
page 3-18/06/97
DIARRHOEA (See page 21)
Few days, not ill, no fever, not passing blood needs oral fluids not medicine.
May get some benefit from CODEINE PHOSPHATE 30mg x 4 (but do not
give this to children).
Breast fed children should continue breast feeding.
Long time (over 1 week), or passing blood and having abdominal pain, may
be AMOEBIASIS or GIARDIA,
give METRONIDAZOLE 200 mg for 5 days
adult
2
x3
child
3-10
1
x3
child
<3
1/2
x3
Severe, ill patient, high fever, passing just blood/mucous, may be
SHIGELLA dysentry, so
give
CO-TRIM OXAZOLE
see dose below
or
TETRACYCLINE
see dose below
adult
child 8-15
child 3-8
4
2
1
x 4 or 6
x4
x4
EPILEPSY
or
PHENOBARBITONE 30mg
PHENYTOIN 100mg
Start on 1
x2
If the fits are not controlled on the starting dose then slowly increase the
dose until the fits are controlled. (Usually 200 - 300mg daily of Phenytoin is
needed, with benefit unusual above 500mg. For Phenobarbitone the ususal
dose is 60 - 180mg daily).
EYES
Severe infection, with a lot of pus discharging, give hourly cleaning and
drops of CHLORAMPHENICOL.
For eyes that have been red and itching for weeks, with a slight discharge,
the cause may be TRACHOMA,
give TETRACYCLINE EYE OINTMENT for at least 2 weeks x 2
FILARIA
Treatment is only useful in the acute attack - when the leg or arm is tender
and warm, with large painful lymph nodes. (It does not help to give medicine
for a leg that has been swollen just the same for a long time.) Use
DIETHYLCARBAMAZINE 50mg tablets, (known as Banocide or Heterazan).
Dose is 6mg/kg/day for 20 days
Over 50kg
2x3
41 - 50kg
1 x5
31 - 40kg
1 x4
20 - 30kg
1 x3
up to 20kg
1 x3
page 4-18/06/97
INFECTIONS
For patients ill with meningitis or pneumonia we should give, each day until they start to improve,
adults 8 lakh
i/m PROCAINE PENICILLIN
child
4 lakh
For IMPROVING MENINGITIS / PNEUMONIA
or
EAR infections
or
SKIN infections
or
URINE infections
or
CHEST infections
CO-TRIMOXAZOLE
(400 / 80 strength)
adult <40kg
2
x2
x3
30 - 40kg
1
x2
15-29kg
1
x2
5- 14kg
%
under 5kg
74
x2
For CHEST infections in adults we can also
use TETRACYCLINE 250mg
1
x4
For CHEST infections or for SKIN infections we can use
PENICILLIN tablets
adult 500,000u
x4
child
250,000u
x4
(N.B. NOT Penicillin for urine infection)
For all infections give at least 5 days of antibiotics. For those with severe
illnesses give at least 10 days.
ITCHING
“Piriton” (Chlorpheniramine) or
x 2 or 3
“Avil” (Pheniramine)
1
N.B. Both these tablets can make some people feel sleepy.
LEPROSY
TT
BT
BB
BL
LL
plus
Paucibacillary
Treat with 6 months of
100mg
DAPSONE
600mg
RIFAMPICIN
x 1 daily
one dose monthly
Multibacilliary
Treat with at least TWO years
DAPSONE
100mg
CLOFAZIMINE
100mg
600mg
RIFAMPICIN
CLOFAZIMINE
300mg
x 1 daily
alternate days or 50mg daily
one dose monthly
one dose monthly
page 5-18/06/97
MALARIA
CHLOROQUINE PHOSPHATE 250mg
Day 1 Day 2 Day 3
Over 45 kg
4
3
3
31 - 45 kg
3
2
2
19-30 kg
2
1 y2
1 y2
13-18 kg
1
1
1
10-12 kg
1
y2
y2
4 - 9 kg
y2
y2
y2
Less than 4 kg %
%
%
If the patient is unconscious and cannot swallow, or if he vomits the tablets,
give injections of Chloroquine 4mg/kg every 12hrs until he can take the
tablets, then give the tablets as above. There is no benefit from steroids (eg
dexamethasone) even in cerebral malaria.
OEDEMA
“ESSIDREX”
“LASIX”
Hydrochlorthiazide 25mg
Frusemide 40mg
1 or 2 in a.m.
1 or 2 in a.m.
PAIN
Big adult
Small adult
ASPIRIN 300mg
2
1
x4
x4
(Do not give Aspirin to those patients who have indigestion)
Maximum dose 2 tablets 4 hourly.
Adult over 30 kg
20 - 30 kg
10-19 kg
Less than 10 kg
(Safer for indigestion patients)
Maximum dose 2 tablets 6 hourly.
PARACETAMOL 500mg
2
1
1/2
1/4
x3
x3
x3
x3
"TONICS”
These are basically just iron, vitamins and folic acid, but are much more
expensive than these medicines in tablet form, yet in some cases less
effective (eg. “Haemoglobin tonics” work less well than iron and folic acid
tablets.)
“LIVER TONICS” There is no evidence that these do any good in patients with jaundice, or
any other liver disease.
page 6 - 18/06/97
RECTAL PROLAPSE
Treat for Giardia and Amoebiasis and also for worms (see relevant sections)
SKIN DISEASES
see section on skin diseases Pages 26 - 28
TUBERCULOSIS
Weight (kg)
Rifampicin
Ethambutol
Pyrazinamide
8-11
12-15
16-23
24-31
32-39
40-47
48 and over
150
150
300
300
450
450
600
200 (only if over 6yrs or over
250
375
500
750
1000
1250
1500
300
400
600
800
1000
1200
Isoniazid
(alone)
100
100
200
300
300
300
300
Isoniazid /
Thiacetazone
75/37.5
75 / 37.5
75 x 37.5 x2
75 / 37.5 x3
300/150
300/150
300/150
NB.AII these drugs are given ONCE daily usually in the morning or on an empty stomache.
Doses of Streptomycin daily injection
above 50 kg
35 - 50 kg
25 - 34 kg
12-24 kg
1gm
750 mg
500 mg
250 mg
VAGINAL DISCHARGE
Itchy, with thick white discharge, probably is “thrush”, so apply
GENTIAN VIOLET
x2 daily
Heavy discharge, thin, yellowish, with bubbles, may be “Trichomonas", give
METRONIDAZOLE 200mg 1 x 3 for 5 days
Mucous discharge, itchy, can also be due to threadworm; if the patient has
threadworm then treat (as below).
page 7- 18/06/97
WORMS
Hookworm + Roundworm + Threadworm
MEBENDAZOLE 100mg for 3 days 1
LEVAMISOLE
adult
1
< 15kg 1
x2
x150mg
x 50mg
BEPHENIUM 500mg (single dose)
above 10kg
10 tabs
below 10kg
5 tabs
Threadworm alone MEBENDAZOLE 100mg
Roundworm alone
LEVAMISOLE (Vermisol)
adults 150mg
<20kg 50mg
PIPERAZINE
Tapeworm
all ages over 10 kg 1 tab
1 dose
adults
child 10-15
child 5-10
child 2-5
child 1-3
MEBENDAZOLE
x1
x1
12 tabs
10 tabs
7 tabs
5 tabs
3 tabs
2x2
3 days
SYPHILLIS
BENZATHINE PENICILLIN 24 lakhs i/m
Penidur LA12 x2vials
This full dose should be given as a single injection to both the patient and
their partner.
GONORRHOEA
Single injection of PROCAINE PENICILLIN 24 lakhs i/m for both the patient
and their partner.
page 8-18/06/97
CHEST TUBERCULOSIS
DIAGNOSIS OF TB
consists of 3 steps - History, Examination and Investigation.
In the HISTORY we should remember that many diseases apart from TB
also cause coughs. Bronchitis, pneumonia, heart disease, viral illnesses or
cigarette smoking can all cause coughs. To help us decide if a patient’s
cough is due to TB we should ...
ASK
How long has the cough been present?
Is there fever also? Since when?
Is there sputum? With blood?
Is the patient losing weight?
Does the patient smoke?
Has the patient had previous TB treatment ? If so then ask,
When ?
How long for ?
Was there any improvement?
(Those who took a full year’s treatment regularly will probably not have a
relapse of their TB, those who only took 3 months treatment almost certainly
will. For those in between it is very difficult to know.)
EXAMINE
Weight
General condition
Temperature
Respiratory rate
Breath sounds. Are they normal ?
Are they increased (bronchial breathing) ?
Are they decreased ?
Are there extra sounds (Crepitations or Pleural rub) ?
Percussion note - Is it normal or dull ?
Remember that in adults with TB the abnormalities in the chest are often at
the upper lobes, but in children they are often in the lower lobes. Young
adults sometimes have “pleural TB", this may give a pleural rub, but
sometimes there is a pleural effusion with the pleural TB and we find that
this causes the breath sounds to be greatly reduced (and also causes the
percussion note to become very dull).
The INVESTIGATION that we use most commonly is the sputum test.
We should test the sputum of anybody who has had a cough for more than
a month, especially if they also have fever, or weight loss, are coughing
blood, or have abnormal signs in their chest.
Remember though that it is not a perfect test; if it is positive then the
patient certainly had TB, but there are cases where the test is negative even
though the patient has TB. In particular remember...
Small children usually will not cough out their sputum.
Pleural TB often is not sputum +ve.
The test quickly goes negative after starting TB treatment, so it is not a
reliable test in those who have been recently taking treatment.
If the patient does not give us an EARLY MORNING sputum then it is
harder to find the TB bacteria when we examine it, we may make a mistake
and call it negative.
page 9- 18/06/97
So for patients who we think might have TB but who have had a negative sputum test we
should be prepared to repeat their test if they continue to have cough, fever and weight loss.
(If this 2nd test is also negative we should remember that the test may be wrong and put the
patient on a trial of TB treatment. If the symptoms improve on treatment then we can say that
the patient almost certainly does have TB, and give a full course of treatment.
Sputum testing after recent TB treatment
For those patients who come when they have recently taken irregular of incomplete TB
treatment it is often difficult to know whether to give more TB treatment, especially as recent
TB treatment can often cause the sputum test to stay negative for several months.
To help to decide we should
ASK the history
EXAMINE the patient in the usual way
TEST the sputum
If the sputum test is positive then the patient needs the full course of treatment.
If the sputum test is negative then we have to decide if we think the patient really did have TB,
or whether he was given TB treatment for the wrong reason (some patients, for example, are
given TB treatment when they really have chronic bronchitis or a smoker’s cough).
If we think that it was not really TB and the sputum test is negative then do not give further TB
treatment.
Write down the patient’s details, including details of the examination and his weight. Give
treatment for any other illness that he has.
If we thin that the patient really did have TB and think that the sputum test is negative because
of the recent TB treatment then it is probably best to give one year’s treatment with
Thiacetazone I Isoniazid. (We dod not need to give a third TB drug because the negative
sputum test shows that the TB is already coming under control and is therefore unlikely to
develop resistance).
Preparing a sputum specimen to look for TB
1.
2.
3.
4.
5.
6.
7.
8.
From the specimen of sputum that the patient gives take out the part that is the
thickest and yellowest, using a thin stick. Spread this very thinly onto a glass slide
(Remember always to write the patient’s number onto the back of the slide first).
Pass this side of the slide quickly through a flame using a spirit lamp or a lighter. (
This is to kill the TB germs, so that we do not catch TB as we prepare the slide.)
Place the slide on a rack and then cover it completely with Cartool Fuschin. Heat
the slide from underneath with a spirit lamp, until you see steam coming from the
slide. Do not let the Carbol Fuschin boil. After the slide has started steaming leave
it for one minute, then again warm it until it steams. After this leave It again for
another four minutes.
Wash the slide with water.
Cover the slide completely with Acid-Alcohol, leaving it on for one minute.
Wash the slide with water.
Cover the slide with Methylene Blue, leave it on for 10 -15 seconds.
Wash the slide with water and then leave it to dry.
Results of sputum test
+
++
+++
++++
indicates very few TB germs present
indicates some TB germs present in some fields of view
indicates a few TB germs present in most fields of view
indicates many TB germs present in most fields of view
page 10-18/06/97
TREATMENT OF CHEST TB
It is probably best to start treatment with 4 drugs (and certainly always with at least 3 drugs) and then always
with at least 2 drugs for the rest of the course.
NEVER TREAT WITH ONE TB DRUG ALONE, because the TB bacteria will develop resistance to it.
Treatment always needs to be continued for a long period of time because the TB bacteria are very strong.
Some of them can continue to survive inside the body for many months even though the patient is taking
medicine and his condition is improving.
TREATMENT FOR SPUTUM POSITIVE TB (and pleural TB)
EITHER
1.
SHORT COURSE, MORE EXPENSIVE
2 months of Rifampicin, Ethambutol, Pyrazinamide, Isoniazid (with Thiacetazone)
Z‘
then, 6 months of Thiacetazone I Isoniazid *
OR
2.
LONGER COURSE, LESS EXPENSIVE
2 months of Rifampicin, Ethambutol, Thiacetazone . Isoniazid
then, 10 months of Thiacetazone / Isoniazid *
TREATMENT FOR PARTIALLY TREATED TB or SPUTUM NEGATIVE TB
12 months of Thiacetazone / Isoniazid *
Remember that when taking Isoniazid patients can develop numbness, tingling or burning. This can be
precented by giving Vitamin B6 (Pyridoxine). The dose given should be at least 10mg or Vitamin B6 daily.
Doses of TB medicines in milligrams
Weight (kg)
Rifampicin
Ethambutol
Pyrazinamide
8-11
12-15
16-23
24-31
32-39
40-47
48 and over
150
150
300
300
450
450
600
200 (only if over 6yrs or over
300
400
600
800
1000
1200
250
375
500
750
1000
1250
1500
NB:
Isoniazid
(alone)
100
100
200
300
300
300
300
Isoniazid /
Thiacetazone
75 / 37.5
75 / 37.5
75 x 37.5 x2
75 / 37.5 x3
300/150
300/150
300/150
All these drugs are given ONCE daily, usually in the morning or on an empty stomache.
page 11 -18/06/97
CHEST TB FOLLOW- UP
Each time we see the patients in the clinic we should ...
ASK
Are they on time for their tablets, or late?
How are they?
Have the cough and fever stopped?
(Remember that TB patients can still get ill with malaria, amoebiasis,
headaches,indigestion, etc.; these will need treating in the usual way.)
EXAMINE Weight
INVESTIGATE
All sputum positive cases should have a repeat sputum test after 2 months
For those continuing to cough remember that all TB patients, especially smokers will continue
to have some cough, usually not so bad as before.
TB patients are more likely than others to suffer from bronchitis, so for those patients on
TB treatment whose cough gets worse, with increased sputum and maybe a fever, give
antibiotics (for at least 5 days) as well as their TB treatment.
The few patients who do not improve may have a resistance to their TB medicines. Check
first that they are taking their TB medicines properly. Then check their sputum; if this is
more positive than before then probably it is resistance to the medicines. If the sputum test is
negative continue the original TB medicines, but remember that they may have developed a
new problem, such as lung cancer.
Those who are resistant to the medicines that they are taking should be given 2 or 3 new TB
medicines (e.g. Streptomycin, Rifampicin or Pyrazinamide). Ideally treatment should be
started with 3 new drugs for at least 2 months, then continued with at least 2 drugs for the
remaining 14 months. Using drugs such as Streptomycin, Rifampicin or Pyrazinamide makes
this extremely expensive, so we should be very careful before diagnosing resistant TB.
page 12 -18/06/97
TB LYMPH NODES
Lymph node TB is usually in the neck (cervical glands), or occasionally in the axilla, and is
usually less severe than chest TB.
The patients have swellings in the neck, sometimes discharging pus often a slight fever
sometimes other enlarged lymph nodes
ASK
How long have the swellings/discharge been present ?
Is there fever ?
Are there pains or sores anywhere else ?
EXAMINE
Weight
(If possible in doubtful cases check the temperature regularly for a
week or two).
Look at the head, the ears and the mouth for any signs of infection, because
anybody with sores on the scalp, or infected ears or sore throat will have enlarged
glands in the neck. (We must treat these conditions before diagnosing any neck glands
as TB). Remember that in children it is usually easy to feel glands in the neck even if
they are not enlarged.
Examine the swellings. If it is TB there will usually be many glands. The glands
are not tender, but they are usually stuck to each other - they are not separate, like the
enlarged glands secondary to an infection. Often there will be scars on the neck from where
there has previously been pus discharging.
Another illness that gives swellings of the glands in the neck, with some fever and
weight loss is “lymphoma” (lymph gland cancer). These patients will not usually have scars, or
pus discharging, and usually the glands will be separate, not stuck together.
Sometimes it can be difficult to tell the difference between TB lymph glands and
lymphoma; one way to be sure is to send the patient for a "biopsy” operation (where one of the
glands is removed and then studied under a microscope). This is difficult to arrange with our
patients, so we usually just give TB treatment and then see if they improve over the next 2
months. If they do improve we can call it definite TB and continue the full course of treatment.
If they do not improve, we should remember that there can be other causes of swellings in the
neck and send the patient to hospital.
TREATMENT
2 months Ethambutol and Thiacetazone I Isoniazid
thenlO months of Thiacetazone/ Isoniazid
page 13 -18/06/97
NON-CHEST TB
BONE TB
Bone TB is found most commonly in the spine, though it can also be in the knee, the elbow,
the wrist or even the fingers. The patient with TB spine comes complaining of backache for a
long time, often a slight fever and sometimes an abscess discharging over the spine.
EXAMINE
Weight
Spine
Look for and feel for a deformity.
If it is TB there is a deformity based at one place - which is tender if you
press it firmly. The movements of the spine are greatly decreased (on
bending the movement is at the hips, not between the vertebrae of the
spine). There may be an abscess or pus discharging over the spine.
X-RAYS
If available these show a characteristic deformity (as shown in the textbook
“Adams Orthopaedics”, page 189,190).
TREATMENT
As for sputum positive TB
N.B. Do not expect the patient’s backache to improve quickly. Often it
takes several months for it to improve.
TB MENINGITIS
To make a diagnosis of TB Meningitis a lumbar puncture is necessary, but this is worth doing
because the treatment of TB meningitis is slightly different from other types of TB. (Double
doses of Isoniazid are given, i.e. 600mg for adults, 20mg/kg/day for children).
We should suspect TB Meningitis in any patient with meningitis (fever, headache, stiff neck,
inability to bend the back) who does not improve after a few days of antibiotic treatment.
Children with TB Meningitis however often do not have the usual signs of stiff neck and inability
to bend the back. To be able to diagnose TB Meningitis we should send those children we
suspect may have it to the hospital for a lumbar puncture. (This means that if possible we
should send those children who are ill, with no obvious cause, who are not improving after
chloroquine and antibiotics
page 14 - 18/06/97
CHILDREN WITH TB
This is always a difficult diagnosis; children are not able to explain their symptoms, they are difficult to
examine and they do not provide us with sputum samples for examination.
We should therefore always think about TB in children who have fevers which are not improving with
treatment, or who are losing weight - especially if they are coughing.
We must remember though that in this area many children get whooping
cough, so we must know how to tell the difference between this and TB.
WHOOPING COUGH
T.B.
1.
Child has bouts of very severe coughing
but is usually quite well in between.
Cough does not come in
severe bouts, but child
is not well in between.
2.
Except in small children the cough
often results in the typical “whoop".
There is no “whoop”.
3.
Child is often not losing weight,
except forthose who are vomiting
at the end of each severe bout of
cough.
Child is usually losing
weight.
4.
Chest is normally clear.
Chest often not clear
5.
Cough lasts for 3 - 4 months then
stops without treatment.
Cough for months or
years unless treated.
6.
Antibiotics not useful unless the child.
gets a bronchitis or pneumonia (we call
this a “secondary infection”).
Antibiotics not useful.
page 15-18/06/97
Treating a child with a cough
If the child just has a cough and cold, looks well and has no other illness then NO
TREATMENT is needed.
If the child is unwell with a cough, or has a fever with a cough, we must examine its breathing
and its chest (as well as checking for and treating any other illnesses). We should also weigh
the child. Unless we find a cause for its illness apart from its chest trouble then a child who is
unwell with cough and fever should get antibiotics.
After antibiotics if the child still has cough and fever, or cough and weight loss, we have to ask
ourselves “is it whooping cough?"; usually the answer will be “no”. We should then call the
child ?TB and start treatment with Rifampicin and Thiacetazone/lsoniazid. If the child
obviously improves then we can call it definite TB and give the full course of treatment with 2
months of Rifampicin, Thiacetazone/lsoniazid followed by 10 months Thiacetazone/lsoniazid.
If it does not obviously improve we should still give TB treatment but keep looking for signs of
other diseases
Treating an ill child with no cough
ASK the mother the usual questions:
How long has the child been ill ?
Does it have a fever? With rigors ?
Does it cough? Since when ?
Does it have a headache ?
Is it feeding well ? Is it vomiting ?
Is the stool normal ? Any blood ? Any worms ?
EXAMINE and weigh the child.
If the child is well, has no history of fever, and nothing to find on
examination, then no special treatment is needed. (Tell the mother to come
back in 1 week if she is still worried).
If the child looks unwell, or has a history of fever and you don’t find
anything on examination, give chloroquine (in case the child has malaria).
If this gives no improvement and the child still looks unwell or still has a fever then it may have
an infection in its urine. (This is quite common in children, making them feel unwell, giving
them a fever, but giving nothing to show on examination - making it difficult for us to
diagnose.) If possible arrange a urine test; if not possible then give Co-trimoxazole for a week.
After chloroquine and antibiotics if the child is still unwell or still has fever then it may have TB.
We should call it ?TB and start treating (as above).
page ] 6 - 18/06/97
MALARIA
Malaria is very common and can be very serious. We should consider malaria in any patient who
has fever and rigors, with headache and body pains. Sometimes we will be able to feel an enlarged
spleen in these patients, sometimes not. We should treat for malaria even if we cannot feel a
spleen (unless the fever and rigors are clearly due to another illness, eg. renal infection,
pheumonia).
The best treatment for malaria is still Chloroquine, this should be the first choice for adults and the
first choice for children.
Primaquine is used in treating patients who live in areas where malaria is rare. To given in to
patients in our area causes a weakening of resistance to future attacks of malaria, so we do not use
it.
CEREBRAL MALARIA
Much of the malaria in this area is falciparum malaria - the type that can lead to cerebral malaria.
Here also the best treatment is Chloroquine tablets. If the patient is unconscoius and cannot
swallow, or if he vomits the tablets, then Chloroquine injection 4mg I kg every 6 hours until he can
take the tablets, then give a full course of tablets. There is no benefit in giving steroids (eg.
Dexamethasone) even in cerebral malaria. If the patient’s condition remains serious or deteriorates
then, if possible, arrange transfer to a hospital for consideration of intravenous Quinine, or other
treatments.
MALARIA IN PREGNANCY
Malaria is more common and more severe in pregnancy (eg. cerebral malaria is more common) and
can give complications in the pregnancy (eg. miscarriage).
It is important to treat quickly any pregnant lady we suspect of having malaria. The safest treatment
is Chloroquine.
CHLOROQUINE PHOSPHATE THERAPY
250 mg
Over 45 kg
31 - 45 kg
19-30 kg
13-18 kg
10-12 kg
4-9 kg
Less than 4 kg
Day 1
Day 2
Day 3
4
3
2
1
1
%
%
3
2
1 y2
1
72
%
%
3
2
1 v2
1
%
%
%
If the patient is unconscious and cannot swallow, or if he vomits the tablets, give injections of
Cholorquine 4mg/kg every 6 hours until he can take the tablets, then give the tablets above. There
is no benefit from steroids (eg. dexamethasone) even in cerebral malaria.
page 17- 18/06/97
POSSIBLE REASONS FOR FEVER CONTINUING AFTER CHLOROQUINE
1.
Wrong dose of Chloroquine was given.
2.
3.
Correct dose of Chloroquine was given, but was not taken as instructed, or was vomited.
Wrong diagnosis, the patient symptoms were due to eg meningitis or typhoid. OR, incomplete
diagnosis as well as malaria the patient also had eg. TB or Kala-azar
4. Re-infection; the chloroquine was effective but the patient got re-infected (this would normally
take at least 2 weeks after giving chloroquine for the fever to start again).
5. Resistant malaria (probably very uncommon in this area). This would give a fever which
returned whithin 2 weeks, or which did not settle at all. It could be a) Partial resistance which
could be treated with further chloroquine, or b) Complete resistance which would need treatment
with another drug, eg. Pyrimethamine / Sulphasoxine “Metakalfin”.
So, for fever continuing after a course of chloroquine, check that,
1.
2.
3.
The correct dose was given
The correct dose was taken properly, without vomiting
There are no other causes for the fever eg. meningitis, typhoid, Kala-Azar
After these have been done
If the fever improved at first and has returned more than 2 weeks after taking chloroquine, given
another course of choloquine
OR
5. If the fever did not settle, or recurred within 2 weeks of giving chloroquine, then give
Pyrimethamine/Sulphasoxine “Metakalfin”.
4.
Dose
Adults over 50 kg
35 - 49 kg
25 - 34 kg
15-24 kg
7-14 kg
less than 7 kg
page 18-18/06/97
3 tablets
2 tablets
1 % tablets
1 tablet
% tablet
% tablet
FEVER AND RIGORS
The most common presenting symptom in our clinics is “fever and rigors”. Often the cause is malaria, but it
could also be meningitis or pneumonia or renal infection or shigella ....
This section will first of all give a short description of the features of these illnesses that present as “fever
and rigors" then will go on to consider how we should try to distinguish these different illnesses when we are
seeing patients in the clinic.
MALARIA
History
Examination
Fever, usually with rigors
Headache + pains all over
(No cough, normal stool + urine)
Often NAD , patient may look well.
Sometimes may have fever (+ rigors) in the clinic.
Often the spleen is palpable.
MENINGITIS
History
Examination
Fever, sometimes rigors.
Headache (+ eyes hurt to look at the light).
Pain all over.
In children: often vomiting, sometimes fits.
Ill-looking patient.
Fever.
Stiff neck + cannot bend back.
PNEUMONIA
History
Examination
Fever, sometimes rigors.
Cough sometimes with blood.
Chest pain, worse with cough or deep breath.
Breathing difficulty.
Ill-looking patient.
Fever.
Rapid, difficult respirations.(Children are usually breathing at more than
60/minute, with a grunting noise and flaring nostrils). Breath sounds may
be normal, may be crepitations or pleural rub, may be decreased, may be
bronchial breathing.
page 19- 18/06/97
RENAL (URINE) INFECTION
History
Fever, usually rigors.
Pains all over, especially back + sides.
Very painful to pass urine (burning pain).
Usually passing urine frequently.
Examination
Fever
Renal tenderness
So, for the patient who comes into the clinic with “fever and rigors”,
we should always ...
ASK
How long has there been fever ?
Is there any pain ? Where is the pain ?
Is there a cough ?
Are the stool and urine OK ?
EXAMINE
Look for anaemia.
Feel for the spleen.
If they have a cough -note the respirations
Listen to the chest.
If they have no spleen, examine for renal tenderness.
If they look “ill”, CHECK FOR NECK STIFFNESS.
According to what we leam from the history and examination we give the treatment as
follows ...
Those with no spleen, no other signs.
Chloroquine
Those with spleen, no other signs.
Chloroquine
Those with no spleen, obviously suffering from something else
treat that illness as appropriate.
Those you can’t decide
? Malaria
+ ? Meningitis or Pneumonia
or Renal infection.
Treat for both illnesses that you are suspecting, making
sure to give a proper, full course of treatment for both
illnesses.
page 20- 18/06/97
DIARRHOEA
In all patients with diarrhoea remember that because they are losing fluid from their bodies they
must therefore increase the amount of fluid that they put back into their bodies (i.e. they should drink more).
This is especially important in small children, who become dehydrated
more quickly. We should always tell their mothers how to make sugar / salt solution and tell them to give
some of this each time the child passes loose stool. (If it is a breast fed child they should continue breast
feeding).
Sometimes the patients will be vomiting also. If the vomiting is only occasional then they can still
drink the sugar/salt water (or take the breast milk) in between vomits. Some of the fluid will of course come
out with the vomit, but most of it will pass on from the stomach into
the body. If the vomiting is severe and frequent then the patient will need to be
given fluid intravenously.
To prepare sugar/salt solution ...
Into 1 litre of water
add 5 (flat) teaspoons of sugar
plus
1 (flat) teaspoons of salt.
OR
Into 1 (200ml) glass of rice water
add a 3-flnger pinch of salt.
Most diarrhoea patients will have “simple diarrhoea” and will need no other treatment; those
with either prolonged or bloody diarrhoea will need extra treatment.
Using I.V.I.s
Continue trying to give the patient oral fluids (by mouth or by naso-gastric tube), this will
speed up his re-hydration and also decrease the number of bottles of I.V.I. he needs - saving
his money !
Keep a record of the patient’s pulse, BP and the number of times he vomits and passes
stool.
As the pulse and BP improve the need for intra-venous fluid is less; we should concentrate
again on trying to give oral fluids.
Children’s progress can be followed by measuring their weight on admission and during the
illness. Of the weight is falling then the child is losing fluids still, if the weight is increasing then
we know that the child is gaining fluid. Knowing exactly how much fluid to give to a small child
is hard. The simple guidelines are to give about 200mls for every 10kg weight in the first 30
minutes, then each hour to give about 40mls for every 10kgs weight, plus the volume that you
think the child has lost in diarrhoea and vomits in that hour.
page 21 -18/06/97
"SIMPLE DIARRHOEA
Patient not ill.
Treatment
No blood in stool.
No fever.
Lasts only a few days.
No special medicine; the patient may get some relief from
Codeine Phosphate 30mg
x 3 - 4.
( Do not give this to children).
PROLONGED DIARRHOEA (Giardia or mild Amoebiasis)
Lasting for more then a week.
Patient not ill.
No fever.
Not passing blood.
Treatment
METRONIDAZOLE 200mg for 5 days
Adults
2
Child 3-10
1
Child <3
%
x3
x3
x3
BLOODY DIARRHOEA "DYSENTRY”
(2 main types)
1.
AMOEBIC DYSENTRY
Patient usually not so ill.
May have slight fever and abdominal pain.
Passing blood mixed with stool.
Usually opens bowels less thanlO times in 24 hours
Treatment
2.
METRONIDAZOLE 200mg for 5 days
Adults
2
Child 3-10
1
Child <3
1/2
x3
x3
x3
SHIGELLA DYSENTRY
Starts suddenly, patient ill.
High fever.
Passing just blood/mucous, little stool.
Usually opens bowels more than 10 times in 24 hours.
Treatment
CO-TRIMOXAZOLE for 5 days
1
Adult < 40kg
Child 6-12
1
%
Child % -6
Child < %
%
x3
x2
x2
x2
CHOLERA
is a very severe form of “simple diarrhoea". The patient is passing what looks just
like rice water every few minutes. He is often dehydrated. It is treated like “simple diarrhoea”,
e. the most important part of the treatment is to give fluids. In addition to this though there will
i.
be some benefit from giving TETRACYCLINE 250mg x 4 for 5 days.
page 22- 18/06/97
TYPHOID
Typhoid is caused by bacteria that enter the body when food ordrink is taken that has been contaminated
from the faeces of a previous typhoid patient. (The contamination is often spread by people not washing
their hands after passing stool, or is spread by flies.)
Symptoms
1st week
Patient becomes gradually weak with headache, body pains, often a slight
cough and maybe constipation. There is a fever, rising higher and higher
during the week.
2nd week
Spleen becomes palpable. By the end of this week the patient is very unwell
and develops typical mental changes, becoming “distant” i.e. not able to
concentrate on, or to understand, what is happening to him or around him.
Also at this stage the typical typhoid diarrhoea begins, “pea soup diarrhoea”.
3rd week
Patient passes into a coma, then dies.
From this description of typhoid it is easy to see that it can be very easily be confused with
malaria in the earlier stages (fever, rigors, headache + palpable spleen). We will usually have
given chloroquine first; the fact that the patient does not improve after the chloroquine should
make us think about typhoid.
How do WE recognise typhoid ?
The patient is ill.
The temperature is always raised.
The spleen may be palpable.
There is a relatively slow pulse. *
There is no improvement after chloroquine.
* By “a relatively slow pulse" we mean that the pulse rate does not rise with increasing
temperature as it does in most other illnesses. (Usually for each 1 degree rise in temp, the
pulse rises by 10 beats per minute.) e.g.
- patient with pneumonia may have temp. 99 and pulse 90 then later temp. 103 and pulse 130
- patient with typhoid would have temp. 99 and pulse 90 then later temp. 103 and pulse 95.
Treatment
Give
This must be for 14 days (if we only give 5 days there will usually
be a recurrence).
CHLORAMPHENICOL 2
x4
or
CO-TRIMOXAZOLE
2
x2
There is also a milder version of typhoid known as paratyphoid; this is similar to, though
usually not so severe as, typhoid itself. If we have a patient with some of the features of
typhoid (who has not improved after a course of chloroquine) we should think of paratyphoid
and give a 14 day course of Co-trimoxazole.
page 23- 18/06/97
KALA-AZAR
This is an infectious illness which is transmitted by sandfly bites.
The patient
becomes gradually ill usually has a low fever (though often the patient does not
realise that he has a fever).
becomes more and more weak and anaemic,
less and less able to resist infections
develops a very large spleen
sometimes has oedema of the legs.
On examination
There is often anaemia
There may be patches of dark skin, often on the face
the spleen is enlarged
We should think of kala-azar in any patient who has a large spleen. First of all though we
should remember that a large spleen can be due to malaria and therefore give a course of
chloroquine, telling the patient to come to the clinic again in 1 or 2 weeks.
After taking chloroquine:
1. Spleen gets bigger or fever continues
patient needs kala-azar treatment
2. Spleen gets smaller AND fever stops
patient needs no treatment,
see again after 1 month
do K.A. blood test.
If it is +ve give kala-azar treatment
3. Spleen stays same ? still fever
If you think that the patient will not come back after taking chloroquine, you can do the blood
test at the first visit to the clinic, however we do not usually do this because the K.A. blood test
can also be positive in malaria.
The K.A. blood test can be negative during the first 3 months of kala-azar, so if the patient’s
spleen is getting bigger after taking chloroquine we should try to send the patient for a bone
marrow test, which is a much better test for kala-azar. If this is positive then treatment should
be given.
If a bone marrow test is not possible then give a trial of kala-azar treatment with Stononate;
judge the results of your treatment by whether the fever stops, whether the spleen gets smaller
and whether the patient feels better.
The K.A. blood test is not good for showing which patients have relapsed after treatment (A
positive K.A. test could be due to either partially treated disease which has relapsed, or due to
recent disease which has been successfully cured). If there is any doubt about a relapse then a
bone marrow test should be arranged.
page 24- 18/06/97
Treatment of Kala-azar
20 daily injections of Stibonate (Sodium Antimony Gluconate)
Adults 40 kg or more
8 mis i/m
35 kg
7 mis im
30 kg
6 mis im
25kg
5 mis i/m
20kg
4 mis i/m
15kg
3 mis i/m
10kg
2 mis i/m
5kg
1 ml i/m
After 20 injections if the spleen is more than 3 fingers thick then another 10 injections
should be given. Many hospitals and doctors only give 10 or 12 injections. This will fail to cure
25% of patients, so it is best to give them all 20 injections.
A course of chloroquine should always be given (unless the patient has recently had
chloroquine) before starting the kala-azar treatment. After the course of injections the patients
should be given Iron and Folic Acid for several months, because most of them will be very
anaemic.
Remember that many kala-azar patients also have TB; always ask about
cough, then do the chest examination and sputum test if necessary.
Doing the K-A blood test, the “aldehyde test”
1.
Take about 1-2 mis of blood from the patient
2. Leave the sample in a test tube or small bottle for a few hours until the blood and the serum
separate
3.
Carefully pour out the serum into a separate test tube or clean bottle.
4.
Add 1 or 2 drops of formaldehyde to the serum
5.
For the test to be positive the serum should change from clear and fluid to white and solid
(like the change in an egg white when it is cooked). Note how long it takes for the test to
become positive.
++++
+++
++
+
Positive within 2 minutes
Positive within 10 minutes
Positive within 2 hours
Positive overnight
page 25-18/06/97
SKIN DISEASES
When we try to learn about skin diseases it is essential to have photographs to look at. We
could not provide photographs in this manual, so what we have done is to provide reference numbers for the
photographs in the book “Dermatology" in the Diocesan medical library. This means that if you see 12.8
written in the text then you should go to the “Dermatology" book, turn to chapter 12 (i.e. the first part of the
reference number) and then find the 8th photograph in that chapter ( i.e. the second part of the reference
number).
SCABIES
This is an infectious disease, caused by small insects burrowing into the skin. See 21.4.
The patients complain of an itchy rash.
Examining the skin we find a rash, most commonly between the fingers or on the hands or
the wrists. Men often have scabies on their genitalia, while women often have it on their
stomachs (especially if they are carrying small babies) and the babies often have it on their
bodies rather than on their hands. See 21.11.
When examining a baby with a rash always remember to look at the mother; if she has
scabies then it is very likely that the child also has scabies.
Often the scabies becomes infected; instead of seeing dry, scaly lesions we then see the
area around the rash is swollen, warm and painful, with pus discharging. When it is like this we
should first of all treat it with soap + water and Gentian Violet, as well as antibiotics (eg Cotrimoxazole). Once the infection is settling down then we can give the normal scabies
treatment.
Should be given to everyone in the house who is affected
(not just the patient who comes to the clinic).
Use 25% Benzyl Benzoate. “Ascabiol"
Full strength for adults
% strength for children
% strength for babies.
Day 1.
Wash all over, wash all the clothes.
Apply the ointment over the whole body below the neck.
Leave the ointment on for 24 hours.
Day 2.
Wash all over again.
Apply the ointment again.
Leave the ointment on for 24 hours.
Day 3.
Wash off all the ointment.
Treatment
page 26 - 18/06/97
FUNGAL INFECTIONS
Fungal infections can affect the skin, the scalp, or the finger nails. On the skin they are
usually very itchy.
One of the commonest places to get fungal infection is between the toes, "athlete’s foot”.
see 10.2. (This type is more common at the time when the people are standing in the wet
fields, doing the rice planting.)
On the body there are usually itchy, round patches, with slightly raised edges, sometimes
healing in the centre. See 10.6, 10.7 and 10.8.
On the scalp the patient notices a bald patch; on examining this patch there is incomplete
loss of hair (some short hairs remain), and the skin of the scalp is scaly, not smooth. See
10.13.
Fingernails become dark in colour and deformed. See 10.15 and 10.16.
Treatment
Body (+feet)
Scalp
Nails
apply Whitfield’s ointment x 2 daily
Griseofulvin tablets 125mg x 3 daily for 1 month
Griseofulvin tablets 125mg x 3 daily for 6 months
Griseofulvin doses (can all be taken at the same time)
50 kg or over 500mg x 1
Adults
30 - 50 kg
125mg x 3
20 - 30 kg
250mg x 1
below 20 kg
125mg x 1
IMPETIGO
This is a very common condition, caused by bacterial infection. It starts as pus-filled
blisters, see 12.1 and 12.2, which break down to give superficial erosions (shallow blisters), see
12.3 and 12.4 and then the typical yellow crusts, see 12.6. Often there are small areas affected
around the main areas, “satellite lesions”, see 12.8.
This combination of shallow ulcers and yellow crusts is seen surprisingly often in our clinics,
sometimes as impetigo on is own, sometimes as impetigo complicating other conditions (such
as scabies).
Treatment
Soap + water (very important to soak away the crusts, which
contain a lot of bacteria).
Gentian Violet, applied daily.
Antibiotics in the more severe cases.
page 27- 18/06/97
ECZEMA
This is a disease that lasts, off and on, for a long time. It gives the patients dry, itchy
rashes affecting most commonly the front of the elbows, the backs of the knees and the neck or
the wrists.
Examination
the skin is thickened, dry and scaling and the rash is often
symmetrical (i.e. the same on both sides of the body).
Treatment
Aqueous cream or Zinc Oxide
Lasser’s paste
Icthammol or Coal Tar
Steroid ointments; these are very effective for treating eczema, but
they can make other conditions e.g impetigo much worse. We
should not use steroids unless we are sure that the patient has
eczema. If the itching is bad give antihistamines ( e.g. Piriton )
CORNS AND CALLOUSES
These are both terms used to describe areas of thickened skin. Most commonly they are
found on the feet. In our clinics we often see patients who have very thick skin on their feet;
when the skin begins to crack it is painful, and sometimes becomes infected.
The simplest way to treat this condition is to tell the patient to soak the whole foot in warm
water for 15 minutes twice daily, then to wash it with soap and try to rub off the excess skin.
Sometimes though this is not enough to get rid of the coms or callouses and then we should tell
the patients to apply Salicylic Acid ointment 6%, twice daily until the condition clears.
page 28- 18/06/97
ANTE-NATAL CLINICS
At each visit the mother makes to the clinic we should ...
ASK ..
about previous difficult deliveries; women who have had previous Caesarians or
difficult deliveries should go to hospital for the next delivery.
about the present pregnancy
when did it start ?
are there any problems ?
ALWAYS ASK ABOUT FEVER
Remember that pregnant women get ill with other illnesses besides the pregnancy. In
particular they are more likely to get trouble with malaria and urine infections (and malaria is
very often dangerous in pregnancy, so give chloroquine if you think that a pregnant woman
might have malaria).
EXAMINE
Weight
Eyes, mouth + tongue - for anaemia, vitamin deficiencies
Spleen
Size of the uterus
Legs for oedema
Blood pressure
We should always be on the look-out for pre-eclampsia; this is the early stage of the illness
that progresses to eclampsia. Eclampsia causes fits and often death in pregnant women. Pre
eclampsia consists of
OEDEMA,
RAISED BLOOD PRESSURE
and
PROTEINURIA.
Ideally all pregnant women should have the BP measured, urine tested for albumin and legs
examined for oedema at each visit. Obviously in busy clinics it is very difficult to do all this, but
we should remember that eclampsia is nearly always in the first pregnancy and say that ...
Every primigravida should have her BP measured and her legs examined for
oedema every time.
Every woman with oedema, or increased BP or weight gain of more than 1/2kg per
week should have a urine test for albumin.
Any woman with increased BP or oedema, with albumin in the urine should be told that it
might be something serious and advised to go to hospital for a check-up.
How often should women attend ante-natal clinics ?
Ideally it should be
every month up to 28 weeks
then
every 2 weeks up to 36 weeks
then
every week.
It would be difficult to get most of the mothers to come that often, but try to get them to
come...
then
±
_
,
every month up to 32 weeks
every 2 weeks from 32 weeks until delivery
page 29- 18/06/97
ROUTINE ANTENATAL TREATMENTS
Iron, folic acid and multi-vitamins at every visit
(usual dose 1 x 2 of each)
Tetanus toxoid immunisation x 2 during the pregnancy
( and a booster dose every 4 years afterwards)
Give the first injection when the woman first comes to the clinic, then give
the second dose after at least 4 weeks -but during the same pregnancy if
possible.
SPECIFIC TREATMENTS WHEN PREGNANT FOR PROBLEMS
Malaria
Chloroquine is safe
Amoebiasis, Giardia
Metronidazole is safe
TB
Rifampicin, Pyrazinamide,
Ethambutol, Thiacet/lsoniazid are safe
Do not give Streptomycin
Vomiting, Nausea
usually no treatment needed,
but if very bad give “Avomine” or antihistamine
Indigestion
Antacids are safe
Pain
Aspirin is safe, but after 28 weeks it is best to give
Paracetamol
Antibiotics
Penicillin is safe
Ampicillin is safe (chest, ear, urine)
Co-trimoxazole is safe up to 28 weeks
After 28 weeks we should only use Co-trimoxazole for treating typhoid or shigella.
For other infections we should try to use penicillin if that is suitable. For infections
like urine or ear infections, where penicillin is not suitable, we can give Ampicillin - but this is
expensive. As an alternative we can give Trimethoprim (i.e. Co-trimoxazole without the
Sulphamethoxazole ). Give a prescription for "Tuliprim” or “Zotran" 100mg x 3 for at least 5
days.
For urinary infections we can give Nitrofurantoin “Furadantin” 100mg x 4 for at least
5 days. (However if the patients with urinary infection have high fever and renal tenderness
then it is best to give Ampicillin or Trimethoprim).
page 30- 18/06/97
IMMUNISATIONS
The vaccines that we have available at the moment are,
POLIO
DTP (Diphtheria, Pertussis and Tetanus)
DT (Diphtheria and Tetanus)
MEASLES
BCG
It is also possible to get vaccines for the prevention of typhoid, but these are not available
to us at the moment so we shall not describe their use here.
We should try to immunise all children against Tetanus, Diphtheria and Pertussis
(Whooping cough), Polio, Measles and TB.
All adults and especially all pregnant women should be immunised against Tetanus. If we
have a good supply of Polio vaccine then we should also try to immunise all the adults against
Polio also.
Remember that THERE ARE TWO TYPES OF TETANUS IMMUNISATION, Tetanus
Toxoid Vaccine and Anti-Tetanus Serum. For routine immunisations we should always be
giving Tetanus Toxoid Vaccine.
Tetanus Toxoid Vaccine stimulates the body to make its own protection, "antibodies". After
a course of Tetanus Toxoid Vaccine the body then has effective and long-lasting protection
against Tetanus. It does however take a long time for the body to make these antibodies, too
long to wait if the body has a serious, deep, dirty wound.
Anti-Tetanus Serum provides the body directly with antibodies against Tetanus, so the
protection it gives takes effect at once. It does not however stimulate the body to make its own
antibodies, so the protection only lasts as long as the injection lasts - i.e. only a short time.
We should use Anti-Tetanus Serum for a patient with a deep, dirty wound who has never
had Tetanus immunisation with Tetanus Toxoid Vaccine. (We should remember also to give a
course of Tetanus Toxoid Vaccine afterwards, to give protection against Tetanus from any
future wounds.)
Remember though that the Anti-Tetanus Serum is made from horse’s blood and can,
sometimes, give dangerous reactions in people. We therefore only give it when there has been
a deep, dirty wound - the type which is more likely to cause Tetanus.
REMEMBER - THE MOST IMPORTANT PART OF PREVENTING TETANUS IS TO CLEAN
ALL WOUNDS AS WELL AS POSSIBLE.
page 31 - 18/06/97
INFANTS UNDER AGE 2
If possible start at age 6 weeks, (although if you see the child before this stage give the
“zero dose" of polio and then the full immunisation course starting 4 weeks later).
Give 3 doses of DTP and Polio (they can be given together)
Give the doses 1 month apart if possible, try not to leave more than 3 months between
doses.
If the child is seriously ill then the immunisations should not be given, but it is safe to give
them if the child has a cough and cold, or a simple diarrhoea.
After the immunisations - especially the 2nd and 3rd if the child has the Pertussis vaccine the child may develop a fever, and may have some pain at the site of the injection. This is not
harmful, treat by giving some Paracetamol.
Booster doses of DT and Polio should be given at 4 years.
Measles or MMR vaccine should be given at 9 months.
CHILDREN AGE 2 - 10
As above, but without the Pertussis ( use DT not DTP). Give the booster dose after 3
years.
ADULTS
3 doses of Tetanus Toxoid Vaccine, and Polio - if available, with 1 month between each
dose.
Booster doses should be given every 10 years.
page 32-18/06/97
ESSENTIAL DRUGS
This is a list of drugs that we think every dispensary in the diocese should always have in stock.
For explanation of what each of the medicines is needed for please see the first section of this book.
•
Iron
•
Vitamin B tablets
•
Vitamin A capsules
•
Folic acid tablets
•
Paracetamol tablets
•
Aspirin
•
Antacid tablets
•
Co-trimoxazole tablets
•
Penicillin injection
•
Tetracycline eye ointment
•
Metronidazole tablets
•
Chloroquine tablets
•
Diethylcarbamazine tablets
•
Mebendazole tablets
•
Ethambutol tablets
•
Thiacetazone / Isoniazid tablets
•
Rifampicin tablets
•
Dapsone tablets
•
Clofazimine
•
Phenobarbitone (or Phenytoin) tablets
•
Whitefield’s ointment
•
Benzyl benzoate solution
•
Gentian violet
Ferrous sulphate tablets
eg.
page 33- 18/06/97
DIAGNOSING SICK CHILDREN USING WEIGHT CHARTS
NORMAL chart
unless the mother says that her child is ill, no special attention or
treatment is needed.
all children should be given Vitamin A every 6 months.
Usually give the children a supply of Iron/Folic Acid tablets (eg
those supplied by the Government) for 1 week of each month.
NO WEIGHT GAIN
for 1 or 2 months.
If the mother says the child is well then there is no need
for special treatment.
If the mother describes any illness then we should
examine and treat the child.
NO WEIGHT GAIN
or WEIGHT LOSS
for 3 or 4 months
for 1 month
ASK the mother
What does the child eat ?
What is the stool like ? Frequent ? Bloody ?
Does the child have fever ?
Worms ?
Is the child coughing ?
EXAMINATION
Must include chest, abdomen + spleen, ears.
If nothing is found wrong
If the child has bloody diarrhoea,
or loose stool for > 1 week
give worm treatment
Levamisole 50mg x 1
or Mebendazole 1x2 for 3 days
give Metronidazole
(or Co-trimoxazole for shigella )
If the child has fever,
cause not found
give Chloroquine
cause found
give appropriate treatment
and ask to see the child again in 1 week.
After 1 week if the child still has fever and we can’t find the cause, it may be
because the child has a urine infection. This is quite common in children, but very difficult to
diagnose without laboratory tests of the urine. We should therefore give a 5 day course of Cotrimoxazole in case there is a urine infection.
If the child still has a fever after Chloroquine and antibiotics (which it has taken
properly) and we can’t find the cause for the fever then we should try TB treatment (as on page
16).
page 34- 18/06/97
WEIGHT LOSS
for 2 months or more
ASK the mother
What does the child eat?
What is the stool like? Frequent? Bloody?
Does the child have fever?
Worms?
Is the child coughing?
EXAMINATION must include chest, abdomen + spleen, ears.
If nothing is found
give worm treatment AND Metronidazole
If there is fever
do the same as described above (ie. treat obvious cause, then
try chloroquine, antibiotics, TB medicines)
If there is no fever, but the weight continues to fall after the treatment for worms and
amoebiasis / giardia
try antibiotics (because a urine infection can give weight loss
without any fever)
If still losing weight then try TB therapy (as on page 16)
UNDER 5s CLINICS
The purpose of under 5s clinics is to see a group of children regularly to try and help them to stay
healthy and grow strong. This is done partly by prevention and partly by treatment.
Prevention
1 By health education we can help to prevent diseases due to dietary deficiencies or
to poor hygiene and we can teach the mothers how to correctly treat some childhood
illnesses (eg diarrhoea ).
2.
By immunisations we can prevent Polio and Tetanus.
Treatment
The first stage in treating sick children is to identify the sick child. Sometimes the mother
will rpalise when her child is sick, but sometimes she will not and then it is our job to find out
which STs; sick, to make the diagnosis and to start the treatment.
page 35 - 18/06/97
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