Standard Treatment Guideline
Standard Treatment Guideline
Standard Treatment Guideline
Government of Chhattisgarh
Department of Health & Family Welfare
STANDARD TREATMENT GUIDELINES FOR MEDICAL OFFICERS
Published :
July 2003
Editorial Board :
Dr. T. Sundararaman, Director, SHRC.
Dr. Premanjali Deepti Singh, Programme Coordinator, SHRC.
Dr. A.T. Dabke, Dean, JNP Medical College & DME, GoC.
Contributors :
Dr. N. K. Goyal, HoD ENT, JNP Medical College, Raipur.
Dr. A. K. Sharma, HoD Surgery, JNP Medical College, Raipur.
Dr. S. L. Adile, HoD Ophthalmology, JNP Medical College, Raipur.
Dr. Abha Singh, HoD Obstetrics & Gynaecology, JNP Medical College, Raipur.
Dr. Suparna Shastri, HoD Pharmacology, JNP Medical College, Raipur.
Dr. N. Gandhi, HoD PSM, JNP Medical College, Raipur.
Dr. G B Gupta, HoD Medicine, JNP Medical College, Raipur.
Dr. Shashank Gupta, Professor of Medicine, JNP Medical College, Raipur.
Dr. V. K. Mishra Asstt. Professor of Medicine, JNP Medical College, Raipur.
Dr. M. K. Sahu Asstt. Professor of Medicine, JNP Medical College, Raipur.
Dr. P. Beck Asstt. Professor of Medicine, JNP Medical College, Raipur.
Dr. U. S. Painkra Asstt. Professor of Medicine, JNP Medical College, Raipur.
Dr. R. K. Patel Asstt. Professor of Medicine, JNP Medical College, Raipur.
Dr. Biswajit D, PG Scholar, JIPMER, Pondichery.
Dr. Mahesh S, PG Scholar, JIPMER, Pondichery.
Editorial Coordination :
V. R. Raman, Programme Coordinator, SHRC.
Editorial Assitance :
Dr. Ankur, PG Scholar PSM, JNP Medical College, Raipur.
Dr. Kamlesh, PG Scholar PSM, JNP Medical College, Raipur.
Printed by :
Chhattisgarh Samvaad, Raipur.
Published by :
Department of Health & Family Welfare, GoC
With Support of Chhattisgarh Basic Health Services Project
2
Introduction
3
effective for the same level of expenditure.
This is a first attempt at such a book in this state and as such should
be considered more like a draft for discussion. We look forward to your
feedback so that we could improve the book further.
4
S
5
Contents
6
Standard Treatment Guidelines
7
Contents
::-::
8
Standard Treatment Guidelines
SECTION-I
9
Clinical Services
The list of service given below states the lowest level at which
each service is available. It follows that specific service is
available in all levels.
10
Standard Treatment Guidelines
X-ray
Bacterial Infection Typhoid* Typhoid fever Tetanus
(presumptive) Diphtheria
Filariasis Pertussis
Pulmonary Leptospirosis*
Tuberculosis Acute Meningitis*
Leprosy (for Extrapulmonary
diarrhoea tuberculosis**
pneumonia, UTI etc. Lepra reactions
see appropriate system) Tetanus
Microscopy- Widal test Culture
Blood smear; Csf examination Serology
Sputum AFB including Histopathology
CSF examination biochemistry Ventilatory support
for cells, and stains
Grams stain
Protozoal Malaria- simple Malaria complicated
Kala-azar
Blood smear
examination-
microscopy
STD Syphilis* All forms of syphilis AIDS disease
Gonorrhoea* All cases of chancres
and chancroids,
Urethritis
HIV positive
cases,not
complicated
Urine microscopy HIV test for Serology
AIDS
VDRL
11
Clinical Services
12
Standard Treatment Guidelines
13
Clinical Services
14
Standard Treatment Guidelines
SURGERY
Clinical Services PHC CHC District Hospital
related to : and all 100 bedded
hospitals
Basic Technique Incision & Drainage Excision & Biopsy
Emergency
patients of trauma
etc. for Resuscitation
& stabilization
Gastro Intestinal Herniorrhaphy Exploratory
disorders Emergency Laparotomy
Appendicectomy Obstructed
Fistula Hernia
Piles Chronic & acute
Fissure Appendicitis
Ano rectal peptic perforation
Abscesses Intestinal
Rectal prolapse obstruction
Intussusception
Volvulus
Gastrojejunostomy
Drainage of abd.
Abscess
Haemorrhoidectomy
Cholecystectomy
Proctoscopy,
Sigmoidoscopy,
Endoscopy,
Neonatal Surgery.
15
Clinical Services
16
Standard Treatment Guidelines
17
Clinical Services
In all the above areas each CHC receives a visit on a fixed day every month by a specialist.
The specialist could be from private sector if none are avaiable in public sector.
18
Standard Treatment Guidelines
19
Clinical Services
20
Standard Treatment Guidelines
21
Symptom Analysis
SECTION-II
SYMPTOM ANAL
SYMPTOM YSIS IN PRIMAR
ANALYSIS Y HEAL
PRIMARY TH CENTRE SETTING
HEALTH
22
Standard Treatment Guidelines
Symptom Analysis in
Primary Health Centre Setting
23
Symptom Analysis
1 . PAIN
When any part of the body is overused or injured or diseased, we feel pain. Pain is
thus, a warning to us of disease. So that we can rest that part and take necessary
corrective measures. It follows that not all pain is bad. It serves a purpose. It tells us
of the need for rest or indicates an underlying disease. Treating pain alone is not
enough. But if the pain is too much one can get relief from pain relieving drugs.
2 . HEADACHE
24
Standard Treatment Guidelines
3. ABDOMINAL PAIN
25
Symptom Analysis
Pain during urination- the Urinary tract infection. Give plenty of fluids
frequency of passing urine may Urinary Calculi See Page 40
be increased. Especially in a
woman
26
Standard Treatment Guidelines
4. CHEST PAIN
Clinical pattern Likely Diagnosis Action Required
Sudden chest pain or Angina Cease all exercise.
discomfort, especially in those Tab. isosorbide dinitrate 5
above 45 years of age. mg sublingual.
· Pain retrosternal After the episode advise
· Burning, crushing or tab. 5 mg or 10 mg four
dull aching in type times daily.
· Radiating to left arm or Look for and if present
to root of neck or back treat co- morbidity like
· Aggravated or coming hypertension and diabetes
on during exercise mellitus.
· Relieved by rest or See Page 202
spontaneously in a few
seconds to minutes
Pain as above but persists Unstable angina ( can also See Page 203
for over five minutes or occurs be myocardial infarction)
many times a day or occurs
even while at rest, or
occurring for first time; or
occurs with exercise but is not
relieved by rest
As above but with crushing Myocardial Infarction See Page 204
pain and sweating and
excessive anxiety
If pain is retrosternal, Gastro- oesophageal One may be able to
burning in nature and more reflux disease (reflux differentiate it from angina
after meals – oesophagitis), on clinical grounds but in
some cases especially the
elderly investigations to rule
out angina is a must.
Treat as for gastritis
(antacids and ranitidine 150
mg twice daily) with a tab.
metoclopramide -10 mg half
hour before meals and at
bedtime or tab.
domperidone taken similarly.
Pricking or aching chest Pleuritis – pleural pain Tablet paracetamol for
pain aggravated with deep relief. Treat cause.
breaths and coughing. X-rays may be needed if
Auscultation may show a pain persists beyond 2 days.
pleural rub.
Pricking pain with local Costochondritis or other Tablet paracetomol
tenderness or aggravation superficial muscular causes
with movement
Other causes of chronic Pericarditis Lung Treat as for main disease
persistent pain infections Lung tumours-
later stages.
27
Symptom Analysis
General measures –
Daily mild exercise.
Avoid smoking.
Avoid fats in food.
Weight reduction if overweight.
Reducing mental tensions or physical strain.
are all essential steps that must go along with drug treatment.
5. OTHER PAINS
General Precautions
1. Do not use aspirin for abdominal pain or those with nausea and vomiting.
2. In most situations, one must ensure an early referral especially if it does not cure
within three days or if one of the above features are present.
3. Note – a lot of new painkillers available in the market offer little or no advantage
over paracetamol. All of them have much more side effects than paracetamol. Always
prefer paracetamol.
28
Standard Treatment Guidelines
6. FEVER
Very often, fever subsides by itself in 3-4 days. These self-limiting fevers
are generally caused by viruses. All other fevers need treatment.
General guidelines
Meals should be light. Avoid oily, spicy food. But do not starve the patient.
Record the fever using a thermometer. If it is more than 37o Celsius, there is
fever. If it more than 39.5o Celsius, then one must sponge the patient with tepid
water to lower the temperature and refer the patient if the fever does not come
down.
29
Symptom Analysis
30
Standard Treatment Guidelines
If smear if negative repeat blood smear and look for other causes.
If there are typical features of chills and shivering, followed by high fever
and then sweating; often has headache also, is probably malaria–treat as
malaria.
If smear is negative or report is delayed more than one day or not available and
chloroquine has been given consider the following :
31
Symptom Analysis
When to refer ?
Refer all fevers where no diagnosis is established and if after one round of antibiotics
over three to five days there is no improvement of fever.
If the patient is very ill, too weak to eat or drink or is dehydrated and
needs admission.
7. COUGH
Why do we cough ?
Most types of cough do not require drug treatment. Basically cough cleans the windpipe
throwing out irritating material, which may reach it from outside or is produced locally.
Therefore, cough is a friend not an enemy. Some of the cough is due to allergy due to
irritants. Some common irritants are smoke, dust particles, pollen grains, germs.
General guidelines
2. Cold dry air worsens cough. Warm, humid air is beneficial. Simple steam inhalation
and lots of warm fluids provide the best relief. Few drugs are better than this.
32
Standard Treatment Guidelines
If the cough is dry (i.e. Allergic or due to irritant Avoid irritants, give
without sputum) and no or mild upper respiratory steam inhalation. Normal
fever: illness-. saline nasal drops
33
Symptom Analysis
8 . BREATHLESSNESS
Breathlessness on exercise or at rest is a manifestation of lung or heart disease or of
severe anaemia. Breathlessness of sudden onset especially in younger persons is usually
due to asthma or respiratory infection or a foreign body in respiratory tract. Acute
breathlessness also occurs in heart failure.
34
Standard Treatment Guidelines
History of blood loss Suspect anaemia Start oral Iron and refer.
(maybe due to heavy (See page 175)
menstrual flow, piles, hook
worms etc) and patient looks
pale;
Signs of anaemia present
Chronic cough for at least Suspect chronic Stop smoking;
two months in a year obstructive pulmonary see page 210
History of smoking, disease (chronic bronchitis
or emphysema)
With or without wheezing Asthma Give salbutamol and
steam inhalation.
(See page 206).
Prompt treatment with
antibiotics for intercurrent
infections
When to refer ?
If foreign body swallowed does not come out on coughing and Hemlich’s
manoeuvre; rush the patient.
If heart failure (acute and chronic) or ischemic heart disease is suspected, then the
patient needs to be referred to higher centre for establishing diagnosis after which
routine follow up can be done at primary health centre.
If wheeze is severe, or is not relieved within 12 hours and patient may need admission
for treatment with nebulizer/ventilation.
Any anaemia that is severe enough to cause breathlessness and/or haemoglobin
is less than 5 gm/100 ml. Or anaemia not responding to oral iron over a month,
for fixing cause of anaemia.
9 . VOMITING
Vomiting occurs due to a wide variety of illness. Some of them are trivial and self-
limiting. Some of it is serious and needs immediate attention.
Repeated vomiting causes loss of salt and water. Persistent over days, it results in
starvation & electrolyte imbalance.
35
Symptom Analysis
Treatment
Vomiting during travel Advice travel after light meal and not
on empty stomach.
Pinch of ginger may help.
Vomiting due to pregnancy- Reassure the patient.
Advice plenty of fluids.
If severe, see page 93
Vomiting associated with injuries, Give rest to injured part.
sprains, fractures Give paracetamol and refer.
Tab. metoclopramide
Adult 10mg thrice daily may help.
Child from 30-60 kg 5 mg thrice daily.
10-30 kg 1-2.5 mg thrice daily.
Child below 1 year 1 mg twice daily.
Vomiting due to eating spoilt, irritating It is self-limiting /
food or some drugs. Stop the offending food or drugs.
Give sips of cold water or ORS fluid.
Antacids /H2 Blockers.
Give metoclopramide as stated above
Vomiting with diarrhoea See section on diarrhoea Page 37
Vomiting with fever- See page 30
Vomiting with unilateral headache Suspect migraine- rest in bed. Tab.
Paracetomol and plenty of fluids. Page 24
Vomiting with Chest pain, perspiration It may be ischemic heart disease – treat
as described page 202
When to refer?
36
Standard Treatment Guidelines
General Guidelines
37
Symptom Analysis
When to refer ?
If diarrhoea does not stop in two weeks despite antibiotics and anti amoebicides.
Precautions
Do not give drugs like Imodium or loperamide that stop diarrhoea by slowing
bowel movements. Dicyclomine can be given for cramping abdominal pain.
1 1 . CONSTIPATION
A person passing dry hard stools less than once a day. It may develop suddenly
(acute) or be long-standing (chronic).
Acute constipation is usually serious, especially if there is also vomiting, abdominal
pain and distension of abdomen and the patient does not pass flatus at all. Such
cases may be referred at once.
Constipation after a bout of diarrhoea also needs no treatment. It becomes all
right on its own.
Diagnose as constipation only if stool frequency is less than once a day.
Faulty bowel habits- habitually not going for defecation, on time, or lack of
convenient place.
Faulty diet-low in roughage or water.
Lack of exercise.
Painful lesions near anal region. - If needed do a rectal examination to confirm
this.
In pregnancy and in old people because of difficulty in straining.
In children due to poor diet or poor training of bowel habits.
38
Standard Treatment Guidelines
General guidelines
Almost never are drugs an answer. Indeed one must be careful not to get dependent
on drugs. One may give drugs for a few days and slowly withdraw as changes in
diet and habits improve.
Advise patients to eat lots of green and leafy vegetables and bananas, drink lots of
water, and go for at least an hour’s daily walk.
Let him or her spare an hour each morning at the same time, to go to a toilet till
the problem improves.
Treatment
Bisacodyl can be given for a few days. Dose: Adult Two tablets at night.
When to refer ?
In most of cases it cannot be attributed to any specific cause. However note that
many diseases may start with fatigue. Therefore this symptom requires a full,
methodical examination.
Diagnosis
Look carefully for anaemia. In both men and women this is one of the commonest
causes of fatigue and is often associated with body ache and mild breathlessness
on walking some distance.
Check weight and look for signs of malnutrition. (Calculate BMI – Body Mass
Index- weight in kg. / Ht in m2. If below 18 the patient is malnourished. Normal is
20 to 25 range)
Ask for any immediate cause like excessive work, loss of sleep, recent illness,
travel etc
Ask if there are any associated symptoms which points to fatigue being secondary
to a disease: is there loss of appetite, weight loss, fever, cough, dyspnoea, abdominal
pain, jaundice, swelling of body or lymph nodes or enlarged liver or spleen.
Check blood pressure for hypertension. - It maybe the cause of fatigue
Ask if patient is feeling depressed and has problem sleeping. It may be due to
depression.
39
Symptom Analysis
Treatment
If the fatigue is associated with any of the symptoms of other disease mentioned
above go to the corresponding page and treat accordingly.
If not, talk to the patient whether any ‘personal causes’ could be responsible. If a
“placebo” is required better to choose.
a low dose of the Ferrous sulphate with folic acid (see page 175) since anaemia
is so common anyway and since anaemia is associated with fatigue.
Calcium is also a good choice especially if there is much body ache and in
women, children and adolescents.
When to refer
In males after a single episode & in females with recurrent UTI refer to the CHC
for ultrasound to rule out urinary stones.
If fever does not subside within three days
40
Standard Treatment Guidelines
If it is not corrected by drinking water or occurs along with swelling of the feet
and/or face then consider oliguria and anuria.
Test the urine for albumin (if albumin is present heating the urine will cause it to
turn white). If albumin is present it likely to be a renal problem. (Page 219).
If the urine if dark coloured and microscopic examination of urine shows red or
white blood cells this is also due to a kidney problem. (See page 218, 219).
If urine is scanty and there is breathlessness on lying down with JVP elevated
with pedal oedema with or without basal lung crepitations - a heart problem is
likely (see page 194).
1 3 . 5 PAINLESS HAEMATURIA
suspect malignancy –
Refer to urologist for further tests.
1 3 . 6 RETENTION OF URINE
Refer to higher centre equipped for surgery.
One can relieve bladder distension by putting catheter
Percutaneous drainage - draining the urine from the bladder from the supra-
pubic area before referring - if the distension is excessive and painful.
If needed Suprapubic Cystostomy can be done in CHC before sending to district
hospital
41
Symptom Analysis
42
Standard Treatment Guidelines
15. JAUNDICE
There are five viruses that are commonly associated with hepatitis called
Hepatitis A, B, C, D and E virus. Of these two, hepatitis A and E spread
through faecal contamination of water. When there is an outbreak of
jaundice in a village it is probably this virus. Almost always this jaundice
becomes alright on its own. Except in pregnant women where it can be
life threatening. Three other types of viruses spread through the blood
and through unprotected sexual contact (hepatitis B, C, D). These types
are more severe, tend to worsen and have more long term
complications.
Sometimes, especially with hepatitis B and D hepatitis turns severe due to cell
necrosis.
Patient develops confusion, stupor and then coma and it is difficult to save his or
her life.
Pregnant women are prone to develop this picture with all viruses but commonly
with hepatitis E.
43
Symptom Analysis
Sometimes the liver disease goes on for years without becoming well.
Such patients have frequent intermittent episodes of jaundice.
Elevated liver enzymes over 6 months is enough to make this diagnosis.
Eventually it can become well but more often leads to cirrhosis of the liver and
portal hypertension and end stage liver disease develops.
Sometimes jaundice is due to obstruction to flow of bile and not due to a virus.
In such cases the yellowing of eyes is very marked and may even be greenish.
There is much itching and the stools are always whitish in colour.
Usually the liver is enlarged.
Ultrasound of the liver confirms obstruction best and the patients should be referred
to a centre with ultrasonography facilities.
Refer to higher centre as these cases need surgery.
44
Standard Treatment Guidelines
There are no specific drugs to cure jaundice. Fortunately most persons become well on
their own.
Remember many drugs commonly used are harmful when given to a person with
jaundice.
Referral for further work up in higher centre with tests for type of haemolysis.
Vaccine
Vaccine against hepatitis B is available.
However it is not essential except for those in some special occupations or those
whose spouse has had jaundice and tested positive for hepatitis B virus while they
themselves are still testing negative.
45
Symptom Analysis
46
Standard Treatment Guidelines
If no diagnostic even at this simple level is available and one would take over
12 hours to reach the CHC and there is fever with loss of consciousness then
If patient is still able to swallow one can give
One dose of amoxicillin 500 mg
and
Four tablets chloroquine
and
Some glucose or sugar solution to drink and then send the patient.
If not able to swallow
One can give the above as injection - or through a ryles tube
The most important concern is that the patient does not choke on any vomit or even
aspirate saliva or even choke by his tongue falling back. The key to this is putting the
patient in “safety position” (see book on first aid).
47
Symptom Analysis
In all the above three situations the critical decision to make is whether it is still progressing
and may lead on to respiratory paralysis. If there is doubt of this the patient is best referred
to a centre, which has a ventilator.
48
Standard Treatment Guidelines
These are involuntary jerky movements that occur in episodes and then become
completely normal. This is usually accompanied by loss of consciousness. Often there is
biting of tongue and/or urinary incontinence.
Diagnosis
Clinical picture of the seizure is adequate for diagnosis.
18.1 Generalised tonic clonic seizures : Episodic involuntary jerky movements of the
limbs, followed by loss of consciousness, lasting from a few seconds to a few minutes.
Tongue biting causing bleeding, foaming at the mouth, urinary incontinence , a typical
epileptic cry preceding the fits, and exhaustion and deep sleep after the fits, and occurrence
during sleep all are features that confirm the diagnosis. Diagnosis is based only on a good
history or observing the fits.
18.2 Atypical generalised seizures : Rarely the typical tonic clonic phase is not seen.
There may be only a tonic phase or only a clonic phase.
18.3 Complex Partial Seizures : There is impairment- not loss- of consciousness with
or without complex stereotyped movements (like smacking of lips) and a typical aura which
gives a diagnosis of complex partial seizures. The characteristic clonic jerky motor seizures
are not present or develop later.
18.4 Simple partial seizures : Jerky movements of a part of the body with normal
consciousness.
18.5 Absence Seizures : If there is just a momentary stare or jerk or fall, with quick
recovery, occurring in children, often many times a day then one may suspect absence
seizures.
Fever and Seizures : If there is fever along with fits one must ask the patient
to proceed immediately to the CHC as it maybe cerebral malaria or other
brain infection.
49
Symptom Analysis
- If ineffective after 10 minutes, repeat the dose. Do not give more than 2
doses within six hours.
When to refer ?
If fits do not stop
Eclampsia
Suspicion of intacranial space occupying lesion
50
Standard Treatment Guidelines
Sometimes we are called to see a baby, less than a year old, that is constantly crying.
Check whether his neck is rigid and its anterior fontanelle (soft spot on the head)
is bulging (check for this in the upright position)– if so refer at once to a CHC. - it
may be meningitis.
Check whether the throat is congested and tonsils enlarged and inflamed-
may be throat infection. see page 84
If there is stuffy or running nose. It is probably just a cold. Some warm salt
water in nostrils and using a syringe without needle to suck out the mucus
may give relief. (see page 83). Remember to check for breathing rate
anyway.
Check if there is any swelling and pus anywhere- maybe its an infection- see
page 28
Check if there is any fracture of the bones-on touching that part the child’s crying
increases; there may or may not be a history of injury. If there is refer
Check if the child is passing stools. If not try oil syringing. If she passes stools and
crying stops then it is constipation .If she still does not pass stools it may be
serious. Especially if there is vomiting as well. Refer at once.
If child is not passing stools or gas and abdomen is distending then refer
at once to CHC. If not give tablet or syrup paracetomal for pain relief.
If between one year and two years of age and pain is not severe, also give
half tablet albendazole treatment for worms. If above two years give one
tablet albendazole.
51
Symptom Analysis
52
Standard Treatment Guidelines
If you suspect poisoning, and cannot find out what the poison is: do the following
immediately :
Make the person vomit. Put your finger in his throat or tickle the back of his throat
with a spoon, or make him drink warm water with a lot of salt in it.
You may also give him a tablespoonful of syrup of ipecac, followed by one glass of
water.
If you have it, give him a cup of activated charcoal mixed in a cup of water in case
of a child. (for an adult, give 2 glasses of the mixture).
Put in a well-greased stomach tube through mouth and pour in 2 litres of salt
water through the funnel.
Lower the end of the stomach tube below the level of the bed. The liquid in the
stomach will come out.
Have him drink all he can of milk, beaten eggs, or flour mixed with water.
If you have it, give him a tablespoon of powdered charcoal. Keep giving him more
milk, eggs, or flour and water and make him vomit till the vomit is clear.
If the pupils are dilated widely and skin is dry and hot suspect dhatura
or atropine like substance causing poisoning;
53
Symptom Analysis
Most often we can find out the poison only by understanding the situation, the
possible poisons the patient had access to and asking the relatives to get any
empty chemicals or drugs container from their house – from which we can make a
guess.
Try to find the poison taken by examination of the patient and from talking to
relatives and friends and start treatment accordingly. Do not make him vomit.
If he has stopped breathing, then give him mouth-to-mouth breathing. Seek help
at once.
If the patient has to be shifted after ventilatory arrest best to put in an endotracheal
tube and shift him with artificial respiration done with an Ambu’s bag.
Sometimes we get patients who say they have been bitten by something but do not
know what it is. They did not see what bit them. It could be a poisonous snake bite for which
they should rush to the hospital or some insect bite which is not dangerous. Here are some
tips to diagnose :
If there are no fang marks it could still be a snake bite. Often the fang
marks are not seen or missed. It could also be a scorpion sting or insect
bite.
If there is any bleeding from any site – gums, in urine, in stools etc
If the eye lid droops and eye movements side to side become less
or if there is difficulty in breathing.
54
Standard Treatment Guidelines
Even without the above, one should treat as snakebite if one knows or
strongly suspects it is a snakebite. (See page 167)
55
Mental Skin Eye ENT
SECTION III
56
Standard Treatment Guidelines
Mental illness is common in the community. Often it is not recognised. Often, even if
recognised it is not seen as something for which medical help is to be sought. Hence health
care providers may have to detect this in the families when they visit them, or during school
health programs or during health camps. Or when they present to medical officers with
various physical complaints. At times relatives or patients themselves come to medical
officers with complaints and since there are few psychiatrists available we would need to
manage them. If there is a Psychiatrist accessible at least one consultation to establish
diagnosis and start drugs is advisable.
Mental illness may be recognised by the following :
Talking nonsense and acting in a strange manner considered abnormal.
Becoming very quiet and not talking or mixing with people.
Claiming to hear voices or see things others cannot hear or see.
Becoming very suspicious and claiming that some people are trying to
harm them.
Becoming unusually cheerful, cracking inappropriate jokes and saying
that they are very wealthy and superior to others when it is not really so.
Becoming very sad and crying without reason.
Talking of suicide or having attempted it.
Getting possessed by god or spirit and being said to have become victim
of black magic.
“Dull” and not mentally grown up like others of their age and slow
development since birth.
Whenever we find a person with mental illness we should discuss it with the family.
Often they have not so identified it and may be calling it evil eye or/are just angry with the
person for misbehaviour or have quietly ignored her.
57
Mental Skin Eye ENT
Is he aware that he is mentally unwell and needs help or does he thinks himself
to be normal. If he knows he is abnormal it may be only a behavioural problem.
On the other hand if he is frankly abnormal in behaviour but himself does not
recognise it then we are dealing with a psychosis.
General Guidelines
Advise others not to talk or act in way that provokes him further. Keep away
individuals whom patient does not like.
Try to gain confidence by asking “ what are your problems” “what is troubling
you” “Let me try and help” etc.
Drug Treatment
Try to convince him that medicines would help and that he should regularly see
the doctor. If there are symptoms like: flight of ideas, feeling of grandeur, hearing
voices talking amongst themselves- start on an antipsychotic drug like -
Haloperidol - 1 to 5 mg P.O. or IM or IV.
or
When to refer
If he does not calm down and is getting violent.
He has to be tied down use a long towel or long cloth to tie hands. Do not use
a chain or rope.
In the worst situation One can throw a blanket on him and hold him with others
help and take to a referral hospital.
58
Standard Treatment Guidelines
The other symptoms that characterise depression are : Sleep is poor. Patient
usually goes to sleep without problem but wakes up early and frequently.
Appetite is usually very poor and they feel that their energy to do any work is
very low.
There may be frequent crying and patient may admit that mood is very depressed
& suicidal thoughts are common.
General Guidelines
Take time to talk to the patient. Often there are immediate causes for the
depression but the extent of depression is out of proportion to the known causes.
Counsel him/her to understand that he or she needs help.
Persuade him to eat something.
Drug Treatment
Often paranoia does not have other such features and then the doctor has to
consider whether the patients’ belief has a basis.
But usually the patient supports his belief by frankly abnormal reasoning and
ideas, which helps decide on treatment.
59
Mental Skin Eye ENT
General Guidelines
Be fair and honest. Do not tell lies as this patient trusts no one and it is very easy
to lose his trust.
Do not question his beliefs or suspicions. Do not state that his or her beliefs are
wrong.
Allow him or her to talk about their suspicions. Collect information without
passing judgement.
Draw his attention to other problems – sleeplessness, poor appetite etc and use
that to convince him or her to see a psychiatrist if needed.
Drug Treatment
or
All abnormally confused persons must be examined for organic causes of delirium
immediately. If the confusion is with :
Fever : it may be due to early infection of brain (encephalitis or meningitis
see page 143)
During or after fits : delirium or frankly psychotic behaviour lasting from
few minutes to few hours is well known, Treat accordingly see page 212
High blood pressure – then it may be hypertensive or uraemic
encephalopathy – treat accordingly : see page 196, 198
A diabetic person on treatment- hypogycaemia may present and be cause
of abnormal behaviour or vague confusion - see Page 46
Ask whether he or she has taken any drugs – some drugs can cause this
confusion.
Refer all the cases after initiating the treatment.
60
Standard Treatment Guidelines
General Guidelines
Counselling is important.
Drug Treatment
Anxiolytic drugs can be tried for short periods.
diazepam 5mg HS or SOS
61
Mental Skin Eye ENT
Most patients with skin problems present late. By then they have scratched and this
has got secondarily infected and now the feature is of the secondary bacterial
infection. We need to treat this secondary infection and examine again to find out
the primary cause.
Diagnosis rests usually on recognising the clinical pattern. Sometimes microscopy
of scrapings of the lesion can confirm the diagnosis.
Did it start suddenly (over one or two days or even over one or two hours)?
If yes :
Think of urticaria – may start over minutes; presents with many
papules that often change shape over hours; is always itchy: and
often associated with insect bite or allergy. Rarely there maybe an
associated difficulty in breathing. If this develops it is an emergency
If not think of herpes simplex – vesicular lesions start over a few
hours. Often occurs as part of fever and some other serious infection.
Often around or in mouth, on face, or in eyes.
If the same type of vesicular lesions are in one or more lines and
they are very painful think of Herpes Zoster
Zoster.
62
Standard Treatment Guidelines
Scabies : Presents with many scratch marks and few small papules
especially between fingers or toes. This usually comes along with
impetigo. (See page 65)
Ring worm (not due to a worm but due to fungus) : Tinea cruris
Skin scrapings for microscopy show plenty of small hyphae that confirm
diagnosis.
Leg Ulcers : If over the leg or foot or ankle there is an ulcer that
does not heal— think of chronic leg ulcers. (See page 251)
Eczema : If there are large macules and small papules in the lower
limb or elsewhere that is full of weeping vesicles, with lot of itching
and scaling of skin; then consider eczema. This may also present
with impetigo. (See page 69)
Other common skin disorders are the dry scaly skin of malnutrition and
hypothyroidism.
63
Mental Skin Eye ENT
This is an infection of skin by bacteria. It affects those who because of water scarcity
or other problems bathe less and live in crowded spaces. It spreads easily especially
amongst children. It commonly occurs in patients with lice or scabies or tinea
infection.
Clinical Presentation
Management
Pierce vesicles,
incise and drain pus,
remove crusts.
Look for lice, scabies or ringworm and if present treat for the same. If it is present
on the scalp, shave head before treatment for more effectiveness.
Cotrimoxazole is less effective but that too can be tried if the above three drugs
are not available.
64
Standard Treatment Guidelines
2.2. SCABIES
This is an infection of the skin caused by a small insect mite. It occurs commonly
where there is a lack of water, overcrowding or poor hygiene.
Clinical Presentation :
Itching more at night.
On examination one can see scratch marks and small papules between and on
the fingers and toes. Also seen in genital area, armpits and under folds of skin.
Management :
Then apply gamma BHC solution ( or benzyl benzoate emulsion) to the whole
body – except for face. Do not apply near or into orifices. Allow to dry on skin.
Clinical Presentation
A number of vesicles that come suddenly. Commonly they are seen around the
mouth or even within it when the person is having high fever due to pneumonia or
other cause.
Sometimes it affects the eyes causing redness, watering and decreased vision. This
needs to be seen by an eye specialist.
Management
65
Mental Skin Eye ENT
Clinical Presentation
A number of vesicles that come suddenly. Commonly they appear in a line along a
nerve – on the face, on the chest, on the back or on a limb.
There is very severe pain that comes with these vesicles. It may start one or two
days before and last months after the vesicles have healed.
Sometimes it affects the eyes causing redness, watering and decreased vision. This
needs to be seen by an eye specialist.
Management
Treatment as for herpes simplex but also add paracetamol for pain relief.
If pain is severe can be referred to tertiary care centre for pain relief Acylovir
started at once is believed to reduce duration &severity but in view of cost little
effectiveness in most it need not be insisted on.
2.5. URTICARIA
This is an allergic reaction of the skin. One needs to find out what the person was
allergic to and remove it now and avoid it later.
Clinical Presentation
The lesion start over minutes; Many papules form that may change shape and size
over hours; It is always itchy: The insect bite can often be seen as a small dark dot
on the popular area.
Rarely there may be an associated difficulty in breathing. If this develops it is an
emergency
Management
66
Standard Treatment Guidelines
2.6. YAWS
This is an infection of the skin and bones that is spread by flies. More in forest
areas.
Clinical Presentation
Presents with an ulcer on the skin with small surrounding ulcers and frambesiomas-
small crinkled swellings.
It can affect mucous membranes as well.
Benzathine penicillin
Children : 50,000 to 100000 IU in single injection.
2.7. CANDIDIASIS
2.7.1 PARONYCHIAL LESIONS
Diagnostic features
Common in people who do wet work
Commonly affects the posterior nail folds more than lateral folds
Nail fold shows erythema, boggy swelling, and occasionally discharge of pus on
pressing
Nail may show ridging and become discoloured
Gram stain of pus shows gram-positive oval shaped budding yeast cells
Treatment
General Guidelines
67
Mental Skin Eye ENT
Tr e a t m e n t
General Guidelines
Eliminate conditions leading to moisture and maceration
Expose the areas for drying up of the lesions and avoid tight clothes Wear
loose cotton clothes
If lesions are inflammatory, tepid water compresses 3 to 4 times a day help
to cool and soothe
2.7.3 THRUSH/PERLECHE
Diagnostic features
Whitish plaques loosely attached to oral or vaginal mucosal membranes. On
removal, the underlying mucosa is bright red and moist.
Treatment
2.7.4 VULVOVAGINITIS
Diagnostic features
Vulva shows erythema and oedema with severe itching and vaginal discharge
Scraping of lesions shows presence of fungal forms especially on mucous
membranes, but usually not seen with infection on skin.
Cultures show growth of Candida albicans within 48 to 72 hours
Treatment
Clotrimazole vaginal tablet (100 mg) one tablet at bedtime for 7 days
Recurrent vulvovaginal candidiasis
General Guidelines
To wear cotton underwear and avoid tight clothes.
68
Standard Treatment Guidelines
Treatment
General Guidelines
2.9. ECZEMA/DERMATITIS
These are synonymous terms signifying inflammatory response of skin to
different factors.
General Guidelines
69
Mental Skin Eye ENT
Treatment
Treatment It is according to stage of dermatitis.
Infected eczema
Acute eczemas
If Infection Present
Condy’s lotion (1:8000 Potassium Tab. Erythromycin (250 to 500 mg)
Permanganate) one tablet q.i.d. for 5 days
3-4 times per day till oozing stops
Tab. Chlorpheniramine Maleate (4
mg) one tablet t.i.d. for 5 to 10 days
Subacute eczemas
Zinc Oxide cream or paste, applied on gauze piece, which is then applied to the
skin and dressed
Or
Calamine lotion
Plus if infection present.
Tab. Erythromycin (250 or 500 mg) one tablet q.i.d. for 5 days.
Tab. Chlorpheniramine Maleate (4 mg) one tablet q.i.d. for 5 to 10 days.
70
Standard Treatment Guidelines
Chronic eczemas
Diagnostic features
Treatment
General Guidelines
Review patient after 3 weeks
Diagnostic features
Treatment
71
Mental Skin Eye ENT
General Guidelines
Avoid dryness of skin
Review patient after 2 Weeks
Diagnostic features
Treatment Guidelines
Control pruritus with Tab. Chlorpheniramine (4 mg) one tablet t.i.d. for 3 days
Clobetasone Butyrate cream (0.05%) topically for 2 weeks.
General Guidelines
72
Standard Treatment Guidelines
Diagnostic features
Superficial scaly hypopigmented macules often large and irregular,
occuring on face neck, trunk or limbs.
Treatment
Miconazole cream 2%
or
topical clotrimazole 1% Cream
twice a day for a few weeks
Tab. Fluconazole 400mg - single dose.
Diagnostic features
Drug Treatment
73
Mental Skin Eye ENT
2.11. PSORIASIS
Diagnostic features
General Guidelines
Drug Treatment
Local plaques :
Topical steroids e.g. Hydrocortisone, 1% for the face. Apply sparingly once daily
And
Betamethasone Dipropionate 0.1% diluted in aqueous cream to make a 1:10 or
1:5 concentration. Apply twice daily (for palms and soles)
This is an irritant - avoid contact with eyes, tender areas or open wounds
Refer if
No response to treatment
Uncertain diagnosis
Severe psoriasis and complications
74
Standard Treatment Guidelines
Less common complaints are night blindness and injuries to the eye
Differential Diagnosis
Acute conjunctivitis :
Inflammed conjunctiva with turbid discharge- may be viral, bacterial or allergic.
75
Mental Skin Eye ENT
76
Standard Treatment Guidelines
If the discharge is watery and there is no redness of the eye it can be due to
infection of tear glands or blocking of tear ducts:
77
Mental Skin Eye ENT
Inability to see only in the night: This is common in children and is due to lack of
vitamin A. Check also if there are Bitot’s spots and xerophthalmia
In adults, even if malnourished night blindness due to vitamin A deficiency alone is
rare and is due to other causes
78
Standard Treatment Guidelines
4.1.1 WAX
Dark brown mass seen in ear canal. Soda glycerine ear drops 2-3 drops
Decreased hearing blocking of ear with thrice daily for 4 days.
pain in ear. Tab Ibuprofen as required.
Later cleaning of ear locally for 5 days.
4.1.2 FURUNCLE
Small boil in ear canal. Cap Amoxycillin 500mg thrice daily for
Pulling ear causes pain. 5 days
Bursting may lead to purulent discharge Tab Ibuprofen 400 mg thrice daily for 5
days.
4.1.3 PERICHONDRITIS
79
Mental Skin Eye ENT
4.1.6 OTOMYCOSIS
Intense itching in ear canal with pain in Refer to ENT surgeon at District Hospital
ear. or at Medical College Hospital
White filter paper like debris or blackish Dry mopping of ear with sterile cotton
debris in ear canal. wick
2% Acetic acid ear drops 2 drops thrice
daily for 5 days
Tab Ibuprofen 400 mg SOS
keep ear dry with cotton wool in ear.
Avoid dip in pond/river
If not responding Refer to District Hospital
Severe pain in ear and deafness. Dry mopping of ear canal with sterile
High-grade fever with mucopurulent cotton wick if discharge present.
discharge and then relief in pain.
Cap Amoxycillin 250 mg thrice daily for
5 days.
Tab Ibuprofen 400 mg thrice daily for 5
days.
Tab Chlorpheniramine 4 mg thrice daily
for 5 days.
Tab Paracetamol 1 tab as required.
Keep ear dry and avoid pond/river bath.
If not responding Refer to ENT surgeon in
District Hospital
Non foul smelling, copious in amount Keep ear dry and avoid pond/river
bath.
Reduced hearing Treat associated infections of pharynx/
nose/sinuses
If not responding :
80
Standard Treatment Guidelines
T T
T T
Keep sterile cotton plug for few hours in Sterile cotton plug in ear
ear canal.
NO ear drops to be instilled
T T
If bleeding continues Refer immediately to ENT surgeon/
Refer to ENT surgeons District Neurosurgeon District Hospital or
Hospital / Medical college hospital Medical college hospital
81
Mental Skin Eye ENT
EPISTAXIS
Record BP
T T
T
T
If bleeding persists
T
If bleeding persists
T
Anterior nasal packing of nose with ribbon gauze soaked in liquid paraffin
If bleeding persists
T
82
Standard Treatment Guidelines
83
Mental Skin Eye ENT
4.2.4 SINUSITIS
Painful ulcers in oral cavity Avoid mucosal irritants like beetle nut/
tobacco /lime chewing. Usually self
limiting. No treatment needed
Usual practice is to give-
Tab vitamin B complex 1 tab once daily
for a week
And / Or
A. Chlorhexidine mouth wash 2-3 times
a day for a week and
B. Local application of boroglycerine
gel or paste. and
C. Tab metronidazole 400 mg TDS x 5
days If severe one can try: A, B, C.
84
Standard Treatment Guidelines
85
Mental Skin Eye ENT
86
Standard Treatment Guidelines
87
Mental Skin Eye ENT
6.1 CARIES
most common cause - the bad tooth-
One can see that the tooth surface is irregular with small holes or
even broken down.
The pain is more while eating. Once advanced the pain can occur
at any time.
For caries :
Tab. Paracetamol
When possible person should go to dentist.
If mild, tooth is filled so that it does not worsen further.
6.2 GINGIVITIS
When gum around the tooth is infected and swollen and
sometimes one can see pus
Tablet paracetomol
plus
Capsule amoxycillin –
three doses per day for six days- 250 mg for adult and half that for
children. thrice a day better to refer to a doctor.
88
Standard Treatment Guidelines
SECTION IV
89
Obstetrics & Gynaecology
OBSTETRIC PROBLEMS
1. CONFIRMATION OF PREGNANCY
Usually based on clinical grounds
Further confirmed by examination
If facilities available reliably done by urine test for pregnancy: 6 weeks after
last menstrual period or 15 days after missing period.
Collect a sample of morning first voided urine and send for pregnancy test
(agglutination inhibition for detection of HCG in urine),
Antenatal counseling
General Advice
On diet
Light exercise
Avoid heavy work
Rest
90
Standard Treatment Guidelines
Drug Treatment
Inj. Tetanus Toxoid 2 doses in first pregnancy 1st dose in first visit,
0.5 ml or unimmunised patients followed by
at least one dose in 2nd dose after 4 weeks
subsequent pregnancies of the first dose.
To be To be effective 2nd dose must be given at least 3 weeks before child birth.
Daily Iron supplementation during pregnancy ( from second trimester)
Tab. Ferrous Sulphate + Folic Acid combination-
100 mg Ferrous Sulphate with .5 mg Folic Acid
Tab. Calcium Lactate (500 mg) or calcium carbonate one tablet daily is also
advisable.
91
Obstetrics & Gynaecology
3. INDUCTION OF LABOUR
Induce after assessing
Maternal condition,
Foetal condition
Favorability of cervix. (Bishops Score)
If induction is medically indicated - induce by Inj. Oxytocin in dextrose 5 %
Watch the patient for
Uterine contractions-frequency of contractions
Maternal condition - BP pulse hydration, nutrition
and for signs of Exhaustion
Foetal condition - listen foetalheart every 30 min. If foetal heart
rate is less than < 100/min. stop infusion
Use oxytocin with great caution as fetal distress can occure from
hyperstimulation and, rerely, uterine rupture can occur. Multiparous women
are at higher risk for uterine rupture.
All high risk patients should be referred to secondary level with caesarean section
capability for institutional childbirth.
High risk cases can be grouped into the following categories:
Chances of difficult labour or poor outcome by history
Short statured primi
Age less than 18
92
Standard Treatment Guidelines
Preterm labour
Intrauterine foetal death (even if single)
No Progress after 6 hours after rupture of membrane
93
Obstetrics & Gynaecology
Non-drug treatment
Counselling
Reassurance
Emotional support
Rest
Life-style adjustments – e.g.- change of home to visit parents etc.
Restrict oral intake for 24-48 hours, but ensure adequate hydration.
Frequent small carbohydrate meals
Treatment in CHC
Investigations in CHC
If ultrasound is available Rule out molar pregnancy and twins; complicated cases
should be managed accordingly.
Refer
The following cases should be referred to the tertiary centre
Hematemesis
If diagnosis is in doubt
6. ANAEMIA IN PREGNANCY
mild 8-11
moderate 5-7
severe below 5
94
Standard Treatment Guidelines
General Guidelines
Non-drug treatment
Diet rich in protein and iron to be recommended
Drug treatment
Prophylaxis
95
Obstetrics & Gynaecology
Treatment at CHC
Confirm iron deficiency anaemia Inj. Iron Dextran (50 mg / ml elemental
iron) 2 cc IM on alternate day after test dose x 10 injections
Blood transfusion if Hb< 5 gm & in last trimester.
Diagnosis & management of sickle cell disease, Haemoglobinopathies,
Pancytopenia in cases not responsive to iron.
Manage congestive cardiac failure where indicated.
7. ABORTION
Where process of abortion has started but has not progressed to a state from
which recovery is impossible.
Diagnosis
Uterine size corresponds to the period of amenorrhoea.
External os is closed.
Investigations
In PHC
Haemoglobin for anaemia.
Blood group & Rh typing for Rhesus incompatibility
Urine routine & microscopic.
Urine pregnancy test.
VDRL for syphilis
In CHC
Ultrasonography – for viability of foetus.
Normal findings - well formed gestational sac with central echoes
from foetus.
Blighted ovum- loss of definite gestational sac absent foetal echoes &
absent foetal heart.
Advice -
To report if bleeding or pain increases.
Reexamination after 1 month for evaluation of foetal growth.
96
Standard Treatment Guidelines
Treatment At CHC
Diagnosis
Investigation
Same as threatened abortion.
Treatment
General
To take care of general condition.
Maintain strict asepsis.
97
Obstetrics & Gynaecology
Before 12 weeks-
Dilatation & curettage, evacuation of the uterus with blunt curette.
After 12 weeks-
Induction By syntocinon drip
Rarely by Hysterotomy
When the entire products of conception are not expelled, instead a part of it is
left inside the uterine cavity is called incomplete abortion.
Diagnosis
History of expulsion of a fleshy mass per vaginum followed by
Treatment
Dilatation & evacuation
When foetus is dead & retained inside the uterus for more than 4 weeks.
Diagnosis
Management – In CHC
98
Standard Treatment Guidelines
An abortion associated with clinical evidence of infection of the uterus & its
contents is called septic abortion.
Commonly associated with, illegal induced abortion.
Diagnosis
Pyrexia- Temperature 100’.4” F for 24 or more
Purulent vaginal discharge
Pain in lower abdomen
Per-vaginal examination- shows patulous os & boggy feel of uterus &
purulent discharge
Investigations
In PHC
In CHC
Blood urea
Serum creatinine
Coagulation profile
Ultrasound if needed
Treatment
Refer to CHC
If there would be a significant time loss to CHC then, before referring to CHC
start
Inj. Ampicillin 1 gm
Inj. Gentamicin 80 mg
IV Metrogyl 100 ml
Check for ruptured uterus or other complications as septic abortion is usually seen
in illegally done and unsafe abortions.
99
Obstetrics & Gynaecology
Treatment in CHC
Drug TTreatment
reatment
Inj. Ceftazidime or Inj. Cefotaxime or Inj. Cefoperazone1 gm 12 hourly
And
Inj. Gentamicin 80 mg IM 8 hourly
And
Inj. Metronidazole 100 ml IV 8 hourly
Surgical
Treatment
As per specific diagnosis of underlying diseases, in consultation with a gynaecologist.
The aim is to reduce chances of abortion in current pregnancy
100
Standard Treatment Guidelines
9. ECTOPIC PREGNANCY
Implantation of fertilized ovum out side the uterine cavity, commonly the fallopian
tube
Symptoms and Signs
In PHC
Start IV line with dextrose & normal saline;
Investigations - in CHC
Ultrasonography;
Colpocentesis;
Surgical Management
In CHC
Arrange blood;
Laparotomy & surgical management;
101
Obstetrics & Gynaecology
Diagnosis
Investigations
HCG value
Estimation of uterine size
Ultrasonography
A large for date uterine size with no evidence of foetus on ultrasound
with raised HCG value is confirmatory.
and
X-ray Chest
Treatment
Evacuation of the uterus is to be done as soon the diagnosis is established
in CHC/District Hospital
For expulsion of mole
where facilities for blood transfusion is available
D&C
102
Standard Treatment Guidelines
Surgical Management
Hysterectomy
Indications
Profuse bleeding with cervix not dilated;
Age more than 35 years;
Completed family life;
Profuse bleeding;
Sepsis or Perforating mole.
Prophylactic chemotherapy
Follow up
After evacuation of mole repeat USG after 48 hrs and 15 days
Contraception
11.1 PRE-ECLAMPSIA
Diagnostic features
Absolute rise of B.P equal to or more than 140/90 mm Hg. (rise in systolic
pressure of at least 30 mm Hg or a rise in diastolic pressure or at least 15
mm Hg more than the previously known blood pressure). The rise should
be evident on at least two occasions 6 hours apart or a single reading of
B.P. of 160/110 mm Hg or more.
Urinary proteinuria
Pitting oedema over the ankles.
Rapid gain in weight of more than 0.5 Kg/week or more than 2 Kg
103
Obstetrics & Gynaecology
104
Standard Treatment Guidelines
Non-drug treatment
105
Obstetrics & Gynaecology
11.2 ECLAMPSIA
Drug Treatment
This may begin at PHC for and no time should be lost on initiating treatment.
Control of convulsions
Loading dose
Magnesium sulphate 4 gm in 20 ml of Dextrose 5% IV over 5 minutes
And
Inj. Magnesium Sulphate 10 gm or 50% (5 gm IM on each buttock) prefeably
with 2% lidocaine
If convulsion recur after 15 minutes, give 2g magnesium sulfate (50% solution)
IV over 5 minutes.
Maintenance dose
Magnesium Sulfate 5 g (50% solution) +1 ml lidocaine 2% IM every 4 hours
into alternate buttocks.
Continue treatment with magnesium sulfate for 24 hours after delivery or the
last convulsion, whichever occurs last.
Tab Nifedipine (10 mg) Sublingual if blood pressure is greater than 110 mm Hg
Sublingual Nifedipine can cause a sudden fall in B.P.
Management at CHC
Delivery should take place as soon as the woman’s condition has been stabilized.
Delaying delivery to increase fetal maturity will risk the livers of both the woman
and the fetus. Delivery should occure regardless of the gestational age.
Induction by Oxytocin or Prostaglandins
If the cervix is favouralbe (soft, thinned, partiallydilated), rupture the membranes
and induce by syntocinon (see page 92)
106
Standard Treatment Guidelines
Caesarean Section
If vaginal delivery is not anticipated within 12 hours (for eclampsia) or 24 hours
(for severe pre-eclampsia).
If there is foetal distress foetal heart rate is < 100 or > 160/minutes.
If cervix is unfavourable
Postpartum Care
Continue anticonvulsive therapy for 24 hours after delivery or last convulsion,
whichever occurs last.
Continue antihypertensive therapy as long as the diastolic pressure is 110
mmHg or more
Continue to monitor urine output.
Watch carefully for the development fo pulmonary oedema, which often occurs
after delivery.
Prevention
If the mother is Rhesus negative and the child when tested after birth tests Rhesus
antigen positive it is imperative to give anti D immunoglobulin to the mother within 72
hours of delivery. This prevents Rhesus incompatibility in the next child. If this is not
done or despite it a Rhesus negative patient develops foetal loss or severe IUGR in
subsequent pregnancy one can suspect Rhesus incompatibility..
If mother is Rh-ve delivering Rh +ve foetus, Anti D immunoglobin 300 microgram
IM should be administered within 72 hours of delivery
For abortion in Rh-ve mother 100 microgram of Anti D immunoglobin is given IM
Investigations in CHC
Indirect Coomb’s test to detect antibody
107
Obstetrics & Gynaecology
Drug treatment
Tocolytic Agents
This is indicated when - the duration of pregnancy is 28-32 weeks.
- membranes are intact and labour is not
advanced. Cervix dilation is not >3 cm.
Inj. Isoxsuprine (Beta adrenergic stimulants) is used in the acute suppression
of labour.
Dose
Isoxsuprine HCl 40 mg in 500 cc of Dextrose. @30 drops./mt
Watch for fall of B.P. and tachycardia. The maternal pulse should not exceed
more than 100/minute.
Maintainence therapy- Isoxsuprine orally 10 mg 6 hourly
Corticosteroid therapy given to the mother to enhance foetal lung
maturation
GA 30-32 weeks - give injection Dexamethasone 12 mg 12 hourly
4 doses
Wait for 48 hours, and then deliver the patient
Management
Bed rest
Strict Asepsis is to be maintained
Sterile vulval pad
Beyond 37 weeks
If labour dose not start within 6 hrs induce by oxytocin drip
If GA is less than 37 weeks
Give injection Dexamethasone 12 mg 12 hourly doses for Foetal
lung maturity.
Wait for 48 hours, and then deliver the patient
Give Inj Ampicillin 500 mg 6 hourly or cap Ampicillin 500 mg 6
hourly to Prevent infection.
If signs of infection are present –Induce immediately.
108
Standard Treatment Guidelines
If the baby’s general condition is good and weight is more than 1500 gms then
the baby can be treated at PHC.
Bleeding from genital tract after the period of viability of the foetus (28 weeks)
until term when patient goes in to labour. Main causes are Abruptio placenta
and Placenta praevia
109
Obstetrics & Gynaecology
Clinical features
However in most of our situations the condition is diagnosed only after profuse life
threatening bleeding has started. Once such bleeding has started the only course is to
start on blood transfusion and plan for early caesarean section to deliver the child.
Treatment
No conservative line of treatment at PHC. all cases are to be referred to CHC
Assess the amount of bleeding.
Start IV Line, Restore blood volume by infusing normal saline and refer.
at CHC
Type I and Type II anterior
vaginal delivery can be expected.
Type II -b, III & IV.
Elective/emergency caesarean section has to be done at the earliest.
Explain the need of blood transfusion and send the relatives for donating
blood
110
Standard Treatment Guidelines
Excessive blood loss after the child is born. If blood loss is more than 500 cc in
normal delivery and 1000 cc in Lower segment caesarean section & twins is called
Post-partum Hemorrhage.
ATONIC PPH (80%) failure of the uterus to contract after delivery results in
execessive bleeding This is more often seen in Multiple pregnancy. Hydramnios;
Big baby; Multiparity & Induction with Oxytocin.
TRAUMATIC PPH (20%) Tears in the genital tract cause bleeding. This is seen
with Instrumental delivery, Malpresentations and Malpositions and with Episiotomy
wounds.
A well contracted uterus per abdomen rules out Atonic Post-partum haemorrhage.
Then one would need special examination to diagnose cervical tear and
vaginal tear.
Management
Patient should be assessed for general condition, amount of blood loss whether
placenta is expelled or not and condition of uterus whether contracted or atonic.
PPH requires prompt and effective management, failing which it may result in
complications like hypovolemic shock, coagulation failure, renal failure, hepatic
failure, adult respiratory distress syndrome and may also result in maternal death.
Treatment
At PHC
Continue to massage the uterus
Start infusion to replace blood loss
Give 20 units of Oxytocin in 1000 ml Saline. Give @ 60/mt or fast.
contnuing dose : infuse 20 units Oxytocin in 1000ml saline @ 40drops/mint.
Methyl ergometrine maleate 0.2 mg IV may be repeated IM after 15 mint. (Caution.
Contraindicated in heart disease, hypertension).
Refer to CHC
If bleeding is not controlled
Refer with Blood grouping and Rh typing and arrangement of blood
111
Obstetrics & Gynaecology
Management
Meticulous repair of Episiotomy, Vaginal laceration and cervical laceration with
chromic catgut No. 1
Small oozing from vaginal mucous membrane - pack with sterile Povidone-lodine
gauze.
Refer to CHC
If bleeding is not controlled or tears which cannot be sutured at PHC where suturing
may be done by the gynaecologist.
Diagnostic features
A rise of temperature reaching 100.4o F for more, (measured orally) on two
separate occasions at 24 hours) with in first 10 days after delivery.
During delivery the woman’s protective barrier against infections is temporarily
reduced and this may lead to infections the cause of fever may be a serious
complication and is often preventable.
Drug treatment
Antibiotic treatment, where appropriate, should be guided by the presumed
source of infection. Empiric therapy consists of:
After defervescence,,
Inj. Ampicillin IV can be changed to Cap. Amoxicillin (500 mg)
8 hourly.
112
Standard Treatment Guidelines
Non-drug treatment
17. CONTRACEPTION
TEMPORARY METHODS
Dose
113
Obstetrics & Gynaecology
PERMANENT METHODS
There are vasectomy for males & tubectomy for females. Detailed instructions on the
procedure is given to surgeons trained on this.
17.4 VASECTOMY
Haemoglobin
Urine - Routine & microscopy surgery.
done by
Mini laparotomy
Laparoscopic Sterilization
114
Standard Treatment Guidelines
Start treatment for anaemia, UTI or hyperglycemia before referring for the procedure
& while awaiting it.
All pregnant women should be screened for gestational diabetes mellitus around 24 to
30 weeks of gestational age.
If positive this should be confirmed by fasting blood sugar (FBS) and postprandial
blood sugar estimation.
All such cases should be seen by specialist but follow up till delivery can be done at
primary health care center however send the patient to CHC for delivery.
Interpretation
FBS value more than 120 mg/dl is suggestive of diabetes
One hour glucose tolerance test i.e. measuring blood sugar one hour after oral
intake of 50 g of glucose: A value more than 200 mg/dl is suggestive of diabetes.
A valve greater than 140 mg/dl - further screening with GTT is required
115
Obstetrics & Gynaecology
116
Standard Treatment Guidelines
3. JAUNDICE IN PREGNANCY
Jaundice associated with pregnancy may be due to one of the following:
More often jaundice in pregnancy is due to viral hepatitis which has a more fulminant
course in pregnancy.
Management
Referred to CHC
Manage as for jaundice, keeping three points in mind.
GYNAECOLOGY
1. DYSMENORRHOEA
Treatment
All women have a small amount of vaginal discharge. This is clear milky or slightly
yellow. There is no itching or bad smell. Such discharge is more during pregnancy
and after child birth and during sexual activity. This is not to be confused with
abnormal white discharge. Often the patient with such a complaint only needs to
be reassured. However if one of the following symptoms is there in addition she
must be examined :
117
Obstetrics & Gynaecology
Diagnostic steps
In all cases Per Vaginal & Per Speculum examination should be done necessarily to
rule out early malignancy.
Also where possible especially in a woman above 45 years Paps smear in CHC is
also indicated and swab is taken for microscopy and if possible culture.
The general approach to diagnosis is as follows :
If the discharge is bloody or admixed with even a few spots of blood (not to be
confused with periods)
If answer is, yes then refer to district hospital or tertiary care centre as it may be
an early stage of cancer or other serious infections. Since often such blood
spots may go unnoticed especially with coloured garments it is advisable to
look for malignancy with a PV & PS examination all women with such a
complaint.
If the woman has fever or tenderness or pain in lower abdomen and /or
childbirth/abortion in last two weeks then it may be a serious infection of
uterus or related parts.
This too needs urgent referral to CHC. See section on pelvic inflammatory
disease in page 122.
If the woman has only a yellowish, badly smelling discharge with varying
amounts of itching then it may be a trichomonal infection or bacterial infection
or chlamydial infection.
Diagnostic confirmation is by microscopy but this is not sensitive enough.
Treat with Metronidazole 200 mg thrice daily for seven days with husband
also getting the same dose during the same period.
Ensure that the woman is not pregnant before metronidazole is prescribed.
Note these are sexually transmitted diseases & sexual partners must be
treated where possible.
If the discharge looks like curd or spoilt milk and itching and burning sensation
is severe with inside of vagina becoming very red – it may be due to yeast
(candidial infection). This is more common in women who are immuno-
depressed, like in pregnancy or diabetes or sick, malnourished women or
women getting steroid drugs etc. Usually candidial white discharge is not
sexually acquired.
118
Standard Treatment Guidelines
Treatment
Treatment
If anaemia is present treat with iron & folic acid tablets.
Refer to gynaecologist.
119
Obstetrics & Gynaecology
Treatment
Combination pills of oestrogen and progesterone like Mala-D given for three
cycles.
If there is
Severe bleeding
Bleeding for many days
No response to initial medical management
Do a D & C and send for histopathology
Treatment
Always do a D & C
If normal endometrial histopathology-
Treatment
Tab Medroxy Progesterone Acetate 10 mg 1 Tab daily from Day 15 to Day 25
x 3 cycles.
4. MENOPAUSE
120
Standard Treatment Guidelines
5. FIBROID
Diagnosis
Dysmenorrhoea
As anaemia,
Investigation
Treatment
Diagnosis & definitive treatment is done at the level of CHC or District Hospital
where a gynecologist is available
If patient is asymptotic/ Uterine size < 12 weeks
No further treatment
Only surveillance
If patient is having dysmenorrhoea or abnormal uterine bleeding then,
Tab paracetamol (500 mg) 1 Tab 3 times a day for 5 days.
Tab medroxyprogesterone acetate 10 mg 1 tab once daily for 21
days.
Treat for anaemia with Iron and folic acid tablets symptomatic care at primary
level
If patient requires child bearing or is symptomatic refer to gynecologist for
myomectomy or hysterectomy.
6. PROLAPSE OF UTERUS
121
Obstetrics & Gynaecology
Diagnostic features
Pain in lower abdomen/ Backache
Fever
Usually no history of missed period
Dysmenorrhoea, dyspareunia, dysuria, rectal tenesmus
H/o IUCD insertion may be there.
H/o any vaginal procedure done in recent past.
Vaginal discharge present with pain in abdomen
Tenderness or mass in one of the fornices.
Investigations
Complete blood count
Urine microscopy and albumen, sugar
Pregnancy test.
Ultrasound examination of pelvis where available.
Treatment at CHC or DH
General Guidelines
Admit
Monitor daily vital signs and abdominal girth,
Give treatment for symptomatic relief.
Also ensure Hydration with IV fluids if needed.
122
Standard Treatment Guidelines
Drug Treatment
Inj. Ciprofloxacin 200 mg IV twice daily
Inj. Metronidazole 500 mg IV three times a day.
Or
Injection cefazolin I/v 3 times daily
Injection Gentamicin 60 mg I/v 3 times daily
After fever subsides switch to oral treatment (as described earlier)
Continue Cap. Doxycycline 100 mg 1 BD x 14 days.
Refer
If per vaginal examination or ultrasound shows tubo-ovarian mass-
Refer to tertiary care centre.
Remember to rule out the following causes before making a diagnosis of pelvic
inflammatory disease:
Ectopic pregnancy
Acute appendicitis
Torsion of ovarian cyst
Corpus luteum cyst
Amoebic colitis
Endometriosis
Cystitis
8. INFERTILITY
Only after two to three years of regular family life if there is still no pregnancy does
infertility needs to be investigated.
In PHC
Begin by counselling and encouraging regular relationships timed for maximum chance
of impregnation – 14 days before the next expected periods.
If still investigations are requested insist that both husband and wife must be investigated
Investigations In CHC
For husband - Semen analysis
- VDRL Test
For wife - Hb
- VDRL test
- Urine-routine & microscopic
- D and C
- Cervical mucus examination
All patients of infertility should be referred to a gynecologist where the above tests
are done and further specific treatment is given
123
Infectious Diseases
SECTION V
124
Standard Treatment Guidelines
1. TYPHOID FEVER
This is an infection of the blood and organs caused by a bacteria called Salmonella
typhi, which is transmitted either directly (dirty hands) or indirectly (contaminated
food or water) from faeces to mouth.
Clinical features
Fever for over one week duration.
Diagnosis
Needs a positive Widal test
and/or
Blood culture positive for Salmonella typhi.
Diagnosis can be based on the positive Widal test. This test usually becomes
positive around the 8-10th day. It takes two days to read even if the laboratory
is available locally.
Supportive laboratory test — Leucopenia seen in a blood smear would favour
a diagnosis of typhoid if malaria has been ruled out.
If however Widal test is not available even at the CHC or district hospital one
can treat presumptively at the CHC and decide on further treatment depending
on response.
125
Infectious Diseases
Ideally needs a blood culture also. This facility is not available in most districts.
It should become available in the district hospital.
Complications
which may appear during illness and during convalescence even under therapy
include :
Lower G. I. tract bleed
Severe abdominal pain and vomiting
Loss of consciousness.
Add on one of the two antibiotics mentioned below (each district should have a six
monthly updated advisory on antibiotic choice). Remember the fever takes days to
stop but by third day patient should be feeling a bit better and fever should be less.
Chloramphenicol (PO)
Adult and Child - 50-100 mg/kg/day in 4 divided doses.
Child 2 weeks to 1 year - 50 mg/kg/day in 4 divided doses.
Infants under 2 weeks - 25 mg/kg/day in 4 divided doses.
Duration : 14 days or alternatively three to five days after total resolution
of fever
Alternatives (If resistance or contraindication to chloramphenicol) :
Ciprofloxacin (PO)
Adult and Child - 10-20 mg/kg/day in 2 divided doses. maximum adult
dose 1.5 gm/day
Normally contraindicated for children below 15 years : risk of lesions of
the weight bearing joints. But can be used in typhoid fever.
If patient cannot take antibiotics by mouth, use IV but change to oral route
as soon as possible.
126
Standard Treatment Guidelines
Prevention
2. MALARIA
This is an infection due to the protozoa Plasmodium transmitted by the female
anopheles mosquito.
There are four plasmodial species of which in Chhattisgarh state we see two species
commonly : P. falciparum and P. vivax.
Incubation period : is about 9 to 12 days for P. falciparum and more than 15 days
for the other three species.
Clinical Features
Simple malaria
It commonly presents with typical chills and rigor followed by high fever and
then sweating.
This occurs daily in Plasmodium falciparum and once in two days for
Plasmodium vivax.
Headache and bodyache are also invariably present.
Sometimes they may present with continuous fever, malaise and headache.
Severe Malaria
Encephalopathy :
- Clouding of consciousness,
- Coma (lasting more than 1/2 hour in children who just had
convulsions)
- convulsions (more than 2 times/24 hours, in children – to exclude
febrile convulsions: see page 49)
- delirium
- focal neurological deficits.
127
Infectious Diseases
Chronic malaria
It presents as
Low-grade fever,
Weight loss,
Splenomegaly
Severe anaemia with pancytopenia
All of which should persist over two weeks or even longer.
Diagnosis
One of the above clinical features supported by positive blood smear
examination for malarial parasites:
Fever with Splenomegaly in a patient with the above mentioned clinical features
make diagnosis of malaria more likely.
Confirmation of diagnosis always depends on seeing the parasite in the blood
In all cases thick and thin smears should be done.
That blood smears may be negative in the severe and chronic forms
and this would need repeated smears.
Treatment
Simple malaria
For child
child: 10 mg/kg for first two days and then 5 mg/kg for next day.
128
Standard Treatment Guidelines
Primaquine :
In high risk areas known for over 30% P.. falciparum or any
death add Primaquine in every case
If blood report will become available within 24 hour reliably
and no epidemic is ongoing one can wait for the report and
treat with primaquine only is if it is positive.
Resistance to chloroquine
Before considering a diagnosis of resistant malaria, check :
That treatment has in fact been taken.
That the correct dose for weight has been prescribed.
That there has not been under-dosage due to confusion between the
expression of the dosage as chloroquine base and as chloroquine salt.
whether there has been diarrhoea or vomiting within one hour of taking the
medication.
the expiry date of the drug.
129
Infectious Diseases
To diagnose resistance
we must have a falciparum positive blood smear on the first and the third/
seventh day of treatment.
One must also suspect resistance if the same person comes back repeatedly
with a diagnosis of malaria.
Chloroquine resistance has also been recently described with P. vivax also.
Sulfadoxine + Pyrimethamine
Tablets available containing 500 mg sulfadoxine + 25 mg. of
pyrimethamine :
Dose Single dose
< 1 year 1/4 tablet
1-4 years 1 tablet
5-8 years 1 1/2 tablet
9-14 year 2 tablet
> 14 years 3 tablets
It may be given for smear positive cases of falciparum malaria, which did not
improve with chloroquine :
It is contraindicated in :
Pregnant women
Lactating women
Children < 2 months verity.
Not to be given in association with chloroquine or cotrimoxazole.
Must not be used for prophylaxis.
For cases of chloroquine and/ or sulfadoxine - pyrimethamine treatment failure,
quinine is the next course (in pregnancy it is the second recourse)
Quinine (PO) : 30 mg / kg / d divided in 3 doses x 7 days;
It has to be strictly given at 8 hours interval between each dose
in association with
Tetracycline (PO)
Child and adult : 25 mg/kg/ d x 10 days
or
Doxycycline (PO)
Adult and Child above 8 years : 200 mg/ d in 2 divided doses x 7-
10 days
130
Standard Treatment Guidelines
SEVERE MALARIA
Initial dose should be halved in patients who took oral quinine, quinidine or
mefloquine in previous 12 to 24 hours.
Switch to oral quinine as soon as patient is able to swallow.
Complementary treatment
131
Infectious Diseases
Prevention
3 . MEASLES
Measles is a highly contagious viral illness that spreads through droplets in the air.
The disease mainly affects children under 3 years. The younger the patient, the
higher the risk of death. Malnutrition increases this risk.
Epidemics can occur only if the number of un-immunised children at risk is large
enough. Hence the spacing of outbreaks largely depends upon immunization
coverage. Refugees, displaced people, slum inhabitants, malnourished and
hospitalised children are particularly at risk.
The incubation period is about 10 to 12 days. It is spread by infected persons
(from 3 to 4 days before the appearance of the rash to 3 days after).
Clinical features
High fever with rhinorrhoea (running nose) and conjunctivitis and cough in first
three days.
Next three to four days a characteristic maculo- papular rash develops all over the
body. The rash is reddish and on pressure becomes pale. It usually starts over the
face and spreads down to neck, chest and then to abdomen and legs over the next
four days. Once the rash reaches the feet there is no fever and the skin starts to
peel. Look for koplicks spots in the mouth.
Diagnosis
Based on clinical features
Complications
Respiratory: Laryngitis, Otitis, Bronchitis and Pneumonia.
Severe diarrhoea
Conjunctivitis, Vitamin deficiency leading to blindness.
Malnutrition.
Encephalitis
132
Standard Treatment Guidelines
Treatment
Treat fever (see page 29).
Check and correct hydration status (oral rehydration salts if necessary, see page
181).
Prevent vitamin A deficiency : vitamin A supplementation 2,00,000 IU
If xerophthalmia or corneal involvement is seen
Infant 6 months to 1 year: 100000 IU / dose at d1, d2, d8
Child over 1 year: 200 000 IU/ dose at d1, d2, d8
Prevent ocular complications : tetracycline eye ointment 1% : 2 applications/d x 5
days
Prevent mouth ulcers : gentian violet, 2 applications/ d for 5 days.
Maintain adequate food intake and continue breast-feeding.
Preventive antibiotic treatment should be given to children with a high risk of
complications like severe malnutrition, HIV infection, night blindness.
If complications occur, treatment of secondary respiratory infections at least for 5
days with :
Cotrimoxazole (PO) :
Adult sulfamethoxazole 800 mg with
trimethoprim 160 mg every 12 hours,
in more severe infections; increased to
sulfamethoxazole 1.2 g with
trimethoprim 240 mg every 12 hours
133
Infectious Diseases
Prevention
Immunisation :
Measles vaccine one single dose as soon as possible after 9 months of age.
During an epidemic :
immunize children between 6 months and 5 years of age.
Children first immunised between 6 and 9 months of age must receive a booster
dose, which will be given after their first birthday.
In population at risk and in refugee camps :
immunize children from 6 months to 5 years.
Children first immunized between 6 and 9 months of age will have to receive a
booster dose after their first birthday.
4 . CHICKEN-POX
This is a viral disease presenting as fever with vesicular rash.
Diagnosis
It usually presents as a macular rash which soon becomes a vesicular rash which
gets infected to form pustules and finally crusts, dries and falls off leaving scars
most of which are temporary.
At any given time the rashes are at different stages of evolution - Some of the
rashes are vesicular while others are pustules).
Complications
Complications are the same as listed for measles.
Treatment
Treatment remains the same as for measles except that there is no immunisation
recommended.
Acyclovir can be tried in severe cases and in malnourished children if available.
Dose in children 80 mg/ kg/day in 4-5 divided doses for five days.
Prevent secondary skin infection with antibiotics as it can lead to post streptococcal
glomerulonephritis.
5 . POLIOMYELITIS
It is an acute viral infection spread through the faeco-oral route. It affects young
children (under 5 years of age) more. Increasingly young adults are affected (shift
towards an older age range).
134
Standard Treatment Guidelines
Paralytic poliomyelitis (acute flaccid paralysis, AFP) occurs in children less than 17
years of age. Of those infected with the virus few develop paralysis : for each paralytic
case, 100 to 200 others are inapparent. Active surveillance to detect new paralysis
cases is therefore crucial for epidemic control.
Clinical Presentation
Paralytic poliomyelitis
Can be precipitated by intra muscular injection.
Paralysis, asymmetrically and affecting one or more limb (“morning paralysis”),
often for two days prior to onset of paralysis patient is febrile, which is accompanied
by headache, vomiting or diarrhoea.
At the initial stage, though rare, urinary retention may occur.
We have to differentiate this from the Guillain-Barre syndrome, where there is
symmetrical quadriparesis and associated respiratory difficulty.
All cases of paralysis must be referred to a doctor and polio surveillance officer.
Diagnosis
Based on clinical features
Treatment
Prevention
The oral vaccine is recommended.
Immunization schedule
Before 1 year, 4 doses : At birth, and at 6, 10 and 14 weeks.
Booster 1 year later, and at 6 years of age.
135
Infectious Diseases
6. DIPHTHERIA
Disease caused by the local proliferation (usually Upper Respiratory Tract Infection)
of the diphtheria bacillus and by the diffusion of the diphtheria toxin into the body.
Clinical features
Commonly presents as pseudomembranous tonsillitis (white patch seen
over reddened Tonsils) and / or accompanied by toxic signs
Fever > 39°C, oliguria,
Enlarged cervical lymph nodes and oedema of the neck
Haemorrhagic signs : cervical or thoracic purpura, gingival
haemorrhage, epistaxis)
May also have Laryngitis (croup) often secondary to tonsillitis, which can
lead to asphyxia and death.
Sometimes other localization: rhinitis often unilateral, mucous membranes
or skin lesions.
Diagnosis
Based on the clinical features.
Confirmation is by collection of pharyngeal swabs and culture will allow
the isolation of the toxigenic strain of Corynebacterium diphtheria.
All cases suspected of diphtheria must be notified and referred to district hospital.
Complications :
caused by the toxin; determine prognosis.
Cardiac -Myocarditis : arrhythmia, atrio-ventricular blocks.
Polyneuritis: can begin up to 3 months after the onset of diphtheria: palatal
and oculomotor paralysis (muscles of accommodation) as well as paralysis
of the diaphragm and limb muscles.
Renal function may also be affected : oligouria,-anuria, haematuria.
Treatment
If diphtheria is strongly suspected clinically initiate the treatment before receiving
the results of the laboratory investigations.
Serotherapy Inj. Diptheria antitoxin
Antitoxin obtained from horse serum.
Drug regimen depends upon severity and duration of symptoms :
Rhinitis : 10-20 000 units I.M..
Tonsillitis : 15-25 000 units I.M. or I.V..
Laryngitis–Pharyngitis : 20-40 000 units I.M. or I.V..
Toxic signs : 40-60 000 units I.V..
136
Standard Treatment Guidelines
Immunization
7 . PERTUSSIS
Whooping cough is a childhood disease due to Bordetella pertussis.
In poor living conditions, it can contribute to malnutrition and to increased childhood
mortality.
This emphasises the role of immunization.
137
Infectious Diseases
Infants less than 3 months may develop apnoeic or cyanotic attacks, which
may lead to death this implies close and permanent surveillance of the sick
infant.
Complications
Coughing may impair feeding and precipitate malnutrition.
Subconjunctival haemorrhages, epistaxis, haemoptysis, pneumothorax.
Secondary infections of the upper and lower respiratory system.
Encephalitis. Risk of death.
Treatment
Some authors recommend antibiotic treatment during the catarrhal stage (only).
Erythromycin (PO) to be given for 7 days
dose as on page no. 137
or
Chloramphenicol (PO)
dose as on page no. 126
Can use salbutamol - 0.1 ml /kg/dose for cough.
During the paroxysmal stage, antibiotics are useless.
Advise the mother to ensure
- adequate hydration.
- to humidify air if possible.
- above all to ensure adequate nutrition (continue breast-feeding and
give supplements) in spite of the child’s anorexia and vomiting.
- Advise the mother to feed the child after each fit of coughing associated
with vomiting.
for secondary infections
antibiotics (PO, 1M or IV depending on severity):
Amoxicillin (PO)
Child : 50 mg/kg/ d divided in 2-3 doses x 5-10 days
dose as on page no. 133
If amoxicillin is not available
give ampicillin (PO) : 100 mg/kg/ d divided in 2-3 doses x 5-10 days
Adult 500 mg every 4-6 hours;
Child under 10 years, half the adult dose
or
Chloramphenicol (PO)
dose as on page no. 126
or
cotrimoxazole (PO)
dose as on page no. 133
138
Standard Treatment Guidelines
Infants less than 3 months should be admitted to hospital and observed continuously:
be cause of risk of apnoea or asphyxia.
Prevention
Immunization integrated into the Expanded Program on Immunization. A good
protection requires 3 injections, each at least one month apart.
First year of life- three doses of anti-tetanus vaccine at 6, 10 and 14 weeks.
Booster dose. In Second year of life (at 18 months)
Immunization of non-immune infants, who have been in contacts with pertussis
cases and are not yet ill, will attenuate the disease.
8. FILARIASIS
This is a disease caused by microfilarial species transmitted by the Culex mosquito.
1. Early
Fever with chills and sweating.
Dull aching testicular pain.
Lymphangitis may be present.
Unilateral pitting pedal oedema
2. Later
Persistent Pedal oedema.
The swelling may be more on one leg. Rarely upper limbs may be involved.
The oedema may become non-pitting.
There may be areas of redness and even pus formation with pain over the
swelling. This indicates bacterial infection occurring on the swelling.
3. Much later
The swelling is gross and the leg is thickened (Elephantiasis)
The scrotum may also be swollen
There are repeated episodes of fever and leg pain and eventually the infection
may spread to the blood.
Diagnosis
Early stage - Peripheral smear examination during the febrile period which may
show microfilaria.
Later stages - Micro-filariae may not be seen on the peripheral smear as the adult
forms are lodged deep inside. There maybe micro- filaria in the blood during
fever but this is not certain. It is for the doctor to consider various possibilities and
decide whether to treat for filariasis.
139
Infectious Diseases
Treatment
Early stage
Albendazole : 400 mg dose once
And/or
Diethylcarbamazine.
Diethylcarbamazine is essentially a drug that kills the microfilaria.
Adult & Child above 10 years : 6 mg/kg/ d x 12 days. Preferably in
divided doses x 12 days
Child Under 10 years : half the adult dose.
Contra-indications child < 5 years, pregnant women, lactating women during
the first week.
Side effects are due to breaking up of microfilaria (allergic manifestations,
pain, fever) and respond well to anti-histaminics and paracetamol.
Postural hypotension may occur which responds to corticosteroids. (single dose for
1 to 2 days).
Later stages
Foot end elevation during sleep.
Tie a crape bandage firmly around the leg to prevent oedema formation.
Massage the leg at night.
Promptly treat infection as soon as possible. Most of the disfigurement is
due to such repeated infections.
When there is no active infection ( that is no redness or pain) then one can
give a tablet of albendazole and then 7 days of diethyl carbamazine. This
can be repeated every month for 6 or more months. (check)
Supplementary Treatment
Lymphangitis
Paracetamol (PO)
Adult : 1500 mg/d divided in 3 doses
or
Ibuprofen 400 mg thrice a day
If there is associated fever and/or spreading redness or pus: treat as for impetigo
140
Standard Treatment Guidelines
Chlorpheniramine (PO)
Adult 4 mg every 4-6 hours (maximum 24 mg daily)
Child under 1 years, not recommended
1-2 years 1 mg twice daily,
2-5 years, 1 mg every 4-6 hours (maximum 12 mg daily).
9. LEPTOSPIROSIS
A zoonosis that sometimes affects humans caused by leptospires (spirochaetes)
characterised by fever and acute hepato-renal failure of infectious origin.
The reservoir is an animal - usually rodents (especially the sewer rat), cattle, pigs,
dogs, horses, and wild mammals.
Contamination may be direct (contact with animals) or indirect through skin or
mucosal contact with water contaminated with urine of infected animals
(swimming, poor hygiene).
Its incubation period is of 7-14 days.
Clinical features
Fever with Jaundice, often recurring with three peripheral smears which are
negative for malarial parasite (which is a commoner cause of fever and
jaundice).
May also have :
Conjunctival haemorrhage
Hepatosplenomegaly
Severe renal insufficiency : oligouria,-anuria
Pulmonary symptoms: cough, haemoptysis
Bleeding diathesis
Aseptic meningitis.
Diagnosis
Ideally needs serological tests for confirmation : Dark ground microscopy even if
available is not as reliable and culture is difficult. Send fresh specimens of Blood,
Urine and CSF to a referral centre indicated.
Otherwise treat for malaria and then is no response and other diagnosis are ruled
out treat presumptively for leptospirosis.
Treatment
Rest and treatment of fever with paracetamol (do not give acetylsalicylic
acid because of the risk of haemorrhagic disorders).
141
Infectious Diseases
Crystalline Penicillin
Child : 100 000 IU / kg / d in 2 - 4 divided doses x 7 days
Adult : 5-6 Million IU / d 2 - 4 divided doses x 7 days
Tetracycline (PO)
Child> 8 years : 50 mg / kg / d divided in 3 doses x 7 days
Adult : 1.5-2 g/ d divided in 3 doses x 7 days
Prevention
Rat control, sanitation of working places (drainage) and water hygiene.
Avoid swimming in endemic areas.
Clinical features
Heterogeneous clinical manifestations have been classified and 4 main groups
identified :
Encephalitis -Japanese encephalitis
Fever, neck stiffness, stupor, disorientation, paralysis
Flu-like syndrome Dengue
Fever lasting 3 to 5 days, muscle and joint pain, headache
Arthritis accompanied with rash
Haemorrhagic fevers.
Treatment
No definitive treatment is available
No effective antivirals against arboviruses and no role of steroids
Treatment is supportive and symptomatic. This is often life saving in an unconscious
patients.
Maintain airway
Maintain adequate hydration and nutrition
Prevent aspiration
Prevent bedsores.
Paracetamol, intravenous fluids if needed.
Usually self limiting, it may leave various degrees of residual defects and occasionally
it is life threatening.
142
Standard Treatment Guidelines
Prevention
Vector control
Individual : mosquito nets, repellents...
Collective : sanitation, destruction of vector breeding sites...
Veterinary control
Clinical features
Diagnosis
143
Infectious Diseases
If all above signs and symptoms are there and CSF has some of the
features as listed above but with lesser intensity it could be a viral
meningitis.
If the patients illness is long standing and the CSF shows high proteins
and predominantly lymphocytes it may be tuberculous meningitis.
Differential diagnosis
Treatment
Antibiotic treatment
Bacterial Meningitis
Ideally based on grams stain and culture and sensibility. Though cultures are
envisaged only at district level, grams stain should be done wherever microscopy
is available.
Antibiotic treatment is then based on this :
Meningococcus – gram negative cocci
Pneumococcus – gram positive diplococci
Hemophilus – gram negative bacilli
Streptococcus – gram positive cocci in short chains
Staphylococcus – gram positive cocci
144
Standard Treatment Guidelines
In both cases, switch to oral treatment as soon as possible; total duration 8-10
days.
If lumbar puncture is not sterile on the 3rd day, treatments can be combined. Then
chloramphenicol must be given 1 hour after the ampicillin, otherwise antagonism
will result.
or
Ceftriaxone (1M)
Dose as stated above
Because of the high incidence of Pneumococcus in this age group,
ceftriaxone is recommended for child below 3 years when laboratory
facilities are not available
Tuberculous meningitis
Treat as for extrapulmonary tuberculosis in category-I (see page 151)
145
Infectious Diseases
Aseptic meningitis
Antibiotics are not needed. However due to lack of reliability in making the diagnosis
it is advisable to empirically treat with penicillin and chloramphenicol as indicated
above.
As a general rule give antibiotics for at least 14 days or till patient has been
afebrile for 5 to 7 days.
District hospitals should (based on culture reports) release six monthly advisory on
antibiotic choice in meningitis.
Supportive therapy
Ensure adequate nutrition and hydration (infusions, gastric tube if
necessary).
Convulsions : Diazepam I.V.. or Intra rectal 0.25 mg - 0.3 mg/kg/dose.
(see page 50)
Coma : nursing care (prevention of bedsores, mouth and eyes care)
Purpura associated with shock :
Treat shock by restoring blood volume
plus
Dexamethasone (direct IV) :
Child : 0.5 mg/kg.
Adult : 16-20 mg.
Otherwise steroids have no role. Sometimes in severe cases with grade
III coma steroids has been advocated to buy time for antibiotics to act.
Steroids are helpful in Influenzae meningitis.
To Prevent GI-Bleeding - Ranitidine 2 mg/kg/day.
146
Diagnosis
12. PNEUMONIA
Clinical Features
Clinical picture of High fever (> 39o C)
Cough
Difficult breathing
Chest pain
Tachypnea with
Dullness to percussion
Diminished breath sounds
Inspiratory crepitations
Sometimes bronchial breath sounds on examination.
Diagnosis
Treatment
Depends on age and presence of clinical signs indicating respiratory distress :
Signs of severity :
Chest indrawing
Tachypnea (respiratory rate > 60/min. in infants under 2 months, >50/
min. from 2 to 11 months, > 40/min. from 1 to 5 years)
Intercostal recession
Alar flare, stridor
Cyanosis, respiratory pauses.
Each district should have its advisory for choice of antibiotics updated at least six
monthly or as and when need arises.
Classical pneumonia in adult and child >5 years (abscence of serious signs)
Benzyl PPenicillin
enicillin
Neonate 80,000 units/kg daily in 2 doses.
Infant 1 to 4 wks 1.2 lakh units/kg/day in 3 doses
Child 1 month to 12 yrs 1.5 lakh units/kg/day in 4 doses
Adult 1.5 to 4 MIU / d divided in 3 doses x 5
days (500 mg 6 hourly for 7-10 days)
147
Infectious Diseases
or
Co -trimoxazole (PO)
Co-trimoxazole
Dose as on page no. 133
148
Standard Treatment Guidelines
13. TETANUS
This is a disease caused by a toxin released from a bacteria clostridium tetanii.
It causes repeated spasms and eventually death in most cases.
It has an incubation period of 14 days- time between onset of injury to the first
symptom which usually is trismus.
Clinical features
The characteristic symptoms and signs are :
Trismus. (lockjaw)
Rigidity- abdominal, neck, opisthotonus
Period of onset of spasms - Time between the first symptom to onset of spasm
is usually 7 days
Provoked spasms (Any bright light or sound) as well as spontaneous spasms in
later stages
Respiratory paralysis requiring ventilatory support
Autonomic disturbances- Sweating, inappropriate tachycardia or bradycardia,
hypothermia or hyperthermia, hypotension or hypertension.
Diagnosis
Diagnosis rests on clinical picture.
Diagnosis in Neonates -
Tetanus is particularly common in new born of mothers who have not received
tetanus toxoid injection during pregnancy
In such children a refusal to take feeds (due to difficulty in sucking) and then
generalised rigidity are the main features.
Treatment
Treatment depends on the grade of tetanus.
Grade 1 - Only Trismus, no Spasms
Grade 2 - Trismus + Infrequent Spasms
Grade 3 - Trismus + frequent Spasms
Grade 4 - Trismus + spasms + Autonomic disturbances
Grade 3 and Grade 4 Tetanus may require tracheostomy and ventilatory care.
149
Infectious Diseases
General Guidelines
Keep the patient in calm, dark room
Ask patient to rest on one side on a smooth surface with soft bedding if possible,
so that they do not hurt themselves during the spasms
Arrange to transport patient to a CHC
If there is a wound- clean, disinfect with chlorhexidine solution and dress the
wound.
Drug Treatment
While in transport sedation for the patient
Diazepam tablet can be given
Injectable sedatives may be given taking care that Respiratory failure does
not occur
Amoxicillin can be Started if transportation will take time. This is not a major
part of treatment but plays a minor role and can be given.
For grade I TTetanus
etanus
sedation and hospitalization in a quiet room is adequate.
For grade 2 Tetanus or aboveideally needs in addition to the above :
Anti tetanus immunoglobulin (which is very costly and difficult to avail)
250 units IV.
OR
Anti tetanus serum
AND
Tracheostomy
a surgically made hole in the windpipe Where an endotracheal tube should
be kept inserted : (so that if during a spasm air entering the lungs is
blocked by laryngeal spasm. He can breathe through the hole.)
For Grade 3 and Grade 4 TTetanus
etanus
may require tracheostomy and ventilatory care
Severe patients
Severe patients would require intravenous sedation and often
neuromuscular paralysis with artificial ventilation which is available in very
few centres.
Even with all this chances of survival in severe tetanus is low. Hence the
focus is on prevention.
Prevention of tetanus
Immunization Schedule
First year of life- three doses of anti-tetanus vaccine at 6, 10 and 14 weeks.
Booster dose. In Second year of life (at 18 months)
Then a booster dose at the age of 5 years and after that it should be taken once in
five years- life long.
150
Standard Treatment Guidelines
Since the latter prescription is difficult to meet the advise is to take an anti tetanus
injection after an injury however minor, if one has not had such an injection in the
last five years. And for those who have never had anti-tetanus injection even in
childhood it is better they take three doses one and half months apart. Remember
that tetanus can come at any age not only in children and prevention is equally
important in all ages.
Prompt - cleaning and dressing of wounds is also essential and goes a long way
to prevent tetanus.
14. TUBERCULOSIS
Clinical features
Diagnosis
Pulmonary Tuberculosis
Any patient with sputum for AFB is positive irrespective of what above
mentioned symptoms he has.
Any patient with clinical features given above and who has an X-ray
appearance suggestive of tuberculosis even if he is sputum AFB negative.
Any child who has one or more of the symptoms of tuberculosis as given
above on whom a PPD skin test (montoux) is positive – even if it is sputum
negative.
151
Infectious Diseases
Extra-pulmonary tuberculosis
Diagnosis based on clinical picture
Confirmation
By examination and culture of body fluid showing AFB or growing AFB on culture
(pleural fluid, cerebrospinal fluid, ascites, etc.)
Or mantoux positive in young child
Tissue biopsy showing typical granuloma or AFB.
Tr e a t m e n t
Treatment depends on categorization
152
Standard Treatment Guidelines
Relapse
A patient declared cured of TB by a physician, but who reports back to the health
service and is found to be bacteriologically positive.
Failure
A smear-positive patient who is smear positive at 5 months or more after starting
treatment. Failure also includes a patient who was initially smear-negative but who
becomes smear-positive during treatment.
Default :
A patient who, at any time after registration, has not taken anti-TB drugs for 2
months or more consecutively.
Drugs used for treatment
The doses are as per the following table :
Drug regimen
153
Infectious Diseases
Any patient treated with category one or category three who has a positive smear at 5,
6 or 7 of treatment should be considered a Failure and started on category II treatment
afresh.
Patient Education
Ensure importance of good nutrition is understood.
Importance of living and working conditions needs to be understood.
Importance of completion of course of drugs and how to access the drugs
regularly needs to be explained.
154
Standard Treatment Guidelines
15. LEPROSY
This is an infectious disease caused by Mycobacterium leprae that affects the skin,
mucous membranes and peripheral nerves.
Man is the only significant reservoir of infection and transmission often occurs
through household contacts.
Clinical Features
Paucibacillary type
Multibacillary type
There are Six or more hypopigmented skin patches, which are usually
thickened and have decreased sensation.
Patients have thickening of skin and nodules.
More than one peripheral nerves are thickened.
Patients have marked wasting of one or more muscle groups.
Skin smear shows plenty of bacteria.
155
Infectious Diseases
Diagnosis
Confirmation is best done by Skin scraping with Microbiological examination using
Ziehl’s stain
Treatment
Principles of management
The increasing frequency of strains of Hansen’s bacillus resistant to dapsone poses
a serious threat to leprosy control programmes. There is also a need to reduce
duration of therapy.
Therefore the strategy is of multiple drug therapy.
The patients with multi-bacillary forms of leprosy are the most exposed to
the risk of drug resistance. They are also the most contagious persons.
The treatment of multi-bacillary leprosy has two objectives :
To reduce transmission in the community.
To cure the patient.
Moreover, the emergence and spread of drug resistant strains of Hansen’s
bacillus has to be prevented.
Furthermore therapy exposes to the risk of severe adverse reactions. For
this reason, as well as to ensure compliance, supervision of patients under
treatment is necessary.
The program therefore must be well planned, organised and must include.
Ensuring therapeutic compliance.
Management of complications.
Good patient education
156
Standard Treatment Guidelines
PB adult treatment
Once a month : Day 1
2 Capsules of Rifampicin (300 mg x 2)
1 tablet of Dapsone (100 mg)
Once a day : Day 2-28
1 tablet of Dapsone (100 mg)
Full Course : 6 blister packs over 6 months
For children younger than ten the dose must be adjusted according to body weight.
MB adult treatment
Once a month : Day 1
2 Capsules of Rifampicin (300 mg x 2)
3 Capsules of Clofazimine (100 mg x 3)
1 tablet of Dapsone (100 mg)
Once a day : Day 2-28
1 Capsule of Clofazimine (50 mg)
1 tablet of Dapsone (100 mg)
Full Course : 12 blister packs over 12 months
MB child treatment
Once a month : Day 1
2 Capsules of Rifampicin (300 mg +150 mg)
3 Capsules of Clofazimine (50 mg x 3)
1 tablet of Dapsone (50 mg)
Once a day : Day 2-28
1 Capsule of Clofazimine every other day (50 mg)
1 tablet of Dapsone (50 mg)
Full Course : 12 blister packs over 12 months
For children younger than ten the dose must be adjusted according to body weight.
157
Infectious Diseases
This is usually due to viral infections with one of the hepatotropic viruses. Acute viral
hepatitis is the most common form though chronic hepatitis is also prevalent.
Diagnosis
Clinical jaundice
Serum liver enzymes elevated with high serum bilirubin on blood test.
For chronic hepatitis: one or both of the above persistent over six months.
Also where possible check for hepatitis B antigen presence
If there is hepatic failure or altered sensorium suspect that the patient has
fulminant hepatitis and hepatic encephalopathy.
Treatment
No specific treatment available currently.
General Guidelines
Rest
low fat, low protein diet
Avoidance of alcohol
Nausea and vomiting may require treatment
If hepatitis B antigen positive do the same test for the spouse
If negative in spouse immunize spouse against hepatitis B.
(Ideally one should recommend hepatitis B immunoglobulin. which however
is too costly)
Steroid have NO role in acute hepatitis or fulminant hepatitis.
158
Standard Treatment Guidelines
Treatment at CHC or DH
Diagnosis
Pain and marked tenderness in right hypochondrial region of abdomen and
on pressure over right lower rib cage.
Enlarged tender liver on palpation.
Diagnosis is confirmed by ultrasound.
Treatment
Abscess needs drainage through a wide bore needle as used for pleural
aspiration. Ideally done under ultrasound guidance.
Tablet metronidazole 400 mg thrice daily for ten days.
18. TRACHOMA
159
Infectious Diseases
Clinical features
Always examine the patient by everting the upper eyelid and searching for follicles
(whitish granulations on an inflammatory base) before commenting on trachoma.
Stage I
Bilateral conjunctivitis (with some follicles present).
Stage II
Characteristic follicular conjunctivitis associated to a vascular pannus across
cornea. : Frank trachoma
Stage III
Trachomatous scarring : diffuse infiltration and thickening of the palpebral
conjunctiva and of the cornea with scarring pannus. Complete cure is no
longer possible.
Stage IV
Trachomatous scarring is complicated by the inversion of the edge of the lids
producing an entropion. Irritation by eyelashes (trichiasis) causes more severe
ulceration and scarring of the cornea. Blindness results.
Diagnosis
Based on clinical features
Treatment
Treatment is always local.
Systemic antibiotics are not recommended.
Stage I
Tetracycline 1% eye ointment 2 times/ d x 4 to 6 weeks.
Stage II
Same treatment as above, for 2 to 3 months.
Stage III
Local disinfection and tetracycline 1% ointment.
Stage IV
Only surgical treatment can be effective even if scarring remains.
If necessary local disinfection and tetracycline 1% eye ointment.
Prevention
Personal hygiene (hand and face washing).
Control of flies.
160
Standard Treatment Guidelines
19.1 SYPHILIS
It is a sexually transmitted disease due to Treponema pallidum.
Clinical features
Single painless ulcer on the genitals with rounded, well-defined edge and indurated
base. Often accompanied by inguinal lymphadenopathy.
A history of exposure to sexually transmitted disease 3 weeks prior to symptoms
(range : 9 to 90 days) is common and makes the diagnosis more likely.
Diagnosis is often missed in women. Exclude PID : routine bimanual and abdominal
examinations should be carried out on all women with a presumptive STD.
Secondary syphilis presents with mucocutaneous rash, adenopathy, arthritis and
constitutional symptoms.
Tertiary syphilis presents usually as a differential diagnosis for cardiovascular or
neurological disease.
Diagnosis :
Confirmation by Blood VDRL test.
Other serological tests may become available at district hospital.
Treatment
For tertiary disease this dose should be repeated weekly for three weeks.
If allergy to penicillin
161
Infectious Diseases
19.2 CHANCROID
Clinical Features
It is a sexually transmitted disease due to Ducrey bacillus : Haemophilus ducreyi
Deep, painful single or multiple ulcers on the genitals, with a soft irregular base
usually accompanied by painful and voluminous inguinal lymphadenopathy. Fistula
formation may develop.
Incubation period is of 3 to 5 days after exposure (range: 1 to 8 days).
Treatment
Erythromycin : 1.5 - 2 g/ d in 4 divided doses x 7 days
or
Ciprofloxacin 500 mg twice daily for 3 days.
or
Ceftriaxone 250 mg IM single dose
Fluctuant lymph nodes may require needle aspiration through adjacent intact skin.
Ulcer should show objective signs of healing within 7 days.
If no clinical improvement is evident, consider whether :
the diagnosis is correct,
treatment is taken as instructed,
micro-organism is drug-resistant (a high degree of resistance to
standard therapy has been reported in HIV patients.
20. A.I.D.S.
162
Standard Treatment Guidelines
Categorisation
AIDS disease
This is the most serious form of HIV infection characterised by the occurrence of
opportunistic infections and neoplasia.
Once AIDS develops, the disease tends to progress rapidly especially if no treatment
is given.
Clinical features
MAJOR SIGNS
Weight loss of more than 10% of baseline body weight
Chronic diarrhoea for more than a month
Continuous or intermittent fever for more than a month
MINOR SIGNS
Persistant cough for more than a month
Generalised pruriginous dermatitis
History of herpes zoster
Repeated minor infections
Oropharyngeal candidiasis
Progressive or generalised chronic herpetic infection
Generalised lymphadenopathy
Confirmed HIV infection in mother
Generalised adenopathy
163
Infectious Diseases
Diagnosis
Clinical WHO definition of AIDS cases for the purposes of surveillance.
Investigation
A positive ELISA test
with (ideally)
Confirmation by western blot.
Rabies is a disease that usually affects dogs and many wild animals. Sometimes
when an infected animal bites human beings it can spread in them and become
fatal. Inoculation can be by bite or lick of dog or cat or bite by many types of wild
animals.
Incubation period varies from 2 weeks to several months depending on the severity
and site of inoculation. An animal infected with rabies sheds rabies viruses in its
saliva for upto 14 days in dogs and cat) before the animal develops signs of the
disease.
164
Standard Treatment Guidelines
Treatment
Once rabies disease starts it is invariably fatal.
The aim of treating a dog bite or wild animal bite is to prevent rabies or tetanus
from occurring by post–exposure immunization given early after the bite or lick
of the infected animal.
Wash the wound well with soap and water and the dry.
Clean wound with chlorhexidine solution or other antiseptic solution. Do not
stitch up the wound.
Give tetanus vaccine (toxoid) one dose. Repeat another dose after six weeks
if person has not had any tetanus vaccine ever.
As far as possible observe the animal for 14 days. If the animal is normal
then there are no chances of it being rabies. No need to give rabies vaccine.
If within the next 10 to 14 days the animal develops rabies then give a full
course of rabies vaccine available at the PHC.
If the animal bit without provocation or was known to be biting many others
and is suspected of being rabid do not wait 14 days. Start rabies vaccine at
once if there has been any bite or lick. If after 10 days the animal is alive and
well we can then stop the vaccine.
If the bite was a serious bite and the animal is suspected to have rabies give
not only the vaccine but rabies immunoglobulin as well.
If the animal is not to be seen again then we have to assume that it had rabies
and give treatment with a full course of vaccines. If the bite was a serious bite
then in addition give rabies immunoglobulin. This is costly and seldom available.
165
Infectious Diseases
Rabies vaccine
Intra-muscular injection in the deltoid, never in the buttocks.
The old vaccines (e.g. duck embryo, horse serum) are much less
expensive but require a lot of injections (7 to 14) and can be followed
by allergic and / or neurological complications.
The current vaccines made on cell cultures are much less prone to
adverse side effects.
Both drugs given above are costly and often not available. Often for
lack of availability rabies immunoglobulin is not given but it is important
that where indicated a full dose of rabies vaccine is certainly given.
All wild animal bites do not require anti rabies vaccine unless there is a
known association. Wild dogs and foxes and wolves have known
associations.
Bear bites , which are quite common have on the other hand no known
association with rabies and anti tetanus vaccine is adequate.
In most situations when in doubt the line of action would be to give anti
rabies vaccine but not give anti- rabies immunoglobulin.
166
Standard Treatment Guidelines
If one sees fang marks, then one knows that it is a poisonous snakebite. Most
often, the bite marks are not so clear. There may be just one fang mark, or just a
row of teeth marks, or a ragged tear at the site of the wound. When in doubt,
always look for the local and general signs of poisoning.
Commonly three types of Snakebites are seen.
Haematotoxic- Viper.
Neurotoxic- Cobra
Both Haemato and Neurotoxic- Krait
Main signs
Supplementary features
Pain at the site of bite. There may also be pain in abdomen as well as diarrhoea.
There is seldom any local swelling.
Vomiting, hypotension and collapse may occur.
Pain and local swelling starts almost immediately but may not develop upto
two hours after the bite. Increase in local swelling, which may become severe/
massive over 2-3 days with bruising.
Vomiting, hypotension and abnormal bleeding from or into any site may occur
within 15 minutes. Untreated shock and haemorrhage may occur upto a week
after the bite.
Blister formation around the site and spreading blister suggests a large dose
of venom and this may precede tissue death. Tissue death (necrosis) at site of
bite presents often with an offensive, rotten smell.
Patient may develop decreased urine output and subsequently overt renal failure.
Respiratory involvement in the form of acute pulmonary oedema may develop.
167
Infectious Diseases
Begin treatment with anti-snake venom for poisonous snakebite if one of the
following signs are there :
Fang marks present and/or cellulitis, blister formation present.
Clotting time is prolonged more than 10 minutes
Patient has active bleeding from any site.
Patient has ptosis and external ophthalmoplegia.
Treatment maybe started at PHC, but patient must be referred at the earliest
to a CHC
If the patient has any of these above signs, patient requires to be initiated on
treatment and at same time referred to a district hospital.
Treatment
General Guidelines
Keep the surroundings quiet; do not move the bitten part. The more it is
moved, the faster the poison will spread through the body. If the bite is on the
foot, the person should not walk at all.
Wrap the bitten area with a wide bandage or clean cloth to slow the spread
of poison. Wind the bandage over the hand or foot, and up the whole arm or
leg. Keeping the arm or leg very still, wrap it tightly, but not so tight that it
stops the pulse at the wrist or on top of the foot. If you cannot feel the pulse,
loosen the bandage a little.
Then, put on splint to prevent the limb from moving. Keep the wounded part
below the level of the heart.
Also, ice helps to reduce pain and slow the poison. Wrap the arm or leg with
a plastic sheet and a thick cloth. Then pack crushed ice around it. (Too much
cold can damage the skin. If it gets so cold it aches, let the person decide
when to remove ice for a few minutes).
168
Standard Treatment Guidelines
Transport the person, to the nearest centre which has anti snake venom and
start on an adequate dose at once. If signs of severe envenomation are present
give anti-snake venom (ASV) before one transports the patient further to CHC.
Give
Paracetamol, not aspirin, for pain.
Tetanus Toxoid.
If the bite becomes infected, give penicillin.
If respiratory paralysis is imminent (low single breath count), accompany the
patient ,keeping an Ambu’s bag and face mask ready.
Specific Treatment
169
Infectious Diseases
Some scorpions are far more poisonous than others. To children under 5 years,
scorpion stings can be dangerous, especially if the sting is on the head or body.
Clinical features
In adults, the first time is rarely dangerous. But if it is for the second time, the
person may die, if not treated soon. The body becomes allergic after the first sting.
So it is important to find out if he had an earlier scorpion sting.
Severe pain, redness and swelling at the site of the sting.
Profuse sweating
Tachycardia
Children especially may have signs of shock, sweating, nausea, vomiting and
difficulty in breathing and occasionally develop pulmonary oedema.
170
Standard Treatment Guidelines
Management
If it is for the first time in an adult, do the following :
Give paracetamol and if possible, put ice on the sting or apply firm
pressure bandage to prevent spread of venom.
Infiltration of the site with local anaesthetics may relieve pain and anxiety.
Antihistamine tablets can also be given.
If the sting is for a second time in an adult, or is in children under five, do the following.
If breathing has stopped, give mouth to mouth breathing.
If the person is in shock, treat the shock.
Shift to a centre with inpatient facilities fast.
If there is evidence of myocarditis and pulmonary oedema, strict bed rest and
management of heart failure is indicated.
Prazosin (1 mg p.o. tid for adults) has been tried by physicians and is acceptable
therapy.
Treatment
Apply hot compress on the area of the sting.
For pain give paracetamol and chloropheniramine tablets.
171
Infectious Diseases
172
Standard Treatment Guidelines
SECTION VI
173
Non-Communicable Diseases
Primary Care In
Non - Communicable Diseases
The Primary health centre must play an active role in managing non-
communicable diseases. The failure to do so is a major underutilization
of state resources – largely in the form of underutilising the qualified
medical doctor posted there. Also non-communicable disease may
contribute anywhere from 20 to 40% of the disease load and the failure
to respond to these health issues is a major ethical issue. These are
also diseases of the poor and the poor have nowhere else to go. In the
absence of fulfilling the felt need for curative care for such diseases the
primary health centres credibility is undermined and this in turn results
in diminished co-operation for programmes like family planning or
immunisation.
174
Standard Treatment Guidelines
GENERAL DISEASES
1 . ANAEMIA
This is caused by deficiency of haemoglobin, the red pigment in the red cells
responsible for transport of oxygen.
Anaemia is usually caused by both malnutrition and prolonged blood loss. Often
they go together and the poor diet cannot make up the haemoglobin loss. Repeated
pregnancies also cause anaemia. Another common cause of prolonged blood
loss is hookworms. In women, heavy menstrual flow plus dietary deficiency makes
anaemia a very common disease.
Sickle cell anaemia and thalassaemia are more common in this state and this is
discussed below.
There are many other less common causes for anaemia, not discussed in
this section.
Clinical presentation
Severe anaemia causes general pallor and oedema of feet.
Often, especially if anaemia is moderate or severe, pallor of conjunctiva, the
tongue and the nails is enough to make out a diagnosis.
The patient may present with signs of heart failure.
Diagnosis
A blood test is essential to confirm the diagnosis, to assess severity and to assess
response to treatment.
The common test is blood haemoglobin test.
If Haemoglobin is less than 13 gm/100 ml it is anaemia. Some books
prefer level of 11 gm/ 100 ml. But “11gm/100ml” patients have easy
tiredness for which treatment is needed.
If less than 8 gm/100 ml, it is, moderate anaemia.
If less than 5 gm/100 ml, it is severe, life threatening anaemia.
175
Non-Communicable Diseases
The sickling test also needs to be done in moderate & severe anaemias
Other desirable tests at DH
Serum iron levels
Bone marrow examination.
Tr e a t m e n t
Patient Education
All patients with anaemia need to increase eating of foods that contain iron.
Green leafy vegetables, bajra, ragi, beans, jaggery, meat and fish are all
good sources.
176
Standard Treatment Guidelines
Refer to CHC
All severe anaemia with Hb less than 5 gm% and / or having cardiac failure
for whom blood transfusion should be done.
Anaemia that does not respond to iron and folic acid tablet treatment, even
after one month.
Anaemia that is not microcytic hypochromic.
Anaemia associated with other illnesses such as tuberculosis.
Patients who do not tolerate iron tablets.
Clinical Presentation
Generally symptoms appear in the patients from the age of 3-5 yrs.
Recurrent painful crisis of extremities, joint pain and bony pains.
Moderate to severe grade of anaemia.
Mild to moderate level of Jaundice.
May suffer from recurrent episodes of fever along with painful crisis.
Spleen is enlarged from mild to moderate grade (3 cm - 9 cm) but in many
patients there is massive spleen, which may be tender.
Eventually the disease causes damage of vital organs i.e. heart, kidney, liver.
Diagnostic confirmation
Blood tests
Peripheral smear - may show sickle shaped RBCs; RBCs of varied size and
shape
Sickling test
Electrophoresis at (alkaline and Acidic pH).
177
Non-Communicable Diseases
Treatment
Most of the patients have a short life span i.e. 15-25 yrs. but some
patients do survive upto the age of 40-50 yrs.
Genetic counselling : High risk couples should be identified in the
community and prenatal diagnosis should be provided to the couples.
178
Standard Treatment Guidelines
General Guidelines
Phases of management
Resuscitation (if required) – 1 day
Acute phase – 1 week
Rehabilitation – 1 month
Look for hypothermia – keep warm, if a child let it sleep next to mother.
If anaemia is severe give blood. Otherwise withhold oral iron for 2 weeks and start
iron after that.
Vitamin A deficiency – give 1 lac unit IM on days 1,2 and 28 if child more than
1 year and more than 10 kg. in weight. If less than that give half that dose.
Look specifically for tuberculosis and malaria. If there is fever and it is an endemic
zone presumptive treatment with chloroquine for malaria may be given even as
blood smear is done to confirm.
179
Non-Communicable Diseases
Acute phase (for child that has completed resuscitation stage and is still too weak to eat)
Nutrition must be progressive – not aggressive.
Breast feeding child - allow to breastfeed.
Give small frequent meals orally by spoon. If child too apathic – try 2-3 days of
nasogastric feeding.
Start trial of milk based therapeutic diet providing 100 Kcal and 3 gm protein /
100 ml. Totally about 100 ml/kg/day to be given over 8 to 10 small feeds with at
least one in the night as well
A model acute phase diet
sugar 20 gm 80 Kcal
oil 30 ml 270 Kcal
milk to make 1000 ml 30 gm protein 650 Kcal
total 1000 ml 30 gm protein 1000 Kcal
On day 1 : 50 ml/kg
Increase slowly : 10-20 ml/kg /day to reach 150 ml/kg/day by 7th day (150
Kcal/kg and 3 gm protein/kg per day )
If milk intolerance is present, try skimmed milk base or cereal based formulas :
OR
rice 50 gm
glucose 45 gm
oil 30 gm
egg 1
1 litre water
total 10 gm protein 710 Kcal
180
Standard Treatment Guidelines
Rehabilitation phase (This is how most grade three & four patients of chronic malnutrition
are also managed)
Start with semisolid foods on day 7 and move to solids. If it has to be done at home
advice to feed child as done for weaning at two hourly intervals for a month. The
aim is to provide about 200 kcal/kg/day and 5 gm/protein/kg/day.
Deworm : give albendazole tablets.
Start iron and vitamins.
Rule out tuberculosis & malaria.
Repeat measles vaccination at discharge
Bring immunization up to date within shortest time period.
Regular growth monitoring
Nutrition training and counselling for mother as described in Book 3 of Mitanin
series. Ideally grade three & four chronic malnutrition need 2-3 weeks stay in
rehabilitation centre. But in current context intensive home visits and counselling
by health workers would have to suffice.
Teach diarrhoea and ARI management, by counselling to those providing care to
the child (mitanin model). Local recipes and food, variety is essential.
Reinforce the six key messages of feeding
-Exclusive breast feeding for first six months.
-Adequate supplementary feeding from six months of age.
-Feeding 5 or 6 times daily in the child below five.
-Adding adequate fats and oils.
-Adding adequate ‘green,yellow and reds’
-Feeding through an illness and extra meal for a week.
Aviod PPriscription
riscription of commercial health foods and tonics
181
Non-Communicable Diseases
Severe dehydration the skin pinched up remains in folds for over two seconds,
the eyes are sunken, tearless and dry and so is the mouth. In severe dehydration
there is also oliguria (urine less than 400 ml per day).
Management
Oral Replacement
Replacement of fluid and electrolytes orally can be achieved by giving oral
rehydration salts—solutions containing sodium, potassium and glucose. Acute
diarrhoea in children should always be treated with oral rehydration solution
according to plans A, B, or C as shown.
182
Standard Treatment Guidelines
When glucose and trisodium citrate are not available, they may be
replaced by
Dosage
Fluid and electrolyte loss in acute diarrhoea,
by mouth,
ADULT 200–400 ml solution after every loose motion
INFANT and CHILD according to Plans A, B or C (see above)
183
Non-Communicable Diseases
Parenteral solutions
Solutions of electrolytes are given intravenously, to meet normal fluid and electrolyte
requirements or to replenish substantial deficits or continuing losses, when the
patient is nauseated or vomiting and is unable to take adequate amounts by mouth.
In an individual patient the nature and severity of the electrolyte imbalance must
be assessed from the history and clinical and biochemical examination. Sodium,
potassium, chloride, magnesium, phosphate, and water depletion can occur singly
and in combination with or without disturbances of acidbase balance.
Isotonic solutions may be infused safely into a peripheral vein. More concentrated
solutions, for example 20% glucose, are best given through an indwelling catheter
positioned in a large vein.
Sodium chloride and glucose : solutions are indicated when there is combined
water and sodium depletion. A 1:1 mixture of isotonic sodium chloride and 5%
glucose allows some of the water (free of sodium) to enter body cells which suffer
most from dehydration while the sodium salt with a volume of water determined by
the normal plasma Na+ remains extracellular. Combined sodium, potassium,
chloride, and water depletion may occur, for example, with severe diarrhoea or
persistent vomiting; replacement is carried out with sodium chloride intravenous
infusion 0.9% and glucose intravenous infusion 5% with potassium as appropriate.
Glucose : solutions (5%) are mainly used to replace water deficits and should be
given alone when there is no significant loss of electrolytes. Average water
requirement in a healthy adult are 1.5 to 2.5 litres daily and this is needed to
balance unavoidable losses of water through the skin and lungs and to provide
sufficient for urinary excretion. Water depletion (dehydration) tends to occur when
these losses are not matched by a comparable intake, as for example may occur
184
Standard Treatment Guidelines
in coma or dysphagia or in the aged or apathetic who may not drink water in
sufficient amount on their own initiative.
Excessive loss of water without loss of electrolytes is uncommon, occurring in fevers,
hyperthyroidism, and in uncommon water-losing renal states such as diabetes
insipidus or hypercalcaemia. The volume of glucose solution needed to replace
deficits varies with the severity of the disorder, but usually lies within the range of 2
to 6 litres.
Glucose solutions are also given in regimens with calcium, bicarbonate, and insulin
for the emergency treatment of hyperkalaemia. They are also given, after correction
of hyperglycaemia, during treatment of diabetic ketoacidosis, when they must be
accompanied by continuing insulin infusion.
A concentrated solution of glucose (50%) is used to treat hypoglycaemia.
185
Non-Communicable Diseases
ENDOCRINE DISEASES
5 . DIABETES MELLITUS
This is a disease that is due to an imbalance in the body in its inability to change
food especially sugars and starch to energy and use it well. It occurs because the
key substance insulin is produced inadequately.
Type 1 : Diabetes or insulin-dependent diabetes mellitus is due to a deficiency of
insulin caused by auto-immune destruction of pancreatic beta cells. Patients require
administration of insulin. If onset of diabetes is before 40 it is likely to be type-1
diabetes.
Type 2 : Diabetes or non-insulin dependent diabetes mellitus is due to reduced
secretion of insulin or to peripheral resistance to the action of insulin. Patients may
be controlled by diet alone, but often require administration of oral antidiabetic
drugs or if more severe insulin. Onset is often ,but not always, after the age of 40.
Diagnosis
Diagnosis is based on Investigations
Investigations
At the PHC
Based on a positive urine Benedict’s test.
One must also do further tests for complications – test for ketones in urine to rule
out ketoacidosis if it seems clinically likely.
Check urine for albumen to detect renal involvement.
For monitoring treatment urine benedict’s test done with double emptying of bloder
is useful.
186
Standard Treatment Guidelines
At the CHC
Fasting blood sugar and postprandial blood glucose level.
Fasting levels above 126.
Two hour post- prandial level above 200. is Diagnostic of diabetes mellitus.
Levels lower than this but still raised are labelled as impaired glucose tolerance.
Complications
Emergencies - Diabetic ketoacidosis, Hyperglycaemic coma, Hypoglycaemia
Treatment
The aim of treatment is to achieve the best possible control of plasma glucose
concentration and prevent or minimize complications including microvascular
complications (retinopathy, albuminuria, and neuropathy).
Patient Education
The energy and carbohydrate intake must be adequate but obesity should be
avoided. In type 2 diabetes, obesity is one of the factors associated with insulin
resistance.
Diets high in complex carbohydrate and fibre and low in fat are beneficial.
Diabetes mellitus is a strong risk factor for cardiovascular disease. Other risk
factors such as smoking, hypertension, obesity and hyperlipidaemia should also
be addressed.
Patient needs counselling for proper foot care to prevent ulcers (similar measures
as foot care in leprosy.
187
Non-Communicable Diseases
Insulin
Soluble insulin is a short-acting form of insulin. When injected subcutaneously,
it has a rapid onset of action (after 30–60 minutes), a peak action between 2
and 4 hours, and a duration of action up to 8 hours. When injected intravenously,
soluble insulin has a very short half-life of only about 5 minutes.
Intermediate-acting insulins have an onset of action of approximately
1–2 hours, a maximal effect at 4–12 hours and a duration of action of 16–24
hours. They can be given twice daily together with short-acting insulin or once
daily, particularly in elderly patients. They can be mixed with soluble insulin in
the syringe, essentially retaining properties of each component.
The duration of action of different insulin preparations varies considerably from
one patient to another and this needs to be assessed for every individual.
The type of insulin used and its dose and frequency of administration depend on
the needs of each patient.
For patients with acute onset diabetes mellitus, treatment should be started with
Soluble insulin given 3 times daily with medium acting insulin at bedtime.
For those less seriously ill, treatment is usually started with a mixture of premixed
Short and medium acting insulins given twice daily.
Presentation
Soluble insulin Injection (Solution for injection 40 units/ml, 10-ml vial; 100
units/ml, 10-ml vial.
Oral hypoglycaemics
The most commonly used are the sulfonylureas (glibenclamide) and the biguanide,
(metformin).
Glibenclamide 5 mg : by mouth, ADULT initially 5 mg once daily with breakfast
(half the dose but prefer to avoid in elderly) adjusted according to response
(maximum 15 mg daily)
Metformin 250 mg, 500 mg, by mouth, ADULT 250 to 500 mg every 8 hours
or 850 mg every 12 hours with or after food (maximum 2 g daily in divided
doses)
188
Standard Treatment Guidelines
Treatment
Steps in Treatment
In type-2 diabetes
Start with diet control.
If not controlled add oral hypoglycaemic drugs.
First glibenclamide & then metformin.
Monitor with urine sugar done frequently till control is obtained, then once
monthly.
If still not controlled start on insulin.
In type-1 diabetes
Start with an intermediate acting insulin given once a day and increase till
control is obtained at least over part of the day.
If needed and feasible, add a second dose of soluble insulin with it or intermediate
acting insulin 12 hours later depending on nature of control achieved.
During medical and surgical emergencies
Insulin treatment is almost always required; soluble insulin should be used & it
must be substituted for oral drugs before elective surgery.
Treatment of diabetic ketoacidosis
Needs hospitalization- CHC level care
Correct dehydration – this is the main step and may need rapid infusion of normal
saline. Infusion of Normal saline with Potassium supplementation to continue till
CVP is corrected to 8-11 cms or clinically dehydration abates.
Get the blood sugar value and start on Plain Insulin infusion @ 8-10 units per
hour. Increase from second hour as required.
Give sodium bicarbonate if there are clinical signs of acidosis.
Once blood sugar is corrected to below 250 mg, start on 8 to 12 units plain insulin
in 5% Dextrose till blood sugar comes below 160 mg, increase insulin in drip if
required.
Then change over to split dose insulin by calculating the total Insulin that was
required to bring sugar to normal values
189
Non-Communicable Diseases
Clinical features
WHO propose a classification according to different grades:
Grade 0 : Thyroid is neither palpable nor visible.
Grade 1 : Thyroid is palpable, but not visible when the neck is in the normal
position.
Grade 2 : Thyroid is palpable and visible when the neck is in the normal position.
Complications
Local : swallowing disturbances, collateral circulation, and compression of the
trachea, which can lead to severe respiratory disorders.
Malignant transformation of a goiter induced by iodine deficiency is rare.
Cretinism in neonates : iodine deficiency during pregnancy may lead to hypothyroidy
during foetal life.
2 types of cretinism are described :
Myxoedematous cretinism (severe hypothyroidy, growth disorders
(stunting), myxoedema).
Neurologic cretinism (severe mental retardation, deafness, muteness,
psychomotor deficiencies) as well as cretinism.
Iodine deficiency during pregnancy increases the risk of spontaneous abortion, of
foetal and perinatal deaths and of low birth weight.
Therefore it is a very serious public health problem in areas where iodine deficiency
is endemic.
6.1 HYPOTHYROIDISM
Clinical Features
Presents with chronic fatigue, bodyache, obesity, intolerance to cold, constipation,
and menorrhagia in women. For any of these symptoms one must exclude
hypothyroidism.
Diagnosis
Diagnosis can be made in advanced cases clinically by typical symptomatology,
hypothyroid appearance, skin and hair changes and hung up ankle reflexes.
There may be pericardial effusion as well.
Investigation
Thyroid hormone assay-T , T , TSH for confirmation.
3 4
Earlier presentations can be made out only by blood tests for thyroid hormone
levels, to be made available at district level.
190
Standard Treatment Guidelines
6.2 HYPERTHYROIDISM
Clinical Features
This presents with intolerance to heat, increases appetite and loss in weight, chronic
fatigue, fine finger tremors, palpitations and typical eye signs- lid lag, stare, retraction
of upper lid.
Diagnosis
Typical clinical presentation in advanced cases
Investigation
For confirmation. Earlier presentations can be made out only by blood tests for
thyroid hormone levels.
Thyroid hormone testing should become available at district level. Blood samples
may be sent for the same in those cases where diagnosis is suspected but not
certain.
Treatment
If clinically diagnosis is certain one can start on treatment. Without hormonal assay.
But it is always better to conform by getting T , T , TSH done.
3, 4
Euthyroid goiter
Goiter results from an adaptation to chronic iodine deficiency. Therefore treatment
is not urgent.
Women in reproductive age group who have not completed their family &
adolescent girls must be given iodine therapy.
All females in such villages are well advised to take iodised salt.
Surgery should not be considered except in cases with severe complications
(obstruction of the trachea...).
Hypothyroid goitre
Drugs are aimed at correcting hypothyroidism if it exists and restoring a normal
thyroid function. Usually, the thyroid function comes back to normal within 2 weeks.
In children, goiter can disappear after several months. In adults it takes more time
or it does not subside at all, even if the thyroid function comes back to normal.
Iodine treatment can be harmful in patients suffering from a chronic hypothyroidic
goiter. Hypothyroidism often presents without goitre.
Levothyroxine (0.1 mg) – The main drug for treating hypothyroidism.
Start with half tablet (0.05 mg) increase to one tablet a day and go up to
two tablets depending on clinical response.
191
Non-Communicable Diseases
Thyrotoxicosis
Propylthiouracil and Carbamizole (Antithyroid drugs) are used in the
management of thyrotoxicosis.
These drugs are also used to prepare the patient for thyroidectomy.
These drugs are usually well-tolerated, with mild leucopenia or rashes developing
in a few percent of cases, usually during the first 6–8 weeks of therapy. During this
time the blood count should be checked every 2 weeks or if a sore throat or other
signs of infection develop.
The drugs are generally given in a high dose in the first instance until the patient
becomes euthyroid, the dose may then be gradually reduced to a maintenance
dose which is continued for 12–18 months, followed by monitoring to identify
relapse.
There is a lag time of some 2 weeks between the achievement of biochemical
euthyroidism and clinical euthyroidism.
Presentation
Propylthiouracil tablet
Tablets. 50 mg, 100 mg by mouth,
Dose :
ADULT 300–600 mg daily
until patient becomes euthyroid; dose may then be gradually reduced to a
maintenance dose of 50–150 mg daily.
Beta-adrenoceptor antagonists (beta-blockers) (usually propranolol) may be
used as a short-term adjunct to antithyroid drugs to control symptoms but their use
in heart failure associated with thyrotoxicosis is controversial.
Prevention
Prevention programs are recommended in areas where iodine deficiency is proven
and recognised as a major public health problem. The two main objectives are to
prevent cretinism and to reduce foetal and perinatal mortality.
192
Standard Treatment Guidelines
Every 3 years
child less than 12 years 0.5 ml
child over 12 years and adult 1 ml
In pregnancy
Iodine can be administered during pregnancy without any adverse effect, especially
in endemic areas (WHO recommendations).
Prevention of cretinism and hypothyroidy is optimised if given before conception or
during the first trimester of pregnancy.
Prevention given later or during pregnancy will reduce myxoedematous cretinism
but will have limited impact on neurologic cretinism.
193
Non-Communicable Diseases
CARDIOVASCULAR DISEASES
7 . CARDIAC FAILURE
This is a condition caused by the inability of the heart to pump out as much blood
per minute as it should.
Diagnosis
Clinical Features
Orthopnoea/pedal oedema
Tachycardia,
Elevated jugular venous pressure. Enlarged tender liver, pedal oedema,
auscultation showing basal lung crepitations
Investigation
In a CHC
Chest X –Ray to confirm failure and look for predisposing pulmonary disease,
ECG to rule out any ischemic causes for cardiac failure
echocardiogram to diagnose:
rheumatic valvular disease,
ischemic heart disease
cardiomyopathy is underlying cause of disease. Echo cardiography also
helps assess severity of ventricular dysfunction and rule out endocarditis.
Treatment
General Guidelines
Ensure salt is excluded or at least limited in diet.
In mild cases for restricting salt in diet it may be enough to avoid highly
salted items like pickles, papads etc. and put a bit less salt in cooking and
not to add any salt while eating.
194
Standard Treatment Guidelines
For severe cases cook separately without salt and give the day’s
quota of salt- about half spoon of salt in a small container, leaving to the
patients choice to add it to whatsoever he chooses. The more the leg swelling
and breathlessness the more the need to restrict salt.)
Avoid exertion- more severe cases would need bed rest.
Treat Anaemia if present
Prevention and prompt treatment of infections especially respiratory infections :
Encourage to take prescribed drugs;
Treat cause – see relevant sections.
Drug Treatment
Tablet furosemide five days a week.
Adults 40 mg once daily
Children 1 to 2 mg/kg for preferably given in the morning hours, preferably
Tablet digoxin
0.25 mg orally daily – skipping dose on the last two weekend days
may start initially with 0.125 mg.
Tablet enalapril
2.5 mg once daily if blood pressure is maintained (above 100 systolic),
to be increased to 2.5 mg twice a day
then further based on clinical judgement in two divided doses per day.
Potassium substitute
liquid 0.5 to 1 daily – as one teaspoon thrice daily.
Especially if long standing treatment with furosemide and digoxin is being
undertaken to prevent hypokalemia and digoxin toxicity.
195
Non-Communicable Diseases
Give Digoxin 0.25 mg orally; if patient is not on digoxin, then the dose can be
repeated after 12 hours for digitalization.
Enalapril 2.5 mg once daily to be increased to 2.5 mg twice a day then
further as required- may be given if not hypotensive
If blood pressure is not maintained – treat as shock.
Transport to a hospital certified for this purpose (functional CHC/district hospital)
If no definite cause is ruled out
Add Injection thiamine 100 mg/day for two days and continue with oral
thiamine at same dose for several weeks.
If there is evidence of endocarditis :
Treat with two antibiotics :
Benzyl penicillin 4 to 6 m. units IV 4 hrly
and
Gentamicin (3 to 5 mg/kg as a loading dose followed by 1.5- 3 mg./kg/
day) in 3 divided doses
for at least three to six weeks
or
AMOXICILLIN 250-500 mg thrice a day
and
Ciprofloxacin (if oral treatment is essential as daily injection over along
period cannot be organised).
If culture reports are available then choice of antibiotics would be guided
by this.
8 . HYPERTENSION
Hypertension is defined by a blood pressure consistently above 160/90 mm Hg in
adult and 140/90 mm Hg in pregnant woman.
Blood pressure (BP) must be measured several times with the subject lying down
and at rest before we confirm the diagnosis. Just one reading is not enough.
Diagnosis
Blood pressure above 160/90 on more than three occasions at least.
A diastolic between
For systolic the cut off is 180 for Grade II, above which it is Grade III.
196
Standard Treatment Guidelines
Investigations
Urine for albumin for acute renal dysfunction
Blood urea
for renal dysfunction
Serum Creatinine
ECG and echocardiogram to assess impact on heart,
For other causes of secondary hypertension it would need referral to tertiary
care centre.
Treatment
Therapy must be regularly supervised and not abruptly interrupted; otherwise side-
effects can be serious. Often the treatment is lifelong.
Patient Education
Low salt diet.
Weight reduction if obese.
Stop smoking if a smoker.
A regular isotonic exercise schedule especially if by nature of work one has to
sit at one place all day long.( like a 30 minute walk daily).
197
Non-Communicable Diseases
And / or
or
Amlodipine (PO) in single daily dose starting from 2.5 mg going upto 10 mg
per day.
or
Enalapril (PO) in two divided doses, starting from 5 mg going upto 20 mg per
day.
If atenolol is contraindicated one can start with amlodipine or enalapril.
If still uncontrolled refer to a specialist
Hypertensive crisis
Abrupt, marked increase in blood pressure, usually over 200/130 which may lead
to rapid damage to kidneys, heart and the eye or lead to encephalopathy and
coma. This needs urgent lowering of blood pressure.
Tab. Nifedipine 5 mg to be chewed and swallowed or if in soft capsule to be
squeezed under the tongue. Repeat after half hour till blood pressure gets
controlled. Meanwhile start on oral antihypertensive medication as indicated
earlier.
In a CHC setting one can choose to add
Inj hydralazine 10 mg IV every 10 to 15 minutes upto a maximum of 50 mg
or
Injection sodium nitroprusside 0.25 to 10 micrograms/kg/min. as an IV
infusion- diluting in 5% dextrose.
All such cases need to be evaluated for secondary hypertension later.
198
Standard Treatment Guidelines
Treatment
Anti streptococcal antibiotic therapy
Oral Penicillin V 500 mg twice a day for 10 days
or
Procaine penicillin 8 lac units once daily IM for 7-10 days
or
Injection Benzathine Penicillin 1.2 million units single dose
or
Erythromycin 500 mg 6 hourly
Medical therapy for rheumatic fever
Aspirin -2 gm four times a day for 4-6 weeks, for children 100mg/kg/day in
divided doses
After these taper depending on falling ESR or clinical improvement
or
Prednisolone 1 mg per kg if active carditis is present. Carditis also needs strict
and absolute bed rest.
199
Non-Communicable Diseases
Clinical presentation
Signs of early cardiac dysfunction or failure
Dyspnoea
Orthopnoea
Tachycardia
bilateral pitting pedal oedema
Diagnosis
at PHC
is by auscultation clearly showing valvular heart disease.
may be referred to CHC for confirmation and to initiate treatment.
200
Standard Treatment Guidelines
Treatment
General Guidelines
Precipitating factors causing congestive cardiac failure to be identified and treated,
these include :
Excessive exertion to be allayed by bed rest
excessive salt in diet to be reduced
diuretics added
Anaemia to be corrected (blood transfusion with packed cells if needed)
antibiotics for respiratory or other intercurrent infections
Prophylaxis and prompt treatment against infective endocarditis
control of rate in chronic atrial fibrillation with (digoxin)
treatment of carditis (with prednisolone)
Drug Treatment
Ensure regular drug intake
Tablet furosemide preferably five days a week.
Adults 40 mg once daily
Children 1 to 2 mg/kg
Preferably given in the morning hours.
Tablet digoxin 0.25 mg orally daily – skipping dose on the last two weekend
days- may start initially with 0.125 mg.
Tablet enalapril 2.5 mg once daily if it is a predominantly regurgitant lesion
and blood pressure is maintained (above 100 systolic), to be increased to 2.5
mg twice a day and then further based on clinical judgement in two divided
doses per day.
Potassium substitute – potassium chloride liquid 0.5 to 1 daily – as one teaspoon
thrice daily. Especially if long standing treatment with furosemide and digoxin
is being undertaken to prevent hypokalemia and digoxin toxicity.
Definitive treatment
Early surgery if symptoms progress despite medical control :
Should be referred to a tertiary care centre, where the patient should be evaluated
for the level of ventricular function, valvular orifice area and the feasibility of surgery
to correct the valvular defect.
201
Non-Communicable Diseases
Tertiary Prevention
The prevention of further complications. This is a role for the PHC to which the
case should be referred back.
Encourage him or her to continue the medicines without interruption.
Help the patient get a weekly supply of drugs from the PHC
Ensure that once in three weeks the patient takes an injection of benzathine
penicillin which is to be kept and taken at the PHC. Alternatively he can take
oral penicillin tablets as prescribed by doctor.
Educate to avoid excessive salt intake, or excessive exertion or anaemia or
infections.
Prompt treatment of respiratory infections and antibiotics( amoxicillin) if there
are any wounds or cuts
If pregnant treat as high risk case and put under medical care.
Rheumatic heart disease can be prevented
Prompt treatment with full dose of antibiotics for sore throat with fever in children.
If a child or adolescent has fever with joint pains of the type seen in acute rheumatic
fever this person must immediately take a full course of amoxicillin or penicillin
and then take once in three weeks an injection of benzathine penicillin .Alternatively
they can take oral penicillin tablets as prescribed by doctor.
Other than surgical correction and intractible failure all other aspects of treatment
must be undertaken at CHC level, once a specialist has confirmed diagnosis.
Even at PHC level prompt management of precipitating causes and tertiary
prevention can be life saving.
Diagnosis
Diagnosis is based on clinical pattern.
Chest pain – Retrosternal, dull aching, constricting or burning, radiating to
neck, jaw, shoulders or arms; usually precipitated by exertion or stress and
relieved by rest or nitrates.
202
Standard Treatment Guidelines
at District Hospital
A treadmill stress test would confirm angina in over 95% of these cases.
Treatment
General Guidelines
Daily exercise
Stop smoking
Dietary modification – low cholesterol ,low fat diet with high roughage
Control of hypertension and Diabetes Mellitus.
Drug Treatment
Aspirin to be given for all the patients- half standard tablet once daily after
meals. 75 – 300 mg PO once daily
Nitrates : Isosorbide dinitrate 10 mg thrice a day.
When pain occurs one tablet can be kept sublingually.
If there is headache lower dose of 5 mg twice or thrice daily can be tried.
Betablockers : First line of therapy along with aspirin
Atenolol 25 – 100 mg / day (PO)
Metoprolol 50 – 450 mg / (PO)
If despite maximal medical treatment, angina is frequent enough to interfere
with quality of life and ischemia is confirmed by ECG with or without stress test
then refer to higher centre for consideration of coronary angiogram and
revascularisation therapy.
203
Non-Communicable Diseases
Treatment
at CHC
If ECG facility is available
Hospitalisation is advisable
Rest
Secure IV access
Sedation Diazepam 10 mg, If pain is severe morphine 2 - 4 mg IV
Aspirin - 160 – 325 mg PO once a day
Heparin - Unfractionated 5000 units IV followed with 1000 to 2000 units
hourly – continued for 48 hours
Bolus 60 – 80 units / kg given as infusion 14 units / kg / hour with clotting time
monitoring.)
Nitrates - isosorbide dinitrate 5 mg sublingually immediately and 10 mg thrice
a day.
For uncontrolled pain one can give Injection nitroglycerine 5-100 micrograms/
min. IV diluted in 5% dextrose titrated for 24 to 48 hours
Add morphine also if myocardial infarction is suspected.
ACE inhibitors – Enalapril 2.5 – 20 mg / day in divided doses twice a day.
Stool softeners – dulcolax 10 mg at night
Diagnosis
Diagnosis is based on clinical presentation and ECG with enzyme studies
contributing in case of doubt.
Clinical Presentation
Retro-sternal crushing Chest pain radiating to neck, arms, lasting for more
than ½ hours during rest.
204
Standard Treatment Guidelines
Associated with
Nausea and vomiting
Increased sweating
Dyspnoea
Symptoms not reduced by rest or nitrates
Note that the pain can often present in atypical patterns including like heartburn
or as epigastric discomfort.
Investigations
at CHC
ECG : diagnosis rests on ECG pattern - Convex ST – segment elevation with
either peaked upright. or Inverted T waves. Q waves in prolonged ischemia
at District hospital
Cardiac enzymes elevated: CK MB;
Echocardiogram : regional wall motion abnormality seen.
Treatment
Bed rest.
Sedation & pain relief : Morphine : 10 mg by slow intravenous infection
(2 mg/mt) followed by a further 5-10 mg if necessary.
Oxygen therapy : 2 – 4 l /min. via a nasal cannula.
Aspirin : 150 – 300 mg PO once a day.
Beta blockers : Atenolol 25 to 100 mg once daily. if pulse rate > 60/mm , BP >
90/60 mm Hg , and lung fields are clear.
Reperfusion therapy :
If presenting within 12 hours of chest pain with ECG showing
ST elevation > 1 mm then give
Inj. Streptokinase 1.5 million units over 1 hour
Contra indications (of pre-perfusion therapy) include :
Active bleeding from any site.
Stroke/TIA < 1 year.
Pregnancy.
Active peptic ulcer disease etc.
205
Non-Communicable Diseases
RESPIRATORY DISEASES
Diagnosis
Clinical picture of recurrent wheezing, episodic in nature with rhonchi heard
on auscultation of the lungs during the episode. May present with cough and
breathlessness also.
If secondary infection present – fever and purulent sputum may be present.
Tachypnoea, cyanosis, elevated JVP, pulsus paradoxus indicate severe episode
and in some this may go on to respiratory arrest.
Differential Diagnosis
Chronic bronchitis,
Left Venticular failure,
allergic bronchitis
206
Standard Treatment Guidelines
207
Non-Communicable Diseases
208
Standard Treatment Guidelines
Status Asthmatics
Severe asthma (also known as status asthmaticus) can be fatal and must be treated
promptly and energetically.
Acute severe asthma attacks require hospital admission where resuscitation facilities
are immediately available.
Severe asthma is characterized by persistent dyspnoea poorly relieved by
bronchodilators, exhaustion, a high pulse rate (usually more than 110/minute)
and a very low peak expiratory flow.
As asthma becomes more severe, wheezing may be absent.
Treatment
Oxygen 40–60% (if available)
Corticosteroids -
for adults,
Prednisolone 30–60 mg by mouth
or
Hydrocortisone 200 mg (preferably as sodium succinate) intravenously
for children
Prednisolone 1–2 mg/kg by mouth (1–4 years, maximum 20 mg,
5–15 years, maximum 40 mg)
or
Hydrocortisone 100 mg (preferably as sodium succinate) intravenously
209
Non-Communicable Diseases
Cough and production of copious mucopurulent sputum for over two months a year
for at least three years.
It is along with chronic emphysema also known as the chronic obstructive lung disease
syndrome where there is chronic breathlessness.
Most common in smokers.
Diagnosis
Diagnosis is mainly a clinical diagnosis with X-ray excluding other causes and
pulmonary function test confirming diagnosis and assessing severity.
Clinical Features
Persistent cough with expectoration
Dyspnoea on exertion
Occasional wheezing
In more severe cases - Tachypnea, pursed lip breathing, intercostal indrawing,
cyanosis
On examination :
Chest hyper resonant on percussion.
Decreased breath sounds.
Rhonchi, with mid inspiratory crackles on auscultation.
AsterixIs in acute exacerbation.
If the patients has gone into cor pulmonale - Elevated JVP and signs of right
side failure may appear.
Investigations
Chest X Ray- in emphysema it shows hyper luscent lung fields with flattened dome
of diaphragm. Decreased vascular markings over lung fields with upper lobe
predominance and sometimes bullae may be seen. In chronic bronchitis the lung
markings are increased. X-ray also exclude tuberculosis, effusions etc.
Pulmonary function tests; both vital capacity and forced expiratory volumes are
reduced, functional residual capacity, and residual volume increased. Differentiate
from bronchial asthma
Arterial blood gas analysis if available shows increased PCO2 compensated for
by raised HCO3.
Most often the diagnosis is clinical and an X-ray and sputum AFB to
rule out tuberculosis is adequate to start treatment. Once treatment is
established at a CHC further case can be treated in PHC.
210
Standard Treatment Guidelines
Management
For Acute exacerbation
exacerbation-Usually precipitated by respiratory infection by H.
influenzae,Streptococcus Pneumonia
Antibiotic of choice –
Cotrimoxazole DS 1 twice a day x 5 days
or
Amoxicillin 500 mg thrice a day x 5 days
or
Doxycycline 100 mg twice a day x 5 days
Oxygen by mask
Inhaled Salbutamol hourly
or
Oral tablets salbutamol 4 mg 8 hourly.
Glucocorticoids to tide over the crisis
Inj Methyl Prednisolone 125 mg IV. 6 hourly for 3 days
or
inj dexamethasone 2 mg 6 hourly.
or
tablet prednisolone 15 mg thrice daily orally.
Inj Aminophylline infusion, followed by 8 hourly injections
Chest physiotherapy
13. BRONCHIECTASIS
Management
Acute excerbation and long term management is as above except that
antibiotics are needed for longer periods of 14 to 21 days or longer.
211
Non-Communicable Diseases
NEUROLOGICAL DISEASE
14. EPILEPSY
This is a sudden excitation of a part of the brain leading to jerky movements of parts
of the body usually with loss of consciousness.
The main types are Generalised Tonic – clonic, Generalised Absence Seizures, Complex
Partial Seizures and Simple Partial Seizures (see page 49)
Differential diagnosis
Ensure that there are enough typical features of epilepsy to rule out pseudo –
seizures( hysterical).
Generalised seizures typically are associated with injuries due to sudden fall, frothy
at mouth, occurrence at sleep, incontinence, an epileptic cry.
In recent onset seizures, in seizures which are progressive and in seizures having
onset in the elderly consider whether the seizures are symptomatic- that is indicative
of underlying structural disease. These cases must be referred to tertiary centre for
investigation. In most cases after a single specialist consultation they can follow up at
the primary health centre.
Investigation
In a tertiary care centre, patients suspected of symptomatic epilepsy can be further
investigated with an EEG, CT Scan and anti epileptic drug levels (if the patient is
already on anti epileptics)
Tr e a t m e n t
General Measures
Help patient to take drugs regularly for at least three years – after the last
episode of fits
Educate to avoid stress factor that precipitate fits like lack of sleep or alcohol
or excessive physical or mental stress
Educate the family to relate to the sick child or adult as a normal person with
a curable disease and not treat it as if he is crippled .To avoid going into traffic
alone or swimming or going near exposed fire so that they do not hurt
themselves if they have fits. But at the same time not to be afraid and over
protect the patient. Particularly do not stop children from school and do not let
misunderstand about the disease wreck a marriage.
When the patient is having a fit (if you are there ) this is what one can do :
Make sure the patient does not hurt himself by a fall or hitting objects nearby.
212
Standard Treatment Guidelines
Loosen clothes, especially around the neck so that the patient does not choke.
If tongue is being bitten and bleeding place a spoon or hard object wrapped
around with a handkerchief in the mouth to prevent it.
Do not try to insert anything into the mouth if the tongue is not obviously being
bitten.
After the fit place the patient in recovery position so that he or she does not
choke on their own saliva.
Stay with the patient till he or she recovers consciousness and help him to go
home or to a known person as they may be confused and disoriented and
even be behaving abnormally for some time after.
Drug Treatment
Start with a single drug, if not controlled with the maximum dosage of that
drug, substitute with another single drug upto its maximum dosage. If still
uncontrolled then only, give combination therapy.
Monitor closely for the adverse effects of the anti-epileptics.
Drugs are to be given at least till 3 years after the last episode of seizure
thereafter it should be gradually withdrawn.
Phenobarbitone
ADULT 60–180 mg at night;
CHILD up to 8 mg/kg daily
Febrile convulsions, by mouth,
CHILD up to 8 mg/kg daily
Neonatal seizures, by intravenous injection (dilute injection 1 in 10 with
water for injections),
NEONATE 5–10 mg/kg every 20– 30 minutes up to plasma concentration
of 40 mg/litre.
213
Non-Communicable Diseases
214
Standard Treatment Guidelines
If still persistent one may require general anaesthesia with muscle relaxants if all
these are refractory. Patient should be referred for this to centre where such facilities
are available.
Febrile Convulsions
Tepid water sponging
Antipyretic - Paracetomol Syrup
Diazepam :
by rectum as solution,
CHILD over 10 kg, 0.5 mg/kg (maximum 10 mg), with dose repeated if
necessary
(Alternative treatment), by slow intravenous injection,
CHILD 0.2 to 0.3 mg/kg (or 1 mg per year of age)
215
Non-Communicable Diseases
Diagnosis
Based on clinical presentation
Abrupt onset of weakness or other neurological deficit that corresponds to
interruption of vascular supply to a specific region of the brain.
Associated features that may be present include head ache, seizures,
vomiting, loss of consciousness.
Investigations
ECG if available to rule out coexisting ischemic heart disease and look for left
ventricular hypertrophy suggestive of established hypertension.
May be referred for CT scan brain where diagnosis is in doubt or where there
is a need to rule out haemorrhagic stroke in view of proposed treatment- like
anticoagulants for cardiac source of embolus. Routine CT in all cases of stroke
is wasteful.
216
Standard Treatment Guidelines
Treatment
Supportive management in an acute stroke includes :
Anti oedema measures with Inj Mannitol.
Control of hypertension (Less aggressive reduction of blood pressure.).
Bowel and bladder care.
Preventing bed sores.
Thrombotic stroke
Aspirin -300 mg per day.
In cases of embolic stroke with a cardiac source for an emboli, chronic
anticoagulation with warfarin is given.
Embolic stroke
Identify source of embolus. Usually it is left atrial thrombus developing in a situation
of mitral stenosis with atrial fibrillation.
This is confirmed by echocardiography.
Oral Anticoagulation of these patients is essential to prevent recurrent stroke.
But one needs rule out haemorrhagic stroke at a tertiary care centre before
starting anticoagulation.
Haemorrhagic stroke
Control hypertension effectively and early.
Withhold Aspirin, warfarin
If still neurological deficit is progressive referral to a neurosurgical unit may be life
saving.
217
Non-Communicable Diseases
Diagnosis
Epigastric pain or discomfort related to food intake. Clinical assessment may
be adequate to make diagnosis and initiate treatment.
Upper gastro-intestinal endoscopy confirms diagnosis and is advised in all
non responsive patients.
Treatment
Non-drug measures :
stop smoking and alcohol
avoid food associated with dyspeptic symptoms
avoid all pain killer drugs.
Antacids : more effective if in liquid form and more effective at about 20 to 30
ml given four times a day. To be given about 20 minutes after a meal. If taken
as tablet it is to be chewed and not swallowed.
Tablet ranitidine : 150 mg twice daily for at least three months.
Other antiulcer drugs are better prescribed only after endoscopic confirmation
of ulcer
Complications include Gastro-intestinal bleeding, gastric outlet obstruction and perforation
all of which would require hospitalization for acute supportive management and surgery.
RENAL DISEASES
1 7 . ACUTE NEPHRITIS
This is clinical syndrome due to glomerular disease which may be a primary disease or
secondary to a systemic process.
Note that sickle cell disease can also present as nephropathy.
Diagnosis
Clinical presentation
Oliguria
Haematuria
Facial puffiness
occasionally pedal oedema
218
Standard Treatment Guidelines
On examination
patient has hypertension
Urine examination which shows proteinuria and RBCs.
Investigation
The presence of RBC casts in urine is diagnostic- however one can diagnose
acute nephritis even in its absence.
Treatment
General Guidelines
Bed rest at home
Adequate fluids – taking care that excess is not given which would increase
oedema but enough is given to ensure at least 400 ml of urine per day. If one
can estimate the previous days urine volume – a water intake of that plus
about 800 to 1000 ml would be adequate.
Salt restriction- especially if oedemas present
Drug Treatment
A tablet of frusemide may be tried if there is water logging and hypertension.
Not to be given if there is no obvious evidence of fluid excess.
Other antihypertensive is required.
Treatment of infections. Especially if there is impetigo a course of penicillin is
indicated.
Refer
Refer to district hospital if urine flow decreases further or if hypertension is not
controlled.
1 8 . NEPHROTIC SYNDROME
This too is due to glomerular disease that can be primary or secondary. The type of
lesion that is most common in children and most responsive to treatment in both adults and
children is called minimal testing disease.
Diagnosis
Proteinuria more than 3.5 gm in 24 hrs. (this is best done by collecting a 24
hrs. sample and then using Esbach’s method to estimate protein in a sample
of the same. If this is not available a 4 + albumin on simple urine heating may
be taken as proteinuria in the nephrotic range.)
Hypo-albuminaemia, hyperlipidaemia
Oedema.
219
Non-Communicable Diseases
POISONING
Diagnosis
The presence of the following is adequate to make a diagnosis
The history,- of taking insecticides or exposure to the same
Pinpoint pupils
Excessive secretions- sweating, bronchial secretions and salivation
appearing as foam at the mouth
Fasciculation and twitching of muscles- leading to weakness in the muscles
Respiratory depression
On examination
The patient would have bradycardia, hypotension and pulmonary edema,
220
Standard Treatment Guidelines
Organochlorine poisoning
Patients in contrast have anxiety, restlessness, Confusion, delirium Seizures and
Coma. Tremor and weakness may be present but none of the other symptoms.
For medico- legal purposes the stomach contents sample would have
to be sent for analysis to the public health laboratory designated for the
purpose.
Treatment
Prevention of further Absorption : Gastric lavage and Body wash
Supportive Care: Airway protection, Nutrition and when indicated Ventilation
Administration of antidotes-
Atropine : Dose: 0.5 to 2 mg/every 15 min. till fully atropinized. Watch for
atropine overdose.
Very high doses of atropine may be needed- one has to increase dose
till pupils dilate and tachycardia develops or signs of atropine toxicity
supervene- confusion, dryness, hyperthermia etc.
Also note that atropine reverses some toxic effects (called muscarinic
actions) : miosis, bradycardia, secretions but does not reverse others
(nicotinic actions) esp. respiratory depression. Thus a patient who
appears to be improving may slip into ventilatory arrest. It is essential
to observe patient closely for ventilation sufficiency.
If there is worsening shift patient to where there is provision for ventilatory
care – if possible along with an escort who can manage respiratory
arrest with face mask and ambou’s bag.
Watch out for skin absorption—effective body wash of patient and gloves for
nurses etc.
Watch for delayed/persistent action
Avoid aminoglycosides and other neuromuscular agents
Manage complications like infection.
221
Surgery
SECTION VII
PRIMARY SURGICAL CARE
PRIMARY
222
Standard Treatment Guidelines
1 . DRESSINGS
Dressing is a set of procedures for treating a wound. A wound is an interruption in
the continuity of the skin secondary to trauma or surgery.
Objectives
Protection
To prevent contamination from the external environment.
To protect against possible trauma
Cicatrization.
To favour tissue regeneration
Absorption
To absorb serous discharge
Disinfection
To destroy pathogenic organisms.
Compression
To stop hemorrhage
Warning : a dressing occludes a wound and in certain conditions (humidity, heat) and can
encourage multiplication of pathogenic organisms.
Equipment
1 box of sterile instruments
1 dissecting forceps no teeth
1 Kocher forceps with teeth
1 pair of scissors
1 dressing tray (clean)
1 drum of sterile gauze pads
1 kidney dish
Cotton wool only to disinfect the tray (never use cotton wool directly on a wound).
Adhesive tape-
Flasks containing antiseptics: chlorhexidine, cetrimide, polyvidone iodine
223
Surgery
Techniques
Instrument preparation and cleaning of the dressing tray
tray..
Use a chlorhexidine-cetrimide solution
Wound examination
Sutured wound and/or aseptic wound
Observe the stage of cicatrization, presence of weeping, appearance of
an hematoma or of an infection.
Septic wound
Check the nature of secretions and if there are new fleshy pimples.
A bluish pus indicates the presence of pyocianic (very resistant bacillus,
spreading very quickly).
Look for any signs of lymphangitis (reddish streaks).
Use new Kocher forceps after removal of the dirty dressing and the first
cleaning of the wound.
224
Standard Treatment Guidelines
Gauze pad
left hand
right hand
Figure -1
igure-1
Clean the periphery of the wound either with a circular movement, or from top to
bottom. Change gauze pads as often as necessary.
Clean the wound from top to bottom with a new gauze pad.
Dry the periphery of the wound and then the wound itself with different gauze
pads.
Dressing a wound
Apply one or several gauze pads to the wound.
Apply strips of adhesive tape
Perpendicularly to the axis of the limb or the body
Leaving the central part free to avoid maceration.
Frequency of dressings
225
Surgery
Procaine benzylpenicillin
Child : 100000 I.M. /kg/ d x 5 days at least
Adult : 4 or 5 Mill / d once a day x 5 days at least.
Or
Amoxicillin (PO) : 1-2 gm/ d divided in 2-3 doses x 5 days
If Amoxicillin is unavailable, give
Ampicillin (PO) : 2-4 gm/ d divided in 2-3 doses x 5 days
Abscess
Antibiotic treatment is useless before incision, but may be needed later.
Burns
Only if they are infected.
During conflicts; disaster relief conditions, or other situations where access
to health care and patient’s follow-up are unlikely :
The systematic use of amoxicillin should be considered.
Wastes
All soiled disposable materials (gauze, cotton, dressings...) should be collected
and burned daily.
2. ABSCESS
This is a collection of pus in the soft tissues. An abscess cavity is not accessible to
antibiotics. Treatment is thus surgical only.
Treatment
Incision and drainage should be performed once the abscess is “ripe” i.e. red
and inflammatory swelling, painful, sometimes with fistula, fluctuant upon gentle
palpation.
Material
Sterile scalpel blade and handle.
Surgical gloves.
Plain curved forceps without teeth (Kelly forceps).
Sterile corrugated drain.
Antiseptic solution e.g. Chlorhexidine-cetrimide solution.
5 or 10 ml. syringe.
226
Standard Treatment Guidelines
Anesthesia
Local anesthesia of an abscess by infiltration with lidocaine is not effective.
Furthermore, the needle may spread the infection further.
If anesthesia is a must - general anesthesia is preferred
Ketamine (IM), 10 mg/kg.
For superficial abscesses, the skin can be briefly numbed using ethyl chloride spray.
Technique
Scalpel : the correct way to hold a scalpel is between the thumb and middle finger
with the handle resting against the palm (see Figure-2.a). The forefinger must
press the blade. It should not be held as one holds a pen or a dagger. The plane
of the scalpel blade should be perpendicular to the plane of the skin.
Incision: the free hand immobilizes the wall of the abscess between thumb and
forefinger. Incise in the long axis of the abscess with a single stroke to breach the
skin. The incision should be long enough to allow insertion of an exploring finger.
Figure -2b
igure-2b
Figure -2.a
igure-2.a Exploration of the cavity with a finger in
Position of the hands for incision of an abscess order to break down loculations
Figure -2c
igure-2c
Drain fixed to the skin
Figures2 : TTechnique
echnique for incision and drainge of an abscess
Precautions : take care not to incise too deeply if the abscess overlies major blood
vessels (the carotid, axillary, humeral, femoral and popliteal regions). After breaching
the skin, blunt dissect down to the cavity using Kelly forceps without teeth.
Explore : the cavity with the forefinger, breaking any loculating adhesions and
evacuating the pus (see figure- 2 b).
227
Surgery
3 . BREAST ABSCESS
The management of breast abscess is slightly different. Usually the abscess is
superficial but deep ones, when they occur, are more difficult to diagnose and to
treat.
Treatment
Early in the infection, non- surgical measures should be applied
non-surgical
Antibiotics
Amoxicillin (PO) : 1-2 gm/ d divided in 2-3 doses x 5 days
If Amoxicillin is unavailable, give
Ampicillin (PO) : 2-4 gm/ d divided in 2-3 doses x 5 days
or
Chloramphenicol (PO) : 1-3 gm / d divided in 3 doses x 5 days.
Anti-inflammatory drugs
Ibuprofen 400 mg thrice daily.
Technique
Incision :
for superficial abscess : radial incision.
For abscess near nipple : peri-alveolar incision.
For deep abscess : beneath the breast
Gentle exploration with finger or Kelly forceps.
Abundant lavage with chlorhexidine-cetrimide solution.
Insertion of a corrugated drain.
228
Standard Treatment Guidelines
Figure -3a
igure-3a Figure -3b
igure-3b
Incisions : radial, Exploration (gentle)
peri-areolar or submammary with a finger or forceps
(figure3c) (figure3d)
Common sites for breast abscess Submammary incision
4 . PYOMYOSITIS
Infection and eventually abscess formation within muscle. At the beginning of infection,
when the muscle is swollen, hot and painful, medical treatment may prevent abscess
formation:
immobilize,
anti. Inflammatory medication - Ibuprofen 400 mg thrice daily
and
Antibiotics
Amoxicillin (PO):
Child : 50 mg/kg/d divided in 2-3 doses x 7 days;
Adult : 2 gm/d in divided 2-3 doses x 7 days.
If amoxicillin is unavailable, give
Ampicillin (PO) :
Child : 100 mg/kg/d divided in 2-3 doses x 7 days;
Adult : 4 gm/d divided in 2-3 doses x 7 days).
Confirmation
Collection is not always easy to diagnose : conduct an exploratory puncture with a
large-bore needle to confirm diagnosis which will reveal pus.
229
Surgery
Material
Anesthesia
Figure -4
igure-4
Technique for incision of muscle abscess
Figure -4a
igure-4a Figure -4b
igure-4b
Generous incision Blunt dissection of muscle using
Kelly forceps : insert closed then
withdrawn slightly opened
Figure -4c
igure-4c Figure -4d
igure-4d
Counter-incision for drain, cutting down
Counter-incision Drain passing through
onto a finger inserted deep in cavity the two incisions
230
Standard Treatment Guidelines
5 . BURNS
Bums are very common, particularly among children who fall onto or roll into cooking
fires. Any burn that affects greater than 10% of the body surface area is considered
extensive and is thus serious and life-threatening because of fluid loss catabolism and
the risk of secondary infection.
Assessing severity
Bums are classified according to depth and extent and each stage of evolution
needs new evaluation.
Upper limb 9 9
Anterior or posterior 18 18
surface of trunk
Lower limb 18 14
Perineum 1 1
231
Surgery
Treatment
No severe signs
75% of fluid should be given through ringer lactate, the remainder as volume expanders
or blood transfusion.
During the first 24 hours, half the fluid requirements should be given in the first 8
hours.
Analgesia
Pentazocine (IM)
Child> 3 years
years: 1 mg/kg/injection
Adult
Adult: 30 mg / injection
and sedation if necessary:
Diazepam (IM)
Child
Child: 0.3 mg/kg/injection
Adult
Adult: 10 mg/injection
232
Standard Treatment Guidelines
Apply sterile Vaseline gauze on burned areas then on top of that, two layers of
non-sterile gauze pads. Do not use either antibiotic ointment or gauze impregnated
with antibiotics or corticosteroids.
Apply a bandage, not tightly
tightly. Do not wrap limbs, especially at the flexures as this
will encourage contractures. Bandage each finger separately
separately,, never together.
Immobilize limbs in the position of function.
Alternatively, “open method”. After wound cleaning leave the burn covered only
with the sterile Vaseline gauze or nothing. Patient is naked and protected by a fine
mesh mosquito net.
Subsequent dressings
Analgesia and aseptic technique as for the first dressing.
Unless infection ensues (ill-smelling, pus), the first dressing should be left undisturbed
for 5 to 7 days. The subsequent dressings should be done every 5 to 8 days.
Remove any black eschars (which may hide purulent areas) and use scalpel to
excise any necrotic tissue: skin, aponeurosis, muscle or even tendon.
Systemic antibiotics if obvious infection (never use topical antibiotics):
Same dressing as the first time. Healing is signalled by granulation tissue: pink,
mat and clear.
(Figure 5)
Dressing a burn : sterile technique, use of vaseline gauze.
PATCH GRAFTING
Skin grafting is necessary for deep second degree and third degree burns, when
the wound is slow to heal but is clean, and flat.
Aseptic technique. Shave the area where patches will be taken (usually anterior
thigh or forearm) and disinfect with povidone-iodine .Infiltrate with lidocaine 1%,
subcutaneous.
Lift up a patch of skin with fine forceps with teeth and excise it with a scalpel. It
should be full-thickness i.e. epidermis plus dermis.
233
Surgery
(Figure 6)
Full-thickness patch skin graft :
sterile technique, taking patches using a fine forceps with teeth and a scalpel
6 . WOUNDS
This chapter concerns only wounds that can be treated at the primary health center level.
Immediate suture of wounds is desirable but not always feasible and in some
circumstances it may be dangerous.
Do not suture a wound later than 8 hours after the accident.
Secondary suturing can be resorted after 8 hours in CHC.
Do not suture an infected wound.
Do not suture a war wound or due to animal bite.
Any break in the skin overlying a fracture is an “open fracture”.
A wound that communicates with a joint is an open joint wound.
Always give tetanus prophylaxis if available (see tetanus).
234
Standard Treatment Guidelines
Preparation
Wound toilet
Shave if necessary, then clean the wound and its periphery with povidone iodine.
Material
(Figures 7 a to 7 g and 8 a to 8 d)
Local anaesthesia
Only necessary for large or deep wounds requiring more than 2 stitches.
Lidocaine 1 % without adrenaline.
Infiltrate subcutaneously via the wound edges.
Exploration
Have an assistant using retractors if necessary. Explore the wound and look for:
Foreign body.
Underlying fracture.
Involvement of nerves, major blood vessels, tendons or joints.
For scalp wounds : underlying fracture (if serious may contain brain tissue).
Closure
Use interrupted sutures (not continuous).
Non-absorbable sutures for skin, absorbable thread for subcutaneous tissues.
Some suture material is already mounted on a needle, others have to be mounted.
For skin use a “cutting” needle (triangular in cross-section).
For subcutaneous tissues use a “round” needle (circular in cross-section).
235
Surgery
(=3/0 or 2/0)
*The more zeros there are, the finer the suture material is.
**Absorbable synthetic: resorbs slowly (over 3 weeks), e.g. vicryl@, Ercedex@,
Dexon@, Ligadex@...
Technique
Schemes on the following pages show the main techniques for suture. (figures 8
to 16)
Drainage
Never use a drain for wounds of the face
Always insert a drain in wounds of the scalp and whenever an hematoma
can be expected or if the wound may weep.
Removal of sutures
Face : day 5.
Other wounds : day 7 or 8.
236
Standard Treatment Guidelines
DIFFERENT INSTRUMENTS
(figure 7c)
Mosquito forceps curved, no teeth (figure 7d)
(also called clamp or hemostat) Retractor (Farabeuf type)
(Farabeuf
HOW TTO
O HOLD INSTRUMENTS
(figure 7e)
Always mount a scalpel blade using a needle holder
holder..
Change blades for each different operation.
237
(Scan 15b)
Surgery
DEBRIDEMENT
(figure 8a)
Debridement of a contused, messy wound :
straightening of wound edges with a scalpel,
Be very careful on the face.
Figure 8 : Debridement
(this should be sparing
sparing,, limited to excision of severely contused or
lacerated tissue that is evidently destined for necrosis)
(figure 9a)
Loop the suture material around the needle -holder in one direction (e.g
needle-holder (e.g.. “over towards me”) and remember
this direction.Take the loose end with the needle holder and pull it through to make the first knot.
direction.Take
(figure 9b)
The second loop should be in the opposite direction
(“under towards me”). Repeat a third knot, changing direction once again.
238
Standard Treatment Guidelines
KNOTS
KNOTS
Slip the knot up towards the nail using the hand that holds the free end,
holding the other length of suture with the needle -holder
-holder..
needle-holder
239
Surgery
240
Standard Treatment Guidelines
(figure 13)
Vertical mattress suture (also called Blair-Donati technique) :
Blair-Donati
allows good apposition of the wound edges.
(figure 14)
Closing a corner
241
Surgery
7 . HEAD INJURY
Treatment-at PHC
Maintenance of airway and breathing.
Stabilize pulse and blood pressure. If required intravenous access should be
established.
Associated injuries to cervical spine, thorax, abdomen and other musculoskeletal
injuries are taken care of.
242
Standard Treatment Guidelines
243
Surgery
8 . THORACIC EMERGENCIES
8.1 PNEUMOTHORAX
Clinical Features
Evidence of fracture of ribs
Air hunger
Hyper-resonant percussion note with absent breath sounds over the affected side
of the chest.
Investigation
Chest X-ray shows absence of lung markings and a strip of collapsed lung medially.
Trachea may be deviated to opposite side.
Treatment
Maintain airway and respiration.
Simple aspiration with a wide bore needle to decompress the pleural cavity.
If rapid re-accumulation occurs, introduce intercostal tube with under water seal
drainage.
REFER
Should be referred to higher centre under water seal drainage
Clinical Features
Decreased Air entry
Increased percussion note
Decreased breath sounds
244
r Trachea pushed to
Standard Treatment Guidelines
Investigation
Chest X-ray shows absence of lung markings and a strip of collapsed lung medially.
Trachea may be deviated to opposite side.
Treatment guidelines
Aspirate the pleural space of affected side with a wide bore needle and insert
intercostal tube in an under water seal drainage bottle.
Refer
Refer the patient to higher centre with under water seal drainage bottle
9. LUMP IN BREAST
Commonly found lump in breast in young females is Fibro adenoma
9.1 FIBROADENOMA
Clinical Features
Solitary, firm, well defined, lobulated, extremely mobile, painless lump in the breast
(mouse in breast)
Treatment
Drug treatment-none
9.2 MALIGNANCY
Common in older women.
Clinical Features
Mass firm, ill defined, usually painless; not mobile. Suspect malignancy.
Sometimes presents late when ulcerated or lymphnodes involved.
Treatment
245
Surgery
All the cases of acute abdomen are to be referred to CHC, which has
necessary surgical facilities. Details of management protocol are not
included at present.
Biliary colic
Appendicular colic
Renal or Ureteric colic
Intestinal Colic - due to worm infection and intestinal obstruction uncommon but
Acute pancreatitis
Peritonitis
Strangulation of gut
Referred pain of male or female genital organs inflammation or torsion
Vertebral retroperitoneal causes
Diagnosis
246
Standard Treatment Guidelines
10.1 APPENDICITS
Treatment
Treatment of acute appendicitis is appendicectomy, if the diagnosis is made
at an early stage usually within 48 hrs.
The surgery is deferred if appendicular mass is formed.
12. HERNIA
Treatment
Treatment of choice is surgery, (elective) in CHC
Prior to elective surgery all factors contributory to raised intra abdominal pressure
like cough, constipation, and difficulty in passing urine should be treated and
controlled
Elective hernia surgery is a clean surgery, which may be herniotomy in children
and herniorrhaphy or hernioplasty in an adult.
247
Surgery
Diagnostic features
Irreducible Hernia which is tense and tender
Abdominal pain and rigidity may appear
There are associated features of intestinal obstruction and strangulation
Treatment
Taxis (physical pressure to reduce) is unjustifiable
Refer
As emergency surgery is required; refer to appropriate surgical centre
13. HYDROCOELE
Diagnosis
Unilateral or bilateral scrotal swelling. Possible to get above the swelling;
Transillumination - positive
Treatment
Treatment of choice is surgery
May be done at CHC
Treatment
Drainage of the abscess. If not drained, it may form a fistulous tract resulting in
fistula in ano. This may be done at PHC level also.
For permanent treatment refer the case to CHC for surgical excision of fistulous
tract if formed.
Diagnosis
Clinical Features
Constipation
Sharp agonizing pain during defecation
Bright streaks of blood in stools
Ulcer at the lower end of the anal canal seen when tightly closed puckered anus is
stretched apart.
248
Standard Treatment Guidelines
Drug treatment
Lignocaine jelly or ointment (5%) applied locally 3-4 times a day;
And
Tab. Metronidazole (400 mg) for 5 days, twice a day.
And
Tab Ibuprofen (400 mg) one tablet 8 hourly
And
Sitz bath (Warm water with potassium permanganate 1:10000 or Povidone iodine)
twice a day
And
Isapghula husk 1-2 teaspoon in water one or two times a day for control of
constipation and straining during defecation
Or
Liquid paraffin (5-15 ml) at bed time for one month, if no relief with local Lignocaine
application
Surgical Treatment
Aim of therapy is to cause complete relaxation of the anal sphincter that will relieve
pain and slowly heal the fissure.
Anal dilation under general anaesthesia;
Fissurectomy & sphincterotomy if needed.
Haemorrhoids are swollen but normally present blood vessels, in and around the
anus and lower rectum, that stretch under pressure, similar to varicose veins in the
legs.
The increased pressure and swelling may result from straining to move the bowel.
Other contributing factors include pregnancy, heredity, aging, and chronic constipation
or diarrhoea.
Haemorrhoids are either inside the anus (internal) or under the skin around the anus
(external).
Haemorrhoids usually are not dangerous or life threatening. In most cases,
haemorrhoidal symptoms will go away within a few days.
Diagnosis
Many anorectal problems, including fissures, fistulae, abscesses, or irritation and
itching (pruritis ani), have similar symptoms and are incorrectly referred to as
haemorrhoids. Diagnosis rest on clinical features and, rectal examination.
249
Surgery
Although many people have haemorrhoids, not all experience symptoms. The
most common symptom of internal haemorrhoids is bright red blood covering the
stool or in the toilet bowl.
However, an internal haemorrhoid may protrude through the anus outside the
body, becoming irritated and painful. This is known as a protruding haemorrhoid.
Symptoms of external haemorrhoids may include painful swelling or a hard lump
around the anus that results when a blood clot forms. This condition is known as a
thrombosed external haemorrhoid.
In addition, excessive straining, rubbing or cleaning around the anus may cause
irritation with bleeding and/or itching, which may produce a vicious cycle of
symptoms. Draining mucus may also cause itching.
Examination of the anus, per digital examination of the anal canal and viewing the
anal canal and rectum through a proctoscope helps define the extent of the lesion
and differentiate from other anal conditions.
If other causes of bleeding suspected, then sigmoidoscopy also needed.
Treatment
Medical treatment
Medical treatment of hemorrhoids initially is aimed at relieving symptoms.
Warm tub or Sitz baths several times a day in plain, warm water for about 10
minutes.
Ice packs to help reduce swelling.
Application of a haemorrhoidal cream for suppository to the affected area for a
limited time. (many such creams available e.g. Anovate, Faktu or Proctosedyl
ointments)
Surgical Treatment
In some cases, hemorrhoids must be treated surgically. These methods are used to
shrink and destroy the hemorrhoidal tissue and are performed under anaesthesia. A
number of surgical methods may be used to remove or reduce the size of internal
hemorrhoids. These techniques include:
250
Standard Treatment Guidelines
Definition
Full thickness necrotizing bacterial infection of the skin of lower limb preceded by
stage of cellulitis.
Common sites
On leg below knee, Commonly lower third of leg just above malleoli,
Skin of dorsum of foot.
Clinical feature
The disease progresses in following sequence. The clinical picture will depend on
stage of patient’s presentation to hospital. There is often a history of thorn prick or
laceration.
Clinical features depend on stage :
251
Surgery
Treatment
Early diagnosis and prompt treatment is needed.
Supportive TTreatment
reatment
Bed rest
Elevation of Limb
Frequent dressing
Drug Treatment
Early cellulitis with papules
Procaine Penicillin—Inj 6 lacs IU 12 Hourly After sensitivity test for
4-5 days.
252
Standard Treatment Guidelines
Clinical Features
Prominent dark-blue blood vessels, especially in the legs and feet (not “spidery”
looking veins)
Aching, tender, heavy, or sore legs
Swelling in the ankles or feet, especially after standing
Treatment
Prevention
Regular exercise improves vein functioning, and weight loss and exercise
decreases the likelihood of blood clots.
At night, keep legs raised on a pillow, (above the level of the heart).
Surgery
Surgical and other Procedures can be tried if the veins are cosmetically unacceptable
to the patient or if there is frequent bleeding and ulceration.
Referral for
Sclerotherapy - injection of a solution into a varicose vein, followed by application
of a compression dressing, in order to obliterate the veins-or surgery for removal of
the varicose vein can be done. At a centre that is undertaking such work.
253
Disease Index
DISEASE INDEX
254
Standard Treatment Guidelines
255
Disease Index
256
Standard Treatment Guidelines
257
Disease Index
258
Standard Treatment Guidelines
259
260
Standard Treatment Guidelines
261