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Federal Ministry

o Health
rectorate General of
o Pharm

udan Stand
dard Treat
nt Guiidelin


Conflict of Interest Disclosure Form

Public health considerations are of primary importance in the development of standard
treatment guidelines. To ensure the integrity and credibility of the process, measures need to be
taken to ensure as far as possible that the decisions taken have been made on the best available
evidence without undue influence from outside interests, whether financial or otherwise.
Each expert in the taskforce and working groups is therefore asked to declare any
commercial interests that might lead to a real, potential or apparent conflict of interest with
respect to his/her involvement in the process of guideline development. The commercial interests
of particular concern relate to manufacturers, importers, distributers, and suppliers of
pharmaceuticals or other services related to the scope of work.
What is a conflict of interest?
A conflict of interest means that the expert or those he/she has a close personal
relationship with (e.g. spouse, family members) or his/her employer have a financial or other
interest in that could unduly influence the experts opinion or decisions in the subject matter
being considered.
An apparent conflict of interest is present when the interest would not necessarily have
any influence but could be perceived by others as doing so, leading to the objectivity of the expert
being questioned.
A potential conflict of interest is one where an interest exists that any reasonable person
would not be certain whether to report it or not.
Types of financial or other interests might include a current financial interest e.g. shares,
ownership, in a pharmaceutical commercial entity, an employment, consultancy, directorship or
other positions during the past 2 years in a pharmaceutical commercial entity.
Performance of any paid work or research during the past 2 years commissioned by a
pharmaceutical commercial entity.
Payment or any other support received or future support expected in the future from a
pharmaceutical commercial entity e.g. support to attend conference, research funding, speaker
How to complete this declaration
If you, your close relations or your employer have any real, potential or apparent conflict
of interest, please describe it in the table below. Only the name of the company needs to be given
(no amounts of money) and, if the interest is no longer current, the year in which that interest
I hereby certify that I have disclosed all relevant information with respect to any matter
involving a commercial entity that may place me in a real, potential or perceived conflict of

intterest situaation. Except as othherwise dissclosed in the table below, I declare that I have no
onflict of innterest to reeport.
I unddertake to inform thee taskforcee of any change
in circumstannces that may
m createe a
onflict of innterest as sooon as it iss known to me.

Date: 29/06/2013


Name: Alya All-Mahdi

Desscription off type of inteerest


Name of comm
mercial Year interest ceased if
nott still currennt


1. Intestinal Amoebiasis (Amoebic Dysentery)

Intestinal Amoebiasis is an infection caused by the parasite Entamoeba Histolytica. The
infection results from the ingestion of viable tetra-nucleated cysts in focally-contaminated food
and water. The organisms then excyst in the terminal illume and divide into vegetative
trophozites that dwell in the lumen of the colon and cecum where they cause both intestinal and
extra-intestinal disease. Infection can lead to intestinal colonization, colitis or extra-intestinal
It is a common infection in Sudan with an infection rate of 28.4%. Pregnant women and
individuals who are malnourished or immune-compromised are most vulnerable to systemic
Signs Symptoms and History
Most cases of Amoebiasis are asymptomatic. Symptoms, when present, are diverse and
depend on the extent of disease. In amoebic colitis, patients may present with abdominal pain,
bloody-mucoid stools and diarrhea.
Criteria for referral :
Symptoms of severe colonic manifestations such as toxic mega-colon should be referred to
secondary care. All symptoms other than those associated with amoebic colitis should be referred
to secondary care. Those are extra-intestinal manifestations such as amoebic abscesses, brain
abscess, cutaneous amoebiasis, empyema, pericarditis, splenic abscess.
The diagnosis of amoebiasis is made by microscopic demonstration of trophozoites or
cysts in fresh or preserved fecal specimens, smears of aspirates or scrapings obtained by
proctoscopy, and aspirates of abscesses or sections of tissue.
Ultrasound or CT scans can identify liver abscesses and other extra-intestinal sites of
infection. Serological testing exists for the diagnosis of long-term infections.
Patients may be referred to secondary care settings for aspiration of cysts may be
necessary if it is easily acceptable.
First Line.
Metronidazole 800mg 8 hourly followed by 400 8 hourly with food for 5 days
Metronidazole 10mg/kg daily
Second Line.
Tinidazole 2g daily for 3 days
Tinidazole 50mg/kg in three divided doses for 3 consecutive days

Treatment of cyst passer is by Diluxonide Furate 500 mg TDS for 10 days.

Patient Education
All cases should be instructed about disease transmission, appropriate personal hygiene,
routine practices, and contact precautions.
Public education about personal hygiene, especially the sanitary disposal of feces.
Education of food handlers about proper food and equipment handling and hygiene.
Advice infected individuals to avoid food preparation.
Screen water supplies for the presence of parasitic contamination.
Advice infected individuals against swimming in communal drinking and water sources.


2. Brucellosis
Brucellosis is a febrile illness acquired by contact with infected animals or consumption of
unpasteurized milk or milk products from an infected animal. Brucellosis is endemic in the
Middle East and Africa and affects a wide range of domestic and wild animals. The common
causative agents in this area are Brucella melitensis and Brucella abortus. The former infects
mainly goats, sheep and camels, while the latter infects mainly cattle.
History symptoms and signs
The disease onset may be gradual. It begins with mild illness with intermittent fever and
night sweats, nausea, fatigue, headache, myalgia and arthralgia. The patient may present with
lymphadenopathy, hepatospleenomegaly and arthritis of the large joints.
Brucella spp. is found in the blood, urine, cerebrospinal fluid and bone marrow in the
acute stage, but often undetectable in the chronic stage.
Serum agglutination test (SAT): SAT is a practical and least expensive test, but must be
interpreted carefully. It has higher sensitivity, but lower specificity than culture. An increased
level of Brucella agglutinins more than 1:160 is suggestive of Brucellosis. In acute Brucellosis
the levels are usually above 1:320. In order to avoid false negative results due to the pro-zone
phenomenon, the serum should be diluted serially until 1:1280.
Blood cultures: to be carried out in specialist centres. Common laboratory findings: These
include leucocytosis or leukopenia, anaemia, increased erythrocyte sedimentation rate (ESR) and
abnormal live function tests.
Adults :
Streptomycin 1 gm IM (or Gentamicin 80 mg intramuscular 12 hourly) once daily for 2-3 weeks
and Doxycycline 100 mg by mouth 12 hourly for four to six weeks.
Trimethoprim-Sulfamethoxazole (TMP-SMX) 5 mg/kg 12 hourly for six weeks (maximum 480
mg /24 hours) plus Gentamicin 4mg/kg IV or IM once daily for two weeks.
People at risk should be advised to:
Avoid consuming unpasteurized or untreated milk or milk products.
Boil fresh milk before consuming it.

Wear protective clothing while handling carcasses or products (placentas) of potentially

infected animals.
Avoid eating raw meat.
Animals should be vaccinated against Brucellosis. Vaccine is to be given to young calves.
Informing the public health authorities if there is an outbreak of the disease.


3. Cellulitis
Cellulitis is an acute bacterial infection of the dermis and subcutaneous tissue. The most
common bacterial causes are Streptococcus pyogenes and Staphylococcus aureus. Bacteria can
enter through a break in the skin which may be caused by trauma, insect bites, eczema, burns,
laceration or fungal infections. This results in a hot red tender inflamed area of the skin. Cellulitis
often affects the legs, usually one leg but may occur anywhere in the body.
History Signs and Symptoms
Patients should be asked about history of trauma, injury or insect bite in or around the
affected area.
Cellulitis presents with an acute onset of red, painful, hot, swollen, and tender skin, with
possible blister or bullae formation. Fever, malaise, nausea, shivering and rigors may accompany
or precede the skin changes. Later, in more severe cases, there may be spreading lymphangitis of
the same limb.
Criteria for referral
Only people with mild or moderate cellulitis without systemic symptoms should be
managed in primary care. Admission to hospital is necessary if the person is very young, elderly,
or frail, or there is:
Severe or rapidly deteriorating cellulitis, or an uncertain diagnosis systemic symptoms (e.g.
possible necrotizing fasciitis).
Severe systemic illness.
A co-morbidity that may complicate or delay healing (e.g. peripheral vascular disease, chronic
venous insufficiency, morbid obesity, immunosuppression, intravenous drug use).
Lymphoedema (gross swelling of the limb).
Facial cellulitis.
Periorbital cellulitis (refer to an ophthalmologist).
Cellulitis that has spread from an adjacent structure (e.g. osteomyelitis) or through the blood
People who have failed to respond to oral antibiotics.


A swab should be considered if there is a visible break in the skin for entry of bacteria
(e.g. an open wound); other investigations are not usually necessary.
The cause should be identified where possible, such (e.g..a break in the skin) and exclude
other diagnosis such as deep vein thrombosis.
Assessment should include determining the severity of cellulitis, and identifying systemic
signs and symptoms, spreading lymphangitis of the same limb, and relevant co-morbidities.
Drain pus if any and cleanse open wounds. Wounds may require dressing depending on
the severity. Compression should be avoided in the acute phase.
Patients should be advised to:
Drink adequate fluids to prevent dehydration.
Elevate the leg for comfort and to relieve oedema (where applicable).
Elevate the bed covers to prevent contact with the affected areas.
In uncomplicated cellulitis, a high-dose oral antibiotic should be prescribed for 7 days:
First Line: Cloxacillin 1-2 g by mouth 6 hourly.
Second Line: Clindamycin 300 mg by mouth 8 hourly.
Follow Up:
Patients should be reviewed after 48 hours of starting oral antibiotics until the lesions and
symptoms have completely healed. Patients with diabetes and the elderly require closer
Patient Education
Patients should be advised not to touch the affected area and to complete the course of prescribed
Paracetamol or ibuprofen may be taken to relieve pain and fever.
Skin breaks should be treated early.
Eczema and other skin conditions should be managed with the use of appropriate medication and
emollients to prevent skin cracks.


4. Typhoid Fever (Enteric Fever)

Enteric fever is a febrile illness caused by S. Typhi. The disease is spread through faecooral route by ingestion of contaminated food or water. Humans are the only known reservoirs.
Enteric fever is a public health problem of global magnitude. Each year 12.5 million cases are
reported in the developing countries. It remains a serious endemic health problem in Sudan and
other developing countries. The mortality rate is as high as 30% if not treated.
Signs Symptoms and History
The symptoms and signs are not specific in the majority of cases. The incubation period is
usually 6-14 days. Fever is the main presenting symptom. The fever is usually remittent and
gradually increases in stepladder fashion (use of antibiotic affect the fever pattern), headache,
malaise, anorexia, abdominal pain, and cough. Constipation presents initially and followed by
diarrhoea. Other symptoms were less frequent, such as vomiting, sore throat neuropsychiatric
symptoms and behavioural changes that occur during late presentation.
The commonest signs on physical examinations are abdominal tenderness usually over the
right lower abdomen, splenomegaly in about 50% of cases, and hepatomegally in 30%. Rose
spots occur in about the second week in 20-30% of cases are discrete/irregular pink maculapapular rash that blanches on pressure usually found on the anterior chest and abdomen and last
for 3-5 days occur during week 12. Relative bradycardia cannot be accurately determined.
Criteria for referral
All cases with complications should be referred. Complications occur late (third/fourth
week) such as intestinal haemorrhage and perforation in about 2-8% of cases. Other
complications include:lobar pneumonia, cholecystitis, meningitis, osteomylitis, severe neuropsychiatric manifestation, leucopenia, neutropenia and encephalopathy.
Blood, stool, urine or bone marrow culture showing presence of Salmonella typhi..
Widal test is the recommended serological testing . Two readings of Widal test using the
Tube method are recommended. An average of one week between the samples is the golden
standard. The peripheral white blood count is usually normal in most of the cases in spite of the
presence of fever unless late complications occurred.
Treatment of typhoid fever
Adequate rest;
Rehydration and correction of electrolyte disturbances;
Antipyretic therapy as required preferably tepid bath and sponging;

First Line
Adults : Ciprofloxacin 500 mg by mouth 12 hourly for 7 -10 days depending on clinical
Children: Ciprofloxacin (use with caution): 10 mg/kg by mouth 12 hourly for 7-10 days
depending on clinical response.
Pregnant women and children ( when ciprofloxacin is not indicated): third generation
cephalosporin (oral cefixime) 15-20 mg/kg by mouth per day in two divided doses for 10-14
Ceftriaxone intravenously 50-75 mg/kg per day in one or two divided doses for 10- 14
Second Line
Adults: Azithromycin 1g by mouth once, followed by 500mg once daily on the next 14 days.
Children: Azithromycin by mouth 10-20 mg/kg /once daily for 5 days.
Follow up
Follow up cultures need to be carried out to ensure that the patient is no longer a carrier.
Availability of safe drinking water, proper sanitary disposal, excluding disease carriers from
food handing.
The use of oral or parental vaccine is recommended but the vaccine does not provide full
protection from infection.
Patient education
Hygiene hand washing and appropriate disposal of faeces and urine;
Eating a healthy diet - non bulky, high-calorie meals;
Early and rapid commencement of treatment.


5. Allergic Rhinitis
Rhinitis is a common problem in primary care which is often managed sub-optimally. It
causes considerable morbidity and has been shown to have a detrimental impact on peoples
ability to concentrate at school and at work. Rhinitis and asthma often present together, and
symptomatic rhinitis can be associated with poor asthma control and increased risk of
exacerbations. There is therefore a clear need to recognize and treat rhinitis according to
guideline recommendations.




rhinorrhea (excess nasal secretion), itching, nasal congestion and obstruction.

conjunctival swelling and erythema, folds in the skin below the lower eyelid known as
DennieMorgan folds, rings under the eyes, eyelid swelling, lower eyelid venous stasis
swollen nasal turbinates, transverse nasal crease
middle ear effusion

To be done by referral to specialist
Skin prick tests
Serum total and specific immunoglobulin E
Criteria for referral
When Allergic rhinitis is associated with pregnancy or co-morbidities it should be referred to a
Children with asthma with suspected IgE-mediated food allergy who are at increased risk of
fatal food reactions.
Children in whom there is diagnostic uncertainty or who need specialist investigations or
specialist care.
In severe seasonal allergic rhinitis, children should be referred to specialists.
Middle ear effusion and deafness.
Patients with seasonal allergic rhinitis who are unresponsive or intolerant to conventional
treatment may benefit from referral for consideration for immunotherapy.
red flag symptoms to look out for include bloody purulent discharge, pain and nasal
blockage (often unilateral and may be signs of malignancy), nasal pain, stuffiness, nosebleeds,
rhinitis, crusting, and nasal deformity due to a perforated septum which may be the first signs
of suspected Wegeners granulomatosis.
Development of allergic nasal polyposis.

Nasal irrigation with normal saline.
Warm fluids
For management of symptoms such as sneezing, rhinorrhea, itching and conjunctivitis.
Sedative antihistamine (Chlorphenamine)
Adult: 4mg by mouth every 4-6 hours (maximum 24 mg daily)
Child - Less than 1 years old- not recommended
Child- 2-5 years old: 1mg every 4-6 hours (maximum 6 mg daily)
Child- 6-12 years old: 2mg every 4 -6 hours ( maximum 12mg daily)
Non Sedative antihistamine:
Adult :10mg by mouth daily
Child more than 6 years old: 10 mg daily, 2-5 years: 5mg daily
OR Cetirizine
Adult: 10mg by mouth daily
Child: more than 6 years old: 10mg daily, 2-5 years:5mg daily
For relief of nasal congestion:
Pseudoephedrine: ( should not be used for long term or in patients with hypertension)
Adult: 60mg by mouth every 6 hours
Child 2-5 years of age: 15mg every 6 hours
Child 6-12 years of age: 30mg every 6 hours
Topical decongestants : ( should not be used for more than 7 days as stopping them after
protracted use can lead to a rebound nasal congestion )
Adult: xymetazoline 0.1% nasal drops : 2-3 drops to be instilled into each nostril 2-3 times daily
Child: xylometazoline 0.05% nasal drops( not recommended for children under 3months of age) :
2-3 drops to be instilled into each nostril 2-3 times daily.
For control od symptoms associated with sneezing, rhinorrhea, itching and nasal congestion. It is
the choice of therapy for perennial rhinitis.

Beclometasone Dipropionate Nasal Spray ( 50 micrograms per metered

Adult and child over 6 years. 100micorgrams ( 2 sprays) into each nostril twice a day.
Prednisolone : Short courses of oral tablets in cases of severe symptoms.


Allergic rhinitis in children

It is important to explain all the treatment options to the parents, to encourage compliance,
and to demonstrate how to use nasal sprays.
First line treatment should include once-daily long-acting antihistamines or intranasal
corticosteroid given continuously or prophylactically for symptoms of rhinorrhoea, sneezing, rash
or conjunctivitis or nasal obstruction.

Second line treatments

For nasal congestion the combination of corticosteroid nasal drops and a topical decongestant
can be useful for short term use only (less than 14 days.)
Patients should be assessed for response regularly.
Avoid triggers such as foods, dust, soap, perfumes and medications that have caused an
allergic reaction in the past.
Patient education
Patients should be advised to ask detailed questions about ingredients when eating away from
home and to carefully examine ingredient labels.
If child allergic to certain foods, one new food at a time should be introduced in small
amounts so symptoms of allergic reactions can be identified.


6. Leishmaniasis
Leishmaniasis is a group of diseases caused by over 20 pathogenic species that belong to
main four subgroups: L. donovani (the most common in Sudan); L. tropica; L.ethiopica; and L.
The main vector is Sand fly.
Leishmaniasis presents with a variety of clinical manifestation as four clinical forms:
Visceral Leishmaniasis (VL, kala-azar), Cutaneous Leishmaniasis (CL), Mucocutaneous
Leishmaniasis (MCL), and Post kala-azar dermal Leishmaniasis (PKDL).
Visceral Leishmaniasis represents the major burden and is endemic in Gadarif, Sennar,
Blue Nile, White Nile, South and North Darfur states.
Signs Symptoms and history:
Prolonged, irregular fever, enlarged spleen, weight loss and wasting, enlarged lymph
nodes, anemia and cough. Other signs and symptoms are hepatomegaly, nasal bleeding, diarrhea,
vomiting, insomnia, arthralgia, ascites, uveitis and rarely oedema and jaundice.
Patients become gradually ill over a period of a few months and nearly always die if not
Visceral Leishmaniasis could be diagnosed through different techniques based on the level
and set up available. The below investigations should be carried out in specialist centres or in
secondary care settings.
Parasitological diagnosis: through preparation of blood smear from lymph node aspiration
sensitivity, bone marrow aspiration, or splenic aspiration. Lymph node aspiration is simple but
less sensitive (52-65%). Bone marrow, a painful procedure, gives higher sensitivity (up to 75%).
Splenic aspiration is the most sensitive (90-95%) but hazard of splenic rupture may occur, an
issue necessitates for the procedure to be done at hospital level where facilities for blood
transfusion must be available.
Serology: Several immunological blood tests that identify specific antibodies against
leishmania are available. DAT and rK39 can be used in Sudan.

Treatment of Visceral Leishmaniasis:

First line:
Combination of Sodium Stibogluconate (SSG) 20mg/kg IM/IV as a single daily dose and
Paromomycin Sulfate, 15mg/kg IM as a single daily dose for 17 days.
Sodium stibogluconate, 20,g/kg IM/IV as a single daily dose for 30 days; or Meglumine
antimonite (Glucantime) 20mg/kg IM/IV as a single daily dose for 30 days.
In case of pregnancy, and contra indication to Sodium Stibogluconate: Ambisome
(Amphotricin B liposomal) 3mg/kg IV as a single daily dose for 14 days.
Vector control: Integrated Management of Vector control as a Policy
Use of insecticide treated nets.
Indoor Residual house Spraying
Patient Education:
health education materials
train village health volunteers (VHV)
Raise the awareness of community leaders


7. Malaria
Malaria is a parasitic disease caused by the plasmodia species. The most frequent species
is p. falciparum (95%) with foci of p. vivax, p. malariae., and p. ovale. The whole of Sudan is
endemic with the disease with the north bearing the lowest enemicity and the southern areas with
the highest endemicity. A national malaria indicator survey (2009) showed a prevalence of
malaria of 1.8% where the annual incidence is estimated to be 44.8 per 1,000 population (2010).
Malaria burden is currently witnessing a decline in the overall trend with some areas at the border
of pre-elimination phase.
Signs, symptoms and history
Uncomplicated malaria (UM): UM is defined as a case of fever (or history of fever) in the
presence of asexual form of the parasite (trophozoite stage) in a peripheral sample of blood from
the patient.
Patients usually present with fever, headache, committing, sweating and malaise in
Uncomplicated Malaria.
Criteria for referral
The presence of the one or more of the followings to make the diagnosis of Severe
Impaired level of consciousness (cerebral malaria), respiratory distress, repetitive
convulsions, circulatory collapse, abnormal bleeding, jaundice, haemoglobinurea, pulmonary
oedema, prostration, severe anaemia: (hb <5 gm/dl), hypoglycemia (<2.2 mmol/l <4mg /dl),
hyperlactaemia (lactic acidosis), hyperparasitaemia: (250,000/l or ring stage 5% of rbcs), renal
impairment or acidosis.
Light microscopy or rapid diagnostic test (RDT) is used to confirm the diagnosis of
Tepid sponging for treatment of fever


Uncomplicated malaria:
First line treatment: Artesunate plus Sulfadoxine Pyrimethamine (AS+SP):
( Available as separate scored tablets containing 50mg of atesunate and tablets containing
500mg of sulfadoxine and 25mg pyrimethamine)
Artesunate (AS): 4 mg/kg once a day for 3 days.
Sulfadoxine/Pyrimethamine (SP): 25mg/kg/1.25mg/kg once in the first day, only.
(NOTE: (SP) is contraindicated in the first trimester of pregnancy. )
Second line treatment: Artemether - Lumefantrine (AL 20 mg/120 mg):
( Available as a fixed-dose formulation with dispersible or standard tablets containing 20mg
of Artemether and 120mg Lumefantrine)
Dose: 1.7/12mg/kg body weight of artemether and lumefantrine every 12 hours for 3 days
The dose schedule per age/weight is shown in the table below.
Day 2
Day 3
Morning Evening
Morning Evening
8 hrs
The use is not recommended. Give oral quinine instead
3< 8
(NOTE:Al is contraindicated during pregnancy and patient less than 5 kg body weight)
Treatment of vivax malaria:
The standard A/L regimen is to be given for 3 days as shown in the table above.
Follow up treatment:
Primaquine: 0.25mg/kg every 24 hours for 14 days ( to prevent relapse).
Age in Weight
in kg

Day 1

no of

Pre-referral treatment for patients with severe malaria:

Quinine : 10mg/kg intramuscular every 8 hours until urgent referral.

Artesunate: 10mg/kg via the rectal route every 24 hours until urgent referral.

Follow up:
Check blood smears daily to ensure that parasitemiae decrease with treatment until a negative
test result is documented.
Follow patients closely to document resolution of fever and malaria symptoms and to ensure
tolerance and compliance with malaria drug treatment.
Treat with a different drug in accordance if parasites are again identified on thick smear, or on
recurrence of symptoms and it is confirmed that the patient was compliant with the initial
antimalarial regimen.
Patient education
Patients should be advised:
To complete their antimalarial regimen even if symptom resolution occurs early.
To contact their physician for advice if they cannot tolerate their medication (e.g., bitterness
of quinine or gastrointestinal distress from doxycycline) rather than discontinue it on their
That return of malaria symptoms may occur despite seemingly adequate treatment, due to the
recrudescence of drug-resistant parasites. patients to return for clinical and laboratory
evaluation if they become febrile or experience flu-like symptoms within 10 weeks of
completing malaria treatment.
That an episode of malaria does confer immunity against the disease; thus, mosquito
avoidance and repellent measures and chemoprophylaxis must be used during subsequent
travel to malarious areas.
If they want to donate blood, they should inform the blood bank of recent disease.


8. Diabetes Mellitus
Diabetes mellitus (DM) is the commonest metabolic disorder worldwide. The International
Diabetes Federation predicts that the number of people living with diabetes will rise from 366
millions in the year 2011 to 552 millions in 2030.
Poorly controlled diabetes is associated with acute and chronic complications. These
include diabetic ketoacidosis, hyperosmolar non-ketotic coma, drug- induced hypoglycemia, and
microvascular and macrovascular complications. Micro vascular complications of diabetes
include diabetic retinopathy, diabetic nephropathy and neuropathic disease (both peripheral and
autonomic). Macrovascular complications include cerebrovascular disease, peripheral arterial
disease and coronary heart disease. The latter being the major cause of morbidity and mortality
among the diabetic population.
Treatment should consider:
Correction of any associated cardiovascular risk factors such as smoking,
hyperlipidemias, and obesity as well as monitoring of blood pressure and treatment of
Diabetes management requires teamwork. The doctor should work closely with other
health providers and persons with diabetes.
Self-care is an essential strategy.
Education of the person with diabetes and his /her family is an important aspect of

The health care system should ensure that people with diabetes have access to the basic
requirements essential to practice self care.

Record keeping is critically needed and should be considered a basic requirement for the
management and follow up of all cases.
Objectives and priorities of treatment must be tailored to individual needs; therapy targets
should be determined for each individual.
Classification and pathogenesis of diabetes
Type 1 diabetes is due to immune- mediated beta cell destruction leading to absolute insulin
deficiency. It is usually a disease of childhood.
Type 2 diabetes represents more than 90% of diabetes in the community and is common in the
obese adult population and children. It results from insulin resistance, beta cell dysfunction or
combination of the two factors.
Gestational diabetes embraces all degrees of glucose intolerance diagnosed for the first time
during pregnancy.


Other types of diabetes that include genetic defects of beta cell function (maturity onset DM
of the young MODY), disease of the exocrine pancreas (chronic pancreatitis, cancer of the
Signs, symptoms and history
Diabetes has florid clinical presentations but patients may remain fairly asymptomatic and
may present for the first time with chronic complications such as diabetic septic foot or ischemic
heart disease. Common clinical symptoms are: polydypsia, polyuria, polyphagia, weight loss,
frequent infections mainly of the skin and genito-urinary tract, blurring of vision, peripheral
neuropathic symptoms.
A casual blood glucose level of 200 mg/dl (11.1 molls/l) or more taken at any time of the day
regardless of the time of the last meal;
A fasting blood glucose of 126 mg/dl (7.0 mol/l) or more with no calorie intake for at least 8
Glucose Tolerance Test: 2 hour post prandial blood glucose of 200 mg/dl or more during a 2
hr period using an oral equivalent of 75 gm of glucose in water.
Blood Pressure, urine test, renal function should be assessed.

Life Style Modifications. Intended to improve patients well being and produce a modest
sustainable weight reduction for the overweight patient ranging between 5 10% of body weight
at time of diagnosis:
Increased physical activity and structured exercise training with a minimum of 150
A diet consisting of restricted calorie and saturated animal fat content. Simple sugars are
excluded with encouragement of a high fiber diet such as vegetables and fruits.
Stopping smoking

Insulin therapy:
Indicated for all diabetes type 1 patients in addition to type 2 patients with beta cell failure or
oral therapy intolerance. Insulin therapy is indicated for all type 1 diabetic patients and the
pregnant diabetic ladies.
Insulin can be used in the newly diagnosed type 2 diabeti patient presenting with gross
hyperglycemia, severe diabetic symptoms, ketonuria or infection. They may later be evaluted for
the need of permanent use or replacement with oral therapy.
The types of insulin:

o Short acting regular insulin: Actrapid and Humulin-R

o Intermediate acting insulin(NPH): Insulatard and Humulin-N
o pre-mixed human insulin: Mixtard and Humulin 70/3o
o Long acting insulin (Glargine): Lantus
Oral anti-diabetic agents: indicated for type 2 patients in combination with life style
o Insulin sensitizers:
Metformin Most indicated in overweight type 2 diabetics
Thiazolidindiones (TZD)
o Insulin secretagogues:
sulphonylureas (glibenclamide, glimepiride, gliclizide is preferred in the
elderly)- As initital therapy for thin diabetics
Treatment algorithm:
Step One Initial Drug therapy (monotherapy): Metformin : start with 500mg by mouth once
a week and titrate every 10-15 days to a maximum of 2g daily
Step Two Two drug dual therapy: Sulphonylurea + Metformin
Step Three Multiple drug therapy: Any more than two of: Sulphonylurea + Metformin +
Thazolidindiones or Insulin
Follow Up:
Patients should be followed up regularly to ensure optimum glycemic control ( Thrre
monthly Glycosylated haemoglobin HBA1c = <7%) or as follows (values in mg/dl):
Source of sample
Pre-meal blood
Bed-time blood
Pre-meal plasma
Bed-time plasma

normal value (mg/dl)

less than 100
less than 110
less than 110
less than 120

target value (mg/dl)


Diabetic Emergencies


Criteria for diagnosis
Hyperglycamia i.e. random blood glucose > 250 mg/dl, Ketonaemia, Ketonuria> +2
ketonuria; metabolic acidosis: pH < 7.30.
Rule out other causes: alcoholic ketoacidosis, starvation ketosis, lactic acidosis, uraemic
acidosis, salicylate intoxication, methanol intoxication.
Signs and Symptoms

Patients may present with polyuria and polydipsia, nausea, vomiting and abdominal pain,
hypovolemia (decreased skin turgor, dry axillae and oral mucosa, low jugular venous pressure,
and, if severe, hypotension), Kussmauls respirations (deep rapid breaths) with acetone odor,
disturbed mental status progressing to stupor and coma.
The patient should be referred to a hospital where appropriate investigations can be carried
out. In the absence of potassium testing, hydration an intramuscular dose of insulin may be given
before transfer. ( 0.9% sodium chloride infusion to be started (3L in 3/.5 hrs). Insulin to be given
intramuscular 0.1 units/kg).

Hypoglycemia is low blood glucose, usually below 60 mg/dL. It should be suspected in all
patients presenting with the below symptoms and signs.
Common precipitants in diabetic patients
Excessive insulin and oral hypoglycemic agents (sulphonylureas), missed meals, renal
Signs and symptoms
These are usually seen with serum glucose of 55 mg/dL or less:
Central nervous system: irritability, tremulousness, visual disturbances, confusion, coma or
seizures. Autonomic nervous system: diaphoresis and palpitations.
Occasionally hypoglycemia may present with focal neurological signs such as hemiplegia or
focal fits.
Rapid bedside checking of blood glucose by glucometer is important to distinguish
between hypo- and hyperglycemic state. However if you are in doubt give IV 50 ml of 50%
If the patient can drink, give 25 gram dextrose in orange juice.
If the patient is comatosed give 25 gm dextrose IV (50 ml of 50% dextrose) and when the
patient is awake a further 25 g to drink.
In patients with inadequate recovery, referral to the nearest secondary care hospital is


If hypoglycemia attack is precipitated by sulphonylurea or long-acting insulin it is

advisable to admit and observe the patient for 48 hours in order to avoid the danger of
recurrent hypoglycemia episodes over the next 24 48 hours. Moreover, after the initial
correction of hypoglycemia start your patient in 10% or 20% dextrose drip over 24-48
hours to maintain blood glucose between 90-180 mg/dl.
In patients with type I Diabetes Mellitus, any infection has the potential to cause
hyperglycaemia which in turn worsens the infection. Therefore patients should perform regular
blood tests for glucose and urine tests to detect ketones. Insulin requirement can also increase and
patients should be able to eat regular meals to meet the insulin increase in dose. Patients with
vomiting and diarrhea lasting more than 24 hours and those with fever above 38.5oC should be
admitted to hospital.

HONKC is a serious acute diabetic(Type2) emergency presenting with severe diabetic symptoms,
dehydration and gross hyperglycemia. It is commoner in elderly patients and often fatal if not
diagnosed and managed early.
For the general practitioner this is foe immediate transfer to hospital. Resuscitative line of
management should be initiated and maintained till safe transfer is arranged.
Assess and document the patient for the degree of dehydration, electrolyte disturbance,
hyperglycemia or any other comorbid condition such as cerebrovascular accident,
myocardial infarction or infection. These may be the precipitating factor or a complication
of the condition.
Estimate plasma osmolality by multiplying: Sodium (Na) + Pottasium (K) concentration
by 2.
Put an intravenous catheter in a large vein to initiate rehydration with normal saline. There
is no need to insist on using a hypotonic saline solution. In the elderly patient with the
possibility of an underlying cardiac disease , one has to be cautious with the rate and
volume of rehydration needed.
Potassium Chloride may need to be included if the result of electrolytes has indicated that.
30 mmol of kcl are added to the first 0.9% Sodium Chloride infusion. There is need also to
make sure that the results of renal function test do not contraindicate the free use of
potassium supplementation.
Insulin therapy is initiated with intravenous or intramuscular regular insulin in the same
lines as used in the treatment of diabetic ketoacidosis. These patients are more sensitive to
insulin therapy than DKA patient so caution has to be exercised regarding the dose and
frequency of injections.

Prophylactic subcutaneous heparin needs to be initiated in a dose of 5000 units 8 hourly.

These patients have an increased tendency to thrombophilia.
In case of clinical suspicion or laboratory evidence of infection antibiotic therapy may
need to be initiated.

Patient Education
Patient Education must take the lead in the management of their diabetes (self care). Their
general care must be multidisciplinary and involve all health care workers. Education programs
should be available and emphasized continuously (Diabetes self-management education, DSME).
Education must provide information and help patients improve their knowledge; their role
is to facilitate and support diabetes self care. The three domains of self care are medication,
nutrition and physical activities. The impact of these domains is assessed by blood glucose


9. Otitis Media
Otitis media is middle ear infection which can exist in an acute or chronic state and occur
with or without symptoms. There are two major types of chronic otitis media. Mucosal disease
with tympanic membrane perforation tubo-tympanic disease, relatively (safe) and attico-antral
disease with or without cholesteatoma (unsafe).
The bacteria responsible for acute Otitis media are: Streptococcus pneumonia,
Haemophilus influenza, and Moraxella catarrhalis. Group A streptococci and Staphylococcus
aureus may also be responsible. In chronic Otitis media mixed infections; gram-negative bacilli
(Pseudomonas, Klebsiella, Proteus, E. coli,), Staphylococcus, and anaerobes predominate.
It is a very common condition; approximately 80% of population has had at least one
episode by the age of 3 years. Otitis media is one the most frequent diseases of infancy. Different
management strategies require that this disease be classified clinically as acute Otitis media or
Otitis media with effusion).If not treated or complications developed this can lead to long- life
morbidity and even mortality.
Complications include: extra cranial or intracranial complications including meningitis,
extradural abscess, subdural abscess, brain abscess, lateral sinus thrombosis, labyrinthitis,
petrositis, facial nerve paralysis, mastoiditis and mastoid abscess.
Signs, symptoms and history
Acute Otitis Media: Patients with otitis media may present with one or more of the following
symptoms: Fever, earache, irritability, ottorhoea, lethargy, anorexia and vomiting, purulent
middle ear effusion. On examination, there may be a bulging tympanic membrane with loss of the
normal landmarks. The membrane will have change in color, (typically red or yellow) with poor
mobility. In severe cases and when left untreated, patients may present with perforation of the
tympanic membrane and discharge of pus. In children otitis media often is accompanied with
conjunctivitis and rhinorrhea.
Acute mastoiditis could be the first presentation of acute otitis media
Otitis Media with Effusion: Those who have otitis media with effusion may be
asymptomatic but will have other features such as: hearing difficulty, delayed speech and
language development, clumsiness and poor balance and bad educational performance.

A White Blood Cell count with differential should be ordered along with an ear swab for
microbiology if discharge is present. An X-ray to the lateral nasopharynx is important to rule out
adenoids. Other useful areas to be x-rayed include the chest and sinuses


An audiological evaluation should be carried out using both audiometry and

NON-PHARMACOLOGICAL MANAGEMENTIf the patient requires any of the following, they should be referred to a secondary care
Myringotomy + grommet tube insertion.
First line:
Adult- Co-Amoxiclav 250/125 -One tablet by mouth 8 hourly for 7 days , increased in severe
infections to Co-Amoxiclav 500/125 One tablet by mouth e hourly for 7 days.
Child- Less than 6 years of age: Co-Amoxiclav 125/62 suspension, 5ml by mouth 8 hourly for 7
More than 6 years of age: Co-Amoxiclav 250/62 suspension, 5ml by mouth 8 hourly for 7 days
Second Line: cotrimoxazole, trimethoprim or erythromycin can be effective, duration of
antibiotic therapy 7-10 days.
Symptomatic management:
Analgesic :
Paracetamol: Adult : 500mg- 1000mg every 4 hours (maximum of 8 tablets in 24 hours)
Child: 36 months 60 mg, 6 months2 years 120 mg, 24 years 180 mg, 46 years 240 mg, 68
years 240250 mg, 810 years 360375 mg, 1012 years 480500 mg, 1216 years 480750 mg;
these doses may be repeated every 46 hours when necessary (maximum of 4 doses in 24 hours)
Decongestant :
Pseudoephedrine: ( should not be used for long term or in patients with hypertension)
Adult: 60mg by mouth every 6 hours
Child 2-5 years of age: 15mg every 6 hours
Child 6-12 years of age: 30mg every 6 hours

Follow up for Acute Otitis Medica:

Patients should be re-examined after two weeks for any remaining effusion.
Referral Criteria:
o Tympanic membrane perforation with or without discharge.
o If tympanic membrane perforation occurs the patient will need further follow up.
Follow up for Otitis Media with Effusion:
A child diagnosed with OME should be observed for a period of 2-3 months.
o Review history of symptoms.
o Otoscopic examination.
o Audiometry and tympanometry may be needed.
Early treatment of any upper respiratory tract infection.
Encourage Breast feeding.
Children who are at high risk of developing Otitis Media are: those in day care, those with
other children, those who live in households where the parent smoke and those who initially
present with hearing or behavioural problems.
Patient Education:
Information for parents, teachers and careers:

They should be aware that AOM and OME are particularly common in preschool children.
In most cases they are transient episodes.
It can be recurrent.
Variable in presentation.
Carers should be given clear information of the circumstances requiring further attendances.
In cases where hearing loss is suspected advice about basic communication is useful.
Basic communication tips:
o Face the child when speaking.
o Get the child attention before starting to talk.
o Background noise should be reduced as much as possible.
o Speech should be clear with normal rhythm and volume.
Nursery or school teachers should be informed if a child has a hearing loss so that they can
facilitate activities in class.
Parents of children with Otitis media with effusion should be advised to refrain from smoking.
Parents should be advised that breast feeding may reduce the risk of their child developing
Otitis media with effusion.
Grommet insertion is not a contraindication to swimming.

Evidence record form


It is important for the transparency of the standard treatment guideline process that the
evidence-base upon which the guidelines are founded is recorded. Expert working groups
(subcommittees) should use this form, or a similar structure and format, for recording the basis of
the decisions



Red Eye

Red eye is a common problem in the community and can be caused by different etiologies.
Common causes of red eye include:
Conjunctivitis (viral, bacterial, allergic or chemical).
Foreign body (conjectival, cornial or subtarsal (under the upper eye lid)).
Corneal ulceration.
Burns (acid, alkali or thermal).
Blunt injury (by a blunt object may cause hyphaema (blood in the anterior chamber)).
Penetrating injury (typically by a sharp object e.gastick cause corneal or scleral penetration).
Lid laceration (in lid or canaliculus).
Subconjunctival hemorrhage.
Other uncommon causes may also result in red eye and these include iritis, scleritis, episcleritis
and acute congestive glaucoma, which requires referral.
Signs, symptoms and history
Obtain a through history to identify if there is a possibility of ocular trauma, contact lens wear,
the time and course of the redness and the presence of eye pain, itch and discharge.
Diagnostic signs: Patients may present with an array of symptoms depending on the etiology of
the red eye. Patients who present with pain, photophobia and watery discharge may have a
foreign body, a traumatic corneal ulcer, herpetic ulcer or acute glaucoma.. Dull, aching eye pain
is the main presentation with iritis, scleritis and episcleritis. Subconjunctival hemorrhage, may be
caused by trauma or it could also be caused by vigorous coughing or vomiting. Trauma to the eye
can present with focal conjunctival injection or iris injury.
1. Conjunctivitis:
a. Infective conjunctivitis : Caused by bacteria and results in a sticky discharge in
both eyes with clear cornea, normal pupil and normal vision and red eyes.
Infective conjunctivitis in the neonate usually occurs in the second day of birth due
to eye exposure to bacteria during birth. It is a bacterial swelling of the eye and can
lead to purulent discharge and eyelid swelling. (Chlamydia and gonorrhoea
infections require urgent referral).
b. Viral conjunctivitis: watery discharge, red eyes and itch.
c. Allergic conjunctivitis: red eyes, excessive lacrimation and itch.
2. Corneal ulcer: white spot or mark on the cornea witch stains with fluroscein. The redness
is most marked around the cornea, excessive watery discharge (lacrimation) + significant
photo phobia.

There are several causes for corneal ulcers most importantly vitamin A deficiency,
malnutrition, longstanding conjunctivitis and herpes simplex, herpes zoster opthalmicus.
3. Iritis: The pupil is small and becomes irregular as it dilates. The redness is most marked
around the cornea, watery discharge (lacrimation) + significant photo phobia. Patients
should be referred to secondary care.
4. Acute glaucoma: redness is generalized and the eye is very painful with poor vision,
dilated pupil, raised intraocular pressure and shallow anterior chamber, The cornea is hazy
due to fluids. Patients should be referred to secondary care.

The eye should be examined carefully by inspecting the eyelids and their undersurface. A
slit lamp should be used to examine the conjunctiva, pupil, iris and cornea.
If suspecting a corneal abrasion or ulcer, stain the eye using fluroscein before the
If suspecting trauma, examine for enophthalmos, diplopia, subconjunctival hemorrhage,
hyphema and retinal detachment. Visual acuity should always be measured in patients presenting
with eye complaints using age appropriate-visual acuity chart.
Criteria for same day referral:

Moderate to severe eye pain or photophobia

Marked redness of the eye
Reduce visual acuity
Suspected penetrating eye injury
Irritant conjunctivitis
Neonatal conjunctivitis
( Patients with suspected raised intraocular pressure should be given intravenous
Acetazolomide and pilocarpine eye drops before urgent referral to secondary care)

(See under separate conditions below)
(see under separate conditions below)
Eye Tear
1. Do not place anything on the eye including eye ointment or eye drops.

2. Place a sterile dressing to cover the eye.

3. Give systemic antibiotics.
4. Refer the patient to the ophthalmologist for same day assessment.
Allergic Conjunctivitis
May be seasonal and occurs with other symptoms such as rhinorrhea and sneezing.
1. Administer antihistamine eye drops ketotifien or sodium cromoglycate
2. Advise patient to avoid suspected allergens.
3. In severe symptoms, give steroid eye drops in addition to a mild steroid e.g.
flurometholone. If no improvement then give dexamethasone eye drops with subsequent
tapering in addition to a mast cells stabilizer e.g. sodium cromoglycate eye drops( 2% for
children and 4% for adults)
Infective Conjunctivitis (Adult)
Infective conjunctivitis caused by bacteria.
1. Wash the eyes daily with clean water.
2. Administer tetracycline eye ointment three times daily for 7 days, or choramphenicol.
3. Refer the patient to the specialist if no improvement in three days.
Infective conjunctivitis (Neonate)
1. Remove pus from the eye using sterile gauze every hour.
2. Administer tetracycline ointment three times daily.
3. Refer the infant to the hospital.
Corneal Ulcer
1. Administer tetracycline ointment to the eye every hour.
2. Administer systemic antibiotic e.g. Doxycycline 100mg capsules.
3. Administer vitamin A 100,000 i.u. for children
4. Refer the patient to ophthalmologist urgently.
Eye Lesions
Foreign Body
1. Carefully remove the foreign body with a cotton swab if it is lying superficially in the eye.
If the object is embedded, refer the patient for removal.
2. Administer tetracycline ointment.
3. Refer the patient is no improvement occurs after 24 hours.

Corneal scratch
1. Administer tetracycline ointment.
2. Close the eye with sterile dressing.
3. Refer the patient to the specialist if no improvement occurs after 3 days.
Subconjunctival Hemorrhage
1. Bed rest for 5 days
2. Refer if no improvement occurs after 3 days.
Eyelid tears
1. Check the eye carefully for other non-immediately apparent eyelid tears.
2. Close the eye the sterile dressing.
3. Administer systemic antibiotics e.g. Doxycycline 100mg capsules.
4. Refer to the specialist.
Chemical and heat burns
1. Wash the eye with copious amounts of sterile water.
2. Administer tetracycline ointment.
3. Refer urgently to the specialist.
Patients should be seen every 24 hours and referred if worsening of the symptoms occurs.
Patient education (if applicable). Patients should be advised to keep foreign objects and
chemicals away from the eye .In instances where an eye bandage has been place, not to remove it
without the doctors advice.



Pulmonary Tuberculosis

Tuberculosis (TB) is an infectious disease caused by mycobacterium species (commonly
mycobacterium tuberculosis, avium, Africans, inter-cellulary). The probability of infectious
transmission to people in contact with TB patients (especially, sputum-smear positive cases) is
considerable. It is very important that health workers identify suspects who have symptoms of
tuberculosis early in the course of the disease and ensure their proper examination.
Treatment of TB patients, specially the pulmonary smear-positives cases, is the best
method to control the TB transmission. The major aim of treatment is to cure the patient, reduce
mortality and morbidity from TB, and prevent relapse, the spread of infection and emergence of
resistant strains.
It is recommended that all TB patients be referred to a specialist centre. The
following is guidance for management of new cases in primary care settings until referral to a
specialist centre is secured
Signs, symptoms and history
History of contact with TB patients should be taken.
The most common symptom of pulmonary tuberculosis is cough for 2 weeks or more,
usually with expectoration.
Other symptoms are: loss of appetite, weight loss, night sweats, shortness of breath,
tiredness, chest pain, loss of appetite, fever, night sweats or coughing up blood.
Chest Radiograph: The chest radiograph or X-ray is one examination that is used to assist
in the diagnosis of TB disease. Typically when a person has pulmonary TB disease, the chest Xray appears abnormal. Although an abnormal chest X-ray ( consolidation, caviatation, fibrosis in
the upper lobe and lower apex) may lead a clinician to suspect TB, only a positive sputum
examination result is an diagnostic.
Sputum Examination: Two separate sputum specimens should be collected for
microscopic examination for acid-fast bacilli (AFB). One on spot and the other in the following
early morning.
Sputum positive Patients are infectious if they have not started treatment, however after two
weeks of starting treatment and once the cough stops, these patients are not infectious.
If patients are being treated in the home setting they should follow the guidelines listed in the
prevention section.
Patients should be advised that TB is curable and that compliance with treatment is

Standardized regimens
The standardized regimens for anti-TB treatment recommended by the National TB Program
include five essential medicines designated as first line: isoniazid (H), rifampicin (R),
pyrazinamide (Z), ethambutol (E) and streptomycin (S).
Table 1.1 shows the recommended doses for adults and children.



Recommended dose
Dose and range (mg/kg body weight)
5 (4-6)
10 (8-12)
25 (20-30)
15 (15-20)
15 (12-18)

Maximum (mg)

Patients aged over 60 years may not be able to tolerate more than 500750 mg daily, so
some guidelines recommend reduction of the dose to 10 mg/kg per day in patients in this
age group (2). Patients weighing less than 50 kg may not tolerate doses above 500750
mg daily.
The recommended daily dose of ethambutol is higher in children (20 mg/kg) than in adults
(15 mg/kg)
The use of streptomycin in children is mainly reserved for the first two months of treatment of
TB meningitis.
Treatment regimen
For all new patients (sputum smear-positive, smear negative and extra-pulmonary), the treatment
regimen consists of an intensive phase of 2 months and a continuation phase of four months. The
following drugs are used:
The intensive phase-Two months (60 daily doses) of HRZE (Isoniazid, Rifampicin,
Pyrazinamide and Ethambutol)
The continuation phase - Four months (120 daily doses) HR (Isoniazid and Rifampicin)
Recommended only for children under 5 years who are exposed to patient with TB (daily
dose of isoniazid according the weight).
For children < 1 years of age- give Isoniazid prophylaxis and carry out a tuberculin test 3
months later. If the test is positive, continue INH therapy for a total of 6-9 months. If the test is
negative, offer BCG vaccination.

For children 1-5 years of age- Carry out a tuberculin test. If the test is positive, offer
isoniazidprophylaxis and if the test is negative offer BCG vaccination.
Prevention of adverse effects of drugs
Isoniazid-induced peripheral neuropathy patient should receive preventive treatment with
pyridoxine, 10 mg/day along with their anti-TB drugs. This should be considered in pregnant
patients, those with epilepsy and diabetes.
Sputum follow up is recommended at the end of the second month, 4th month 6th month of
Directly observed therapy (DOT): in which monitoring by a healthcare provider at least once
per month to monitor for any symptoms and signs of medication toxicity, such as liver injury.
Patients who experience such problem should stop their medication immediately and be
referred to the programme.

1. Patients should be encouraged to live in well ventilated areas.
2. TB patients should be encouraged to follow good cough etiquette, for example, covering
their mouths when they cough, or even, in the early stages of treatment, using a surgical
mask, especially when in closed environments with poor ventilation.
3. Early diagnosis and treatment
4. Assessment of close contacts.
5. BCG (BacilleCalmette-Guerin) vaccination for newborn babies and children under 5 years
of age.
Patient education
Healthcare workers are encouraged to discuss with patients, the nature of TB, its
prevention, spread and treatability.
The importance of adherence to treatment should be highly stressed and patients should be
made aware of the risk of Multi Drug Resistant TB.
Patients should be educated on the doses of drugs to be in management of TB especially
fixed dose formulations.
Healthcare workers should explain the side effects that can possible occur with the use of
TB drugs and the action required.
Patients should be educated about the complications that will arise if they are not adherent
and compliant with TB treatment.



Pain Control in Cancer Patients

As recognized by the World Health Organization, pain control is an essential element of
managing pain in cancer patients [1]. The WHO estimates that 340,000 Sudanese need pain
management for advanced cancer. Without appropriate assessment and management of pain,
these patients are likely to be experiencing unrelieved physical, psychological, spiritual and social
suffering. Many of whom will die needlessly with unrelieved pain.
Signs, symptoms and history
Patients may present with a mixture of symptoms. Pain may be either nociceptive or
neuropathic in origin. Nociceptive pain may arise from a visceral component such as abdominal
organs and is usually not easily localized and patients present with nagging cramping pain.
Patients with somatic pain can easily locate the source which may be dull or sharp and may
worsen with movement. Somatic pain may arise in the bone or the muscles.
Pain which is difficult to localize may also arise from damage of the nerves which leads to
neuropathic pain. This presents with non-typical symptoms such as burning, allodynia,
hyperthesia, tingling, electric shocks, itching and squeezing. Neuropathic pain is typically seen in
patients with post herpetic neuralgia.
Detailed history should be taken. Patients should have been initially diagnosed in the
secondary setting and be under the care of the palliative care team or under the care of a
consultant oncologist.
Patients should be assessed on a regular basis when presenting for prescription re-fills. A
detailed history of the pain, site, intensity and severity, radiation of pain, timing of pain, quality
of pain, aggravating and relieving factors. All these factors will help in identifying the type of
pain and its aetiology. The aetiology might be the primary cancer or a cancer complication such
as metastases and debility or it could be treatment caused.
Other factors to be assessed include the analgesic history, the patients beliefs about the
meaning of pain, the effectiveness of treatment, and possible consequences of drug therapies. The
presence of clinically apparent psychological disorders such as anxiety and depression should be
assessed and addressed appropriately.
Complementary therapies may be offered to patients in chronic pain. There is a lot of
research going on which shows their effectiveness. Therapies include acupuncture, massage,
music therapy, relaxation and yoga. Severe pain may also be controlled by interventional
therapies which can be used for intractable nerve pain. Patients will have to be referred to a
specialist for these types of interventions.

This should follow the WHO ladder for management of cancer pain:
Step One: Non-steroidals Or Paracetamol with added adjuvant therapies e.g. amitryptylline
Step Two: Tramadol +/- adjuvants e.g. amitriptylline
Step Three: Oral Morphine +/- adjuvants.
Pain relief should be given to the patient according to the severity of pain as stated by the
patient, via the oral route on a regular basis and also to cover breakthrough pain.
Parentral administration of analgesics should be avoided unless the patient is very ill and is
not able to swallow.
Pethidine is not appropriate for the management of chronic malignant pain.
Mild pain
Adult : 500mg- 1000mg every 4 hours (maximum of 8 tablets in 24 hours)
Child: 36 months 60 mg, 6 months2 years 120 mg, 24 years 180 mg, 46 years 240 mg, 68
years 240250 mg, 810 years 360375 mg, 1012 years 480500 mg, 1216 years 480750 mg;
these doses may be repeated every 46 hours when necessary (maximum of 4 doses in 24 hours)
Adult- 25-50mg by mouth three times daily.
Ibuprofen :
Adult- 200-600mg by mouth three to four times a day up to a maximum of 1200mg in 24 hours.
Child- over 5 kg body-weight 2030 mg/kg daily in divided doses or 36 months (body-weight
over 5 kg) 50 mg 3 times daily, 6 months1 year 50 mg 34 times daily, 13 years 100 mg 3
times daily, 46 years 150 mg 3 times daily, 79 years 200 mg 3 times daily, 1012 years 300 mg
3 times daily.
Moderate Pain
Tramadol :
Adult and child over 12 years, by mouth, 50100 mg not more often than every 4 hours; total of
more than 400 mg daily not usually required

Severe Pain
Morphine : Typical starting dose in adults: 5mg four hourly and a double dose at bedtime

(starting at a low dose allows for control of symptoms such as nausea and drowsiness. Always
prescribe bisacodyl tablets to prevent constipation)
Frail, elderly or cachexic patients: 2.5mg four hourly and a double dose at bedtime.
Adults previously taking Tramadol at a full dose (400mg daily): 10mg four hourly, with a
double dose at bedtime.
Patients on morphine should always be prescribed bisacodyl 5mg tablets to prevent
constipation associated with the drug.
(Morphine 5mg tablets, Morphine solution, Morphine 15mg Sustained release tablets, Morphine
30mg Sustained Release Tablets)
Neuropathic pain:
An element of neuropathic pain may accompany any pain syndrome and should be
Adult: 25mg by mouth once a day increased to 150mg according to response

Initially, patients should be assessed every 48 hours to identify if there is a need to
increase the dose, check compliance, side effects and rescore the pain. A lot of patients might
need increased doses with the passage of time due to disease progression.
All patients should be started on bisacodyl tabs unless they were previously complaining
of diarrhoea. Patients who experience nausea and vomiting in the first few days will benefit from
A few patients might experience side effects related to the Central Nervous System
revision of all medications and dose reduction might be necessary.
Patient education:
Patients should be taught that since they have chronic pain, they should be on regular pain
medication 24 hrs / day. They show also know that morphine is a safe drug and if used properly
does not cause respiratory distress. When there is pain there is no addiction... and patients can be
weaned off the treatment as they started it.
Patients in chronic pain and using opioid analgesics should be advised to drink plenty of
water and use laxatives regularly to prevent constipation.



Lower Urinary Tract Infection

Lower urinary tract infection is confined to the urinary bladder is also known also as
cystitis. Cystitis is a common infection that affects both sexes but more common in females and
the elderly. The infection is often endogenous, caused by microorganisms originating from the
patients own bowl. Infection is acquired by faecal-genital route, often via periurithral
colonization and ascending to the bladder. Infection is facilitated by partial or complete
obstruction. The most common causative agents are Escherichia coli, Proteus mirabilis and
Klebsiellapneumoniae. Staphylococcus saprophyticusis encountered in young female patients,
while Enterococcus spp infects more commonly elderly persons. Candida spp. is of doubtful
clinical significance if associated with catheters.
Signs, symptoms & history
Patients with cystitis are usually afebrile and the predominating symptoms are dysuria and
increased frequency of micturition. They usually present with typical manifestation that is hard to
miss. They sometimes complain of suprapubic heaviness, discomfort or pain. Occasionally the
urine may be bloody.
Infection in children tends to manifest with different symptoms, depending on the age of
the child. In children less than 2 years, the symptoms are nonspecific. The child may present with
vomiting and fever. When children are over 2 years, they present with more localized symptoms
such as frequency dysuria and flank pain.
Referral criteria
Relapse is defined as infection that occurs 1-2 weeks after cessation of antibiotic therapy and
may be caused by the same organism.
Reinfection which is defined as infection that occurs every 2-3 years to several times a year
and is usually caused by different organisms. Reinfection may be associated with structural
abnormality of the urinary tract.
Urine analysis: Ideally, midstream urine(MSU) specimen is collected in a sterile container
for microscopic examination and culture (contamination from the distal urethra is common).
Urine is examined microscopically for white blood cells (pus cells), red blood cells and bacteria.
The presence of > 8 pus cells per high power field is suggestive of urinary tract infection. In
Gram negative infection other than Pseudomonas spp. bacteriuria may also be demonstrated by
positive nitrite test. Nitrite is formed by bacterial metabolism of nitrate. Then Semi-quantitative
culture is done. Growth of > 100,000 colony forming units /ml confirms the diagnosis.
Patients should be advised to take plenty of fluids with frequent emptying of the bladder.

Treatment is usually empirical using the appropriate antibiotic and should be started as
soon as possible in order to avoid complications. Collect mid stream urine for culture before
commencing therapy.
Adult: Nitrofurantoin 100 mg PO every 12 hours for five days OR TrimethoprimSulfamethoxazole (TMP-SMX) 480 mg every 12 hours for five days
Children: Nitrofurantoin 2mg/kg (max 50 mg) PO every 12 hours for five days. OR
Trimethoprim-Sulfamethoxazole (TMP-SMX) 5 mg/kg every 12 hours for five days.
Follow up: If the patient did not respond after three days of treatment, change the antibiotic
according to the sensitivity report. Continue treatment for 7-14 days with the new antibiotic,
according to response.


Heart Failure

Heart failure (HF) is an abnormality of cardiac structure or function or both leading to failure of
the heart to deliver oxygenated blood at a rate sufficient for the requirements of the tissues.
Many classifications are available for heart failure, the most important are:
a) Systolic Heart Failure: HF with reduced ejection fraction .
b) Diastolic Heart Failure: HF with preserved ejection fraction
Both can either present acute or chronic.
Symptoms and signs of heart failure
Common symptoms:
Shortness of breath
Paroxysmal nocturnal dyspnoea
Less common symptoms:
Nocturnal cough
Satiety- fullness in the stomach
Loss of appetite
Weight gain
Raised Jugular venous pressure
Gallop rhythm/ tachycardia

Reduced exercise tolerance

Lower limbs swelling

Displaced apex beat

Peripheral edema (ankle, scrotal and
Basal crepitations


Pleural effusion
Increased respiratory rate

( respiratory rate >16/min)

Diagnosis of HF is based on clinical presentation

Criteria for Referral:
Patients presenting in acute heart failure should be managed initially and referred to
the nearest secondary care hospital for further management.
Patients should be referred to a consultant cardiologist for assessement and
differentiation of HF where ECG, chest x-ray, echocardiography and other tests will
be carried out

Salt restriction to 2 gm per day (one teaspoonful)

Fluid restriction to 1.5-2 liters per day
Regular aerobic exercise
Stop smoking

Patients should be started on these drugs by their cardiologists. However, in stable
patients with poor control, the following algorithm of treatment can be adopted:
STEP I: Diuretics +ACE-I/ ARBs+ B blockers if still not controlled
STEP II: add mineralocorticoid receptor antagonists and if still not controlled
STEP III: Add Digoxin
Diuretics to relieve the symptoms of congestion:
Loop diuretics:Fruesmide starting dose 20-40 mg by mouth once daily (usual dose
40-240 mg in 24 hours).
Thiazide diuretics: Hydrochlorothiazide starting dose 25 mg by mouth once daily (
usual dose 12.5 -100 mg in 24 hours)


Angiotensin Converting Enzyme Inhibitors and if not tolerated Angiotensin

Receptor Blockers (should only be used in patients with creatinine<2.5 mg/dL and
normal potassium).
Angiotensin Converting Enzyme Inhbitorso Captopril: 6.25-50 mg by mouth tree times a day, Lisinopril: 2.5-35 by
mouth once a day, Enalapril : 2.5-20 mg by mouth twice a day ,
Ramipril : 2.5- 5 mg by mouth twice a day
Angiotensin Receptor Blockerso Candesartan: 4 -32 mg by mouth once a day, Valsartan 40 -320 mg by
mouth in divided doses, Losartan:50-150 mg by mouth once a day.
Beta blockers:
o Bisoprolol: 1.25 mg-10 mg by mouth once a day, Carvedilol: 3.12550mg by mouth twice a day, Metoprolol succinate: 12.5- 200 mg by
mouth once a day
Mineralocorticoid receptor antagonsists (MRA):
o Spironolactone :25-50 mg by mouth once a day.
Calcium channel blockers are used in people with diastolic HF
Treatment of acute HF
(to be carried out as an interim procedure in the absence of a cardiologist. All
patients need to be referred to a specialist cardiologist)
1. Oxygen if oxygen saturation < 90%
2. Diureticsi.v should be used preferably high dose if can be tolerated (fruesmide
40-80 mg 12 hourly). Opiates as morphine or pethidine can be given to
distressed patients with acute pulmonary edema
3. Patient should be referred for further management e.g. opiates, nitrates and
Follow up
1. Compliance with medications
2. Regular weigh of the patient, sudden increase in patients weight
necessitates increase diuretic dose
3. Evaluate the patient for evidence of deterioration
Patient education:

Regular exercise for at least half an hour five days a week

Avoid excess fluid intake (average of 2 litres per day)
Routine weighing at home if possible
Avoid excess salt intake




Human Immunodeficiency Virus

The HIV pandemic created unprecedented burden on the economies and health
care systems of affected countries, particularly in sub-Saharan Africa, where
prevalence is highest. In Sudan, the estimated number of patients living with HIV is
more than 100,000.
HIV causes progressive depletion of the CD4 T cells, resulting in conditions
known as opportunistic infections or malignancies. More than 90% of these are
responsible for AIDS morbidities and mortalities.
Anti-retroviral Therapy has reduced HIV/AIDS related mortality and
morbidity, prolonged life expectancy, and improved quality of life and productivity of
AIDS patient. The goal of treatment is to reduce the number of virus in the blood as
much as possible and increase the number of CD4 as much as possible.
People with HIV infection should be under the care of a physician who is
experienced in treating the infection. However, the following provides a brief
guideline for management of newly diagnosed patients until they are referred to
specialist services.
Signs, symptoms and History
Patients with HIV infection should always be referred to a specialist clinic for
proper assessment of their disease. However, clinical staging is as follows:
Clinical stage One: Asymptomatic, Persistent generalized lymphadenopathy
Clinical stage Two: Moderate unexplained weight loss (under 10% of presumed or
measured body weight),
Recurrent upper respiratory tract infections (sinusitis, tonsillitis, otitis media,
pharyngitis), Herpes zoster, angular cheilitis, recurrent oral ulcerations, papular
pruritic eruptions, seborrhoeic dermatitis, fungal nail infections
Clinical Stage Three: Unexplained severe weight loss (over 10% of presumed or
measured body weight), unexplained chronic diarrhoea for longer than 1 month,
unexplained persistent fever (intermittent or constant for longer than 1 month),
persistent oral candidiasis, oral hairy leukoplakia, pulmonary tuberculosis, severe
bacterial infections (e.g. pneumonia, empyema, meningitis, pyomyositis, bone or joint
infection, bacteraemia, severe pelvic inflammatory disease), acute necrotizing
ulcerative stomatitis, gingivitis or periodontitis, unexplained anaemia (Hb < 8 g/dl),
neutropenia (neutrophils< 0.5 x 109/l) and/or chronic thrombocytopenia (platelets < 50
x 109/l)

Clinical Stage Four: HIV wasting syndrome, Pneumocystis jiroveci pneumonia,

recurrent severe bacterial pneumonia, chronic herpes simplex infection (orolabial,
genital or anorectal of more than 1 months duration or visceral at any site),
oesophageal candidiasis (or candidiasis of trachea, bronchi or lungs), extrapulmonary
tuberculosis, kaposi sarcoma, cytomegalovirus infection, central nervous system
toxoplasmosis, HIV encephalopathy, extrapulmonary cryptococcosis including
meningitis, disseminated nontuberculous mycobacteria infection, progressive
multifocal leukoencephalopathy, chronic cryptosporidiosis, chronic isosporiasis,
disseminated mycosis, recurrent septicaemia, Lymphoma, invasive cervical
carcinoma, atypical disseminated leishmaniasis, symptomatic HIV-associated
nephropathy or HIV-associated cardiomyopathy.
If there is clinical suspicion of HIV, the patient must be referred to a speciliast
centre for testing. HIV infection is tested using HIV antibody testing.
Patients should be advised on the use of barrier methods during sexual contact
and on the risks associated with sharing of needles.
Eligibility Criteria:
Pharmacological Interventions:
Eligibility Criteria:
As a priority, ART should be initiated in all individuals with severe or advanced HIV
clinical disease (WHO clinical stage 3 or 4) and individuals with CD4 count 350
ART should be initiated in all individuals with HIV with CD4 count >350cells/mm
and 500 cells/mm3 regardless of WHO clinical stage.
ART should be initiated in all individuals with HIV regardless of WHO clinical stage
or CD4 cell count in the following situations: Individuals with HIV and active TB
disease , individuals coinfected with HIV and HBV with evidence of severe chronic
liver disease, partners with HIV in serodiscordant couples should be offered, ART to
reduce HIV transmission to uninfected partners .


First Line Antiretroviral Drugs:
TDF + 3TC (or FTC) + EFV as a fixed-dose combination as first line.
If the first line option is contraindicated or not available, one of the following options
should be chosen:
TDF + 3TC (or FTC) + NVP

Laboratory assessment of CD4+, HIV RNA viral load, CBC with differential, and
comprehensive metabolic panel should be carried out every 3 months.
Teach patient to recognize and report important symptoms: Change in pattern or
magnitude of temperature elevation.
Post Exposure Prophylaxis with ART should be offered to subjects inadvertently
exposed to risk of HIV infection (sexual contact, blood to mucous membrane
contact, needle stick injury, blood donation).
The use of barrier methods is advocated to prevent sexually transmitted HIV.
Contact with other person's blood should be avoided. Protective clothing, masks,
and goggles should be worn when caring for people who are injured.
HIV patients can pass the disease to others and should not donate blood, plasma,
body organs, or sperm.
HIV-positive women who wish to become pregnant should seek counselling about
the risk to their unborn child, and methods to help prevent their baby from
becoming infected.
Used needles and sharps should be appropriately disposed off in tightly sealed


Patient education
Patients are on antiretroviral (ARV) therapy a long time. Health workers prepare
patients for ARV therapy during the clinical review and advise patients on the
importance of adhering to the treatment. ARV drugs are very strong medicines.
Patients should be advised about drug interactions and side effects.
All patients with HIV should be counselled about avoiding the spread of the
disease. Infected individuals should also educated about the disease process, and
attempts are made to improve the quality of their life.
Patients should be made aware that they could be a source of infection to others
and should take actions to prevent transmission.



Ischemic Heart Disease

Ischemic heart disease (IHD) is due to imbalance between oxygen supply and
demand of myocardial tissue. It causes 30% of male and 22% of female deaths. Its
clinical manifestations include:
Stable angina
Acute coronary syndrome (ACS)
1-Unstable angina 2- acute myocardial infarction (MI)
Acute MI is divided according to the ECG findings into ST segment elevation
MI (STEMI) and non ST segment elevation MI (NON STEMI)
Risk factors for coronary artery diseases are
1. modifiable (diabetes, hypertension, smoking, hyper-lipidemias, obesity and
lack of exercise)
2. non-modifiable (old age, male, family history)
Symptoms ,signs and history:
Chest pain, chest discomfort, dull or heavy feeling, often retrosternal and may
radiate to left arm or both arms, neck, jaw and back (it can arise from any one of these
sites). Irrespective of its site: when pain is precipitated mainly by exertion, cold
weather, heavy meals, and emotional stress, relieved by rest and sublingual nitrate and
last up to 10 minutes it is most likely due to stable angina (angina pectoris)
Patients with suspected angina should have a detailed initial clinical assessment.
During attack patient may look anxious, pale, cold and sweaty.
In between the attacks, physical examination is frequently negative except for risk
factors (hypertension, diabetes, hyperlipidemias.)
Some patients (elderly and diabetics) may present with silent ischemia which is
accompanied by its atypical symptoms (shortness of breathing, nausea, vomiting,
dizziness, fatigue)
Patients with suspected angina should usually be investigated
Baseline ECG, chest x- ray, CBC and Renal Function Test.
All patients should be referred to a cardiologist for further investigations.

Adopting a healthy life style that includes diet modification, exercise, weight loss and
smoking cessation.

patients presenting with stable angina

Aspirin: 75 mg by mouth once a day (if there is no contraindication)
Beta blockers:. Bisoprolol 2.510 mg (not to be used in asthma and bradycardia)
1. Oral:
A- Long acting nitrates (mononitrates) 20- 60 mg/OD
B-For the immediate relief of angina and before performing activities that are
known to bring on angina:
2. Sublingual tablets: GTN (gyiceryl Trinitrate) dose 0.5 mg or Dinitrate
dose 5 mg or buccal spray (buccal spray or sublingual tabs should not
be used more than 3 times / day).

Angiotensin Converting Enzyme Inhibitors OR Angiotensin Receptor Blockers

B. Patients presenting with symptoms of acute coronary syndrome ( chest
pain not relieved by oral nitrates and ECG changes) should be referred
but start the following:

Aspirin 300mg to be chewed,

Sublingual or spray nitrate
-blocker (e.g. bisoprolol 2.5-10 mg).



Compliance with medication.
Control of symptoms
Psychological Support
Control of risk factors (smoking, hypertension, hyperlipidaemia, diabetes)
Appropriate use of Aspirin and STATINS
Patient education:
Smoke cessation,
Ideal body weight,
Regular exercise at least half an hour five times a week

Avoid sever unaccustomed exertion and vigorous exercise after a heavy meal
or in a very cold weather
Use sublingual nitrate before undertaking an action which will induce angina.
Diet rich in vegetables and fruits, avoid fatty meals



Pelvic Inflammatory Disease

Pelvic inflammatory disease (PID) is a condition of lower abdominal pain in a
woman caused by inflammation of the upper genital tract - uterus, fallopian tubes,
ovaries or pelvic cavity. It is often caused by gonorrhoea or Chlamydia and other
organisms. Tendency to develop PID is more common when there is damage to the
upper genital tract; by a previous infection with gonorrhoea or Chlamydia or
following a termination of pregnancy, dilatation and curettage (D&C) or insertion of
an intrauterine contraceptive device (IUCD).
In remote communities, it is common to misdiagnose PID.
Signs, Symptoms and History
Symptoms suggestive of PID include abdominal pain, dyspareunia (painful
sex), vaginal discharge, intermenstrual or post coital bleeding, dysuria, fever and
sometimes nausea and vomiting. A negative test for gonorrhea and Chlamydia do no
exclude PID.
Diagnosis is mainly clinical:
Abdominal examination for lower abdominal pain, tenderness, masses,
guarding, rebound tenderness, scars, bowel sounds (Always palpate gently).
Vaginal examination with a speculum to look for discharge from the cervix;
followed by bimanual examination for tenderness of the uterus and pain when
moving the cervix.
If resources are available: Take endovaginal swab for culture and urine test to
identify insulting organisms.
Rehydrations take plenty of fluid.
Remove IUCD if in situ.
First line:
Metronidazole:400mg by mouth, twice a day for 14 days
Doxycycline :200mg first dose followed by 100mg daily for 10 days.
Second line:

Ceftriaxone: 500mg IV/IM single dose together with azithromycin 1g by mouth

single dose
Followed by Metronidazole:400mg by mouth twice for 14 days
The partner should receive: doxycycline 200mg first dose followed by 100mg daily by
mouth for 10 days
After 3 days from start of therapy:
Inquire if the patient is complying with doxycycline and metronidazole therapy.
Give azithromycin 1g orally if the patient has discontinued doxycycline.
if no improvement, refer to hospital
After 8 days from start of therapy:
Test for Chlamydia and gonorrhea and if the test is negative and the patient is still
symptomatic, refer to secondary care.
IUCD is not recommended as a contraceptive method for women at high risk of
developing PID. Consider alternative contraception
Patient education
1. Patients must be educated on good compliance to antibiotic therapy as
prescribed by the doctor even if symptoms have disappeared.
2. Patients should be advised that discontinuation of treatment may lead to
3. Patients should be advised that failure to treat the husband at the same time
may lead to the recurrence of the disease



Bronchial Asthma

Asthma is a chronic inflammation of the bronchial airways characterized
clinically by episodic shortness of breath, coughs and wheezes in those who are
predisposed and which may remit spontaneously or as a result of treatment.
Signs Symptoms and history,:
Patients present with breathlessness, chest tightness and sometimes cough. On
examination there may be wheezing, an increased respiratory rate, increased pulse rate
or / and use of accessory muscles of respiration. The diagnosis should be made if more
than one the following symptoms are present:

Chest tightness

Avoidance of triggers
B-blockers, NSAIDS and aspirin
Environmental triggers e.g. pollutants, dust, grass pollen, smoke and chemical
inhalants and fumes.
Occupational triggers e.g. flour dust, smoke animal fur and hair.
It is important to identify these triggers in order to avoid them.
Medications should be reviewed at each visit and adjusted against the condition of
the patient.
Management of Chronic Bronchial Asthma in adults and children > 5 years of


Step 1:
1- Reliever medication- intermittent use of bronchodilators inhaled 2 agonist
(salbutamol) 100 micrograms 2 puffs as needed.
2- If inhaled agonist is required more than once daily move to step 2.
Step 2:
1- Use preventer medication i.e. inhaled corticosteroids (ICS) inhaled Budesonide
200 micrograms 2 puffs 12 hrly.
2- Or inhaled Fluticasone 125 micrograms 2 puffs 12 hourly.
3- Or inhaled Fluticasone 250 micrograms 1 puff 12 hourly.
4- Or inhaled Beclomethasone 100 micrograms 2 puffs 12 hourly.
5- -Reliever medication salbutamol 2 puffs or terbutaline when required.
Step 3:
1- -If no improvement with step 2 then add long acting agonist regularly 12
hourly (LABA) OR use combined preparation of LABA and ICS.
2- -Fluticasone/salmeterol dose 100/50 or 250/50 micrograms 1 puff 12 hourly.
3- -Budesonide/formeterol dose 160/4.5 micrograms 1-2 puffs 12 hourly.
4- Reliever medication salbutamol 100 micrograms 2 puffs as required.
Step 4: ( to be started by an asthma specialist)

Increase dose of ICS in combination with LABA.

Add leukotriene antagonist, oral montelukast 10mg once daily.
Or slow release theophylline.
Reliever salbutamol inhaler as required.

Step 5: ( to be initiated by an asthma specialist)

1- Add oral prednisolone 30-40 mg once daily .
2- Oral salbutamol 4mg tabs 8-12 hourly may be added.
3- Reliever medication with salbutamol inhaler should be used as required every 6
4- Evaluation of the stepping down between 3-6 months.
Management of Chronic Bronchial Asthma in children 2-5 years of age

( children under 2 years of age should be refered to a paediatric specialist)

Step 1:
Occasional relief bronchodilator
Short-acting beta2 agonist as required (not more than once daily)
Preferably by inhalation (less effective and more side-effects when given by
Move to step 2 if needed more than twice a week, or if night-time symptoms at
least once a week, or if exacerbation in the last 2 years
Step 2:
Regular preventer therapy
Inhaled short-acting beta2 agonist as required
Or (if inhaled corticosteroid cannot be used) leukotriene receptor antagonist
Step 3:
Child 25 years:
Inhaled short-acting beta2 agonist as required
Regular inhaled corticosteroid in standard dose
Leukotriene receptor antagonist
Step 4: persistent poor control
Refer to respiratory paediatrician
Stepping down: Regularly review need for treatment

If primary healthcare centers when the above drugs are not available use:


Salbutamol inhalers 2 puffs 6 hourly as required

Short acting salbutamol by mouth 2-4 mg 6 hourly
Short acting theophylline 100-200mg 6 hourly
or sustained release theophylline 200-400mg 12 hourly
Short course of prednisolone and referral to chest specialist.

Criteria for chest specialist referral in adults

1- Failure to respond to step3 regimen
2- Unclear diagnosis
3- Chronic sputum production
4- Persistent non-variable breathlessness
5- Unexpected clinical findings (i.e. crackles, clubbing, cyanosis, cardiac disease)
6- Monophonic wheeze or stridor
7- Prominent systemic features (myalgia, fever, weight loss)
8- CXR shadowing
9- Marked blood eosinophilia (>1 x 109/l)
10- Unexplained restrictive spirometry
11- Suspected occupational asthma
12- Poor response to asthma treatment
13- Severe asthma exacerbations
Management of Acute Sever Bronchial Asthma in adults and children :
Assessment of severity: severity is assessed according to the levels shown below
Acute Severe Asthma

Any one of:

PEF 33-50% best or predicted; child 5-12 years 50%
Respiratory rate 25/min; child 2-5 years 40, 5-12 years 30
Heart rate 110/min; child 2-5 years 140, 5-12 years 125
Inability to complete sentences in one breath.

Put the patient in a comfortable position.

Give supplementary oxygen (at least 6 liters per minute) to all patients with
acute severe asthma to maintain a SPO2 level of 94-98% .
Give beta 2 inhaled nebulized (2.5-5 mg of nebulized solution every 15-30
minutes) via nasal prong or mask- or inhaled beta 2 agonist through a large
volume spacer. (child under 5 years 2.5 mg, 512 years 2.55 mg)
Review patient after 2 hours, if there is significant improvement patient can be
discharged and followed up at the outpatient department

If there is deterioration consider admission to hospital and ask for specialist

If there is marginal or no response continue on the same management and ask
for specialist opinion.
After 4 hour, if there is no improvement or deterioration, consider admission to
high dependency unit and ask for chest specialist opinion.
In acute asthma with life threatening features the nebulized route (oxygen
driven) is recommended.
If the response is poor consider continuous nebulization with appropriate
nebulizer at 15-30 minutes intervals.
Parentral hydrocortisone 100 mg 6 hourly or Prednisilone 40-50 mg daily
( child 1-2 mg/kg (max.40mg) or up to 3 days, or longer if necessary; if the
chid has been taking an oral corticosteroid for more than a few days , give
prednisolone 2mg/kg ( max. 60mg)
Continue Prednisolone 40-50 mg daily for 5 days or until recovery.
Add neubulized Ipratropium Bromide (0.5 mg 4 to 6 hourly) to beta 2 agonist
treatment for patients with acute sever or life threatening asthma with a poor
initial response to beta 2 therapy.
Intravenous Aminophylline is not likely to result in additional
bronchodilatation in compared to standard care; side effects are many, used
only after consultation with senior medical staff.
Antibiotics should not be used unless there is evidence of bacterial infection.
Intravenous fluids are used in patients who are dehydrated.
Investigations (CXR, CBC, Oxygen saturation,and when indicated electrolytes
and ECG).
Indication for referral to intensive care or high dependency units include
Ask for chest specialist opinion

Cyanosis, confusion and coma

Weak respiratory effort, bradycardia and hypotension
Silent chest
Respiratory arrest
All patients transferred to intensive care units should be accompanied by a
doctor suitably equipped and skilled to incubate if necessary.
Start therapy with nebulised oxygen, salbutamol and intravenous
In primary healthcare centers in emergency situations where electricity facilities
are not available for nebulization, salbutamol inhaler can be used with a large
volume spacer plus other medications specified above.

Patient Education:
The Objective of patient education is to improve patient understanding about the
disease, boost his confidence and improve his compliance.
Nature of the disease
Rational of therapy
Teach patient inhaler technique and explain the difference between reliever and
preventer therapy.
Patients need to understand the need to continue using their inhalers even when
symptoms are better
Discuss wrong beliefs



Community Acquired Pneumonia in Adults

Pneumonia is inflammation of the lung parenchyma caused usually by bacteria
and characterized by chest symtoms, clinical signs and radiographic evidence of
consolidation. Other causes include viral, fungal, chemical and physical causes.
Pneumonia acquired in the community is known as community acquired pneumonia
Globally it is estimated that 5 million children less than 5 years die annually
with the disease and in U.K 1 in 1000 population is admitted to hospital with
pneumonia with a mortality rate of 10%.
Sputum, yellowish, rusty or
blood stained
Shortness of breath
Chest pain, plueritic in nature

Increased pulse rate
Increased respiratory rate
Dullness on percussion
Crackles and or bronchial

Chest radiography: for all patients suspected with CAP.
CBC, Urea, Na, K.
Sputum Gram Stain
Sputum cultures: Sputum samples for culture and sensitivity tests for CAP with
moderate severity prior to use of antibiotic therapy.
O2 saturations, arterial blood gases if necessary and available .
If a diagnosis of CAP has been definitely confirmed, and a patient has low severity
pneumonia with no co-morbid disease, then blood cultures may be omitted .
Assessment of severity (Curb Score + clinical judgment) .
Each of the following receives a score of 1:
Urea 8 mmol/l
Respiratory rate 30/min

Blood pressure (SBP < 90 or DBP 60mmHg)

Age 65 years.

Low severity: for home treatment
Moderate severity: for hospital referral
High severity: for urgent hospital admission


For intensive care management


Rest, drink plenty of fluids and avoid smoking .

Simple analgesia such as paracetamol for pleuritic pain.
Assess for volume depletion and may require intravenous fluids
Oxygen therapy: maintain (SpO2) 9498 (PaO2)& PaO2 8 kp
Consider Prophylaxis against thrombo-embolism for immobile patients


Mild pneumonia ( Out patient setting)

S. pneumoniae
M. pneumoniae
H. influenza
C. pneumonia

1st choice


With modifying factors

2nd choice
o High dose amoxacillin + Advanced
o Advanced macrolides
macrolides or
o High dose amoxacillin clavalunate +
o AmoxicillinAdvanced macrolides or
o Oral

Moderate/severe Community acquired pneumonia (with facilities for INPATIENT)


With no modifying factors

1st choice

With modifying factors

2nd choice


S. pneumonia
M. pneumoniae
H. influenza

o Penicillins
Erythromycin iv or
o Cefuroxime
Erythromycin iv


o Cefriaxone iv +
o Advanced macrolides iv or
o Cefotaxime iv +
o Advanced macrolides iv or
o Antipseumonal cephalosporin e.g.

Amoxicillin- 250mg by mouth 8 hourly, doubled in severe injections OR 500mg via
the intramuscular/intravenous route 8 hourly
Benzylpenicillin- 2.4-4.8g (daily)via the intravenous route in 4 divided doses, double
in severe infections
Co-Amoxiclav- 250mg ( expressed as amoxicillin) by mouth 8 hourly, increased to
500mg in severe infections OR 1 g ( expressed as amoxicillin) via the intravenous
route 8 hourly increased to 6 hourly in severe infections.
Clarithromycin- 250mg by mouth every 12 hours for 7 days increased to 500mg
every 12 hours up to 14 days in severe infections OR 500mg via the intravenous route
12 hourly.
Ceftazidime- 1g via the intravenous route 8 hourly increased to 2g in severe
Cefuroxime- 500mg by mouth 12 hourly in pneumonia OR 750mg via the
intravenous or intramuscular route 8 hourly and doubled in severe infections.
Ceftriaxone- 1g via deep intramuscular injection or slow intravenous injection once
daily, double in severe infections.
Cefotaxime- 1g by intramuscular injection or intravenous injection 12 hourly,
doubled in severe infections.
Erythromycin- 250mg to 500mg by mouth 6 hourly (or 1g-2g divided into two
dosed), doubled in severe infections OR 50mg/kg daily via the intravenous route
divided into 6 hourly doses.
Phenoxymethylpenicillin- 250mg-500mg by mouth 6 hourly, doubled in severe


Follow Up
Monitoring in the in-patient setting
mental status,
oxygen saturation and inspired oxygen concentration should be monitored and
recorded initially at least twice daily and
Chest radiograph repeated in patients who are not progressing satisfactorily
after 3 days of treatment
Discharge home
If symptoms improve
temp not > 37.8C,
PR not > 100/min,
RR rate not > 24/min,
systolic blood pressure not < 90mmHg,
oxygen saturation not < 90%, unless they represent the usual baseline status for
that patient


20. Depression
Depression is a broad diagnosis, the cardinal feature of which is depressed
mood and/or loss of interest in various activities accompanied by a constellation of
depressive symptoms such as changes in eating habits, sleeping patterns, fatigue,
indecision, thoughts of death or suicide, feeling of worthlessness, helplessness. These
symptoms are accompanied by significant distress or impairment of functions.
Major depressive disorder is a very common condition with prevalence ranges
from 4% to 16% in various countries. Studies in Sudan have reported a prevalence of
13% in primary health centres in Khartoum and 6% among adolescent girls aged
18yrs in Khartoum. Global burden of disease study showed depression as the fourth
leading cause of morbidity in 1990 and predicted that in 2020 it would be the leading
Signs, symptoms and history
Diagnosis of depression is entirely clinical. It depends on good history taken
both from the patient and close relatives and conducting a mental state examination.
Diagnosis of major depression requires the presence of either:
Low mood OR lack of enjoyment and a combination of other symptoms including:
Loss of energy
Suicidal thoughts
Change in appetite and/or weight
Loss of libido
Feeling of helpless &
Sleep disturbances
Pessimistic thoughts or feelings of guilt
There are other less common symptoms of depression e.g. obsessional thoughts,
Depression can also be divided into:
MILD: few (5 or less) other symptoms; minor functional impairment.
MODERATE: symptoms or functional impairment are between mild & severe.
SEVERE: most other symptoms; marked impairment of function. With or
without psychosis.


Physical investigations are sometimes required to rule out medical conditions

which mimic depression or to detect any co-morbid conditions e.g. thyroid function
test, FBC.
However, depressed patients might present with many physical symptoms and
care should be taken not to carry out unnecessary investigations.
Cognitive behavioral and interpersonal therapies (counselling) are effective in
treatment of mild to moderately severe depressive illness and improve patient
adherence to medication
Exercise therapy, mastery and pleasurable therapies
Electroconvulsive therapy (ECT) in severe or resistant cases
Drug treatment is indicated when mild depression does not respond to nonpharmacologic interventions or in moderate to severe cases.
Patients over 65 years old are more sensitive to side effects of imipramine.
Avoid imipramine in patients with history of heart disease, urinary retention,
glaucoma and epilepsy.
Do not issue large quantities of imipramine; tricyclic antidepressants can be
fatal in overdose!
It may take 2-3 weeks before therapeutic effect occurs
Imipramine : Initially 25-50 mg once a day in the evening. Increase by 25mg
every 3-5 days up to 150 mg orally at night by end of second week.
Sertraline : 50-100mg as a single evening dose
Refer the following cases to a specialist physician or psychiatrist:
Children and adolescents with depression
All cases involving attempted suicide or suicidal thoughts
Patients with severe depression or who do not respond to treatment or with
unusual signs/symptoms
Elderly patients with other co-morbidities e.g. heart disease, epilepsy,


After an episode of depression, continue antidepressants for at least 6 months,

as there is a high risk of relapse in this period
Patients should be followed up to check patient adherence, ensure that
medication is having the desired effect and to titrate the dose to their needs.
Give the maximum tolerated dose for at least 6 weeks before deciding a
particular antidepressant is not effective.
It is not always possible to prevent depression but early recognition of
symptoms and treatment as secondary prevention is important.
Patient education
Advise that it can take 2-4 weeks before antidepressants have an effect and that
they should continue treatment even once they feel better.
Stop antidepressants immediately if mania occurs
Warn carers that suicide risk might increase during the first two weeks of



Systemic Hypertension

Hypertension is defined as that level of arterial blood pressure associated with
significant long-term cardiovascular risk. The diagnosis of hypertension is made when
the SBP is 140 mmHg and or DBP 90 mmHg; provided that the readings are taken
as the mean of two or more properly measured blood pressure readings, in at least 2
different visits, a week apart
Hypertension is a major health problem all over the world. In Sudan
hypertension is the disease of the highest prevalence among the non-communicable
diseases (prevalence of 23.6) and it is one of the 10 leading causes of death. Each
increment of 20 mmHg in systolic blood pressure or 10 mmHg in diastolic blood
pressure doubles the risk of cardiovascular disease, stroke and kidney disease. One
fifth (20.8%) of Chronic Renal Failure cases registered in Sudan is due to
Hypertension. These alarming data support the need for aggressive approach for
Symptoms , signs and History:
Hypertension is usually asymptomatic unless complicated; so blood pressure
measurement must be routinely checked in every person above 20 years of age.
For target organ damage: urine general, CBC, RFT, ECG, CXR, Fundoscopy
Blood Pressure Measurement:
1. The Person should be seated comfortably for at least 5 minutes on a chair with the
arm supported at heart level.
2. Use an appropriately sized cuff (should encircle at least 2/3 of the arm
circumference) above the anticubital fossa.
3. The column should be deflated at 2 to 3 mm/sec. The systolic is when the first
audible sound appears and the diastolic is when the last sound disappears.
4. The column should be read to the nearest 2 mm Hg.
5. Take the mean of at least two measurements spaced by 12 minutes. Measure BP
in both arms at first visit and take the higher value as the reference one.
6. Take multiple measurements frequently in patients with irregular pulse (e.g. atrial
fibrillation) and in older patients.
(Caffeine, exercise, and smoking should be avoided for at least 30 minutes prior to

Classification and diagnosis of hypertension



BP Diastolic
And <80

Pre hypertension 130---139

And /Or 80---89

Stage 1


And /or 9099

Stage 2


And /or 100--- 119



And /or > 120

Recommended response if not

known hypertensive (diagnosis)
Recheck every year if the age
above 40 years
Recheck every 6 months (treat if
DM or CKD)
Check every week for one month
(treat if DM or CKD)
Confirm with two readings
within one week

1. Asses the CVD risk The risk of developing CVD in the coming 10 years {fatal or
nonfatal major cardiovascular event (myocardial infarction or stroke)}. Can be
estimated according to the presence or absence of the following risk factors `: 1age > 55years 2-level of B.P 3-smoking 4-DM 5-Abdominal obesity (Waist
circumference >102 cm (M), >88 cm (F) 6-Family history of premature CVD. 7Hypercholesterolaemia (if cholesterol level measurement is available)
2. Plan of management
*Patients with ISH (isolated systolic hypertension) have the same risk for developing
cardiovascular events as those with high diastolic pressure
Risk assessment

Low risk:
No risk factor

moderate risk:
1-2 risk factors

Stage 2 HTN
SBP 160--179
And/ Or DBP 100
Lifestyle change
Life style change Lifestyle change
Check BP every 6 +
Treatment if persistently Drug treatment if
persistently high over
high over 2 months
one month
Lifestyle change
Lifestyle change
Lifestyle change
Check BP every Treatment if persistently Immediate
high over one month
combination therapy)
consider treatment if
persistently high for
6 months

hypertension Stage 1 HTN
SBP 140-159
SBP 130-139
And/ Or DBP 80-89 And /Or DBP 90-99


High risk:
3 risk factors Or
DM or established

Life style change


Life style change


Life style change

drug Immediate

*Patients with severe hypertension: S.B.P>180 AND OR D.BP.>120 SHOULD

GOAL OF TREATMENT: blood pressure value 140/90 for all patients And
130/80 mmHg for patients with diabetes mellitus, or chronic renal disease.
Weight reduction
Adopt DASH
Dietary sodium
Physical activity

Maintain normal body weight
Consume a diet rich in vegetables, fruits, and
eating plan low-fat dairy products with a
reduced content of saturated and total fat
Reduce dietary sodium intake to no more than
sodium chloride 2.4 g sodium or 6 g
Engage in regular aerobic physical activity at
least 30 minutes daily, most days of the week

Approximate SBP reduction

520 mmHg/10kg
814 mm Hg
28 mmHg
49 mmHg

Initiate the treatment with thiazide diuretics or long acting calcium channel
Choice of other drugs according to compelling indications as shown in the table
Calcium Channel
Converting Enzyme
Receptor Blockers
Beta Blockers
Alpha Blockers

Compelling Indication
Heart failure
Angina, arrhythmias
Heart failure, Left Ventricular dysfunction, post Myocardial
Infarction, Established Ishcemic Heart Disease, Type I diabetic
ACE inhibitor intolerance, Type II diabetic Nephropathy, Left
Ventricular Hypertrophy, Heart failure ,post Myocardial Infarction
Post Myocardial Infarction, Angina
Bnigne prostatic hyperrophy

Start with low dose of a single drug aiming for a reduction of 5 to 10 mm Hg in

blood pressure at each step in order to avoid symptoms related to aggressive blood
pressure reduction.

Decide whether to continue the same management plan or to modify it. if adequate
response is not achieved as follow:
Thiazide Diuretics: after one month
ACEIs, CCBs, ARBs: 2 weeks to 1 month
Better to choose long acting preparations providing effective, 24-hour control of
hypertension to encourages adherence to the regimen
Combination therapy should be used when blood pressure is >20/10 mmHg above
the goals despite adherence to treatment
Steps of combining the drugs are:
FIRST STEP: Thiazide OR CCBS + ACEI / ARB at low dose
SECOND STEP: Thiazide OR CCBS + ACEI / ARB at full dose
THIRD STEP: Thiazide + CCBS + ACEI / ARB (the third at low dose)
Blockers OR Spironolacton OR Other Diuretics OR Centraly Acting Drugs} At Full
Other drugs in the management of hypertensive patient
Aspirin: Should Be Started after B.P. is controlled. Unless contraindicated,
low-dose aspirin (75 -150mg/ day) is recommended for all people needing secondary
prevention of ischemic CVD, and primary prevention in people with hypertension
over the age of 50 years who have a high CVD risk
Statins: Recommended for all people with high BP complicated by CVD and
for primary prevention in people with high BP who have a moderate CVD risk
All the patients with essential hypertension can initially receive the medical
care at primary care level (non-specialist care).
Criteria for Referal if:
Secondary hypertension, -Age less than 20 years, Presence of co -morbidity or
complications: heart disease, stroke, TIA, kidney disease.Albuminuria,
Hyperlpidaemia , sever hypertension (urgency or emergency), resistant
hypertension {(Office blood pressure >140/90 or> 130/90 in patients with
diabetes or chronic kidney disease.
Patients prescribed 3 or more antihypertensive in full doses including diuretics

if possible }, 24hrs Ambulatory blood pressure monitoring is indicated:

to rule out white-coat hypertension.
To uncover apparent drug resistance (office resistance).
To better define resistant hypertension.
To identify hypotensive symptoms while the patient is being treated with
To monitor episodic hypertension,
To identify autonomic dysfunction states.
Frequency of the follow-up visits at PHC level: All patients with hypertension
should be provide with regular follow-up, the follow up intervals can vary from
one week to one year according to patients condition. Arrange follow- up
visits as follows:
STAGE 1: Monthly until goal blood pressure is achieved, then every 3 to 6
STAGE 2: every 2 weeks until goal blood pressure achieved then every 3
SEVERE HYPERTENSION: refer and then F.U.weekly until the goal blood
pressure achieved then every 3 months
In the presence of co-morbidity as DM or heart disease the follow up frequency
might be increased
What to do during the follow-up visit:
Check the blood pressure.
Check adherence to medication
Advise and educate `on life style modification.
Inquire about symptoms that indicate the presence of target organ damage
(complication) e.g. breathlessness, chest pain.
Investigate as required:
One week after initiating ACEIs: Serum creatinine and electrolytes
Annual routine investigations: Lipid profile. renal function test and electrolytes


Avoid overweight, lack of exercise smoking, alcohol intake, excess salt intake,
environmental stress and excessive use of drugs: NSAIDs, oral contraceptive and
Patient education:
Start with adequate explanation of the nature of the disease, the risk factors, in
a simple language.
A written plan should be provided to all patients in order to improve their
adherence to treatment
Consider cultural beliefs and individual attitude in formulating treatment plan.
Involve the whole family to facilitate the adoption of healthy lifestyle and to
increase adherence to the medication.




Epilepsy is a condition characterized by recurrent seizures that may include
repetitive muscle jerking (convulsions). Epidemiological studies have stated that the
prevalence of epilepsy is 0.9/1000 in Sudan.
Signs, symptoms and history
Seizures are either generalized or partial.Generalized epileptic seizures occur
when electrical abnormalities exist throughout the brain. Generalized seizures may
manifest as tonic clonic seizures, myoclonic seizures or absence seizures with
impairment of consciousness.
A partial seizure does not involve the entire brain. Partial seizure do not result
in impairment of consciousness. A partial seizure begins in an area known as the
epileptic focus, but may spread to other parts of the brain and cause a secondary
generalized seizure. Some people who have epilepsy have more than one type of
Patients will be considered to have epilepsy if they suffer two seizures.
However, diagnosing the specific epilepsy syndrome is much more complex and
should be carried out by a specialist consultant to be assessed using
electroencephalographs, CT or MRI scanning as applicable.
Treatment should be started by a specialist and patients may be seen in the primary
care for prescription filling.


A number of considerations should guide the choice of treatment. Each
medication has a particular efficacy, mechanism and side effect profile





Simple or
complex partial






*Associated with severe side effects

Epileptic Emergencies: Status Epilepticus
Status epilepticus is usually defined as 30 minutes of uninterrupted seizure
activity or repeated attack of convulsions during which the patient fail to regain his
This serious condition carries a mortality of 20% and should be treated
1- Immediately on receiving the patient, inject diazepam (valium) 10mg I.V. over
2 minutes and in children (0.2mg-0.3mg/kg Dose) the seizure will often stop, at
least temporarily.
2- Ensure the airway is patent. Suck the pharynx. Remove the vomitus and
dentures and insert an airway. This latter should not be attempted during a
convulsion since it will injure the tongue or break a tooth.
3- Insert an I.V. line and run a glucose drip. Give Oxygen by facemask. Put a
nasogastric tube.
4- Lower temperature by tepid sponging.
5- Carry put a quick thorough medical examination
6- Refer patient urgently to a secondary care setting.

1- For long-term control of seizures, a long acting anticonvulsant should be

given by an NG tube as soon as possible along with the above-mentioned
management. Drugs that can be used are: Phenytoin and phenobarbitone
which should be used at lower doses in remote areas where ECG and ICU
settings are not available.
2- Lower temperature and correct dehydration.
3- Investigate for infestations and metabolic abnormalities and manage
Request B.F. for malaria.
Do total and differential WBC.
Do urine analysis.
Request blood sugar, urea and electrolytes.
4- General management for a comatosed patient should be instituted to prevent
complications, e.g., aspiration pneumonia, injuries and pressure sores.



Bacterial Meningitis

Meningitis is a major health problem worldwide especially in the African belt.
Globally acute bacterial meningitis affects 1.2 million people and is responsible for
135,000 deaths annually. Case-fatality rates of suspected meningitis in Africa
meningitis belt were 4-26%. During epidemics, N. meningitides accounts for 80-95%
of cases. In non-epidemic periods it accounts for 50% of the cases. In 2006 meningitis
outbreaks have occurred in 7 countries in theAfrican meningitis belt. There were 5719
suspected cases reported to WHO. During that period 526 Sudanese were affected
with 23 deaths. The predominant serotype was serogroup A.
Symptoms, Signs and History
The physical exam helps to confirm the hemodynamic and neurologic stability
of the patient, and helps to trigger workup toward suspected primary source of
infection. Classically, meningitis presents with fever and headache accompanied by
meningeal symptoms like neck pain and neck stiffness. These could be accompanied
by signs such as Kernig's (inability to completely extend the leg with the thigh flexed
upon the abdomen) and Brudzinsky's (flexion of the neck usually causes flexion of the
hip and knee or on passive flexion of one lower limb, other limb show similar
Confusion can be seen in severe cases but it is more common in
meningoencephalitis. Presence of rash may suggest meningococcal disease.
Diagnosis depends on clinical suspicion and appropriate investigation.
Treatment should be started on suspicision of meningitis. Common febrile
illnesses in the area should be considered and excluded if appropriate.
Lumbar puncture is the cornerstone in the diagnosis of meningitis. CSF in
acute bacterial meningitis reveals the characteristic neutrophilicpleocytosis (usually
hundreds to a few thousand, with >80% PMN cells). Specific pathogen demonstrated
in 60% of Gram stains and 80% of cultures. Glucose is less than 40 mg/dL in 60% of
patients. Proteins are usually elevated
If suspicion for CNS involvement is high, blood cultures are drawn and empiric
antimicrobials are immediately administered, preferably within 1 hour of presentation.
Patients who have altered mental status or focal neurologic signs or seizures must
undergo brain imaging prior to LP.

Fever reduction with cold sponging.

Consider airway protection in patients with altered mental status.
Selected individuals may require aggressive hydration and hemodynamic
Antipyretics for fever.
Treat seizures according to the usual protocol.
Administer oxygen in hypoxic patient
Establish IV access in all patients.
Institute treatment as early as possible in the disease course, since delay in
instituting treatment may contribute significantly to morbidity and mortality.
If you have to transfer your patient to another facility, make sure to give the
first dose of antibiotics before transfer.
In non epidemic situations:
In non epidemic situations the ideal practice for antibiotics option should be guided by
laboratory examination of the CSF gained by LP.
In absence of these facilities treatment should be adapted according to the most
probable causative organism.
Treatment options for adults:
Ceftriaxone: 100 mg/kg/day by the intravenous route (max 4gr/day) in 2 divided
doses for at least 5 days.(IV/IM)
Penicillin G: 6 million units by the intravenous route 4 hourly OR 24 million
units/day continuous by intravenous infusion for 14 days or until a febrile for 7 days
Once the laboratory examination of the CSF is available, treatment should be
guided by the result of culture and sensitivity.
In epidemic situations:
During epidemics presumptive treatment is justified. Treatment should be initiated
without the need of laboratory confirmation for the causative organism. However, LP
and CSF examination should be standard practice even in outbreak situations.


Federal Ministry of health (FMoH) should be notified as early as possible whenever

epidemic is suspected. When the epidemic crew arrives, their national protocol should
Treatment options for adults include:
Ceftriaxone inj 100 mg/kg/day (max 4gr/day) for at least 5 days.(IV/IM)
Oily Chloramphenicol inj 100 mg/kg as a single dose.(IM) (**)
Penicillin G 6 million units IV every 4 hours or 24 million units/day continuous
IV infusion for 14 days or until afebrile for 7 days
Follow up of patient should be directed towards evaluation of the clinical response at
24, 36 and 48 hrs.
This includes checking the vital signs and neurological examination for possible
Patients should be referred from primary care if he has repeated convulsions or coma,
or if there is no improvement after 48 hrs of chemistry (fever > 38.5, appearance or
aggravation of neurological signs).
Preventive measures for bacterial meningitis include:
1- Immunization (refer to FMOH) against the causative organism if available
2- Avoidance of overcrowding
3- Prophylaxis of those in close contact with patients with meningitis. In case of
Meningococcal meningitis Ciprofloxacin tabs 500 mg po one dose.




Acute tonsillitis is an acute infection of the parenchyma of the palatine tonsils.
which can occur as an isolated episode or in association with upper respiratory illness
including generalized pharyngitis. The clinical distinction between tonsillitis and
pharyngitis is unclear in the literature, and the condition is often referred to simply as
"acute sore throat", which is a common reason for presentation to the primary care
physician especially among pediatrics and young adult population. The socioeconomic
impact is significant due to antibiotic abuse, poor school performance and associated
morbidity of the disease and its complications.
Tonsillitis is usually viral; it is most commonly caused by the rhinovirus, In
tonsillitis associated with infectious mononucleosis, the most common infective agent
is the Epstein-Barr virus.
Common bacterial pathogens include beta-hemolytic and other streptococci,
with the most common being group A beta-hemolytic streptococci (GABHS). In the
literature GABHS is responsible for 15% to 30% of all cases of acute tonsillitis in
children aged between 5 and 15 years and for 5% to 10% of all tonsillitis in adults
while Group C beta-hemolytic streptococci are the cause in about 5% of patients.
Tonsillitis is an infectious condition and can be spread by exposure to an
infected person.
Differential diagnosis includes infectious mononucleosis, diphtheria,
agranulocytosis and malignancy (leukemia, lymphoma and carcinoma) (Take drug
Signs, symptoms and History
The symptoms for tonsillitis are pain on swallowing, fever (>38C [>100.5F])
and tonsillar exudates. Other diagnostic factors include: sudden onset of sore throat,
headache, abdominal pain, nausea and vomiting, presence of cough or runny nose,
tonsillar erythema, tonsillar enlargement, enlarged anterior cervical lymph nodes. The
following tables list differential signs and symptoms for viral and bacterial tonsillitis.
Clinical Picture in Viral and Bacterial Tonsillitis
sudden onset of sore throat
cough or runny nose
Swollen, painful anterior cervical lymph
tonsillar exudates
fever (>38C [>100.5F])
A raised WBC count with neutrophilia
tonsillar erythema
tonsillar erythema

tonsillar enlargement

tonsillar enlargement

The first tests to order must include: microbiology investigations and rapid
streptococcal antigen test. A White Blood Cell count with differential and urine
analysis may be considered
Used solely for viral infections
Avoid overcrowding.
Avoid patient contact.
Warm salt water gargles.

Adult : 500mg- 1000mg every 4 hours (maximum of 8 tablets in 24 hours)
Child: 36 months 60 mg, 6 months2 years 120 mg, 24 years 180 mg, 46 years
240 mg, 68 years 240250 mg, 810 years 360375 mg, 1012 years 480500 mg,
1216 years 480750 mg; these doses may be repeated every 46 hours when
necessary (maximum of 4 doses in 24 hours)
Adult- 25-50mg by mouth three times daily.
Ibuprofen :
Adult- 200-600mg by mouth three to four times a day up to a maximum of 1200mg in
24 hours.
Child- over 5 kg body-weight 2030 mg/kg daily in divided doses or 36 months
(body-weight over 5 kg) 50 mg 3 times daily, 6 months1 year 50 mg 34 times daily,
13 years 100 mg 3 times daily, 46 years 150 mg 3 times daily, 79 years 200 mg 3
times daily, 1012 years 300 mg 3 times daily.


Antibiotic therapy To be used for bacterial infections only

Phenoxymethylpenicillin potassium: children 27 kg:: 250 mg orally two to three
times daily for 10 days; children >27 kg and adults: 500 mg orally two to three
times daily for 10 days.
Procaine penicillin: children 27 kg: 600,000 units intramuscularly as a single dose;
children >27 kg and adults: 1.2 million units intramuscularly as a single dose.
Amoxicillin: children: 50 mg/kg/day orally given in 2 divided doses for 10 days,
maximum 1000 mg/day; adults: 875 mg orally twice daily for 10 days.
Erythromycin base: children: 25-50 mg/kg/day orally given in divided doses every
6 hours For 10 days, maximum 2000 mg/day; adults: 250-500 mg orally four times
daily for 10 days
Dexamethasone sodium phosphate: children >12 years of age and adults: 10 mg
IM/IV as a single dose. To be used in severe and exudative group A -hemolytic
streptococcuspositive acute pharyngitis.
Follow up
AN ASO titer after one week
Criteria referral:
Otitis media, Obstructive sleep apnoea, Peritonsillar abscess (quinsy), Rheumatic
fever (strept), Post streptococcal golmerulonephritis,
Indications for referral and surgery: Recurrent episodes of tonsillis, Hypertrophy
(sleep apnoea), Peritonsillar abscess, Streptococcal carrier, Unilateral enlargement.
Indications for adenoidectomy alone: Recurrent acute otitis media or chronic otitis
media with effusion (serous otitis media).

There are no accepted strategies for the primary prevention of acute tonsillitis.
Avoid overcrowding
Patient Education:
Immediate treatment of any sore throat.
Improve patient and family understanding about the disease.



Diarrhoea and Dehydration

breast fed. Diarrhoeacan be classified into twotypes: acute diarrhoea ( lasting less than 14 days)

The onset may be very abrupt..

The stools are characteristically frequent, watery, and green or bright orange in colour.
Signs of dehydration which rapidly appear include:
Irritability and/or deterioration in level of consciousness.
Sudden and weight loss
Dry mouth
Depressed fontanel
The skin, when pinched, remains in a fold
Sunken and tearless eyes
Fast weak pulse and a low blood pressure
Capillary circulation time more than 2 seconds
Decreased urine output
Stool general
Urea and electrolytes
However, diagnosis is mainly clinical.

Diagnosis mainly clinical
A. Stool General.
B. Urea and electrolytes
The steps to treat diarrhea are shown in the chart below.

Select treatment and treat
appropriately for degree of
Counsel mother

As for symptoms and look for signs indicating other

Treat for any other problems
Teach mothers to give ORS and zinc (if available).
Explain good food choices, including breast- feeding.


Assessment of Severity:
A any 2 signs of the B- any 2 signs of the C- any signs of the
1. Look
General Condition
Mouth and Tongue
Capillary refill
2. Feel
Skin Pinch
Heart rate

Well Alert

Restless, irritable

Lethargic or
Normal and dry
Very Sunken
Very Dry
Drinks normally, not Thirsty, drinks eagerly Drinks poorly
<2 seconds
2-4 Seconds
>4 seconds

Goes back quickly

Goes back slowly



Very Depressed
and Rapid rate , small Very rapid rate, small

3. Classify
No signs dehydration


Plan A

Plan B

of Severe dehydration

4. Hydration plan
Plan C

Pharmacological, non PHARMACOLOGICAL MANAGEMENT and follow-up:

Adopted by Integrated Management of Childhood Illness (IMCI)

Mother Educatin:
C. Breastfeeding: Infants should be exclusively breastfed during the first 6
months. Breastfeeding should be continued until at least 2 years of age, but
complementary foods should normally be started at 6 months of age. Feeding
bottles and teats should never be used.
D. Use of safe water (boil).
E. Hand washing: Hands can easily spread diarrhoeal diseases.
F. Maintain immunization especially that of Rota virus and Measles



Severe Acute Malnutrition (SAM)

Children with severe acute malnutrition their weights are less than 70% of the
expected weight for height (W/H) with a z-score below -3 (standard deviation of the
percentile) or Mid Upper Arm Circumstances (MUAC) <11.0 cm. SAM children at
this stage can either be edematous as in kwashiorkor or marasmic-kwashiorkor or nonedematous as in marasmus. Marasmus is the commonest type and affects children
aged 1-4 years, although it also occurs in older children and adults. And Marasmic
kwashiorkor (mixed form) is a mixed form of SAM.
Signs, Symptoms and History
Symptoms: Children are miserable, sick, and wasted.
The main sign is severe generalized wasting of muscles of the thigh, buttocks,
arms and shoulders. The affected child is very thin ("skin and bones"). Growth
retardation. Apathy is reflected in loss of interest in patient's surroundings..
Associated signs
G. A thin "old man" face
H. "Baggy pants" (the loose skin of the buttocks hanging down)
I. Affected children may appear to be alert in spite of their condition
J. There is no oedema (swelling that pits on pressure) of the lower extremities
K. Ribs are very prominent.
The constant signs are:
L. Oedema, usually starting in the legs and feet and spreading, in more advanced
cases, to the hands and face. Oedema may be detected by the production of a
definite pit as a result of moderate pressure for one minutes with the thumb
over the lower end of the tibia and the dorsum of foot. Because of oedema
children with kwashiorkor may look "fat" so that their parents regard them as
well fed.
M. Muscle wasting as evident in the muscles of inner sides of the thigh, buttocks,
upper arms and shoulders.
N. Growth retardation is documented by anthropometric measurements.
O. Lack of interest in the environment around him (apathy)
Frequently present signs:

P. Hair changes: flag sign due to the presence of different colors in the same hair
shaft ranging from yellow, golden and white colors.
Q. Skin lesions and hypo and hyper pigmented areas.:
R. Paleness: anaemia is frequently present, commonly iron, folic acid and or
S. Oral signs of multi-vitamin deficiencies like angular stomatitis, chelosis and
smooth tongue.
T. Eye signs: conjunctival xerosis (bitots spot)
U. Management of SAM requires special ward with an attached kitchen and
trained personnel
V. The following factors are associated with high mortality and should be
1. The use of ORS for rehydration because of its high sodium content and
replace by RESOMAL.
2. Intravenous rehydration unless the child is severely dehydrated or in
3. Lack of provision of blankets.
4. No feeding by night (when Nasogastric (N/G) tube is used).
5. Giving high protein, high calorie formula initially.
6. Lack of prescription of antibiotics.
7. Lack of provision of Vitamin A.
8. Use of diuretics to treat oedema
9. Lack of close monitoring of dietary formula daily intake.
10. Lack of monitoring progress by anthropometric measurements (wt/ht)
Management of SAM can be divided into 3 phases:
Phase I or Initial Phase (to avoid mortality):
W. Use of Kwashiorkor milk or F7s WHO formula in a dose of 100 mls/kg/day
actual weight.
X. Give feeds orally by cup and spoon, small but often. If the child is not taking
the whole amount use Nasogastric (N/G) tube as slowly running drip.
Y. Divide the daily meal in 6 equal portions and feed 4 hourly.

Z. Treat infections by antibiotics Amoxicillin. Co-trimoxazole, and in severely ill

children with third generation cephalosporin.
Give Vitamin A if not given during the last 4- 6 months (day 1,3,7 and
14) in doses: 50,000 IU in < 11 month old. 100,000 IU in > 12 months old.
200,000 IU > 24 months old.
If the child is dehydrated give RESOMAL in a dose of 5mls/kg/hr and
monitor response.
Give zinc in a dose of 20mg/kg/day for 14 days.
Cover the child well with a blanket or mother to child skin to skin
contact (Kangaroo position).
Phase 2 or Maintenance Phase:
Replace Kwashiorkor milk or F75 by F100, this is the maintenance
FF.The daily dose is 100mls/kg/24 hours divided doses.
Continue monitoring wt/ht.
Start iron therapy if indicated. (leads to high mortality)
II. Arrange for follow-up.
JJ. Discharge if the child reaches or a broaches the expected WT/HT.
Plot weight every other day or wt/ht to monitor improvement.
If the child is showing the signs of recovery in the first week of initial
management shift to maintenance therapy (F100)
Signs of recovery are:
1. Return of appetite
2. Decrease in weight in oedematous malnutrition.
3. Improvement in temperament or increase in weight in nonoedematous type
Failure to respond is an indication to re-evaluate the child.
Ask the mother daily if the child has consumed the amount of feeding
formula during the last 24 hours and increase according to tolerance. There is
no limit to this amount to be used.
PP.Start or complete immunizations.
Mother Education
Encourage breastfeeding up to 2 years. If it necessary dont stop
Introduce a weaning diet at 4-6 months, using locally available foods,
appropriately prepared for the child.

SS.Food for young children should be soft, mashed, with a mixture of different
ingredients, like cereals with pulses, milk, vegetables and fruits, meat, fish or
eggs. Make sure that the food is energy dense by adding oil or sugar.
All children aged 6-11 months should be given a dose of 100 000 IU of
vitamin A every 4-6 months. Their parents should be counseled on increasing
their dietary intake of vitamin A rich food such as dark green leafy vegetables
Immunize all children and monitor their growth monthly.
Encourage family planning (spacing).
Encourage female education
Improve personal and environmental hygiene.
Encourage a balanced diet for pregnant and lactating women.