Final Standard Treatment Guidelines Booklet 04

REPUBLIC OF ZAMBIA
Ministry of Health
STANDARD TREATMENT GUIDELINES,
ESSENTIAL MEDICINES LIST
AND
ESSENTIAL LABORATORY SUPPLIES LIST
FOR ZAMBIA
Standard Treatment Guidelines
ii
iii
iv
v
vi
vii
viii
ix
476
497
498

x
FOREWORD
Achieving long term improvements in rational use of medicines
and care of the sick requires building the competences of the
health care professionals. This second edition of the Standard
Treatment Guidelines is an update of the earlier version
contributing to rational and cost effective health care designed
under the aspirations and spirit of increasing efficacy of decision
making and precision in prevention, diagnosis, treatment,
alleviation of disease and improved quality of life for the Zambian
people as cited in the National Drug Policy.
I commend the European Union under HSSP for technical and

financial assistance to the Zambia National Formulary
Committee for developing and producing these Standard
Treatment Guidelines as an educational strategy for managing
the common conditions afflicting the Zambian people. As usual,
the book has been improved to make it more user-friendly,
pocket size, with information on disease conditions
definitions, diagnoses and on how to develop therapeutic
interventions. The Committee upheld the original intent of
making the document a reference material for all health care
providers, particularly medical doctors, pharmacists, dentists,
nurses, clinical officers and all those with a primary
responsibility for prescribing, dispensing and administration of
medicines.
The first edition proved to be a very popular reference document

to medical students and other health care workers contracted
to provide health services in Zambia. This book is designed to
augment that erstwhile intent. I recommend that you read and
use the information herein to serve better those most in need.
Whether you work at the University Teaching Hospital, Lukulu,
Monze, Chama or Chinyama Litapi, the information will help
you provide good quality, safe, effective and affordable health
care.
Dr. Jabbin Mulwanda

Permanent Secretary - Health Services
MINISTRY OF HEALTH

xii
ACKNOWLEDGMENTS
The Zambia National Formulary Committee is grateful to
the Ministry of Health for the support given to review
and produce the second edition of the Standard Treatment
Guidelines, Essential Medicines List, and Essential
Laboratory Supplies for Zambia. The committee is indebted
to the USAID-supported Rational Pharmaceutical
Management Plus (RPM Plus) and Strengthening
Pharmaceutical Systems (SPS) Programs that collaborated
with the Antimicrobial Resistance Advocacy Working
Group (AWG) for the technical and financial support
towards the development of this book.
It is the spirit of the physicians’ workshop on the

implementation of the 2004 Standard Treatment Guidelines
to support the antimicrobial resistance (AMR) containment
in Zambia, June 27-29, 2005, that inspired the AWG for
continued support to the Zambia National Formulary
Committee to review the STG, particularly on the
management of infectious diseases to promote rational
use of antimicrobials to preserve their effectiveness. Drug
resistant microbes causing public health diseases such
as TB, Malaria, and HIV/AIDS now threaten successful
treatment of infectious diseases. Health gains achieved
by priority health programs - including tuberculosis (TB),
malaria, acute respiratory infections (ARI), diarrheal
diseases, sexually transmitted infections (STIs) and
HIV/AIDS - are increasingly threatened by the growing
worldwide problem of antimicrobial resistance (AMR). If
we do not preserve our heritage of current antimicrobials,
in few years we are going to have hospitals filled with
patients with resistant infections.
Finally we thank the untiring efforts and commitment

provided by the Committee members and those co-opted
to contribute. This book was written by interdependent

xiii
team of reviewers and editors who worked together on
all aspects of reviewing, writing, editing and producing
the book. Each member brought a wealth of knowledge,
talent and experience in health care. Together the
committee members met several times and at different
venues, critically analyzed the revisions and shared their
experiences with evidence to produce this document
with a power to improve the alleviation, provide relief
to ailments and care of the people.
We also thank individuals and groups of professionals

who offered constructive critique of the first edition that
enabled improvements on this document.
Zambia National Formulary Committee 2014-2017

1. Dr. Kor Chiyenu - Consultant Physician, UTH (Chairperson)
2. Mr. Oliver Hazemba - Senior Technical Advisor Management
Sciences fo Health (Vice Chairperson)
3. Dr. Owen Ngalamika - Dermatologist, UTH
4. Mr. Pious Hachizo - Senior Pharmacist - Cancer Diseases Hospital

5. Mrs. Ilitongo Saasa Sondashi - Pharmacist - Lusaka DHO
6. Mr. Billy Mweetwa - National Programme Officer, Essential
Medicines WHO
7. Dr. Sally Trollip - Physician UTH
8. Dr. Maureen Chisembele - Obstetrician/Gynaecologist
9. Mr. Enock Chikatula - Pharmaceutical Services Manager, UTH
10. Dr. Pauline Musukwa Sambo - Oncologist, UTH

11. Mr. George Kadimba - District Pharmacist Lusaka DHO
12. Mr. Boyd Mwanashimbala - Principal Pharmacist -
Rational Drug Use, MOH
13. Mr. Luke Alutuli - Principal Pharmacist Logistics MOH
14 . Dr. Kennedy Lishimpi - Director Clinical care and Diagnostics Services
15. Mr. Abraham Mukesela -Principal Pharmacist Lusaka Province

xiv
16. Dr. Mweemba Aggrey - Nephrologist UTH
17. Mr. Maxwell Kasonde - Public Health Pharmacist, Ministry of Health
18. Dr. Gloria Munthali - Paeds
HIV Coordinator
19. Dr. Susan Citonje Musadabwe - Senior Medical Superintendent
Cancer Diseases Hospital
20. Dr. Francis Simenda - Consultant Chainama Hospital
21. Ms. Anne Zulu - Director, Pharmaceuticals Standards,

Medical Stores Limited
22. Mr. Chikuta Mbewe - Deputy Director, Pharmaceutical Services MOH
Other Technical Reviewers

1. Mr. George Kadimba - Lusaka District Parmacist
2. Mr. Billy Mweetwa - Pharmacist WHO
Design and print

Pro-print Limited
Secretariat
1. Mrs. Ilitongo Saasa Sondashi -Pharmacist - Lusaka DHO
2. Mr. Boyd Mwanashimbala - Principal Pharmacist

Rational Drug Use - MOH
3. Mr. Luke Alutuli - Principal Pharmacist Logistics Management
4. Mrs. Elis Mwanza - Secretary, DCCDs, MOH
5. Mr. Nyambe Sitali - Office Assistant

6. Mr. Victor Kamuhuza - Office Assistant

xv
INTRODUCTION
The Standard Treatment Guidelines were developed after
wide consultations and discussions with healthcare
providers at three tires of the health delivery system –
practitioners, program managers and health economists.
While most of the key information has been retained,
extensive revisions were carried out on some of the
chapters such as HIV and AIDS, psychiatric conditions,
STI, and eye conditions. While some of the changes to
treatment strategies were motivated by the dynamism
of the conditions and availability of more effective
medicines and conformity with national disease specific
guidelines, some of them were influenced by the new
treatment strategies as guided by the World Health
Organization and evidence from clinical studies.
Antiretroviral therapy of HIV infections in adults,
adolescence, infants and children were adopted from
WHO guidelines as recommended for public health
approach. The guidelines are based on a comparison
between various drug therapies and on consideration of
value for money and the most effective, affordable and
current practices that produce health outcomes of
improved quality of life and alleviation of suffering. They
are also based on the essential drugs and medical supplies
concepts to meet the basic health needs of the Zambians
as close to the family as possible as visionalised from
the National Drug Policy.
The essential medicines and laboratory supplies listed in

the Essential Medicines and Essential Laboratory Supplies
Lists are linked to the standard treatment guidelines as
indicative of public health priorities for the pharmaceutical
systems. The lists are based on national clinical choices
that the Government of the Republic of Zambia makes
available and accessible to its citizens at all times. The
medicines and supplies selection was also based on

xviii
sound and adequate information of efficacy from clinical
settings, evidence of performance from different health
care settings, availability in a form in which quality,
stability in the Zambian weather and storage settings,
bioavailability and users are assured. In addition total
cost of treatment and methodology of administration
were also considered.
The Medicines and Therapeutic Committees and hospital

and district health management teams are mandated to
use these Guidelines and Lists as management tools to
improve the quality of the health care delivery and meet
the public health responsibility of transparency and
accountability. Individual health care professionals are
encouraged to use the guidelines as a companion in the
course of health care delivery provision.

xix
ARRANGEMENT OF
INFORMATION
The guideline text divisions into chapters according to a
particular system of the body or an aspect of medical
care has been retained.
Chapters are divided into sections providing introductory

notes for health care providers who include doctors,
pharmacists, nurses and other heath professionals. This
information is intended to assist with decision making
and selection of appropriate treatment.
Descriptive information about the disease or condition

is outlined in the following manner:
• Definition of disease or condition

• Clinical features
• Complications
• Treatment
– Supportive
– Drugs
• Prevention

xx
Prescribers are advised to follow rational prescribing
practices, outlined in these standard treatment
guidelines which emphasise the public priority use
of essential medicines and laboratory supplies and
economic treatment regimes
REVISION OF STANDARD TREATMENT GUIDELINES

CONTENTS
The Zambia National Formulary Committee recognises
the fact that the field of treatment regimens and drugs
is dynamic, thus revision of the guideline contents will
be continuous. Contributions are encouraged and should
be submitted for consideration by the Zambia National
Formulary Committee through the Ministry of Health.
Dr. Kor Chiyenu

Chairman, Zambia National Formulary Committee

xxii
1�
GASTRO-INTESTINAL
CONDITIONS
1.1� ABDOMINAL PAINS
Abdominal pains include gastritis and peptic ulcer disease
1.1.1� Gastritis
This is divided into acute and chronic gastritis. In acute

gastritis there is inflammation of the superficial gastric
mucosa. It can occur as a result of ingestion of drugs
such as acetyl salicylic acid and other non- steroidal anti-
inflammatory drugs (NSAID) and alcohol.
Chronic gastritis is divided into 3 categories:

Type A (autoimmune) gastritis seen in pernicious anaemia
and also in other autoimmune diseases.
Type B (bacterial) gastritis, which is associated with

Helicobacter pylori.
Type C (chemical) gastritis, which is due to repeated

injury with bile reflux or chronic ingestion of NSAIDs.
Clinical features
• Indigestion
• Vomiting
• Gastrointestinal haemorrhage
• Epigastric pain
Most chronic gastritis is asymptomatic
Diagnosis
• Endoscopy
1
Treatment
• Remove offending cause
1.1.2� Chronic Peptic Ulcer Disease
Most peptic ulcers occur in the stomach or proximal

duodenum but can also occur in the oesophagus (with
oesophageal reflux).
Clinical features
• Epigastric pain
• Indigestion
• Flatulence
• Heartburn
• Anorexia; weight loss may occur
Diagnosis
• Endoscopy
• Barium meal
Many patients, particularly the young presenting with

indigestion, can be treated symptomatically for 4-5
weeks without investigation.
Complications
• Reflux oesophagitis may be complicated by peptic
stricture which is characterised by intermittent
dysphagia over a long period.
• Change of the oesophageal mucosa (Barrettes
oesophagus) which is pre-malignant.
• Anaemia and frank haemorrhage
• Recurrent aspiration pneumonia when stricture
formation is present
• Perforation of peptic ulcer
• Pyloric stenosis

2
Treatment
Drugs
Antacids: Antacids often relieve symptoms. They are
best given when symptoms occur or are expected usually
between meals and at bedtime
• Magnesium trisilicate compound, 250-500mg to

chew when required or
• Aluminium hydroxide 500mg-1g to chew when
required or
• Magnesium trisilicate suspension 250mg with dried
aluminium hydroxide 120mg 10ml orally 3 times
daily or
• Aluminium hydroxide (dried aluminium hydroxide
500mg) 5-10ml orally 4 times daily; children 6-12
years 5ml orally 3 times daily or
• Adults 1-4 tablets to be chewed 4 times daily
between meals and at bed time or as required
Ulcer healing drugs

a) H2–receptor antagonists
Cimetidine 400mg tablets twice daily (with breakfast
and at night) or 800mg at night for at least 4 weeks.
Maintenance 400mg at night or 400mg morning
and night.
• Reflux oesophagitis:
Cimetidine 400mg 4 times daily for 4 – 8 weeks.
Ranitidine 150mg tablets twice daily (with

breakfast and at night) or 300mg at night for
4 – 8 weeks, up to 6 weeks in chronic episodic
dyspepsia. Maintenance 150mg at night.

3
• Reflux oesophagitis:
Ranitidine 150mg twice daily or 300mg at night
for up to 8 weeks or if necessary 12 weeks.
b) Proton pump inhibitors

• Omeprazole 20mg tablets daily for 4 weeks followed
by a further 4 – 8 weeks if not fully treated.
Long term management of acid reflux disease.
Omeprazole 10mg daily increasing up to 20mg if
symptoms return. Not recommended for children.
c) Tripotassium dicitratobismuthate (Bismuth chelate)

Liquid 12mg/5ml. 10ml twice daily or 5ml 4 times
daily for 28 days followed by a further 28 days if
necessary. Not recommended for children.
Tablets 120mg. 2 tablets twice daily or 1 tablet 4

times daily for 28 days followed by a further 28
days if necessary.
d) Triple therapy regimens
1 week regimen:
• Amoxycillin, 500mg 3 times daily
Plus
• Metronidazole, 400mg 3 times daily
Plus
• Omeprazole, 20mg twice daily or 40mg once
daily for 7 days
Or
• Clarithromycin, 500mg daily twice daily
Plus
• Metronidazole, 400mg (or tinidazole 500mg)
twice daily
Plus
• Omeprazole, 20mg twice daily or 40mg once
daily for 7 days

4
pain and vomiting. Dehydration can also be a problem
if the diarrhoea is severe. This may be mild, moderate
or severe in nature.
• Mild dehydration: The patient does not show enough

signs to classify as moderate or severe dehydration.
• Moderate dehydration: The patient has two or more

of the following signs:
– Restlessness
– Irritability
– Sunken eyes
– Dry mouth and tongue
– Absence of tears
– Thirsty, drinks eagerly
• Severe dehydration: The patient is classified as

having severe dehydration if there are two or
more of the following signs:
– Lethargic or unconscious; floppy
– Absence of tears
– Very dry mouth and tongue
– Very thirsty, drinks poorly or unable to drink
– Pinched skin goes back very slowly
Other signs in adults and children above 5 years

are absent radial pulse and low blood pressure.
Diagnosis
Investigations are necessary if the diarrhoea lasts more
than one week, i.e., stool microscopy, culture and drug
seusceptability.
Treatment
1. Fluid replacement
Fluid therapy (see section on cholera)

7
• Special tests may be needed for certain parasites
such as cryptosporidium, isospora and microsporidia
• Rectal/jejunal biopsy
• Barium enema
• Full blood count
Treatment
Treat infective causes of the chronic diarrhoea.
• Fluid therapy – Oral fluid use should be stressed

except for patients presenting with severe
dehydration in whom intravenous fluids should be
used. However, even with severe dehydration, oral
fluids should be given concurrently. Fluid
management is as for cholera.
Drug treatment
Antidiarrhoeal agents
• Loperamide 2mg three times daily
• Codeine phosphate 30mg four times daily
• Nitazoxanide 100mg suspension;
Child 1-3 years 5ml 2 times a day with food for 3
days;
4-11 years 10ml 2 times a day with food for 3 days;
12 years and above, 500 mg tablets 3 times a day
with food for 3 days.
Treat specific causes such as:

• Giardia – Metronidazole, 400mg 8 hourly orally for
7 days
• Isospora belli – Co-trimoxazole, 960mg four times
daily orally for 10 days. Give pyrimethamine for
sulpha allergic patients. Recurrencies tend to occur.
• Cryptosporidia – Albendazole, 400mg twice daily
orally for one month may help although HAART with
immune reconstitution is the main line of
management

9
• Dehydration is unusual
Diagnosis
• Stool microscopy
• Sero diagnosis
Treatment
Drugs
• Metronidazole
Adult:
800mg orally 3 times daily for 5 days followed
by diloxanide furoate 500mg TDS for 10 days (for
eradication of cysts)
Child:
1 – 3 years, 200mg orally 8 hourly for 5 days;
3 – 7 years, 200mg orally 6 hourly for 5 days;
7 – 10 years, 400mg orally 8 hourly for 5 days
Or
• Tinidazole
Adult: 2g daily for 2 – 3 days.
Child: 50 – 60 mg/kg orally for 3 days.
Avoid use of anti-diarrhoea agents
Supportive
• Fluid replacement – Refer to chapter 1.5
• Analgesis
Complications
• Fulminant colitis
• Colon perforation
• Peritonitis
• Chronic infection
• Stricture formation
• Severe haemorrhage
• Amoebic liver abscess
• Amoeboma

12
Diagnosis
• Largely clinical
• Stool and rectal swabs for culture
Treatment
1. Rehydration
Patients should be assessed for degree of
dehydration.
Management of mild dehydration

Give Oral Rehydration Salt (ORS) solution or any fluids
after each loose stool.
ORS Dose
Age Amount after each loose stool
Less than
24 months 50 – 100ml after each loose stool
2 – 5 years 100 – 200ml
10 years
and above As much as the patient wants
ORS and other fluids should be continued until diarrhoea

stops. Breast-fed children should continue to breastfeed
normally. Encourage the patient to eat.

14
Management of moderate dehydration (some dehydration
in children)
Give ORS in the first 4 hours as follows:

Age Less 4-11 12-23 24-59 5-14 15 yrs
than mnths mnths mnths years and
4 above
mnths
Weight Less 5-10 10-12 12-19 16-29 30kg

than kg kg kg kg and
5kg above
Amount 150ml 400ml 600ml 1,500ml 2,000ml 3,800ml

in ml per per per per per per
(approx) hour hour hour hour hour hour
• Monitor the patient frequently

• Reassess the patient after 4 hours using the classification
of dehydration. If signs of (moderate) dehydration are
still present, repeat the same management. If patient
shows signs of severe dehydration change management
to that of severe dehydration.
• Patients should be encouraged to eat and drink as much
as they want.
• If child vomits, wait 10 minutes and then continue
giving ORS slowly, i.e. every 2 – 3 minutes.
• Encourage mother to continue breastfeeding.
• For infants less than six months who are not breastfed
also give 100 – 200ml clean water during this period.
Management of severe dehydration

Start intravenous drip with Ringers Lactate or Sodium Chloride
0.9% w/v (normal saline) immediately (give ORS while drip
is being set).

15
Patients below 1 year:
• Give 100ml/kg in 6 hours as follows:
30ml/kg in the first 1 hour then
70ml/kg in the next 5 hours
Reassess the patient very frequently.
• If the patient can drink, give about 5ml/kg per hour
of ORS in addition to the IV fluid.
• Assess state of re-hydration after six hours using
the classification of dehydration level chart; classify
and manage accordingly.
• If the patient shows no sign of dehydration after
treatment with IV fluids or ORS, continue ORS as
follows:
– Less than 24 months old
= 100ml after each loose stool
– 2 – 9 years old
– 10 years or more
= as much as patient wants (at least 300ml)
Patients 1 year and above:

• Give IV fluids, 100ml/kg in 3 hours as follows:
30ml/kg as rapidly as possible (within 30 minutes),
then
70ml/kg in the next 21/2 hours
Reassess the patient very frequently.
• If the patient can drink, give about 5ml/kg per hour

of ORS in addition to the IV fluid.
• Assess state of rehydration after 3 hours using the
classification of dehydration on treatment charts;
reclassify and manage accordingly.
• If the patients show no sign of dehydration after
treatment with IV fluids or ORS continue ORS as
follows:
• 24 months old

16
• 2 – 9 years old
• More than 9 years
= as much as patient wants (at least 300ml)
Drugs
Medicines should only be given according to the sensitivity
patterns.
Recommended Antibiotics
ANTIBIOTICS CHILDREN ADULTS
Doxycycline
One single dose – 300mg
Tetracycline
4 times daily (For children
for 3 days >12 years)
12.5mg/kg 500mg
Erythromycin
Adults:
4 times daily
for 3 days
Children:
3 times daily
for 3 days 10mg/kg 250mg
• Doxycycline is WHO antibiotic of choice for adults

(except pregnant women) because only one dose
is required.
• Erythromycin may be used when the other
recommended antibiotics are not available, or where
V. cholerae is resistant to them.

17
testes and spermatic cord may be involved. The
obstruction phase follows if treatment is not given. This
presents with oedema of the lower limbs and scrota.
Long standing oedema produces thick rough skin which
may ulcerate.
Complications
Tropical eosinophilia is characterized by either
lymphadenopathy, splenomegaly or cough, bronchospasm
and asthma like picture.
Loa loa
Clinical features are caused by adult worms which prefer
the subconjuctival and periobital tissues. The main
features are calabar swellings – painless, localised,
transient, hot soft tissue swellings often near joints. They
last from a few hours to several weeks. Urticaria, pruritis,
lymphoedema, arthritis and chorioretinitis may occur.
A meningoencephalitis like picture may occur during
treatment.
Onchocerciasis
The incubation period averages 1 year. Initially a papular,
reddish, itchy rash occurs. After repeated infection
subcutaneous nodules develop. The nodules may be
associated with genital elephantiasis, hydrocele and
ocular lesions. Ocular lesions are serious and may cause
blindness. Initially there is excessive tear production,
photophobia and the sensation of a foreign body in the
eye. Then conjunctivitis, iridocyclitis, chorioretinitis,
secondary glaucoma and optic atrophy may occur.
Treatment
Wuchereria bancrofti
• Diethylcarbamazine 2 – 6mg/Kg daily in divided
doses for 2 – 3 weeks. The course is repeated after

19
Complication
Growth retardation in children.
Treatment
Adult:
Metronidazole, 2g as a single dose for 3 successive days.
Children:
Sometimes a second or third course may be necessary.
Prevention
• Personal hygiene
• Improvement of water quality
• Boiling water for at least 10 minutes.
The effects of chlorination are variable.

25
2
CENTRAL NERVOUS SYSTEM
CONDITIONS
2.1� MENTAL HEALTH AND PSYCHIATRIC �

ILLNESSES
Introduction
The current etiological formulation of mental disorder is
based on the biopsychosocial model meaning
symptomatology is as a result of the interaction of 3
domains: biological, psychological and social. The
treatment approach therefore must consist of the same
model.
Psychiatric Disorders
Anxiety Disorders
Generalized anxiety disorder
Obsessive compulsive disorder
Social anxiety disorder
Post-traumatic stress disorder
Panic attack disorder
Mood Disorders
Bipolar mood disorder
Bipolar 1 disorder
Depressive disorder
Major depressive disorder
Psychotic Disorders
Brief psychotic disorder
Schizophrenia
Paranoid disorder
Delusion disorder
26
Diagnosis
for the psychiatric disorders are based on Diagnostic and
Statistical Manual (DSM) IV or International Classification
of Diseases (ICD)
2.1.1 Anxiety Disorders
Introduction
The essential feature about these disorders is that a
patient has episodic subjective experiences of false alarm
of impending danger when objectively none exists.
2.1.1.1 Generalised Anxiety Disorder
Definition
Generalized anxiety disorder is characterized by excessive
level of anxiety and worry almost all the time and the
patient has great difficulties in controlling the worry.
Patients usually present with somatic complaints.
Clinical Features
• Excessive worry about all activities in life
• Anticipation of doom in all undertakings
• Restlessness
• Insomnia
• Tremors
• Muscle tension
• Poor concentration and memory
Differential Diagnosis
The differential diagnosis is extensive because worry and
anxiety are seen in many conditions.
Psychiatric
• Major depressive disorder
• Social anxiety disorder
• Post-traumatic stress disorder

27
• Panic attack disorder
• Anaemia
Medical
• Hyperthyroidism
• Chronic obstructive airways disorders (asthma,
emphysema)
• Seizure disorders
• Drug intoxication/withdrawal
• Cardiac arrhythmias
Management
Investigation
• FBC
• TSH (T3, T4)
• Blood glucose
• CXR
• EEG
• ECG
Treatment
Treatment can either be by psychological (counselling
and psychotherapy) or Psychopharmacological. The two
treatment approaches can be used singly or in combination
depending on the etiological factors at play.
Short Term
1. Psychopharmacology
• Alprazolam 0.25 mg (250 mcg) given 2 or 3
times daily. If required, increases may be made
in 0.25 mg (250 mcg) according to the severity
of symptoms and patient response. It is
recommended that the evening dose be
increased before the daytime doses. Very severe
manifestations of anxiety may require larger

28
initial daily doses. The optimal dose is one that
permits symptomatic control of excessive anxiety
without impairment of mental and motor
function. Exceptionally, it may be necessary to
increase the dosage to a maximum of 3 mg
daily, given in divided doses.
Elderly and Debilitated Patients

The initial dosage Alprazolam is 0.125 mg (125 mcg)
2 or 3 times daily. If necessary, this dosage may be
increased gradually depending on patient tolerance
and response
Short courses of treatment should be the rule for

the symptomatic relief of excessive anxiety and the
initial course of treatment should not last longer
than 1 week without reassessment. If necessary,
drug dose can be adjusted after 1 week. Prescriptions
should be limited to short courses of therapy.
• Lorazepam is given as a second-line drug of choice.

Initial adult daily oral dose is 2 mg in three divided
doses of 0.5 mg, 0.5 mg and 1 mg, or two divided
doses of 1 mg and 1 mg. The daily dose should be
carefully increased or decreased by 0.5 mg depending
upon tolerance and response. The usual daily dose
is 2 to 3 mg. The optimal dose may range from 1
to 4 mg daily in individual patients. Usually, a daily
dose of 6 mg should not be exceeded.
The initial daily dose in elderly and debilitated patients

should not exceed 0.5 mg and should be very carefully
and gradually adjusted, depending upon tolerance
and response.
• Diazepam 2mg 3 times daily increased if necessary

to 10-15mg daily in divided doses may be used in

29
the absence of the above-mentioned drugs.
• Sertraline 50 mg once per day is recommended as
the initial dose. A gradual increase in dose may be
considered if no clinical improvement is observed.
Dose changes, if necessary, should be made at
intervals of at least 1 week. Do not exceed a
maximum of 200 mg/day. The full antidepressant
effect may be delayed until 4 weeks of treatment
or longer.
Administer with food once daily preferably with the

evening meal, or, if administration in the morning
is desired, with breakfast. Used with caution in
patients with renal and/or hepatic impairment.
Maintenance
When a satisfactory clinical response has been obtained,
the dose should be reduced (within the 50 to 200 mg
range) to the minimum that will maintain relief of
symptoms.
Psychotherapy – supportive therapy
Long Term
• Cognitive behaviour therapy
Note
Due to the potential for dependence, benzodizepines
must be given for 2-6 weeks followed by tapering over
a period of 1-2 weeks.
Obsessive Compulsive Disorder
Definition
The essential feature is the symptom of recurrent
obsessions or compulsions or both.

30
Obsessions are defined as recurrent, persistent ideas,
images or impulses. Compulsions are behaviours or
mental acts that are repetitive, purposeful, and intentional
that are performed in response to the obsession in a
stereotyped fashion.
Clinical Features
Obsessions
Recurrent and persistent ideas, thoughts, impulses, or
images that are experienced as intrusive and senseless
and cause marked anxiety or distress
Thoughts, impulses are not simply excessive worries

about problems. The person attempts to ignore or
suppress such thoughts or to neutralize them. The person
recognizes that the obsessions are the product of his or
her own mind.
Compulsions
Repetitive behaviours or mental acts performed in response
to an obsession or rigidly applied rules. Behaviours are
designed to neutralize or prevent distress or some dreaded
event or situation, but are excessive or not realistically
connected with what they are meant to neutralize. The
person recognizes his or her behaviour is excessive or
unreasonable (except children). Obsessions/compulsions
cause marked distress, are time-consuming (more than
1 hr/day), or significantly interfere with the person’s
normal routine. If another axis 1 disorder is present, the
content of the obsessions or compulsions is not restricted
to it. Disturbance is not due to the direct physiologic
effects of a substance or general medical condition.
1) Obsessive compulsive personality.
2) Obsessive compulsive disorder spectrum. Bear

31
similarities with OCD.
Trichotillomania
Body dysmorphic syndrome
Tourette disorder
Olfactory reference syndrome
Treatment
Short Term
Drugs
• Fluoxetine 20 mg/day to 60 mg/day is
recommended and total dose should not exceed a
maximum of 80 mg/day
• Clomipramine
Adults: Initiate with daily doses of 25 mg. Dosage
may be increased by 25 mg, as tolerated, at 3 to 4
day intervals up to a total daily dose of 100 or 150
mg by the end of 2 weeks. Thereafter, the dose
may be gradually increased over a period of several
weeks to 200 mg. Doses in excess of 200 mg/day
are not generally recommended for outpatients.
However, in the treatment of severe cases of
Obsessive Compulsive Disorder, daily doses of up to
250 mg may be required
Children and Adolescents: In children aged 10 to 17

years, an initial dose of 25 mg/day is recommended.
This may be increased by 25 mg, as tolerated, at 3
to 4 day intervals. By the end of 2 weeks, patients
may be titrated up to 100 to 150 mg/day or 3
mg/kg, whichever is lower. Thereafter, the dose
may be gradually increased to 200 mg or 3 mg/kg
whichever is lower. A total daily dose above 200
mg should not be used in children or adolescents.

32
Elderly and Debilitated Patients: Initially, 20 to 30
mg daily in divided doses is suggested, with very
gradual increments, depending on tolerance and
response. Blood pressure and cardiac rhythm should
be checked frequently, particularly in patients who
have unstable cardiovascular function.
Psychological
• Cognitive behaviour therapy
• Exposure and response prevention
Long Term
• Cognitive behaviour therapy (exposure and response
prevention).
Social Anxiety Disorder
Definition
The essential feature of social anxiety disorder is excessive
and persistent fear of being in a given social situation
where the person might be exposed to scrutiny of others.
The exposure to or anticipation of the feared situation

causes marked anxiety and the person either avoids the
situations or endures it with significant distress.
Clinical Features
• Tremors
• Palpitation
• Sweating
• Restlessness
These occur in social settings in which patients are pre-

occupied with feelings of being negatively evaluated by
others.

33
1) Shyness
2) Avoidant personality disorder
3) Panic attack
Treatment
Short Term
Drugs
• Alprazalam 250-500 micrograms 3 times daily or
• Lorazepam or 1-4 mg dailly in divided doses as in
generalized anxiety disorders above.
• Fluoxetine 20 mg administered once daily in the
morning. A gradual dose increase should be
considered only after a trial period of several weeks
if the expected clinical improvement does not occur
Long Term
• Cognitive behaviour therapy.
Post Traumatic Stress Disorders (PTSD)
Definition
Post Traumatic Stress Disorders are caused by a severe
psychic-trauma. A psychic-trauma is defined as an
inescapable event that overwhelms an individual’s existing
coping mechanisms.
Clinical Features
The clinical features fall into 3 domains.
1. Re-experiencing
The trauma is re-experienced in the following ways:
a) Frequent intrusive memories of the event
b) Nightmares of the event
c) Flash backs
d) Low self-esteem

34
2. Avoidance
All reminders of the events are persistently avoided
3. Autonomic Hyperactivity
a) Insomnia
b) Irritability
c) Hypervigilance
Diagnosis
a) Acute stress disorder
b) Adjustment disorder
c) Obsessive compulsive disorder
d) Schizophrenia
e) Drug/alcohol use disorder (intoxication)
Investigation
None
Treatment
The principle treatment modality for PTSD is psychotherapy,
such as supportive, psychodynamic cognitive behavioral,
and with medication used to augment the psychotherapy
and help reduce the symptoms.
The goals of treatment are:

• To help patients regain self-esteem.
• To again feel in control of themselves and their lives
(the opposite of the feelings of helplessness
experienced in the trauma).
• To re-work their shattered assumptions.
Phase oriented models are used to conceptualize

treatment.
Phase I (Supportive psychotherapy)

Establishing safety, stabilization, symptom reduction and
the therapeutic alliance.
35
Phase II (Cognitive behavioral therapy)
Dealing with traumatic event; e.g., through remembering,
desensitization, de-conditioning and mourning.
Phase III (Insight-oriented psychotherapy)

Restructuring personal schema and integrating the trauma
into a meaningful life narrative; i.e., putting the trauma
into perspective and moving forward in developing a
positive life.
Drug Therapy
The best approach is to choose a medication based on
the more problematic target symptoms. This may require
a combination of medications, e.g., an SSRI to decrease
numbing (withdrawal from society and becoming
emotionally indifferent) and depression, and a
benzodiazepine (Lorazepam) and a beta blocker
(Propranolol) (titrate the dose) to decrease autonomic
hyperarousal.
Panic Attack Disorder
Definition
A panic attack is referred to as a recurrent unexpected
discrete episode of intense discomfort or fear.
Clinical features
Palpitations, pounding heart, or accelerated heart rate,
sweating, trembling or shaking, sensations of shortness
of breath or smothering, feeling of choking, chest pain
or discomfort, nausea or abdominal distress, feeling dizzy,
unsteady, lightheaded, or faint, derealization (feelings
of unreality) or depersonalization (being detached from
oneself), fear of losing control or going crazy, fear of
dying, paresthesias (numbness or tingling sensations),
chills or hot flushes.

36
Diagnosis
It must meet the ICD 10/DSM IV diagnostic criteria.
a) All types of anxiety disorders
b) Anaemia
c) Angina
d) Asthma
e) Hyperventilation
f) Epilepsy
g) Cocaine
h) Myocardial infarction
i) Migraine
j) Transient ischemic attack
k) Pheochromocytoma
l) Hallucinogens
Treatment
Short Term
1. Drugs
• Lorazepam 2mg Initial adult daily oral dosage in
three divided doses of 0.5 mg, 0.5 mg and 1 mg,
or in two divided doses of 1 mg and 1 mg. A daily
dose of 6 mg should not be exceeded. Initial daily
dose in elderly and debilitated patients should not
exceed 0.5 mg and should be very carefully and
gradually adjusted, depending upon tolerance and
response.
• Fluoxetine: 10mg; initial dosage is 20 mg

administered once daily in the morning. A gradual
dose increase should be considered only after a trial
period of several weeks if the expected clinical
improvement does not occur.

37
Long Term
2. Psychotherapy
a) Behaviour therapy
– Applied relaxation
– Deep breathing exercise
– In-vivo exposure
2.1 Mood Disorders
Introduction
Mood disorders are mental disorders whose primary
psychopathology is the disturbance of mood. The mood
disturbances can either be low (depressed) or high
manic/hypomanic.
Bipolar Mood Disorders
This is a spectrum of disorders which is characterized by

cyclical disturbance of mood, cognition and related
behaviours. It can either present with maniac/hypomania
symptoms or as depression alternating with
mania/hypomania. It consists of:
• Bipolar disorders
• Cyclothymia
• Mood disorder due to general medical condition
• Drug/alcohol induced mood disorder
Bipolar 1 Disorder
Definition
It is a sub type of Bipolar Spectrum of Disorders
characterized by episodes of manic presentation or
alternating episodes of mania and major depressive
disorder.

38
Clinical Features
It is subdivided into 3 domains:
1. Biological
• Too busy to eat or sleep (Good appetite and sleep)
• High energy
2. Psychological
• Over familiarity, high self-esteem, grandiose ideas,
freely expressed over-confidence.
3. Social
• Impulsive, disinhibited (unstoppable) and hyperactive.
Diagnosis
Bipolar mood disorder is a spectrum of disorder. It is
critical to make a definite diagnosis because of treatment
implication.
NOTE: Mania is a cluster of signs and symptoms with a

variety of underlying psychopathology. It is not a
diagnosis.
• Major depressive disorder
• Schizoaffective
• HIV
• Syphilitic encephalitic
• Alcohol/drug induced mood disorder
Investigation
Diagnosis
• FBC, UIE, LFT, EEG, TSH, B12
• Pregnancy test
• Pre-treatment Evaluation
A general medical assessment, including history, physical

examination, and laboratory evaluation focusing on organ
systems potentially affected by each agent, is important
prior to starting these medications.
39
Severity Treatment Dosage
Mild (Monotherapy) Lithium – 300mg 3

Mood stabilizer times a day
Moderate Monotherapy Carbamazepine – 200 –

Mood stabilizer 600mg/day
Severe Mood stabilizer Sodium valproate

and Antipsychotic 250mg
3 times/day
Severe with Mood stabilizer and

psychosis Antipsychotic
Treatment
Treatment selection depends on illness severity, associated
features such as rapid cycling or psychosis, and, where
possible, patient preference.
Short Term
Intermediate
During intermediate phase, doses will be titrated according
to the side effects, therapeutic effect and drug blood
level.
Long Term
Patients will be maintained on the mood stabilizer which
resulted into their recovery. Antipsychotic must be
tapered down slowly over a period of two – three weeks
and finally withdrawn.
Note: A blood level of Lithium 0.8-1.2 mEq/L generally

is required to treat acute onset of episodes of bipolar
mood disorders. (A steady-state, stable blood level the
morning before the first dose of the day). Changes in

40
dosage require monitoring of lithium levels at least every
5-7 days after the change. Some patients require (and
tolerate) levels up to 1.5mEq/L. although higher levels
are not advisable because of the risk of toxicity. Treatment
with lithium alone may have a relatively slow response
rate (up to 2 weeks after a therapeutic blood level) is
established.
Lithium should only be used where blood levels of Lithium

can be monitored.
Depressive Disorders
Definition
A spectrum of disorders which is characterized by a low
or depressed mood. They consist of:
• Major depressive disorder single episode
• Major depressive disorder record
• Dysthmia
• Adjustment disorder with depressed mood
• Mood disorder due to general medical condition
• Substance induced mood disorder
It is therefore vital to make a definitet diagnosis because

of management implications. They have different
treatment, course and prognosis.
Major Depressive Disorder
Definition
This is one of the depressive spectrum of disorders what
man psychopathology is a depressed mood and lack of
anhedonia (loss of interest in all general life activities).
Clinical Features
Clinical presentation falls into 3 domains

41
Biological:
Insomia/Hyperinsomnia/hi fatigue, weight loss/gain,
Agitation/retardation (psychomotor retardation)
Psychological:
Depressed mood, loss of interest in pleasure (anhedonic),
sense of guilt, worthlessness, hopelessness, helplessness
and sometimes suicidal
Cognitive:
Poor attention, concentration and memory
Diagnosis
Bipolar mood disorder with depressive episode
Schizoaffective
Adjustment disorder with depressed mood
Substance induced mood disorder
Mood disorder due to general medical condition
Sad mood
Bereavement
Investigations
FBC, VDRL, TSH, LFT, Drug Screen.
Hamilton depressive scale
Becks depression inventory
Treatment
The treatment of major depressive disorder consists of
antidepressant, psychotherapy and ECT (electroconvulsive
therapy) or a combination of these.
Acute Phase

42
Severity of Major
Depressive Episode Pharmacotherapy
Mild Antidepressants if preferred by patient
Moderate to severe Antidepressants are treatment of

choice (unless electroconvulsive
therapy (ECT) is planned)
With psychotic Features Antidepressants plus antipsychotics

or ECT
Intermediate Phase
Titrate the medication according to side effect and clinical

response.
Long Term Phase

1. Continue with antidepressants
2. Psychotherapy (cognitive behaviour therapy)
3. Taper the antipsychotic and discontinue over the
period of three to four weeks
Psychotic Disorders
Psychosis refers to loss of contact with reality (impairment

in reality testing). It is not a diagnosis but a symptom
of mental disorders with a variety of underlying etiological
factors. It is characterized by delusions, hallucinations
and thought disorders.
Brief Psychotic Disorder
Definition
An acute transient psychotic episode of abrupt onset.
Although it can follow a stressful life event, it may be
the first clinical feature of a primary mental disorder in
a predisposed person.
43
Clinical Features
1) Delusions
2) Hallucinations
3) Disorganized speech (e.g. frequent derailment or
incoherence)
4) Grossly disorganized or catatonic behavior
Investigations
FBC, U/E, LFT, TSH, EEG, CXR, ECG, Drug Screen.
1. Schizophrenform
2. Major depressive disorder
3. Bipolar mood disorder
4. Drug/alcohol induced psychotic disorder
5. Delirium
Treatment
Short Term
1. Hospitalisation:
For diagnostic evaluation and monitoring signs and
symptoms
2. Psychopharmacotherapy: �
•� Antipsychotic - See table (flow chart)�
•� Adjunctive (Benzodiazepine) - Diazepam,
Lorazepam
Long Term
The clinical presentation of brief psychotic disorder is
polymorphic. A long term follow up is advisable to
establish the underlying primary mental disorder.

44
Either Treatment Algorithm
Agree choice of
antipsychotic with
patient Or, if not possible:
Agree choice of
antipsychotic with
patient and/or care Or, if not possible:
Start second-generation First generation antipsychotic
46
antipsychotic or Titrate, if necessary, to
minimum effective dose
Adjust dose according to

response and tolerability
Effective Assess over 6-8 weeks
Not effective Not tolerated or poor compliance

Continue at dose
established as effective Change drug and follow
above process consider use
of either an SGA or an FGA If poor compliance related
tolerability discuss with
patient and change drug
Not effective If poor compliance related to other

factors, consider depot or
47
compliance therapy or compliance
aids

Treatment Repeat above process
resistance (Clozapine) Relapse or acute exacerbation
of schizophrenia
(full adherence to medication
confirmed)
Treatment algorithm
Investigate social or
psychological precipitants Provide appropriate support
and/or Therapy
Continue usual Acute drug treatment required

drug treatment Switch to a different, acceptable
Antipsychotic if approptiate
Assess over at least 6 weeks
48
Treatment ineffective
Switch to clozapine

Replapse or acute exacerbation
of schizophrenia
(adherence doubtful or
known to be poor
ither Treatment Algorithm
Investigate reason Confused ordisorganized Simplify drug regimen

for poor adherence Lack of insight or support Poor tolerated treatment
Discuss with patient Discuss with patient
Consider compliance
therapy or depot
Antipsychotics Switch to acceptable drug (see
recommendations on page …
49
reoccurrence.
• A detailed history should be taken and should include
• An eyewitness account of the seizure (if possible)
• Prior trauma, infection, alcohol or other drug
involvement will call for review of need for continued
treatment
• If it is status epilepticus, establish if the patient has
been taking medication regularly in the last 2 weeks
before the seizure (including dosage and frequency).
Record of other medication used recently
History of family seizures or other neurological disorders
Treatment
Drugs
Most patients will respond favourably to single drug
treatment provided in table_______ on anticonvulsants
(i.e. phenobarbitone, carbamazepine or phenytoin).
Patients who do not respond favourably to maximum
doses of these drugs should be referred for specialist
treatment.
Patients who have not had seizures for two or more

years, neurological signs or symptoms, unacceptable
behavioural change or adverse reaction to drugs should
all be referred to a specialist for possible discontinuation
of drugs.
Supportive
Counseling is necessary for both the patient and caregivers.
Take blood for
• Urea and electrolytes,
• Glucose
• Ca+, Mg + +
• Full blood count
• Arterial gases, and

51
This virus is usually found in animals and is transmitted
to man.
Animals, which may carry rabies virus, include:

Domestic Wild
Dogs Hyenas
Cats Foxes
Wild dogs
Bats
Clinical features
Fulminant encephalitis with convulsions, circulatory and
respiratory failure. Hydrophobia (fear of water) occurs in
advanced stages of the disease.
Dignosis
Investigation
• Taking a good history
• Laboratory investigation by means of
immunofluorescent microscopy of smear from the
cornea or of a skin biopsy
• Brain examination of dead animals or sacrificed
animals
Treatment
Standardised treatment of all animal bites and scratches;
these should be thoroughly cleansed and flushed with
soap and water.
Antibiotics and tetanus toxoid should also be administered.

Administration of antirabies vaccine as soon as possible
after exposure.

53
The human diploid vaccine may be used as follows:
Condition of animal Treatment in case of:

Bite Lick
Healthy, vaccinated
with valid certificate None
Healthy, not vaccinated None
None
Unknown or escaped Vaccine + serum

Vaccine
Rabid or suspected Vaccine + serum
Recommended regimen
1 dose to be given on day 0; day 3; day 7; day 14 and
day 28.
If the animal is proved to be healthy after the tenth day,

no more vaccine is necessary.
All bites by rabid dogs should be reported to the Veterinary

Office.
Prevention
Veterinary precautions, which include vaccination of
domestic animals, eradication of stray dogs and
surveillance control of the epidemiological situation in
the wildlife population.
Pre-exposure vaccination:
This is administered to high-risk population groups, e.g.
veterinary staff and wildlife department personnel.Two

54
doses of human diploid vaccine with one month’s interval,
followed by a booster after one year. Repeat booster
after every three years.

55
2.5. Commonly Used Anticonvulsants in Adults
SEIZURE TYPE First-line Starting dose Commonest Daily Dose Maintenance Dose Dosage Interval
Partial Seizures
Simple Partial Carbamazepine 100-200mg 800mg 400-2000mg 2-4 times a day
Complex partial Lamotrigine (monotherapy) 25mg 100mg 100-200mg 1-2 times a day
Secondary Generalized (Adjunctive VP) 25mg 25-50mg 100-200mg 1-2 times a day
(Adjunctive W/T VP) 50mg 300mg 200-400mg 1-2 times a day
Valproate 50mg 300mg 200-400mg 2 times a day
Phenytoin 100-200mg 300mg 100-700mg 1- 2 times a day
Generalised Seizures Ethosuximide 500mg 1000mg 500-2000mg 1-2 times a day

Abscences Lamotrigine (monotherapy) 25mg 25mg 100-200mg 1-2 times a day
(Adjunctive VP) 25mg 25mg 100-200mg 1-2 times a day
(Adjunctive W/T VP) 50mg 300mg 200-400mg 1- 2 times a day
Valproate 600mg 1000mg 1000-2000mg 2 times a day
Atomic/clonic Lamotrigine (monotherapy) 25mg 25mg 100-200mg 1-2 times a day

(Adjunctive VP) 25mg 25mg 100-200mg 1-2 times a day
Valproate Sodium 600mg 1000mg 1000-2000mg 2 times a day
Tonic – Clonic Carbamazepine 100-200mg 800mg 400-2000mg 2-4 times a day

Lamotrigine (monotherapy) 25mg 100mg 100-200mg 1-2 times a day
(Adjunctive VP) 25mg 25-50mg 100-200mg 1-2 times a day
Myodonic Clonazepam 1mg 6mg 4-8mg 1 at night (3-4 times a day)

SEIZURE TYPE Second-line Starting Dose Commonest Daily Dose Maintenance Dose Dosage Interval
Partial Seizures
Simple Partial Acetazolamide 250 mg 500-750mg 250-1000mg 3-4 times a day
Complex partial
Secondary Generalized Gabapentin 300mg 600-2400mg 900 – 1200mg 3 times a day
Phenobarbitone 30-60mg 120mg 60-240mg 1-2 times a day
Generalized Seizures
Absences Acetizolamide 250 mg 500-750mg 250-1000mg 3-4 times a day
Clonazepam 1mg 6 mg 4-8mg 1 at night (or 3-4 times a day)
Atomic/clonic Acetazolamide 250mg 500-750mg 250-1000mg 3-4 times a day

Carbamazepin 100-200mg 800mg 400-2000mg 3 times a day
Phenobarbitone 30-60mg 120mg 60—240mg 1-2 times a day
Phenytoin 100-200mg 300mg 100-700mg 1-2 times a day
Tonic – Clonic Acetazolamide 250mg 500-750mg 250-1000mg 250-1000mg

Gabapentin 300mg 600-2400mg 600-2400mg 600-2400mg
Phenobarbitone 30-60mg 120mg 60-240mg 1-2 times a day
Myodonic Acetazolamide 120mg 500-750mg 250-1000mg 3-4 times a day
Commonly Used Anticonvulsants in Children
Condition First-line Starting dose Target dose Incremental Dose Interval Usual Frequency
(mg/kg per 24 for initial Size (mg/kg per (days) Effective dose of dosing
hours) assessment of 24 hours) (mg/kg per 24 (times per 24
effect (mg/kg per hours) hours)
24 hours)
Partial Seizures
Simple Partial Carbamazepine 5 12.5 2.5 3-7 12-25 2-3
Complex partial Lamotrigine (monotherapy) - - - - - -
Secondary Generalized (Adjunctive VP) 150microgram 300microgram 14 1-5 1-2
(Adjunctive W/T VP) 300microgram 300microgram 14 1-5 1-2
Valproate 5-7.5 30 10 10 12.5-15 2
Phenytoin 1.5-2.5 7 2.5-5 10 5-9 1-2
Generalised Seizures Ethosuximide 5 15 10 15 10-20 2
Abscences Lamotrigine (monotherapy) - - - - - -
(Adjunctive VP) 150microgram 150microgram 150microgram 150microgram 1-5 1-2
(Adjunctive W/T VP) 300microgram 300microgram 300microgram 300microgram 1-5 1-2
Valproate 5-7.5 5-7.5 5-7.5 5-7.5 12.5-15 2
Atomic/clonic Lamotrigine (monotherapy) - - - - -
(Adjunctive VP) 150microgram 150microgram 150microgram 150microgram 150microgram -
(Adjunctive W/T VP) 300microgram 300microgram 300microgram 300microgram 300microgram 1-2
Valproate Sodium 5-7.5 5-7.5 5-7.5 5-7.5 5-7.5 1-2
2
Tonic – Clonic Carbamazepine 5 12.5 2.5 3-7 12-25
Lamotrigine (monotherapy) - - - - -
(Adjunctive VP) 150microgram 150microgram 150microgram 150microgram 150microgram 2-3
(Adjunctive W/T VP) 300microgram 300microgram 300microgram 300microgram 300microgram -
Valproate Sodium 5-7.5 5-7.5 5-7.5 5-7.5 5-7.5 150microgram
Myodonic 300microgram
Clonazepam 50microgram 1 1 50microgram 1 5-7.5
Valproate Sodium 5-7.5 5-7.5 5-7.5 5-7.5 12.5-15 1
2
SEIZURE TYPE Second-line Starting dose Target dose for initial Incremental Size Dose Interval Usual Effective Frequency
(mg/kg per 24 assessment of effect (mg/ (mg/kg per 24 (days) dose of dosing
hours) kg per 24 hours) hours) (mg/kg per 24 (times per 24
hours) hours)
Partial Seizures
Simple Partial Acetazolamide 2.5 7.5 5-7 1 5-7 2-3
Complex partial
Secondary Generalized Gabapentin 10 10 0 1,2,3 10-20 1-
Phenobarbitone 1-1.5 1-1.5 2 1 2.5-5 1-2
Generalized Seizures
Absences Acetizolamide 2.5 7.5 5-7 1 5-7 2-3
Clonazepam 50microgram 1 1 50microgram 12.5-15 1
Atomic/clonic Acetazolamide 2.5 5-7.5 5-7 1 5-7 2-3

Carbamazepin 5 10 2.5 3-7 2.5-5 2-3
Phenobarbitone 1-1.5 1-1.5 2 1 2.5-4 1-2
Phenytoin 1.5-2.5 7.5 2.5-5 1 2.5-5 2
Tonic – Clonic Acetazolamide 2.5 5-7.5 5-7 1 5-7 2-3

Gabapentin 10 10 0 1,2,3 10-20 1
Phenobarbitone 1-1.5 1-1.5 2 1 2.5-4 2-3
Myodonic Acetazolamide 2.5 5-7.5 5-7 1 5-7 2-3

56
57
58
Uncomplicated Moderately Severe and complicated
Malaria severe Malaria malaria
Fever (<_37.5 0C) Nausea Severe anaemia (Hb<5g/

dl)
Headache Vomiting Jaundice
Sweats and chills Dehydration Drowsiness
Body pains Diarrhoea Shock
Acute gastroenteritis Extreme weakness Convulsions
Respiratory distress
Unconsciousness/coma
Change in behaviour
Hyperparasitaemia
Prostration, i.e.,
generalized weakness,
inability to stand or walk)
Abnormal bleeding

59
Table 2:
Age Weight Number of tablets Artemether (A) +

(years) (kg) per dose 0h, 8h, Lumefantrine (L)
24h, 36h, 48h, 60h per dose
<1 <5 Not recommended
1 -5 5-14 1 20mg A + 120mg L
6 -8 15-24 2 40 mg A + 240mg L
9 -12 25-34 3 60mg A + 360mg L
Over 12 >35 4 80mg A + 480mg L

60
Wt (kg) Age (years) Number of Tablets
5-10 2-11months 0.5
10.1-14 1-2 0.75
14.1-20 3-5 1
20.1-30 6-8 1.5
30.1-40 9-11 2
40.1-50 12-13 2.5
>50 14+ 3

61
Age Years Number of tablets per dose
<1 0.25
1-3 0.5
4-6 0.75
7-11 1
12-15 1.5
15+ 2

62
63
64
65
66
67
68
Adults Paediatrics
Category I Category II Category I Category II
New smear Smear + New uncom- Re-treatment

positives (+) re-treatment plicated cases cases and
Smear negative cases including of TB severe, compli-
(-) and extra treatment fail- cated TB. i.e.,
pulmonary ure, treatment TB meningitis,
after default, miliary TB,
and relapses for spinal TB
smear positive
cases

69
a) Recommende Adult Treatment Dosage
i. Category I New smear positive patients
Intensive phase 2 Continuation Phase 6

months months
Weight in Kg
RHZE EH
30-37 2 1
38-54 3 2
55-70 4 3
>70 5 3
Intensive Phase 3 months

Continuation
2 moths 1 month Phase 5 months
Weight RHZE + S RHZE RHE
30-37 2 0.5g 2 2
38-54 3 0.75g 3 3
55-70 4 1.0g 4 4
>70 5 1.0g 5 5

70
Continuation phase
Intensive phase 2months
Weight in Kg 4 months
RH + Z RH
6 –11 1/2 1/2 1/2
12 – 18 1 1 1
19 – 26 1 1/2 1 1 1/2
27 – 37 2 1 1/2 2
> 38 3 2 3
Weight Intensive Phase 3 months Continuation

Phase
2 moths 5 months
RHZE
R + RHE
+
6 -11 1/2 1/2 0.1g ½
12 - 18 1 1 0.2g 1
19 - 26 1 1/2 1 0.5g 1½
27 - 37 2 1 1/2 0.5g 2
>38 3 2 0.5g 3

71
72
73
before and during treatment with these drugs. Patients
74
treatment.
75
76
77
78
79
80
81
missed), death is likely to occur.
82
•

83
84
85
Syndrome Causal Recommended Recommended
Pathogens regime regime for children
Urethral Neissera Ciprofloxacin 500mg Spectinomycin

Discharge Gonorrhea stat 40mg/kg IM stat
Plus (maximum 2g stat)
Doxycycline 100 bd >8years old
X 7/7 Erythromycin
Chlamydia 50mg/kg/day in 4
doses for 14 days

86
87
Neonatal Gonorrhea Spectinomycin 50mg/kg
Conjunctivitis IM stat
Plus Plus
Chlamydia Erythromycin 50mg/kg PO
QID X 7 days
Normal Saline lavage of the

affected eye

88
89
90
Vaginal Neisseria Adults: Children:
Discharge gonorrhoeae Ciprofloxacin Spectinomycin
and lower 500mg PO stat 40mg/kg IM stat
Abdominal Plus (maximum 2g stat)
Pain Doxycycline 100
bd PO X 7/7 >8years old
Erythromycin
50mg/kg/day in 4
doses for 14 days
Plus
Chlamydia Metronidazole
Metronidazole 5mg/kg body
Trichomoniasis 2g PO stat weight
Plus
Bacterial
Vaginosis
Fluconazole
Vaginal 150mg PO stat
Candidiasis

91
92
93
94
95
Inguinal Buboe Chancroid Ciprofloxacin 500mg PO
BDX3 days
Lympho granuloma Doxycycline 100 BD X
Venerium 14days

96
97
Genital Ul- Syphilis Benzathine Benzathine Peni-
cer Disease Penicillin 2.4M.U cillin 50 000units/
IM weekly X 3 kg IM weekly X 3
doses doses
Chancroid Ciprofloxacin
500mg PO BDX3
days
Acyclovir 20mg/kg
Herpes Gen- Acyclovir 400mg 8 hourly for CNS
italis TDS X 7 days and disseminated
disease; extend
therapy to 21days;
for disease limited
to skin and mu-
cous membranes
for 14 days
Lympho granu- Doxycycline 100

loma Venerium BD X 14days

98
99
100
Genital Genital warts Podophylline Cauterisation
growths (Condylomata 25% topically (i) 0 5 - fluorouracil
Acuminata) by physician cream
weekly till (ii)Trichloroacetic acid
resolved (iii) Cryosurgery
(iv) Electro cauterisation
Benzathine (v) Laser vapourisation
Penicillin 2.4 (vi) Surgical removal
MU IM weekly
for 3 doses
Benzathine Penicillin 50
Condylomata 000iu/kg IM weekly for3
lata doses

101
102
Hepatitis B Hepatitis C
Incubation 60 – 180 days 15 – 180 days
Transmission Blood borne Blood borne

Sexual Sexual
Progression to Occasionally varies Usually

chronicity by age
Etiologic agent Hepatitis B Virus Hepatitis C Virus
Comments Vaccine available Not available
Serologic diagnosis HBsA, IgM anti-HBc HCV RNA; anti HCV

103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
Clinical Stage CD4 available CD4 not available
I CD4 guided Do not treat
II CD4 guided Total Lymphocyte Count <1200*
III Treat Treat
IV Treat Treat
*CD4 count strongly recommended
CD4 count (cell/mm3) Recommendation
<350 Treat all irrespective of clinical

stage
Note: Measure CD4 after stabilization of any inter-current illness

120
Condition Recommendation
HIV positive partner in Discordant Treat all irrespective of CD4 count

Couple (see below)
Hepatitis B Virus Infection (chronic
hepatitis B)*
*Patients testing HBsAg positive with CD4 counts greater than 350
cells/mm3 should have ALT or AST checked and if elevated initiate
HAART. For patients with normal baseline ALT or AST recheck both
ALT or AST and HBsAg in 6-12 months.
If ALT or AST are elevated, or persistent HBsAg then start ART
rregardless
e of CD4 count or WHO staging. If signs of liver cirrhosis an
positive HBsAg start HAART regardless of ALT or AST values.
CD4 count (cell/mm3) Follow Up Actions
>500 Schedule follow up visits for every

6 months
350-500 Schedule follow up visits for every

3 months, with
CD4 count every 6 months

121
122
123
First Line Regimen Second Line Regimen
TDF*/FTC or 3TC EFV 3TC2 LPV/r6

or or
NVP3 AZT1 TDF/FTC5
or 3TC
d4T4/3TC2
* TDF has been associated with renal toxicity: if CrCl <50 ml/min,
initiate therapy with ABC/3TC
1. AZT/3TC/LPV/r is preferred second line regimen for patients

failing Tenofovir based first line.
2. Lamivudine (3TC) or Emtricitabine (FTC) are continued in the
second line regimen because their resistance mutations decrease
viral replication capacity, increase the HIV susceptibility to
Tenofovir (TDF) and AZT
3. For women who have had exposure to sdNVP without tail
coverage with 7 days of AZT + 3TC within the last 12 months
(for PMTCT), do not use a Nevirapine or Efavirenz containing
regimen, use LPV/r. If unsure whether tail coverage for sdNVP
was provided then use LPV/r
4. Stavudine (d4T) is associated with long term toxicity and should
only be used in the second line if AZT cannot be taken
5. TDF mutations can increase HIV susceptibility to AZT and may
increase AZT efficacy, while TDF may maintain some activity
6. If unable to tolerate LPV/r then refer to HIV Specialist.
1. Lamivudine (3TC) or emtricitabine (FTC) are continued in the

second line regimen because their resistance mutations decrease
viral replication capacity. increase the susceptibility to Tenofovir
(TDF) and AZT.
2 If unable to tolerate LPV/r then refer to HIV Specialist for
additional options
3 For women who have had exposure to Nevirapine within 6 months
for PMTCT, do not use a Nevirapine containing regimen.
4 3TC resistance reduce efficacy of ABC, therefore, Didanosine
(ddI) will be substituted for 3TC.
5. D4T should only be used in doses of 30mg to avoid adverse
effects and toxicity.

124
TDF has been associated with renal toxicity: If CrCl <50 ml/min ,
initiate therapy with ABC/3TC
1. AZT300/3TC150/LPV/r 133.3/33.3is preferred second line
regimen for patients failing tenofovir based first line
2. Lamivudine150 (3TC150) or emtricitabine (FTC200) are continued
in the second line regimen because their resistance mutations
decrease viral replication capacity, increase the susceptibility to
tenofovir (TDF/300) and AZT.
3. Tenofovir (TDF) mutations can increase susceptibility to AZT and
may increase AZT efficacy, while TDF may maintain some activity
4. Stavudine (D4T) is associated with long term toxicity and should
only be used in the second line if AZT cannot be taken
5. If unable to tolerate LPV/r then refer to HIV Specialist for
additional options
6. For women who have had exposure to nevirapine within 6 months
for PMTCT, do not use a nevirapine containing regimen.

125
Timeline Clinical Laboratory Other
Baseline Complete History & Physical (including ART Creatinine* (preferable for all RPR (repeat yearly)
2 weeks (1st month) history, current meds cases but required if to start TDF)
preferably (next 3 months Counselling/Education ALT and/or AST** PAP smear (if
unavailable, then
(required if to start NVP) visualization
Risk Reduction with acetic acid
126
Hb,WBC (required if to start AZT) screaning)
Adherence
Complaints

CD4
Fears If available, HBsAg
New illnesses Urine protein Pregnancy testing in women of

reproductive age
if available chemistry panel to include glucose,
cholesterol, triglycerides
Counselling/Education If on NVP-ALT and/or AST

Risk Reduction
Every month for first 3 months Adherence
Complaints
127
Fears
Side effects
New illness/IRIS

At 3 months visit next 6 months As above If on AZT-Hb
If on NVP-ALT
If on TDF- Creatinine*
viral load if available
Repeat PAP at
6 months and if
normal every 12
months
Targeted history & physical If on TDF- Creatinine*
If visual screen only
128
Counselling/Education with acetic acid,
WBC,Hb,ALT repeat as with Pap
smear if normal; if
CD4, viral load abnormal, refer for

Every 6 months throughout. Risk Reduction if available treatment
If on Pl containing regimen, con-

sider Chemistry profile (including
Adherence LFTs, glucose, cholesterol, and
Complaintsside effects triglycerides) on a yearly basis
Fears if normal, if abnormal, treat as
New Illness indicated.
129
130
131
132
•

133
134
135
136
Recommendations
Situation Age When to Start When to Stop
HIV Exposed 4-6 weeks Initiate Discontinue

Infant of age (or Cotrimoxazole Cotrimoxazole
when first prophylaxis prophylaxis
(Defined as a recognized) in ALL infants after exclusion
child born to born to an HIV of HIV infection.
an HIV infected infected mother 3 weeks after
mother or irrespective complete
breastfeeding of any ARVs cessation of
from an HIV received during breastfeeding
infected pregnancy and/ (PCR is
mother, until or labour. negative or
infection can be antibody test is
excluded. negative)

137
Situation Age When to Start When to Stop
HIV Infected 24 months Cotrimoxazole Children <5

infant prophylaxis years:
is indicated Maintain on
(including all regardless of Cotrimoxazole
infants identified CD4 percentage prophylaxis
as HIV infected or clinical status until age 5 years
during the first or WHO stage irrespective
year of life by of clinical and
PCR or clinical immunologic
diagnosis of 24 months WHO clinical response
HIV infection to 4 years stages 2,3 and
with positive 4 regardless of Children > 5
antibody test) CD4 percentage years:
OR any WHO Can be
stage and CD4 reassessed and
<25% consideration
to discontinue
< 5 years Follow adult
Contrimoxazole
recommenda-
prophylaxis
tions
should be in
Presumptive 18 months Start (or accordance with
Symptomatic continue) CTX recommenda-
HIV Disease prophylaxis tion for adults
regardless of and adoles-
CD4. cents.
Any Child with a All ages Administer

history of PCP secondary
prophylaxis

138
139
Criteria < 2years of age* ≥2 years to <5 years of age ≥5 years of age
WHO Staging New

N ew stage 3 or
o 4 event (appearance or
CD4% %CD4+ values fall to <25% %CD4+ <15% n/a
CD4 Absolute n/a ≤200

2 cells/mm3 ≤200 cells/mm3 or
140
50% fall from on-treatment peak or 50% fall from on-treatment peak or
Fall below the base line Cd4 count. Fall below the base line Cd4 count.
*For children under two years, consultation with experienced clinician is required

Preferably, at least two CD4 measurements should be available. Use of %CD4+ in children <5 years and absolute CD4 counts in
those ≥5 years of age is preferred. If serial CD4 values are available, the rate of decline should be taken into consideration.
Recommend second-line regimen: boosted PI component + two NRTI components
First-line regimen Preferred second-line regimen
at failure
AZT/d4t+3TC+ NVP/EFV ABC + 3TCa + LPV/rc
or
TDF+FTC/3TC (in children >12 years of age)
AZT + 3TC+ LPV/r
141
ABC + 3TC+ NVP/EFV
ABC+3TC+AZT/d4t 3TC + EFVb /NVP+LPV/r

or
TDF+FTC/3TC +LPV/r (in children >12 years of age)
(In consultation with paediatric HIV specialist)
AZT/d4t+3TC+LPV/r ABC+3TC+NVP/EFV
ABC+3TC+LPV/r AZT+3TC+NVP/EFV
(In consultation with paediatrics HIV specialist)
142
143
Symptom
Nausea Severe discomfort or minimal intake for > 3 days
Vomiting Severe vomiting of all foods/fluids in 24 hours or

orthostatic hypotension or IV therapy required
Diarrhoea Bloody diarrhoea or orthostatic hypotension or IV

therapy required
Fever Unexplained fever of > 39.6 C (103 F) > 1-2 weeks
Headache Severe or requires narcotic therapy
Rash Moist desquamation, ulceration, or mucous

membrane involvement, suspected Stevens-
Johnson , Toxic Necrolysis(TEN) erythema
multiforme, exfoliative dermatitis, or necrosis
requiring surgery
Allergic reaction Angioedema or anaphylaxis
Peripheral Severe discomfort, objective weakness, loss of

neuropathy 2–3 previously present reflexes or absence of 2–3
previously present sensory dermatomes
Normal activity reduced <50%

Fatigue

144
Parameter Grade 3 toxicity
Hematology
Hemoglobin < 7.0 g/dl
Absolute neutrophil count < 250 mm3
Chemistries
Bilirubin > 3.0–7.5 x upper limits of normal
Creatinine > 1.2–1.5 (<2 yr), 1.7–2.0 (>2yr)
Liver function tests
AST (SGOT) > 10 upper limits of normal or rapidly

increasing
ALT (SGPT) > 10 upper limits of normal or rapidly

increasing
Pancreatic enzymes
Amylase, lipase > 2–3x upper limits of normal

145
New or recurrent Management options b,c,d
event on ART
No New events Do not switch to new regimen

or PLG (T1) Maintain regular follow up
Stage 2 events Treat and manage staging event

(T2) Do not switch to new regimen
Assess and offer adherence support
Assess nutritional status and offer support
Schedule earlier visit for clinical review and
consider CD4

146
Stage 3 events Treat and manage staging event and monitor
(T3) response
Check if on treatment 24 weeks or more
Check CD4f – where available
Institute more frequent follow-up
Consider switching regimen
Stage 4 events Treat and manage staging event

(T4) Check if on treatment 24 weeks or more
Check CD4f – where available
Switch regimen

147
148
First-line Preferred second-line regimen
regimen at [A(II)]*
failure
RTI components PI components
(NRTI/NNRTI)a
2 NRTI + NNRTI ddlc + ABCd LPV/rf

AZT-or d4T- plus or
containing SQV/r9
or
ABC-containing ddlc AZT NFVh
Triple NRTI ddlc + EFVa or NVP
* Strength recommendation/level of evidence.

149
150
Risk factor Prevention/mitigating intervention
High viral load Antiretroviral therapy in pregnancy
Low CD4 count As above + PCP prophylaxis
Advanced Diseases ART. PCP and TB prophylaxis OI treatment

(AIDS)
Chorioamnionitis Identify & treat STI and malaria
Malaria Provide malaria prophylaxis during pregnancy,

IPT & ITNs
Low Vit. A Maternal Vit. A supplementation does not reduce

MTCT
Pre-maturity Comprehensive antenatal care, identify at risk

mothers, provide PCP prophylaxis
Prolonged rupture Comprehensive ANC, safer delivery practices

of Membranes and modified obstetric care
Invasive delivery Discourage scalp vein monitoring, vacuum

procedures extraction, episiotomies and nasal suction
Cracked nipples Counseling on optimal breast feeding practices

& breast care
Breast-feeding Counseling on infant feeding options: EBF, early

and rapid cessation, replacement feeding etc

151
152
153
154
Drug Pediatric Dose Adolescent Dose
AZT 180mg/m2/12 hrs 300mg twice a day
³50kg 150mg 12
hourly
<50kg 2mg/kg 12
3TC 4mg/kg/12hrs hourly
Nelfinavir 55mg/kg/12hours 750mg 8 hourly

155
Frequency of tests Hospital Level 3
Level 1, Level 2
2 weeks after of FBC, LFT, U&creat, FBC, LFT, U&creat,

initiation blood sugar, blood sugar, lipids,
CPK, amylase
3 months after FBC, LFT, U&creat, FBC, LFT, U&creat,

initiation blood sugar blood sugar, CD4,
Viral load
6 monthly FBC, LFT, U&creat, FBC, LFT, U&creat,

blood sugar blood sugar, CD4,
Viral load
Yearly in addition RPR, PAP smear RPR, PAP smear

156
157
Reason for failure Action What to do
Poor compliance Review reasons for Continue with same

within 8-16 weeks of poor compliance and combination or
therapy counsel accordingly. simplify dosing.
Poor compliance > 16 Consider changing Change two drugs.

weeks of therapy therapy.
Review reasons for
poor compliance.
Treatment failure Change therapy. Use drugs not used

in previous regimen
preferably new
classes.
Adverse drug reaction Check drug –drug Change the offending

interactions. drug.
Stop the drugs if
continuation is of no
benefit to the patient.
Depression Psychosocial support Refer to appropriate

care provider

158
Risk Category ARVT Duration
No Risk:
Intact skin No recommendation
Medium Risk: AZT: 300mg po 12

Invasive injury hourly
No blood visible on 3TC: 150mg po 12
needle hourly
Plus LPV/r* 28 days
High risk:
Large volume of AZT: 300mg po 12
blood/fluid, known hourly
HIV infected patient, 3TC: 150mg po 12
hollow bore needle, hourly
deep extensive injury Plus LPV/r* 28 days
**for patients with hemoglobin less the 10gm/dl replace AZT/3tc with
TDC/FTC

159
Generic name Recommended dosage Special Instructions Adverse effects Adverse effects
(trade name) Minor & frequent Serious dose limiting
Nucleoside Reverse Transcriptase Inhibitors
Zidovudine 250mg bid Coution in Nausea Anaemia
Liver or renal insufficiency
ZDV.AZT Preexisting anaemia Headache Leucopaenia
160
(retrovir) fatigue Lacticacidosis
muscle pains
Didanosine 200mg bid To increase absorption Neuropathy Pancreatitis
DdI <60kg 100mg bid take 1 hour before food Nausea

(videx) Contains antacid so may diarrhea Lacticacidosis
affect absorption of other
drug
Generic Name Recommended dosage Special Instructions Adverse effects Adverse effects
(trade name) Minor & frequent Serious, dose limiting
Lamivudine 150mg Generally well tolerated Lacticacidosis

3TC bid
(epivir)
Stavudine 40mg bid Caution in liver Neuropathy Lacticacidosis

D4T <60kg 30mg bid insufficiency
(zerit)
161
Abacavir 300mg bid Caution in: Nausea Hypersensitivity reaction
Liver or renal insufficiency Poor apetite
(ziagen) DISCONTINUE Vomiting
if sysmptoms of fatigue, sleep disturbance

hypersensitivity
Zalcitibine 0.75mg tid Neuropathy Pancreatitis

DdC <40kg 0>375mg tid Oral ulcers Lacticacidosis
(hivid_
Generic Name Recommended dosage Special Instructions Adverse effects Adverse effects
(trade name) Minor & frequent Serious, dose limiting
Lamivudine + Zidovudine 1 tab bid Caution in: Nauseas Anaemia

(Combivir) Liver or renal insufficiency Headache Leucopaenia
Pre-existing anaemia Fatique Lacticacidosis
Muscle pains
Non-Nucleoside reverse transcriptase inhibitors
Efavirenz 600mg nocte Caution in liver disease Skin rash hepatitis
162
(sustiva,stocrin) neurological disturbance
Abn LFTS
Nevirapine 200mg od for 14 days Caution in liver disease Skin rash hepatitis

virimmune) followed by 200mg bid Abn LFTS
Delavirdine 400mg tid Caution in liver disease Skin rash Hepatitis

rescriptor) Headaches
Abn
LFTS
Protease inhibitors
Saquinavir Take with high fat meal Diarrhoea Hyperglygaemia

Hard gel capsule (invirase) 600mg tid Caution in liver disease Nausea Lipodystophy
soft gel capsue (fortovase) 1600mg bid Abn LFTS Abn.
bleeding
Ritonavir 600mg bd Capsules require Nausea Diarrhoea Hyperglycaemia
163
(norvir) (start with 300mg bd then refrigeration Better Weakness Lipodystrophy
increase over 10/7 tolerated with food Skin sensitivity Abn.
Perioral tingling bleeding
Change in taste

Indinivir 800mgtid Take on empty stomach Nausea Kidney stones
(crixivan) Drink 1.5 fluid per day Abdo pain Hypergly
Report loin pain or Headqache Caemia

haematuria Lipodystrophy
Abn bleeding
Nelfinavir 750mg tid Take with food Diarrhoea Hyperglycaemia

(viracept Nausea Lipodystrophy
Flatulence Abn. bleeding
Skin rash
164
Amprenavir 1200mg bid Decreased absorption if Nausea Hypersensitivity rash
(agenerase) taken with fatty meal Vomiting
Diarrhoea

Altered taste
Mood disorders
Perioral numbness
165
4
DISEASES AND CONDITIONS
AFFECTING ENDOCRINE
SYSTEM
4.1� DIABETES MELLITUS
Definition
Diabetes is a chronic disease characterized by persistently
elevated blood glucose due to either:
i an absolute or relative deficiency of insulin
or
ii a defect in the action of insulin (insulin resistance), in
addition to a defect in the metabolism of fats, proteins,
and electrolytes leading to short term and long term
complications.
There are two main types:
a) Type 1 diabetes mellitus (T1DM)
b) Type 2 diabetes mellitus (T2DM)
Other types are neonatal diabetes, which occurs before the

age of 6 months, Maturity Onset Diabetes of the Young
(MODY), and diabetes secondary to other conditions like
surgery, pregnancy, endocrine disorders, drugs and others.
Diagnosis
In most cases, the diagnosis of diabetes is not difficult. The
classic symptoms of diabetes with a fasting plasma glucose
of > 7mmol/L or a random plasma glucose of > 11.1 mmol/L
is adequate. The test must be repeated on at least one
other occasion. This is a blood sample from venous blood
NOTE: Urine glucose can only be used as a preliminary
screening tool in the absence of blood glucose. The patient
should be sent to a level where blood glucose can be done.

166
If only a glucometer is available, then the fasting capillary
glucose level used is > 6.1mmol/L, but the random
capillary glucose remains at > 11.1 mmol/L.
NB. Casual or random is defined as any time of the day
without regard to time since last meal. Fasting is defined
as no caloric intake for at least 8 hours.
Type 1 Diabetes mellitus (T1DM)
This was also previously referred to as Insulin Dependent

Diabetes Mellitus (IDDM). It usually occurs in children
and young adults. Occasionally, it can be found in adults.
Clinical features
Type 1 diabetes patients often present in an acute state.
Clinical characteristics at diagnosis
Symptoms
• Blurred vision
• Frequent urination (polyuria)
• Increased thirst (polydipsia)
• Increased hunger (polyphagia)
• Weight loss but can be normal/underweight
• Tiredness/weakness
Signs
• Weight loss
• Dehydration
Laboratory findings
• Elevated blood glucose
• Ketoacidosis
Treatment
All newly diagnosed patients need to be referred for
initiation of treatment and stabilisation.

167
Drugs
Soluble insulin on its own or mixed with isophane insulin
(0.6 - 1.5 units/kg) subcutaneously over 24 hours in 2
or 3 divided doses per day. Adjust dose to keep the blood
sugar levels between 6 - 8 mmol/L.
Dietary control
• Avoid sugar and sugar containing foods and drinks.
• Take meals regularly.
• Consult nutritionist or dietician on diet modification
Supportive
Monitor the following:
• Blood pressure
• Renal function
• Blood glucose
• Hydration
• Serum electrolytes and minerals
• Urine sugar
• Urine ketones
Treat infections if any.
Teach patient and carers about disease and its
management.
Encourage regular exercise
Regular review of patient at specialist clinic/hospital
4.2� TYPE 2 DIABETES MELLITUS (T2DM)
This was also previously known as Non-Insulin Dependent

Diabetes Mellitus (NIDDM). It usually occurs in older
people and its onset is insidious.
Clinical features
These may be mild and may not cause the patient to
seek medical attention. This condition is often discovered
when a complication arises. There is usually a delay of
many months or years from onset to diagnosis.

168
The following are the common features:
Symptoms
• Obesity
• Blurred vision
• Frequent urination/polyuria
• Bedwetting
• Increased thirst/polydipsia
• Weight loss
• Infarct/angina
• Stroke
• Susceptibility to infections
eg genito tract/urinary tract infections (vulva itching
in women)
• Claudication
• Paraesthesia / pain
• Foot ulcer
Signs
• Dehydration
• Weight loss
Investigation findings
• Elevated blood glucose
• Blood lipid abnormalities
Treatment
Diet and Exercise
Diet and exercise are the mainstay in treatment of T2DM.
This should be tried first in all patients except those with
very high glucose levels and those who are severely
symptomatic. Those who fail to respond to diet and
exercise can then move on to taking drugs.
Drugs
The two main classes of drugs used in Zambia are
sulphonylureas and biguanides.

169
Sulphonyureas
• Glibenclamide. Initially can be given orally once a
day or in two divided doses. Usual dose is 5mg
orally daily taken before breakfast up to a maximum
of 20mg in divided doses before food, depending
on the patient’s response. Doses above 20mg will
not result in any improvement in glucose control.
• Chlorpropamide 250mg orally once a day taken with
breakfast. Dosage may be adjusted to a maximum
of 500mg depending on the patient’s response.
• Sulphonylureas can be given together with
biguanides.
Biguanides
Metformin.
This is the preferred drug in obese patients in addition
to dietary control and exercise. It may also be added in
patients who have reached the maximum dose of a
sulphonylurea without achieving adequate control of
blood sugar levels.
• Metformin 500mg orally 2-3 times daily or 850mg
orally 2-3 daily with or after food. Maximum dose
is 2.55g daily in divided doses.
NOTE:
Dosage increments in oral antidiabetic drugs should
be gradual i.e. at 1 to 2 week intervals.
Insulin
Insulin may be used alone or added on if the combination
of sulphonylurea and biguanide fails to achieve adequate
control of blood sugar.
Insulin is available in two types of preparations:

i. Short duration, soluble forms, for rapid onset of
action
ii. Intermediate duration

170
Most patients are best started on intermediate action
insulin twice daily and a short-acting form may be added
to control any hyperglycaemia which may follow breakfast,
lunch or supper.
It is important to note that variability in absorption within

the same individual and between two individuals can
happen.
Insulin doses should be calculated and determined on an

individual patient basis, gradually increasing the dosage
until the patient stabilises. Care should be taken not to
cause hypoglycaemia.
If diabetes control is poor on diet, exercise and oral drugs,

do not delay starting insulin.
Withdrawal of oral (sulphonylureas & biguanides) drugs

should be commenced only after the insulin therapy has
been initiated. In some patients, metformin and insulin
combination can be given.
Supportive
• Monitor blood glucose levels regularly
• Prescribe appropriate diet
• Careful weight reduction in obese patients
• Encourage regular exercise
• Regular review of patient at specialist clinic/hospital
• Educate patient and carers
Patient and carers education

Patients and carers should be educated on the following:
• Identification of symptoms of hypoglycaemia
• Principles of foot care
• Injection techniques and how to look after syringes
and insulin
• Types of insulin preparations available

171
• Monitoring blood glucose or urine glucose
• Diet control i.e. meal intervals depending on type
of insulin.
Notes
Weight reduction for obese patients and appropriate
diet are key in the process of managing diabetes
mellitus.
Dietary control and exercise should be continued
alongside drug therapy.
4.3� HYPERGLYCAEMIC/KETOACIDOSIS �
COMA/PRECOMA
Definition
Severe uncontrolled diabetes with very high blood sugar
requiring emergency treatment with insulin and
intravenous fluids and with a blood ketone body
concetration of greater than 5mol/L, the common
precipitating causes are infection, management errors
and new cases of diabetes, but there is no obvious cause
in about 40% of episodes.
In Africa, DKA carries a high mortality – through delayed

diagnosis, inadequate treatment and late presentation.
It presents at any age although there is a well defined
peak at puberty.
Clinical features of diabetic ketoacidosis

• Polyuria, nocturia, thirst
• Weight loss
• Weakness
• Visual disturbance
• Abdominal pain
• Leg cramps
• Confusion, drowsiness, coma

172
• Dehydration
• Hypotensions
• Tachycardia
• Rapid and deep respiration (kussmaul breathing)
• “Acetone” odour
• hypothermia
Management
Children
Establish and maintain cardiovascular and renal functions.
Correct fluid and electrolyte deficiencies and imbalances.
Give insulin to reduce blood sugar.
Determine the precipitating causes of the crises.

Look out for and prevent any complications.
Fluid and electrolyte replacement:
i. Sodium chloride 0.9%, rapid infusion 20ml/kg in the
first one hour then asses urine output. When blood
sugar falls to between 10 – 16 mmol/L, change to
dextrose 5% in order to prevent hypoglycaemia.
ii. If potassium level is low or normal, add potassium
intravenously 20 – 40 mmol/L of intravenous fluid.
This should be given after insulin therapy has been
commenced.
Insulin
Soluble insulin 0.1 units/kg/hour, give intravenously, as
a continuous infusion. When blood sugar levels reach 10
mmol/L reduce to 0.05 units/kg/hour.
Once the patient has stabilised, manage as for Type 1
diabetes mellitus
Adults
Conduct assessments and investigations as in children
Fluid and electrolyte replacement:
i. Isotonic (normal) saline (sodium Chloride 0.9%) rapid
infusion 1 – 2L in the first one hour then reassess

173
and repeat as needed. Normally 6-8 litres in the
first 24 hours. When blood sugar falls to between
below 14 mmol/L change to dextrose 5% in order
to prevent hypoglycaemia. If sodium level more
than 150 mmol/L give half strength (hypotonic)
saline.
ii. Sodium bicarbonate (600ml of 1.4%, or 100ml of
8.4% in a large cannulated vein) if pH>7.0
iii. Potassium
1. Add dosage below to each 1L of infused fluid:
(a) If plasma K<3.5mmol/L, add 40 mmol KCI
(b) If plasma K 3.5-5, 5mmol/L, add 20mmol KCI
Insulin
i. Soluble insulin 5-10 units (0.1 units/kg/hour
intravenously), as a continuous infusion NOTE: Soluble
Insulin given as an intravenous bolus is rapidly
destroyed within a few minutes. Intravenous insulin
must always be given as a continuous infusion.
When blood sugar levels reach 10 -14 mmol/L
reduce to 2-4U/h (0.05 units/kg/hour) or titrate
against blood glucose levels and when patient is
able to take oral feeds give soluble insulin 2-3 times
before meals.
OR
ii Initially soluble insulin 20 units intramuscularly stat
then 5-10 units intramuscularly hourly until blood
sugar is 14mmol/L. When blood glucose is 10 –
14mmol/L give 8 units 4 hourly subcutaneously
until patient is able to take oral feeds. When patient
is taking food orally, change to soluble subcutaneously
twice or three times before meals.

174
Hypoglycaemia in Diabetes Mellitus
Definition
This is a condition in which the blood sugar falls to lower
than 3 mmol/L with the attendant signs and symptoms
of disorder. The classical clinical features may however
occur at higher levels than this in some patients, especially
those with poorly controlled type 2 diabetes. The causative
factors include inadequate or delayed food consumption,
alcohol consumption, excess insulin dosage or wrong
injection technique, exercise, inattention or combination
of these factors.
Clinical features
Symptoms
• Weakness
• Fatigue
• Sweating
• Hunger
• Abdominal pain
• Headache
• Nausea
Signs
• Pallor
• Tremor
• Tachycardia
• Irritability
• Speech difficulty
• Inco-ordination
• Loss of concentration
• Drowsiness
• Abnormal behavior
• Disorientation
• Convulsions
• Coma

175
Treatment
In all diabetics in coma, with no means of ascertaining
the blood glucose level, give oral or intravenous glucose.
If patient is conscious and able to take orally give a sugar
containing drink or food. If patient is unable to take
orally give:
i. 20 ml of 50% glucose as an intravenous bolus (OR

50 ml of 20% glucose)
ii. Follow up if necessary with intravenous infusion of
10% or 20% glucose, 100ml/hour.
OR
iii. Administer 0.5 mg to 1.0 mg glucagon intramuscularly
or intravenously. IM or IV Glucagon must be followed
by oral glucose
iv. A continuous infusion of 10% or 20% glucose
(dextrose) may be required for 24 to 72 hours if
overdosage of long acting insulin or sulphonylureas
(chlorpropamide or glibenclimide) is the cause of te
hypoglycaemia
Monitor blood glucose regularly and maintain between

6 and 8 mmol/L.
4.4� DIABETES MELLITUS IN PREGNANCY
Diabetes mellitus in pregnancy is usually seen in women

who are already diabetic before pregnancy or have had
a history of diabetes in the family. However, when this
condition occurs in non-diabetics it usually presents in
the second trimester.
All pregnant diabetic patients should be referred for

specialist treatment. Known diabetic patients should be
counselled before conception and the diabetes should
be well controlled both before conception and throughout
the pregnancy. Insulin use and proper diet should control

176
the blood sugar level effectively. (See also chapter 5).

177
5
OBSTETRIC AND
GYNAECOLOGICAL
CONDITIONS
5.1� ANTE-NATAL CARE
The goal of antenatal care is:

• To provide health promotion. e.g., health education,
counselling.and provide supplementation of iron,
folic acid, iodine, calcium and vitamin.
• To prevent common diseases e.g. malaria, anaemia
and neonatal tetanus
• To detect early signs of disease or complications in
the mother and foetus e.g. proteinuria, hypertension,
syphilis, foetal abnormality, malpresentation and
intrauterine growth retardation.
• To provide a Birth Plan
• Place of delivery
• Complication readiness
• Transportation to delivery site
Four quality antenatal visits are recommended, the first

of which should be before 16 weeks of gestation. During
the first visit the following should be done:
• General, obstetric and gynaecological history
• Full physical examination
• Basic investigation i.e. confirmation of pregnancy,
Hb, HIV, RPR, urinalysis and ultrasound where available
• Supplements i.e. haematinics (iron, folic acid,
mebendazole)
• Malaria and tetanus prophylaxis
• Voluntary Counselling and Testing (VCT)
During the second and subsequent visits the following

178
should be done:
• Examine for growth of foetus
• Maternal well being
• Check on medications given previously
• Check presentation of the foetus
• Discuss place of delivery and mode of delivery
• Discuss warning signs / danger signs
• Malaria prophylaxis
• Iron and folic acid supplementation
• ART for PMTCT or HAART
5.2� NORMAL LABOUR
General care
• Encourage women to be with support person at all
times.
• Encourage ambulation and frequent oral fluid intake
• At delivery woman must choose which position to
take
Monitoring of labour
• Use a partogram on all patients
• Check for foetal and maternal well-being and progress
of labour
• Maintain good infection prevention practices
• Provide active management of the 3rd stage:
– After the baby has been delivered onto the
mother’s abdomen, palpate the abdomen to
rule out the presence of an additional baby(s)
and then give oxytocin 10 units intramuscularly
within 1 minute of delivery
Oxytocin is preferred because it is effective 2 to 3 minutes

after injection, has minimal side effects and can be used
in all women. If oxytocin is not available, give ergometrine
0.2mg intramuscularly or prostaglandins e.g., Misoprostol
600mg sublingual. Make sure there is no additional

179
baby(s) before giving these medications.
• Clamp the cord close to the perineum using sponge

forceps (Spencer wells) and deliver placenta using
controlled cord traction. Allow sufficient flow of blood
to the baby before clamping. Hold the clamped cord
and the end of the forceps with one hand. Place the
other hand just above the women's pubic bone and
stabilize the uterus by gently pushing the uterus up.
This helps prevent inversion of the uterus
• Keep slight tension on the cord and await a strong

uterine contraction or rub a contraction. If necessary
use sponge forceps (Spencer wells) to clamp the
cord closer to the perineum as it lengthens. Do not
wait for a gush of blood before applying traction on
the cord
• When the uterus becomes rounded or the cord

lengthens, very gently pull downward on the cord
to deliver the placenta. Continue to stabilise the
uterus with the other hand.
If the placenta does not descend during 20 - 30

seconds of controlled cord traction (i.e. there are no
signs of placental separation), do not continue to
pull on the cord:
– Gently hold the cord and wait until the uterus
is well contracted again. If necessary use a
sponge forceps to clamp the cord closer to the
perineum as it lengthens
– With the next contraction, repeat controlled
cord traction with counter traction.
Immediately following birth

• Gently perform uterine massage
• Provide oxytocics

180
• Estimate blood loss
• Examine for and repair lacerations
• Examine placenta and membrane for completeness
• Provide close surveillance of vaginal bleeding, uterine
hardness and vital signs during the first 6 hours
postpartum:
– Every 15 minutes for the first two hours
– Every 30 minutes for the next one hour
– Every hour for the next three hours
Promote early and exclusive breastfeeding. In the event

of mother being HIV positive, provide counselling on
breastfeeding options
Social support
• Clarify and reposition to first paragraph
• Analgesia in labour
• Pethidine 100mg IM stat
• Naloxone10 micrograms/kg may be given to a
neonate to reverse Pethidine induced respiratory
depression
5.3� ANTEPARTUM HAEMORRHAGE (APH)
Definition
APH is defined as per vaginal bleeding after 22 weeks
of gestation to delivery of the baby.
The main causes of APH are

• Placenta previa
• Abruptio placentae
• Cervical lesions e.g cancer, ectopy, polyp
• Vasa previa
Clinical features
• Painful or painless PV bleeding
• Provoked or unprovoked

181
• High pulse rate
• Low blood pressure
• Air hunger depending on amount of bleeding
• Signs of shock
Investigation must distinguish between placenta previa

and abruptio placentae. No vaginal examination is to be
performed. Speculum examination should only be
performed after placenta previa has been ruled out.
Refer to a hospital
Emergency care
• Normal saline infusion
• Transfer to hospital for confirmation of diagnosis by
clinician or examination by ultra sound scan, where
available, for clinical examination
• Rh-negative patient may need anti D
Note that antepartum haemorrhage is a serious

complication
5.3.1 Placenta previa
Definition
This is a condition in which the placenta is implanted in
the lower segment of the uterus.
Clinical features
• Painless PV bleeding
• ± malpresentation, high presenting part
• Present foetal heart
• Recurrent vaginal bleeds
• Relaxed uterus
Specific management
If the baby is premature and bleeding has stopped,
conservative management is recommended until 36 -
38 weeks:

182
• Keep woman in hospital until delivery
• Cross match 2 units of blood at all times
• Keep haemoglobin at more than 9g using haematinics
or blood transfusion
• Give dexamethasone 25mg
intravenously/intramuscularly in 2 divided doses
• If there is heavy bleeding proceed to caesarean
section
Plan delivery if foetus is mature, dead, or has major

anomalies
5.3.2 Abruptio placentae
Definition
This is a condition in which there is premature separation
of a normally implanted placenta before delivery of baby.
The patient must be referred to a hospital.
Clinical features
• May have been provoked by Artificial Rapture of
Membrane (ARM), External Encephalic Version (ECV),
hypertensive disorder
• Painful Per Vaginal (PV) bleeding
• Foetus may be dead, difficult to feel foetal parts
• Height of fundus may be higher than dates
• Tender tense abdomen
• Signs of shock
• Retro placental bleeding may be concealed
Specific management
• Nurse in high dependency ward
• Rapid infusion of normal saline or ringers lactate
• Cross match 4 units of blood and commence
transfusion as soon as possible
• Catheterise patient
• Give morphine 15mg intramuscularly stat

183
• Perform artificial rupture of membranes to induce
labour
• Active management of third stage
• After delivery give oxytocin 10 units in normal saline
running at 20 drops per minute for 2 – 4 hours
Be aware of postpartum haemorrhage due to atonic

uterus or coagulopathy.
5.3.3 Cervical lesion (Refer to chapter 8.4)
• Cancer of the cervix

• Cervical ectopy
• Cervical polyps
5.3.4 Vasa Previa
Definition
A condition in which the foetal blood vessels are
unsupported by either the umbilical cord or placental
tissue, traverse the foetal membranes of the lower
segment of the uterus below the presenting part
Vasa previa occurs when foetal blood vessel(s) from the
placenta or umbilical cord cross the entrance to the birth
canal, beneath the baby. It can result in rapid foetal
hemorrhage or lack of oxygen.
Symptoms
• Present with sudden onset of abnormally heavy or
small amounts at rupture of membranes.
• Foetal bradycardia, then death.
Warning Signs
Very difficult to diagnose antenetally before rupture of
membranes
• Low-lying placenta
• Painless birthing bleeding.

184
Investigations
• Ultrasound
• Check the placental cord connection for velamentous
cord insertion .
• Sonography
• Color Doppler
Treatment
Supportive
• Initiate breastfeeding within an hour of birth
• Use of tocolytes to stop all uterine activity
• Bedrest
• No sexual intercourse
• No vaginal examinations
• No lifting
• No heavy straining during bowel movements (use
of stool softeners)
Hospitalization; (if suspected antenatally
• Foetal monitoring
• Regular ultrasounds to monitor progression of vasa
previa
• Steroid treatment to develop fetal lung maturity
• Elective ceasarean delivery, most important
When not diagnosed antepartum, aggressive resuscitation

complete with blood transfusion for the infant if necessary
must be planned for and/or expected.
5.4� POST PARTUM HAEMORRHAGE (PPH)
Definition
This is per vaginal (PV) bleeding of 500ml or more or
any amount resulting in cardiovascular collapse after
delivery of the baby. It is called primary PPH when
it occurs within the first 24 hours and secondary PPH

185
thereafter up to 6 weeks. PV bleeding of more than
500ml or any amount causing cardiovascular collapse
or hypovolaemic shock
This is caused by:

• Atonic uterus
• Genital tract trauma, e.g., ruptured uterus, cervical
vaginal tears and vulval haematoma
• Secondary coagulopathy
• Uterine sepsis
Clinical features
• Excessive vaginal bleeding
• May be in shock
• High pulse rate equal or more than 100/min
• Low BP less or equal to 90/60mm
• Air hunger (restlessness)
• Cold sweat
Emergency care
To provide a timely surgical plan such as hysterectomy,
internal iliac artery ligation
This must be teamwork

• Call for help
• Rub up the uterus for a contraction and to expel
clots
• Repeat oxytocin 10 units intramuscularly
• Give oxytocin 20 units in 1Litre normal saline running
at 20 drops per minute
• Alternatively in the absence of oxyticin give
Misoprostol 1000microgram rectally
• Blood and fluid replacement as required
• Monitor urine output/catheterise the bladder
• If PV bleeding persists yet uterus is well contracted,
check genital tract for trauma and for coagulopathy
• Where available, central venous pressure (in the

186
absence of coagulopathy) monitoring is valuable
• In uncontrollable PPH timely surgical intervention is
important, e.g., hysterectomy
• Nurse in high dependency ward- Special Observation
Unit (SOU) of the hospital
5.5� UNCONSCIOUS OBSTETRIC PATIENT
A pregnant woman may be brought into a health facility

unconscious without much history. Management therefore
will mainly depend on clinical examination and
investigations. The obstetrician should work in collaboration
with the physician.
Differential diagnosis
• Eclampsia
• Cerebral Malaria
• Meningitis
• Hypovolaemic shock
• Diabetic coma
The following should be done as the Airway, Breathing

and Circulation (ABC) of resuscitation:
• Take history from carer and note patient’s previous
notes
• Quick examination should include; blood pressure
(BP), pulse, temperature, jaundice, cyanosis,
hydration, sweating, cold clammy extremities,
respiration, heart sounds, PV bleeding, fundal height,
foetal viability and neck stiffness
• Give intravenous fluids
• Investigation: Cerebral spinal fluid for bacteriology
and biochemistry, blood for haemoglobin level,
malaria slide, blood sugar and urea urinalysis
Treatment
• Intravenous line

187
• ABC of resuscitation
• Transfer to hospital
• Keep patient in high dependency ward (SOU)
• Nurse in left lateral position
• Keep airway patent
• Catheterise
• Treat the cause
5.6� PRE-ECLAMPSIA AND ECLAMPSIA
Definition
Pre-eclampsia is pregnancy-induced hypertension with
proteinuria occurring after 20 weeks of gestation. There
are 2 types; mild pre-eclampsia and severe pre-eclampsia.
When convulsions appear in this syndrome it is then
called eclampsia. This is an obstetric emergency requiring
immediate referral to a hospital
Diagnosis
5.6.1� Mild pre-eclampsia
This is when two measurements of diastolic blood pressure

taken 4 hours apart read 90-100mmHg with proteinuria
up to 2 and above.
5.6.2� Severe Pre-eclampsia

This is when diastolic blood pressure is 110mmHg or
more with increasing proteinuria of 3+ or more.
5.6.3� Eclampsia
This is when there is diastolic blood pressure of 90mmHg
or more with proteinuria of 2+ or more and convulsions.
The signs of impending eclampsia are:
• Epigastric tenderness
• Increased tendon reflexes
• Blurred vision

188
5.6.4� Pre-eclampsia management as an �
outpatient
The reduction of the blood pressure does not abort the
progression of the disease process and its effect on the
foetus. At present the only effective management of pre-
eclampsia is delivery of the baby. The more severe the
disease condition, the greater the risk to both the mother
and the baby. If the risk to the mother's health is
significant the baby should be delivered even if it is non-
viable. If the disease is mild or moderate the baby can
be kept in utero until it is viable provided close observation
is kept on the mother, looking out for the complications
of pre-eclampsia.
All patients with pre eclampsia should have a mid stream

urine (MSU) specimen taken and be seen by a specialist.
A check should be kept on the baby's growth with serial
measurement of symphysio-fundal height. The woman
should keep a kick chart. No antihypertensives are usually
required for mild pre-eclampsia.
Complications
• Cerebral Vascular Accident (CVA)
• Renal failure
• Cardiac failure
• Foetal death
• Eclampsia
The definitive treatment is delivery.

Conservative management.
5.6.5� Mild pre-eclampsia and gestation less �

than 37 weeks
Management should include:

• Monitoring blood pressure
• Monitoring of foetal well being (kick chart, serial

189
scans)
• Monitoring of urine output and urinalysis for
proteinuria
• Renal function test
• Normal diet
Do not give anti-hypertensives, sedatives, tranquillisers
or anticonvulsants.
Severe pre-eclampsia and eclampsia

Once the blood pressure is above 160/110mmHg the
mother is at risk of stroke. The baby should be delivered.
There are four principles involved in the management:

Prevention or control of convulsions
• Control of hypertension
• Maintenance of fluid balance
• Delivery of the baby
General Management
• For patients with eclampsia maintain an airway.
• Monitoring of urine output (should not be less than
30ml/hour) Carry out urinalysis for proteinuria
• Renal function test
• Normal diet
• Maintain strict fluid balance chart
• Do bedside clotting test (failure of clot to form after
7 minutes or a soft clot that breaks down easily
suggests coagulopathy)
• Avoid fluid overload
Management of hypertension
The drug of choice is Hydralazine. The drug should be
titrated against the blood pressure with the aim of
achieving a diastolic pressure of 90 – 100mmHg.
If diastolic BP 110mmHg reduce by giving
– Hydralazine IV 5mg bolus and repeated every
20 to 30 minutes OR
– Nifedipine 10mg sublingually
190
– Give methyldopa 250mg – 500mg every 6 – 8
hours orally for maintainance
Management of convulsions
The drug of choice is Magnesium Sulphate. Diazepam,
despite its effects on the baby, may be used when
magnesium sulphate is not available. Diazepam must be
given intravenously, never orally or intramuscularly.
• Magnesium Sulphate (Mg SO4)

Loading dose: 4g of 20% magnesium sulphate
intravenously, slowly
over 5 minutes, then 5g intramuscularly in each
buttock. (Total loading dose 14g.)
Maintainance dose; 5g Magnesium Sulphate in
alternate buttock every 4 hours. A total of six
maintenance doses is recommended
Before repeating administration, ensure that:

• Respiratory rate is at least 16 per minute
• Patellar reflexes are present
• Urine output is at least 30ml per hour over 4 hrs
Withhold or delay MgSO4 if:

• Respiration rate falls below 16 per minute
• Patellar reflexes are absent
• Urinary output falls below 30ml per hour over
preceding 4 hrs
Keep antidote ready
In case of respiratory arrest

• Assist ventilation (mask and bag apparatus, intubation)
• Give an antidote, calcium gluconate 1g (10ml of
10% solution) intravenously slowly until respiration
begins as an alternative to Magnesium Sulphate:
Diazepam bolus 5-10mg IV over 2 minutes.

191
require resuscitation.
• Keep warm
• Give Oxygen ambu bag as required
• Suction
Post partum care

The patient must be closely monitored for at least
48 hours in a place where maximum care can be
given. This usually means in the labour ward or a
high dependency unit (SOU).

193
5.7� MEDICAL DISEASES IN PREGNANCY
5.7.1� Diabetic Mellitus
Pregnancy may turn otherwise well controlled diabetes into

poorly controlled diabetes. Some women may develop
diabetes during pregnancy. These cases must be referred
to the hospital if attended at a health centre.
The following principles of care should apply:

• Pre-pregnancy counselling
• Pregnancy counselling
• Monitoring blood sugar with necessary adjustments to
medication
• Monitoring foetal growth and looking out for macrosomia
• In labour monitor sugar and progress of labour
• If there is poor progress in labour, deliver by caesarean
section
• Beware of shoulder dystocia
• Watch for hypoglycaemia in baby
• Care for the new born
Follow up mothers
Post Natal Care

• Patient may resort to pre-pregnancy doses of insulin
or hypoglycaemics.
5.7.2� Cardiac diseases
The most common cardiac disease encountered in pregnancy

is Rheumatic Heart Disease (RHD). The most prevalent of
RHD is Mitral Stenosis (MS) and Mitral Incompetence (MI).
(See chapter 7).
Management
• Pre pregnancy counseling

194
•• If case found at booking clinical examination confirm
diagnosis by echo cardiography
•• During antenatal, all conditions that precipitate
cardiac failure e.g. febrile illness, malaria, anaemia
and increased physical activity must be properly
managed
•• Advise bed rest
•• Give digoxin 0.25mg daily
•• Frusemide should only be used in case of pulmonary
oedema
•• Admit to hospital in the 3rd trimester or in case of
pulmonary oedema.
In labour
Keep in high dependency ward in propped up position
for at least 24 hours.
•• Pethidine 100mg IM as required

Cefotaxime 1g 12 hourly (2 doses)
Oxygen PRN
3rd stage
stage
Note: Avoid Ergometrine
Post natal
•• Discharge after 3 –4 days after delivery
•• Discuss contraception
•• Discuss surgical treatment of heart disease
Malaria in Pregnancy
(Refer to chapter 3)

195
• Give Oxytocin 5-10Units IV
Supportive
• Provide psychological support to patient and carer
• Treat infection with appropriate antibiotics
• Provide post-MVA counselling
• Provide family planning counselling
• Facilitate linkages to other reproductive health
services
5.9� MENSTRUAL DISORDERS
It is important to decide whether the menstrual disorder

is truly a menstrual disorder or not. The menstrual history,
type of contraceptive used, history of previous pregnancies,
kind of discharge and related issues must be noted. The
abdomen must always be examined for tenderness or
masses. The vagina should also be examined and the
condition of the cervix and any discharge should be
noted.
5.9.1� Dysmenorrhoea
Definition
This is severe pain associated with the menstrual cycle
and is usually referred to as period pains. This may be
due to gynaecological or non gynaecological reasons.
There are two types:
• Spasmodic
• Congestive
5.9.1.1 Spasmodic
This occurs primarily in teenagers and young multiparous

women, but is not uncommon in elderly multiparous
women.

197
uterus. A vaginal examination, including speculum should
be done to exclude carcinoma of the cervix and uterus.
Hormones and antibiotics should not be given before this
is done.
Refer patient to specialist.

201
6
RESPIRATORY TRACT
DISEASES
Respiratory tract diseases include upper andlowe
uResand lower
respiratory tract infections or as well as obstructive airway
diseases.
6.1� RESPIRATORY TRACT INFECTIONS
6.1.1� Upper Respiratory Tract Infections
Respiratory Tract Infections involve lower and upper or

both respiratory tract systems.These include the common
cold, bronchitis and pneumonia
6.1.1.1. Common Cold

Definition
This is a self-limiting disease caused by viruses and
allergies. If it is viral, it is a highly infectious condition
comprising mild systemic upset and prominent nasal
symptoms
Clinical Features
Symptoms
• Running nose/nasal congestion
• Cough
• Irritation of the throat
• Fever
• Sneezing
Complications
Lower respiratory tract infection (see 6.1.2)

202
Bronchitis and pneumonia
Treatment
• Analgesics;
Aspirin, 600mg 3 - 4 times daily or paracetamol,
500mg - 1g orally 3 - 4 times daily in adults, children;
paracetamol, 10 - 20mg/kg 3 times daily
• Nasal decongestants
• Cough mixtures may offer symptomatic relief
• Take plenty of fluids
Note: (i) Aspirin is not recommended for children

under 16 years.
(ii) Antibiotics are not indicated
Supportive
• Advise patient to take plenty of fluids
6.1.1.2 Laryngotracheobronchitis
Definition
This is an inflammation of the larynx, trachea and bronchus
following an acute viral respiratory infection..
Clinical features
Symptoms
• Pain in the larynx
• Hoarseness of voice
• Irritating persistent cough
• Shortness of breath
• Fever
Signs
• Stridor
• Persistent or recurrent laryngitis
Treatment
Analgesics in early stages

203
• Paracetamol, 500mg – 1g orally 3 – 4 times daily in
adults, 10 – 20mg/kg orally 3 – 4 times daily in
children
Supportive
• Give more fluids and humidification
6.1.2� Lower Respiratory Infections
These conditions include Pneumonia and Bronchitis
6.1.2.1. Pneumonia
Definition
This is an inflammation of the lungs usually caused by
Streptococcus pneumoniae, Mycoplasm pneumoniae and
Staphylococcus aureus Hemophelus Influenzae type B
and atypical organisms such as Jiroveci pneumonia.
Clinical features
These are usually of sudden onset.
Symptoms
• Fever
• Dry or productive cough
• Chest pain
• Chills
• Breathlessness
• Children may be unable to drink or breastfeed
Signs
• Bronchial breathing
• Drowsiness
• Increased respiration rate
• Cyanosis may be present
• Flaring of nostrils
• Chest indrawing
• Increased pulse rate

204
• Crepitations
• Breath sounds may be reduced
• Sputum may be "rusty"
Complications
• Septicaemia
• Lung abscess
• Emphysema
• Heart failure
• Meningitis
Diagnosis
This is based on clinical findings but may be supported
by radiological examinations which show lobar and
bronchial pneumonia.
Treatment
Some patients will need admission particularly if there
is cyanosis or complications.
• Benzyl penicillin, 1-2MU intravenously 6 hourly for
5 days adults, children 25,000 -50,000 units/kg
intravenously/intramuscularly in 4 divided doses for
7 days (as soon as the symptoms and respiratory
rates are controlled change to oral medication i.e
Amoxycillin 250mg for adults and 125 mg/5ml in
children ) or
• Ceftriaxone, 1g - 2g daily adults, children 20 -
50mg/kg daily intravenously/intramuscularly for 7
days. if allergic to penicillin or
• Erythromycin, 500mg adults, orally 6 hourly for 7
days, children 20-30mg/kg in 4 divided doses for
7 days
• Oxygen is indicated if respiratory distress or cyanosis
is present
• Non-opiate analgesics; paracetamol 500mg - 1g
orally 3 - 4 times daily adults, children 10-20mg/kg
orally 3 - 4 times daily

205
Refer early to a specialist if the patient is not rapidly
improving with antibiotic treatment.
6.1.2.2. Pneumonia in Children

If a child has cough or difficulty in breathing then he/
she may have a respiratory tract infection.
Clinical features
May include:
• Fast breathing
• Chest in drawing
• Stridor in a calm child
• Wheezing
It is important to count the respiratory rate of the child.
If the child is : Fast breathing is:
2 months up to 50 breaths per minute or

12 months more
12 months up to 5 years 40 breaths per minute or

more
Classification
• No pneumonia cough or cold: child is classified as
having no pneumonia cough or cold if there are no
signs of pneumonia
• Pneumonia: a child is classified as having pneumonia
if there is fast breathing accompanying wheeze or
cough
• Sever pneumonia: a child is classified as having
sever pneumonia if there is chest indrawing or stridor
in a calm child

206
Treatment
No pneumonia cough or cold:
• If coughing for more than 21 days, refer for
assessment,
• If wheezing give oral salbutamol,
• Follow up in 5 days if not improving.
Pneumonia
Give an Appropriate Oral Antibiotic
FOR PNEUMONIA, ACUTE EAR INFECTION OR VERY SEVERE DISEASE:
AMOXYCILLIN ERYTHROMYCIN
Give three times daily Give four tines daily for 5 days
for 5 days Amoxycillin 2nd-LINE ANTIBIOTIC -
Erythromycin
AGE or TABLET SYRUP AGE or TABLET SYRUP

WEIGHT WEIGHT
250mg 125 mg 250 mg 125/5

per 5 ml mls
2 months 2 months
up to up to
12 4
mnths months
(4-<10 kg) 1/2 5 ml 4-<6kg) 1/4 2.5 mls
12 mnths 4 mnths
up to up to
5 years 12 mnths
(10-19kg) 1 10 ml (6-<6kg) 1/2 5 mls
12 mnths
up to
5 years
(10-19kg) 1 10 mls

207
FOR DYSENTRY:
1st –LINE ANTIBIOTIC:- Nalidixic Acid
2nd –LINE ANTIBIOTIC:- Cotrimoxazole
NALIDIXIC ACID COTRIMOXAZOLE

Give four times daily (trimethoprim +
for 5 days sulphamethoxazole)
AGE or TABLET AGE OR ADULT PEDRIATIC SYRUP

WEIGHT WEIGHT TABLET TABLET
250 mg 80 mg 20 mg 40 mg
trime- trime- trime-
thoprim thoprim thoprim
+400 mg +100 mg +200 mg
sulpha- sulpha- sulpha-
metho- metho- metho-
xazole xazole xazole
per
5 ml
2 mnths 2 mnths
up to up to
4 12
mnths mnths
(4-<6 (4-10
kg) 1/4 kg) 1/2 2 5 mls
4 mnths 2 mnths
up to up to
12 5 years
mnths (10-19
(6-<10 kg)
kg) 1/2 1 3 7.5 mls
12
mnths
up to
5 years
(10-19
kg) 1

208
FOR CHOLERA: * 1st-LINE ANTIBIOTIC:- Erythromycin
*Note: Remember that the most important life saving
interventions for cholera patients is immediate and appropriate
rehydration.
Give Salbutamol
For wheezing with no respiratory distress (chest in-drawing)
SALBUTAMOL
Give three times a day
2 months up to 12 months
(<10kg) 1/2 1/4
12 months up to 12 months
(10-19kg)

209
GIVE THESE TREATMENTS IN CLINIC ONLY
• Explain to the caretaker why the drug is given
• Determine the dose appropriate for the child’s weight
(or age)
• Use a sterile needle and syringe. Measure the dose
accurately
Give an Intramuscular Antibiotic
• For severe pneumonia or severe disease or very severe febrile
illness
FOR CHILDREN • Give first dose intra-muscular

REFERRED chrolamphenicol and refer child urgently
URGENTLY to hospital BEING
WHO CANNOT • If chloramphenicol is not available,
TAKE AN give a first dose of IM benzyl -penicillin
and refer urgently
IF REFERRAL • Repeat the chloramphenicol injection

IS NOT every 12 hours for 5 days
POSSIBLE • Then change to an appropriate oral
antibiotic to complete 10 days of
treatment
• Do not attempt to treat with benzyl-
penicillin alone.
AGE or WEIGHT CHLORAMPHENICOL BENZYLPENICILLIN

Dose: 40 mg per kg To a vial of 600 mg
Add 5.0 ml sterile (1,000,000 units):
water to vial Add
containing 2.1 ml of sterile
1000 mg=5.6 ml at water=2.5 ml
180 mg/ml at 400,000
2 months up to
4 months (4-<6kg) 1.0 ml = 180 mg 0.8 ml
4 months up to
9 months (6-<8kg) 1.5 ml = 270 mg 1.0 ml
9 months up to
12 months (8-<10kg) 2.0 ml = 360 mg 1.2 ml
12 months up to
12 months(10-<14kg) 2.5 ml = 450 mg 1.5 ml
3 years up to 5 years
(14-19kg) 3.5 ml = 630 mg 2.0 ml
210
6.1.2.3. Aspiration pneumonia
More common in newborn babies especially in premature,

respiratory distress, chronically ill, chronic aspirators, post
vascular operations
Treatment
• Gentamycin, 5mg/kg twice a day or I.M 10 mg once
daily
• Ciprofloxacin, 10mg/Kg body weight 3 times daily,
the benefit must outweigh the risk but may be used
for 5 to 17 year olds.
6.1.2.4. Atypical Pneumonia
Signs and symptoms of pneumonia plus extrapulmonary

signs such as arthritis, splenomegaly caused by
Mycoplasma, Chlamydia, PCP.
Treatment
• Erythromycin 500mg orally QID for 14 days for
Chlamydia
• Cotrimoxazole 960mg every 12 hours for 21 days
in combination with a steroid i.e. Prednisolone for
PCP starting with 40mg per day and reducing by
5mg every 3 days for adults
• For children above 4 weeks to adults 120mg/Kg
body weight in 2 to 4 divided doses for 21 days
6.1.2.5. Obstructive Airway Disease
Obstructive Airway Disease can be upper or lower.
6.1.2.5.1. Upper airway obstruction
The condition is caused by viral infection or inhaled

foreign body. The main symptom is stridor.
211
When it is caused by viral infection the condition is called
Croup. Croup is fairly common and is frightening to
parents. Usually admission is advisable. If the infection
has caused epiglottitis, the obstruction may be so severe
as to necessitate tracheal incubation and antibiotics may
be required.
Treatment
• Chloramphenicol 50 - 100mg/kg intravenously in 4
divided doses daily for 5 days
• Humidified oxygen (30 - 40% concentration)
• Dexamethasone 0.3mg/kg intramuscularly stat,
Repeat after 6 hours.
• Naso-tracheo intubation or tracheostomy if
obstruction is severe
Stridor due to Diphtheria

In stridor due to diphtheria, examination of the throat
will reveal a white membrane. Diphtheria infection is
uncommon nowadays.
Treatment
• Benzyl Penicillin IM/IV 25,000 - 50,000 units/kg
intravenously in 4 divided doses for 5 days
Prevention
• Diphtheria can be effectively prevented by active
immunisation in childhood
Stridor due to inhaled foreign body

Stridor due to inhaled foreign body is usually preceded
by sudden chock whilst eating a meal or playing with
small objects.
Treatment
• Remove foreign body

212
Stridor due to inhaled Paraffin
Parrafi
Symptoms
• Smell of paraffin
• Cynosis
• High repiratory rate
• Tachycardia
• Tachypnoea
Treatment
DO NOT INDUCE VOMITING!
• Give milk
• Hydrate
• Give Oxygen
• Antibiotic prophylaxis with Amoxycillin 125mg/5ml
3 times a day
Advice to patients
• Do not put paraffin in soft drink containers
• Clearly label paraffin containers
6.2� LOWER OBSTRUCTIVE AIRWAY �

DISEASES
Obstructive airway diseases are a spectrum of diseases

characterised by obstruction of the lower airway with
asthma and emphysema on either end of the spectrum.
6.2.1� Asthma
Definition
This is an acute or recurrent reversible obstructive airway
disease characterised by increased responsiveness of the
tracheobronchial tree to a variety of stimuli resulting into
obstruction of the lower airways. The attacks can be
precipitated by allergy, (especially to cat, horse or other
animal hair or pollens), infection or exercise. The
213
obstruction can be reversed by treating with beta
adrenergic agents such as Salbutamol.
Clinical features
Symptoms
• Wheezing
• Difficulty in breathing
• Coughing
• Restlessness
Signs
• Prolonged expiration
• Cyanosis if severe
• Rapid pulse
• Dehydration
• Sticky, clear sputum
• Wheezing
If the pulse is over 120/min, the patient's condition must

be regarded as serious and admission to hospital is
urgent.
Chest X-ray is necessary to exclude cardiac problems,

pneumothorax or foreign body in the upper airway.
Treatment
Early vigorous treatment is important. The longer
treatment is delayed the more difficult it is to reverse
the process.
Mild Cases
These cases are not in acute distress and the pulse rate
is usually not above 100/min. They are not cyanosed
or dehydrated.
• Salbutamol, 2-4mg orally three times daily
• Salbutamol inhaler 2 puffs stat. Followed by 1 puff
4-6 hourly

214
Note: Inhaled corticosteroids e.g. beclomethasone, 2
puffs given 10 minutes after salbutamol inhaler may
be used.
The patient must be taught how to use the inhaler. Check

that he can use it correctly. If he/she cannot learn, use
oral Salbutamol 4mg 3 times daily though. it may cause
extrapyramidal symptoms.
Severe cases
The features are:
• Sitting up in distress
• Difficulty in talking and drinking
• Pulse over 120/minute
• Exhaustion
• Dehydration
• Cyanosis
• Silent chest on auscultation
The patient should be admitted to hospital urgently for

close monitoring.
The patient should be nursed on a propped up bed and

be given a sputum cup.
The pulse and blood pressure should be checked every

hour.
If possible, Peak Expiratory Flow Rate (PFR) should be

measured hourly.
Treatment
• Intravenous fluids, 3 litres per day; (1 litre 0.9%
sodium chloride and 2 litres 5% dextrose)
• 20mmol potassium chloride added to 1L of any of

215
above fluids in 24 hrs
• Humidified oxygen through a mask, 3 litres/minute
• Nebulised salbutamol 5mg stat given through a
nebuliser. Follow this first dose by nebulised
salbutamol 2.5mg every 4 hours
• Hydrocortisone, 200mg intravenously 4 hourly
• Start oral prednisolone, 30mg once daily for 5 days
• Aminophylline 250mg i.v. over 5-10mins followed
by a maintennce dose of 100mg (less than 500mg
over 24hours) 8 hourly over 24 hours. If the patient
has heart disease, liver disease or is taking
betablockers reduce the dose of aminophylline.
Always give oxygen with aminophylline. Patients
who have taken oral aminophylline in the last 8
hours should not be given the loading dose.
• Antibiotics. If there is evidence of bacterial infection
give appropriate antibiotic
6.2.2� Emphysema
This is an irreversible obstruction of the airways

characterised with destruction of the alveoli and
bronchioles by fibrosis.
Clinical Features
Symptoms
• Severe shortness of breath with slight exertion
• Recurrent coughs
• Slight wheezing
• Barrel chest
Signs
• Barrel chest
• Clubbing of fingers
• Hyper inflated lungs on X-ray
• Air trapping on X-ray
Treatment
Treat causes of exacerbations of the conditions
• Hydrocortisone 200mg intravenously 4 hourly for 24
hours and maintain on oral Prednisolone 30mg on
alternate days
• Suction of the fluid from the airway
• Give an appropriate antibiotic i.e. Erythromycin
500mg while awaiting sputum results
Supportive
• Give up the habit that caused the emphysema e.g.
stop smoking,
• Give oxygen
Prevention
• Stop smoking
Reduce industrial exposure
• Wear gas masks
7
CARDIOVASCULAR DISORDERS
7.1� HYPERTENSION
Hypertension is one of the leading public health problems

worldwide. It is often asymptomatic, easily detectable, and
potentially easily amenable to treatment. Yet, if left untreated
it often leads to fatal complications. Since hypertension
tends to be asymptomatic, public education about the
dangers of hypertension plays a significant role in the overall
management of hypertension.
Definition
The World Health Organization defines grade 1 hypertension
as office blood pressures ranging from 140–159 mm Hg
systolic or 90–99 mm Hg diastolic, grade 2 hypertension as
pressures of more than 100 mm Hg systolic or
100–109 mm Hg diastolic. The baseline figures do not apply
to children, diabetic mellitus patients, renal patients and
pregnant women (hypertension in pregnancy, refer to chapter
5.6). The frequency of hypertension increases with age.
Risk Factors with Adverse Prognosis:

• Black race
• Youth
• Male sex
• Persistent diastolic pressure greater than 115mmHg
• Smoking
• Excess alcohol intake
• Hypercholesterolemia
• Diabetes Mellitus
• Obesity
Classification of Hypertension
The National Heart, Lung, and Blood Institutes classify blood

219
pressure as normal, prehypertension, hypertension stage
1, and hypertension stage 2.
1. Normal (optimal)
Systolic (mmHg) Diastolic (mmHg)
< 120 < 80
2. Hypertension
Stage Severity Systolic Diastolic

Range Range
(mmHg) (mmHg)
Prehypertension 130-139 80 - 89
I mild 140 - 159 90 – 99
II (moderate-
severe) > or = 160 > or = 100
From the Seventh Report of the Joint National Committee

on Detection, Evaluation, and Treatment of High Blood
Pressure
Aetiology of Hypertension
• Primary (essential) Hypertension
• Secondary Hypertension
• Systolic Hypertension
• Hypertensive Crises (acute hypertension)
7.1.1� Primary Hypertension
This is hypertension for which there is no specific

identifiable cause. About 90% of hypertension cases fall
under this category.

220
7.1.2� Secondary Hypertension
This is hypertension due to a specific underlying condition

or conditions. Some of the causes include the following:
• Renal Parenchymal Diseases
e.g. glomerulnephritis
• Renovascular Diseases
e.g. atherosclerotic (mainly older men) and fibroplastic
(mostly younger women) diseases.
• Endocrine Diseases
e.g pheochromocytoma , Cushing’s Syndrome.
• Cardiovascular Disease
e.g. coarctation of aorta
• Pregnancy (gestational hypertension)
• Drugs
e.g. oral contraceptives, erythropoietin, steroids
7.1.3� Systolic Hypertension
7.1.4� Hypertensive Crises
These are clinical situations associated with blood pressure

rising to levels usually above 130 mmHg diastolic. There
are two types: hypertensive emergency which is
associated with acute end-organ dysfunction (brain, heart
and kidneys). In this setting there is a high risk of causing
irreversible damage to the brain, heart or kidneys if blood
pressure is not controlled within an hour or so.
Hypertensive urgency is the other setting with equally
markedly raised BP but without significant signs or
symptoms suggestive of end organ damage. In this
setting BP reduction may be gradual over 24 hours.
Other terms used in this situation are accelerated-
malignant hypertension depending on retinal findings
during funduscopy examination. If there are haemorrhages
and/or exudates on the retina then it is referred to as
accelerated hypertension but if there is papiloedema

221
then it is called malignant hypertension. From a therapeutic
point of view both forms are treated in practically the
same way.
Clinical Features
Hypertension is usually asymptomatic until when it has
caused complications and damage to target organs. At
this point the symptoms are thus associated with the
affected organ.
Symptoms
• Palpitations
• Dizziness
• Blurred vision
Signs
• Tachycardia
• Cerebral vascular insufficiency
• Lung crepitations
• Hypertensive retinopathy
Complications
• Atherosclerosis
• Cerebral vascular insufficiency
• Cerebral vascular accident
• Congestive heart failure
• Coronary artery disease
• Peripheral vascular insufficiency
• Dissecting aortic aneurysm
• Hypertensive nephropathy and renal failure
Management
• To document presence or absence of end organ
damage
• To exclude possibility of a secondary cause of
hypertension and other co-morbidities.
222
Investigations
• Urinalysis
• Fundoscopy
• Electrocardiogram
• Chest x-ray
• Echocardiogram
• Urea, creatinine and electrolytes
• Random blood sugar
• Lipid profile
• Abdominal ultrasound
Treatment
The objective of treating high blood pressure is both to
prevent and lower related complications such as strokes,
renal failure and heart failure.
Hypertension not responding to treatment should be
referred to a specialist for further investigations.
Prevention
• The initial approach to treatment is that of lifestyle
modification. i.e. smoking cessation, weight reduction
to optimal weight, BMI less than 25, regular exercise,
reduction in alcohol intake, dietary modifications
(e.g. salt reduction, fat free diet.)
Drugs
Goals of therapy –blood pressure less than 140/90 mm
HG and less than 130/80 mm Hg for those with diabetes
and chronic kidney disease.
Stepwise approach, use of combination of drugs for better
effect.
Step 1.
Start with Diuretics ( e.g. Amiloride + Hydrochlorothizade
(5/50mg) orally daily)
or
Calcium channel blockers (Nifedipine retard 20 mg two
times daily orally or Amlodipine 5 -10 mg once daily

223
orally)
or
Angiotensin converting enzyme inhibitors ( Captopril 25-
50 mg two or three times daily orally, Enalapril 5-20
mg once daily orally) . Those who cannot tolerate ACE-I
may be given Losartan potassium 50-100 mg once daily
orally.
Step 2.
Use a combination of drugs from different groups (e.g.
Diuretic + ACE I, or Ca channel blocker + ACE I), Diuretic
Calcium channel blocker).
Step 3.
Use a combination of Diuretic + ACE I + Ca channel blocker
Step 4.
If not controlled as above, optimize the dose, add further
diuretic therapy
or
Alpha blocker (Prazosin 0.5mg two to three times daily
orally – initial should be at bed time to avoid postural
hypotension – then increase to 1-3 mg two to three times
daily after three to seven days, maximum daily dose 20
mg)
or
Add beta blocker – Atenolol 50-100 mg once daily orally,
Propranolol 40-80 mg two or three times daily orally
or
Hydralazine 25-50 mg two or three times daily orally
Beta blockers are no longer preferred as a routine initial
therapy for hypertension, however can be used in younger
people, patients with cardiovascular risk or existing
ischemic heart disease, those with contraindications or
intolerance to ACE I, ARB as adjunctive drugs to other
antihypertensive.

224
Emergency – very severe to malignant hypertension:
• Start with Labetalol 50 mg IV over at least a minute,
repeated after five minutes if necessary, maximum
dose is 200 mg
Or
• Hydralazine 10 mg IV stat followed by 5 mg IV every
30 minutes until diastolic BP is 110 mm Hg or less
• Frusemide 40-80mg IV may be used as adjunctive
therapy as a stat dose.
7.2� CONGESTIVE HEART FAILURE
Definition
This is a condition in which an abnormality of cardiac
function is responsible for the inability of the heart to
meet the requirement of the metabolising tissues
Causes
Some underlying causes of heart failure:
• Valvular Heart Disease e.g. mitral valve disease
• Viral Myocarditis
• Congenital Heart Disease
• Hypertension
• Cardiomyopathies
• Pericardial diseases
• Ischaemic heart disease
• Arrhythmias
• Thyroid dysfunctions
• Anaemia
Precipitating Causes
• infection including endocarditis
• anaemia
• thyrotoxicosis
• arrhythmias
• systemic hypertension
• pulmonary embolism
• pregnancy
225
Forms of Heart Failure
• Diastolic
• Systolic
• High output
• Low output
• Right sided
• Left sided
Clinical Features
Symptoms
• Fatigue
• Shortness of breath at rest or on exertion
• Orthopnoea
• Paroxysmal Nocturnal Dyspnoea
• Cough
• Anorexia
• Swollen legs
• Abdomen distension
Signs
• Neck vein distension or raised JVP
• Basal crepitations (rales)
• cardiomegaly
• S3 gallop
• Hepatomegaly
• Hepatojugular reflux
• Pulmonary oedema
• Tachycardia
• Oedema
• Pleural effusion
• Ascites
Management
Investigations
• Chest x-ray
• ECG
• Echocardiogram

226
• Full Blood Count
• Liver function test
• Urea, creatinine, electrolytes
• Urinalysis routine and microscopic
• HIV test
The following tests are not routinely ordered unless there

is a clinical indication:
• cardiac enzymes
• Thyroid function tests
• Cardiac catheterisation
Treatment
This is divided in 3 parts:
• Treat precipitating cause
• Correct underlying cause e.g. valve replacement in
Mitral valve disease

• Control congestive heart failure state
General Measures
• Restrict physical activities
• Restrict salt and water
• Lifestyle modification (no smoking, no alcohol,
nutrition)
New York Heart Association functional class. (NYHA)

1. Class I Asymptomatic
2. Class II Symptomatic on moderate exertion
3. Class III Symptomatic on mild exertion
4. Class IV Symptomatic at rest
Drugs
1. Class I
Asymptomatic
• Most patients do not require medicine but will require
lifestyle modifications.

227
2. Class II
• Captopril 12.5mg to 25mg twice a day orally
OR
• Lisinopril 5 - 10mg daily orally
OR
• Enalapril 5mg to 20mg daily orally (if patient develops
a persistent dry cough replace with Losartan 50mg
daily orally.
• Hydrochlorothiazide 25mg daily or oral Frusemide
20 – 40mg daily
• Beta blockers (Carvedilol 3.125mg twice daily orally,
increase dose at least every two weeks to 25mg
twice daily, if patient is over 85Kg then maximum
dose 50mg twice daily or use Metoprolol 50 – 100mg
daily orally)
3. Class III
• Captopril 25mg 2 to 3 times daily
OR
• Lisinopril 10mg to 20mg daily
OR
a persistent dry cough
• Frusemide 40mg – 80mg twice a day orally (monitor
potassium levels)
• Digoxin 0.125mg – 025mg daily
• Isosorbide dinitrate 5mg to 10mg twice a day +
Hydralazine 25 – 50mg twice daily orally if patient
cannot tolerate ACE inhibitors
• Acetylsalicylic Acid (ASA) 75mg once daily
4. Class IV
• Captopril 25mg 2 to 3 times daily
OR
• Lisinopril 10mg to 20mg daily
OR

228
a persistent dry cough replace with Losartan
50mg daily orally.
• Frusemide I.V. 40mg – 80mg once or twice a day
(monitor potassium levels)
• Digoxin 0.125mg – 025mg daily
• Isosorbide dinitrate 5mg to 10mg twice a day +
Hydralazine 25 – 50mg twice daily orally if patient
cannot tolerate Ace inhibitors
• Spironolactone 25 – 50 mg once or twice daily orally
• B-blockers should not be used in Class IV CHF.
7.2.1� Cardiogenic shock
This is advanced cardiac failure with inadequate peripheral

perfusion
Clinical Features
Symptoms
• As above but severe
Signs
• BP less than 90mmHg systolic
• Pulse feeble or non detectable
• Cold extremities
• Peripheral cyanosis
• Poor urine output
• Comatose
Treatment
• ICU care
• Oxygen
• Dopamine 5-10 micrograms per Kg/bwt per minute
I.V. infusion (dilute 400mg in 500ml of 5% Dextrose
infusion rate to be calculated according to body
weight)
• Dobutamine 5-10 microgram/kg/min IV infusion
229
• Transvenous endocardial biopsy
Treatment
• There is no specific treatment.
• Cardiac failure (refer to chapter 7.2) and embolic
problems should be treated.
• Cardiac transplantation should be considered in
severe cases.
7.3� MYOCARDIAL INFARCTION
Definition
This is a necrosis of part of the cardiac muscle due to
sustained myocardial ischemia of more than 30 minutes
and formation of thrombus within the affected coronary
artery.
Clinical Features
Symptoms
• Chest pain of greater severity and duration (>30
minutes) than in angina but similar in nature
• Sweating
• Extreme distress
• Abdominal pain
Some infarcts may be painless e.g. in the elderly and

diabetics
Signs
• Distress
• Coldness and clamminess of extremities
• Tachycardia
• Raised or lowered blood pressure
• Cyanosis
• Arrythmias

232
Complications
• Arrhythmias
• Heart Failure
• Hypotension
• Pericardial effusion
• Systemic embolisation
• Dressler’s syndrome (autoimmune syndrome-
pericarditis, pneumonia, pleurisy)
• Papillary muscle rupture
• Cardiogenic shock
• Rupture of ventricular septum or ventricular wall
• Left ventricular aneurysm with Left Ventricular Failure
Management
• Investigations
• ECG
• Cardiac enzymes (troponin T and I, CPK) – MB fraction
• Echocardiography
• Chest X-Ray
• Urea and Electrolytes (U + E)
• Full Blood Count
• Erythrocyte Sedimentation Rate
• Lipid profile
• Myocardial perfusion scan
Diagnosis requires at least two of the following:

• History of ischaemic-type chest pain
• Evolving ECG changes
• A rise and fall in cardiac enzymes
Treatment
Keep under close observation and refer for management
in intensive care unit.
Drugs
• Oxygen by mask or nasal catheter
• Access to IV line

233
• Morphine 5-10mg intravenously at about 1mg per
minute
• Glyceryl trinitrate 0.5mg sublingually
• Aspirin 300mg orally to chew stat
• Streptokinase, 1,500,000 units in 100ml of 0.9%
saline intravenously over 1 hour (If presentation is
less than 12 hours after onset of pain) (Do not give
if there is stroke or active bleeding in the last 2
months, blood pressure > 200mmHg, surgery or
trauma in last 10 days, bleeding disorder, pregnancy,
diabetic retinopathy, previous streptokinase or any
thrombolitic treatment in the last 5 days to 1 year).
• Heparin, 5000 I.U intravenously stat, then 1000 I.U
hourly intravenously for 24hrs for 3-5 days.
• Low Molecuar weigh heparin Clexane (Enoxaparin)
1mg/kg SC twice daily.
• ACE inhibitors i.e. Enalapril 5- 10mg daily.
• Beta blockers e.g. Atenolol 50mg daily.
• Antacids e.g. IV Ranitdine 50mg three times daily.
• Laxatives, e.g. Lactulose 15 – 30ml two – three times
daily orally.
• Diazepam, 5mg orally daily.
• Aspirin, 75-150mg daily.
• Statins e.g. Simvastatin 10 – 20mg daily orally
• Isosorbide dinitrate, 10mg three times a day
If pain continues;
• Nitroglycerine I.V. infusion 10 – 200
micrograms/minute
• Refer for PCI (coronary intervention).
Supportive
• Reassure the patient and carers
• Continuous ECG monitoring
• 24 hour bed rest
• 24 hour Temperature, Pulse and Respiratory rates
• 24 hour blood pressure readings
• Daily 12 lead ECG, Chest X-Ray, cardiac enzymes,
234
and U&E for 2-3 days
• Refer patient for coronary angiography, refer to
specialist as soon as possible.
Prevention
• Low lipid diet
• Stop smoking
• Regular exercise
7.4� ANGINA PECTORIS
Definition
This is chest pain due to myocardial ischemia
Clinical features
Symptoms
• Chest pain: The pain is central/retrosternal and may
radiate to the jaw/or arms.
• Breathlessness
Signs
• Fourth heart sound
• Anxiety
• There may be no signs
Management
• ECG
• Exercise ECG
• Echocardiogram
• Lipid profile
• Myocardial perfusion scan
• Coronary angiography
Treatment
Drugs
• Aspirin, 75 - 300mg orally once daily
• Glyceryl trinitrate, 0.3 - 1mg sublingually, repeated

235
as required or
• Isosorbide dinitrate, 5 - 10mg sublingually, 30 -
120mg orally in 2 divided doses daily.
• Atenolol, 50 - 100mg orally daily
• Nifedipine, 10 - 20mg orally once or twice daily
• Statins e.g. Simvastatin, 10 – 20mg daily orally
Coronary angioplasty
Surgery
• Coronary by-pass
Supportive
• Manage co-existing conditions
• Stop smoking
• Weight loss
• Encourage regular exercise
7.5� PULMONARY OEDEMA
Definition
Acute left ventricular failure due to various cardiac
conditions or due to severe mitral stenosis with pulmonary
hypertension
Clinical features
Symptoms
• Breathlessness
• Wheezing
• Profuse sweating
• Productive cough
• Bloodstained sputum
Signs
• Paroxysmal dyspnoea
• Anxiety
• Blood stained sputum

236
• Tachypnoea
• Peripheral circulatory shut down
• Crackles
• Wheezing
Diagnosis
Investigations
• Arterial gases
• Pulse oximetry
• Chest X-Ray
• Central venous pressure
• ECG
• Echo
• Cardiac enzymes
Treatment
The patient should be placed in a sitting position.
Drugs
• Frusemide, adults: initially 40mg to 120mg I.V. Stat,
thereafter continue Frusemide 20mg-daily orally or
40mg on alternate days
• Morphine 5mg to 10mg I.V. slowly
• Oxygen 60% via mask
• Glyceral trinitrate, 0.3 - 1mg sublingually, repeated
as required
Underlying conditions should be treated
7.6� RHEUMATIC FEVER
Definition
This is an inflammatory disease that occurs in children
and young adults (5 - 15 years) as a result of infection
with group A streptococci. It affects the heart, skin, joints
and central nervous system. Pharyngeal infection with
group A streptococcus may be followed by the clinical
syndrome of rheumatic fever. This is thought to develop

237
because of an autoimmune reaction triggered by the
infective streptococcus and not due to direct infection of
the heart or the production of a toxin.
Clinical features
Revised Jones criteria for the diagnosis of rheumatic fever
Major
• Carditis
• Polyarthritis
• Sydenham’s chorea
• Erythema marginatum
• Subcutaneous nodules
Minor
• Arthralgia
• History of rheumatic fever
• Fever
• Increased P-R interval on ECG
• Raised ESR
• Increased C-reactive protein
Evidence of streptococcal infection

Raised ASO titre (or increased titre of other specific
antistreptococcal antibodies)
Positive throat culture
Diagnosis
Investigations
• Throat swab
• Serology
• ESR
• ECG
Diagnosis is made on the basis of two or more major

criteria or one major plus two or more minor criteria plus

238
evidence of antecedent streptococcal infection.
Treatment
Drugs
• Benzathine penicillin 0.6 – 1.2 mega units
intramuscularly stat or
• Phenoxymethyl penicillin 500mg orally 4 times daily
for 7 days. For recurrences 250mg daily until the
age of twenty or for 5 years after the latest attack
or
• Erythromycin, 250 – 500mg orally 4times daily for
7 days. For recurrences 125 – 250mg once daily
until the age of twenty or for 5 years after the latest
attack
• Prednisolone 1 – 2mg/kg per day divided into 4
equal doses for 10 days (in severe carditis)
Chronic rheumatic heart disease

More than 50% of those who suffer acute rheumatic
fever with carditis will later develop chronic rheumatic
valvular disease predominantly affecting the mitral and
aortic valves.
Complications
• Congestive cardiac failure
• Pulmonary oedema
Management
Investigations
• Chest X-Ray
• ECG
• Echo
Treatment
• Treat underlying complications.
• Give prophylaxis against recurrent rheumatic fever
with Benzathine-Penicillin 1.2 – 2.4 MU monthly for

239
life
• Give prophylaxis against infective endocarditis
Refer
• For further evaluation if patient has significant heart
murmurs
• All patients with increasing cardiac symptoms.
7.7� CARDIAC ARRHYTHMIAS
Definition
This involves the disorders of cardiac impulse formation,
automaticity, impulse conduction, heart rate and abnormal
ectopic activity.
Clinical features
Symptoms
• palpitation
• missing heart beats
• Dizziness and syncope
Signs
• increased or decreased pulse and heart rate ( more
than 100 or less than 60/min)
• Irregular pulse and heart rate
• Features of heart failure
• Bradyarrhythmias (sinus bradycardia, sinus node
dysfunction, atrioventricular blocks), heart rate
<55/min
• Tachyarrhythmias (atrial fibrillation and flutter,
supraventricular and ventricular tachycardias).
Premature atrial and ventricular contractions.
Investigations
• ECG
• Ambulatory ECG monitoring (Holter)

240
• Serum electrolytes level
• Echocardioagraphy
• Stress ECG test, TFTs
Management
Bradyarrhythmias:
• Sinus bradycardia – no treatment required unless
symptomatic, remove offensive drugs (e.g. B-
blockers, digoxin), if symptomatic –Atropine 0.6mg
IV or cardiac pacing
• Sinus arrhythmia – no treatment needed
• Atrioventricular block 1st degree – treat underlying
causes (carditis, drug toxicity).
• Atrioventricular block 2nd degree – may require
cardiac pacing, refer to specialist
• Atrioventricular block 3d degree – cardiac pacing,
refer to specialist.
Tachyarrhythmias:
• Supraventricular tachycardia
Heart rate 150–220/min on ECG narrow QRS complex
strictly regular tachycardia – start with vagal
stimulation ( unilateral carotid massage, Valsalva
maneuver), drug of choice Adenosine 6mg IV push,
if no response give 12mg IV push. Other drugs –
Verapamil 2.5-5.0mg IV slowly. Diltiazem 15-20mg
IV over 2 min. Propranolol 1-2 mg IV bolus. Refer
to specialist.
• Ventricular tachycardia
Heart rate 130-180/min, on ECG wide QRS complex
not strictly regular tachycardia– if the patient’s
condition is unstable – defibrillate at 50-100 + 200.
• If patient is stable, pharmacological treatment:
Amiodarone 300mg IV over 10 min, followed by
infusion at 1mg/min for 6 hours; Lignocaine 100mg
IV bolus, followed by infusion of 4 mg/min for 30
min, 2 mg/min for 2 hours, then 1 mg/min.
241
In case of multifocal Ventricular tachycardia use Magnesium
sulfate1-2 g IV.
Correct reversible causes hypokalemia, digoxin toxicity.
Atrial fibrillation:
• Rate control can be achieved by Digoxin 0.125-0.25
mg once or two times daily orally, Verapamil 40 to
80mg three times daily orally, Diltiazem 60mg three
times daily orally
• Amiodarone 200mg three times daily orally 1st
week, then reduce to 200mg two times daily
(maintenance dose 200 to 400mg daily)
• Electrical cardioversion (refer to specialist)
• Anticoagulation therapy (to reduce the risk of systemic
embolization) – Aspirin 75-150mg once daily orally,
Warfarin 2.5-10mg once daily orally (to maintain
INR 2,5 to 3,5).
• Use warfarin, if no INR available, aspirin 75-150mg
orally once daily.
Premature atrial contractions

No treatment required. If symptomatic: B-blockers (e.g.
Propranolol 20-40mg orally 2-3 times daily, Verapamil
40-80mg orally 2-3 times daily.
Premature ventricular contractions

No treatment if asymptomatic, if symptomatic or frequent
– B-blockers ( Propanolol 40-80mg three times daily
orally), Amiodarone 200mg three times daily orally for
5-7 days, then reduce to 200mg two times daily
(maintenance dose 100-200mg daily).
Monitor for possible side effects: Thyroid function test,
LFTs, consult ophthalmologist and CXR once a year.

242
7.8� CARDIOPULMONAY RESUSCITATION �
AND ADVANCED CARDIAC LIFE �
SUPPORT
Basic life support (BLS)
Goals of resuscitation – to maintain cerebral perfusion

until cardiopulmonary function is restored.
Important change: A-B-C changed to C-A-B (circulation

first).
1. Check responsiveness by gently shaking the patient.
2. Call for help, fetch defibrillator and oxygen and
airway adjuncts, resuscitation kit.
3. Position the patient on a firm flat surface.
4. Open the patient’s airway and assess for the presence
of respiration.
5. Check circulation (palpate for carotid pulse), if not
present start CPR.
6. Initiate chest compressions (position both hands
over the lower part of the sternum and compress
at the rate of 30 compressions/ 2 breaths). At the
rate 100 chest compressions/min, depth in adults
2 inches, infants 4 inches.
7. Once the patient is intubated, ventilation can be at
a rate of 12-15 per minute without pausing for
compressions.
Advanced cardiac life support
Advanced cardiac life support (ACLS) is an extension of

BLS and usually is implemented by a team leader with
the use of necessary facilities.
1. IV access with IV fluid e.g. before NS
2. Attach defibrillator-monitor.
3. Assess cardiac rhythm.

243
If Ventricular tachycardia or ventricular fibrillation:
• Defibrillate
• Epinephrine 1mg IV push, repeat every 3-5 minutes
• Consider antiarrhythmic drugs – Amiodarone 300mg
IV push or Lignocaine 1.0-1.5mg/kg IV push or
Magnesium sulfate 1-2g IV push
Identify and treat reversible causes 4-“T: Tension

pneumothorax, Thrombosis (coronary and pulmonary),
Tamponade cardiac, toxins, 4 “H” hypovolemia, hypoxia,
hypothermia, hypo and hyperkalemia, acidosis.
If asystole:
• Continue CPR
• Epinephrine 1 mg IV push every 3-5 minutes until
there is a cardiac rhythm or CPR is stopped
• Treat reversible causes (see above)
• Atropine is no longer recommended for asystole and
PEA (Pulseless Electrical Activity).
• Termination of rescuscitation: terminate rescuscitation
after 5 cycles of CPR and defibrillation, also if prognosis
of underlying condition is poor.

244
8
MALIGNANCIES
8.1� LEUKAEMIAS
Definition
These are diseases characterised by the proliferation of a
single malignantly transformed progenitor cell in the
haemopoietic system. Acute leukaemia if untreated has a
rapidly fatal course. Chronic leukaemia has a more prolonged
course but patients invariably die from it. Leukaemia is
classified according to the morphological cell type involved
and the speed of evolution of the disease.
Acute Lymphoblastic Leukaemia (ALL)
Acute Myelogenous leukaemia (AML)
Chronic Lymphatic Leukaemia (CLL)
Chronic Myeloid Leukaemia (CML)
Acute Lymphoblastic Leukaemia (ALL)
Definition
Proliferation of lymphoid cells in the bone marrow
Clinical features
Any age may be affected but commonly 4-8 year olds. Male
to female ratio is 1:1
Symptoms
Fatige, headache, palpitations, bleeding into skin, nose
mucous membrane, infections such as sore throat pneumonia
and bone pain.

245
Signs
Bone tenderness, splenomegaly, lymphadinopathy, pallor
and bruises.
Signs include pallor, bruising, petechial haemorrhages,

bleeding gums and gum hypertrophy, lymphadenopathy,
splenomegaly and/or hepatomegaly, haemorrhages in
the optic fundi. Hard enlarged testicles indicate that the
testes have become infiltrated with leukaemic tissue.
Opportunistic infections do occur.
Management
Diagnosis
a) Full blood count which shows a
normocytic/normochromic anaemia
b) The white cell count maybe normal or raised (normal
4 -11 x 109/L 50,000 or more
c) The platelet count is usually reduced (normal 150
- 4000 x 109/L) below 150 /9/L
d) Characteristic leukaemic cells in blood and bone
marrow
e) The CSF prepared sediment may show blast cells if
meningeal leukaemia is present.
f) The periferal smear show lymphoblast.
Treatment
Supportive care
i) Blood and platelet transfusion, I.V.
ii) Appropriate antibiotics at the first sign of infection
iii) Correction of dehydration, treatment of
hyperuricaemia arising from chemotherapy with
allopurinol and I.V. fluids
iv) Barrier nursing, prophylactic antibiotics e.g.
cotrimoxazole to prevent pneumocystis carinni
(jerevici)
v) Emotional support

246
Chemotherapy
This is done in 3 steps
i) Remission induction:
Vincristine 2mg/m2 I/V every 1-2 weeks
Prednisolone 60mg/m2 daily
Daunorubicin 40mg-75mg/m2 daily
ii) CNS prophylaxis:

Intrathecal methotrexate 5mg/kg weekly
Cranial irradiation
iii) Maintainance chemotherapy:

Mercaptopurine (daily)100-200mg daily
Children 2.55/kg body weight per day.
Methotraxate Children 12.5mg/Methotrexate
(weekly)
Vincristine and prednisolone (monthly)
For 2 –3 years.
Prophylaxis
Methotraxat
Methotraxate Danorubicin Ara-c
10mg 10mg 20mg
12.5mg 12.5mg 25mg
15mg 16mg 30mg
Bone marrow should be performed in all suspected cases

and will show more than 5% lymphoblasts
Lumbar puncture may be done. If meningual leukemia

is suspected this will show blasts in the CSF.
Relapse is common in blood, CNS or testis
Prognosis
Is better in children where the cure rates for children are
70 – 90%; it is very poor in adults where 20% cure rates
have been recorded. Worse prognosis in blacks.

247
Acute Myelogenous Leukaema
Definition
Proriferation of myeloid cells in the bone marrow and
blood. This has got unfavorable prognosis and increases
with age.
Clinical features
1. Marrow failure causes
a. Anaemia
b. infection often positive
bleeding from the gums
c. disseminated intravascular coagulation
2. Leukaemic infiltration
a. bone pain, tender sternum
b. CNS signs (cord compression, cranial nerve lesions)
c. Gums hypertrophy, testes, orbit ((proptosis)
d. Hepatosplenomegaly
e. Lymphadenopathy
f. Skin and peri-anal involvement
3. Constitutional features
a. malaise
b. weakness
c. fever
d. polyarthritis
Management
Diagnosis
i) The white cell count is variable
ii) Bone marrow biopsy – diagnosis depends on this.
Treatment
Chemotherapy
1. Very intensive. The main drugs used include
daunorubucin, cytosine 100-200mg per square

248
meter for 5 days I/V or subcutaneous. arabinoside
and thioguanine 2mg/kg body weight daily.
Long term maintainance is generally considered to be

less effective
2. Bone marrow transplant (BMT) – allogeneic

transplants is possible in acute conditions.
Intrathecal prophylaxis as on page247.
Supportive care
i) Blood and platelet transfusion
ii) Barrier nursing
iii) I.V. antibiotics
Chronic Lymphatic Leukaemia (CLL)
Definition
This is the infiltration of the bone marrow and blood
relatively mature lymphocytes common in people above
60 years of age.
Clinical features
Symptoms include:
i) Bleeding
ii) Weight loss
iii) Infection
iv) Anorexia
v) Lethargy
vi) Fever and sweating
Signs include:
i) Enlarged, rubbery, non tender nodes
ii) Hepatosplenomegaly
iii) Pallor

249
Complications
i) Auto-immune haemolysis
ii) Infection - bacterial or viral (mostly of the respiratory
tract).
iii) Bone marrow failure
Diagnosis
i) FBC Mild anemia – normocytic/normochromic type.
ii) The white cell count is > 15 x 109/L of which more
than 60% are lymphocytes
iii) The platelet count is usually normal in the early
stages
iv) Bone marrow shows mainly more mature
lymphocytes
Treatment
Chemotherapy
This is not always needed but may postpone marrow
failure. Chlorambucil 0.1–0.2mg/Kg body weight orally
daily is used to decrease the lymphocyte count.
Prednisolone 60mg/m2
Steroids are used if there is auto-immune haemolysis.

i) Transfusions
ii) Prophylactic antibiotics
Chronic Myeloid Leukaemia (CML)
Clinical features
Definition
This is the infiltration of the bone marrow and blood with
relative mature myeloblasts.
It accounts for 15% of leukaemias and often occurs in

middle age of 45 - 55 with a slight male predominance.

250
Symptoms
a) Symptoms of anaemia
b) A large spleen (swelling of the abdomen)
c) Priapism
d) Gout
e) Sweating, fever and loss of weight
f) Bruising
Signs
Pallor, splenomegaly, hepatomegaly, bleeding into the
mucous membrane and there may be evidence of
infection.
Management
Diagnosis
i) FBC which shows raised WBC (often .100 x 109/L)
ii) Low Hb
iii) Platelets may be raised normal or reduced.
v) Abundance of neutrophils in the blood film but whole
spectrum of myeloid precursors including a few blast
cells
vi) Bone marrow may present
pesent
present with the whole spectrum
of myeloid precursors including a few blast cells.
Mega karyocyte may be abundant.
vii) Philadelphia chromosome on chromosome
preparation
viii) Levels of Vitamin B12 and B12 binding proteins are
elevated
Treatment
i) Treatment of choice is hydroxyurea 30- 50mg/kg
body weight in two devided doses or busulfan 2-
4mg daily
ii) Allogeneic bone marrow transplant
iii) Splenectomy can reduce discomfort, radiation to
spleen may reduce discomfort.

251
• Excision biopsy
• FBC, ESR, LDH, LFTs, U/Es
• CXR
• Abdominal Ultrasound
• CT chest abdomen and Pelvis
• HIV and CD4 count
For advanced stage disease bone marrow aspiration and
trephine
Treatment
The choice of treatment is determined by the stage of
the disease. It consists a combination of radiotherapy
and chemotherapy.
Stage I & II – 4 cycles of chemotherapy plus involved

field radiation therapy.
Stage III & IV – 6 – 8 cycles of combination chemotherapy

plus radiotherapy for residual localized disease.
Chemotherapy
ABVD regimen:
• Doxorubicin 25mg/m2 D1 & 15 IV
• Bleomycin 10 units/m2 D1 & 15 IV
• Vinblastine 6mg/m2 D1 & 15 IV
• Darcabazine 375mg/m2 D1 & 15 IV
Repeat every 28 days
MOPP regimen:
• Mechlorethamine 6mg/m2 IV
• Vincristine 1 – 1.4mg/m2 IV D1 & 8
• Procarbazine 100mg/m2 orally from D1 – 14
• Prednisolone 40mg/m2 orally from D1 – 14
Repeat cycle every 28 days.

253
CHOP, Chemotherapy, Chemotherapy
viii) CSF examination done at the first intrathecal
treatment
Treatment
This is associated with tumour lysis syndrome, so IV pre-
hydration and allopurinol must be given before starting
chemotherapy
Regimen
Patients with localised disease receive 3 cycles of CODOX-
M.
Patients with multiple site involvement are treated with

CODOX-M alternating with IVAC and intrathecal therapy
for 4 cycles each.
CODOX-M and CODOX-M alternating with IVAC
CODOX-M
• Cyclophosphamide 800mg/m2 D1 and 200mg/m2
D2-5 IV
• Vincristine 1.5mg/m2 D1 IV (max 2mg)
• Doxorubicin 40mg/m2 D1 & 8 IV
• Methotrexate 1.2g/m2 continuous IV infusion on
D10, then 240mg/m2 IV each hour over 23hrs
• Folinic Acid 192mg/m2 IV D11 starting from the
12th hour of methotrexate infusion, then 12mg/m2
IV every 6hrs for next 48hrs
• G-CSF support starting
G-CSF (Filgastrim) on daystarting
support 13 untilon day 13 until
granulocyte
granulocytecount
count is (Filgastrim) above 1X109/L
is above 1X109/L
CNS prophylaxis
• Cytarabine 30mg/m2 IT D1 & 3
• Methotrxate 12mg/m2 IT D15 (Not more than 20mg
total dose)
• Hydrocortisone 20mg/m2 D1, 3 and 15
• Folinic Acid

256
bone scan.
Treatment
This depends on the stage of the disease.
i) Early Breast cancer
• Breast Conserving Treatment: wide local excision
with axillary dissection, then Adjuvant Radiation
therapy and/or chemotherapy
• Modified Radical Mastectomy with an axillary
dissection. Adjuvant Chemotherapy and
radiotherapy will depend on the histopathological
findings (stage).
ii) Locally Advanced Breast Cancer – must be treated
with all modalities (Surgery, Chemotherapy and
Radiation therapy)
iii) Metastatic Breast Cancer – Chemotherapy and where
indicated hormonal therapy
Treatment Regimens
1. Chemotherapy
• AC – Doxorubicin 60mg/m2 IV D1and
Cyclophosphamide 600mg/m2 IV D1 repeat every
21 days for 4 cycles OR
• CAF – Oral cyclophosphamide 100mg/m2 D1 –
14, Doxorubicin 30mg/m2 IV D1 and D8, and 5
Fluorouracil 500mg/m2 IV D1 and D8. Repeat
every 28 days for 6 cycles OR
• FAC – 5 Fluorouracil 500mg/m2 IV D1 &8,
Doxorubicin 50mg/m2 IV D1, and
cyclophosphamide 500mg/m2 IV D1. Repeat
every 21 days for 6 cycles OR
• CMF Cyclophosphamide 100mg/m2 PO D1 – 14,
Methotrexate 40mg/m2 IV D1 & 8, and 5
Fluorouracil 600mg/m2 IV D1 & 8 every 28 days
for 6 cycles
• TAC – Docetaxel 75mg/m2 D1 IV, Doxorubicin
50mg/m2 IV D1, and Cyclophosphamide

258
Classification
1. Epithelial – Adenocarcinoma, adenosquamous,
papillary serous
2. Stromal tumours – Sarcomas of the uterus
Prognosis and adjuvant treatment are dependent on the

grade, histology and stage of the cancer.
Clinical Features
• Postmenopausal bleeding
Diagnosis
• History and physical examination
• Endometrial biopsy
• CXR
• Abdominal and pelvic ultrasound
• FBC, U/Es, LFTs
Treatment
1. Primary treatment is surgery TAH and BSO plus minus
pelvic lymphadenectomy. For patients who refuse
surgery or are medically inoperable curative
radiotherapy is indicated.
2. Adjuvant treatments depend on stage, grade, and
histology; Radiotherapy with either vaginal
brachytherapy alone or in combination with external
beam radiation therapy at 2Gy to 50Gy.
3. Systemic therapy include
a. Hormonal Therapies with medroxyprogesterone
actate 400 – 800mg po twice weekly, Tamoxifen
20mg daily
b. Chemotherapy TAP ie Cisplatinum 50mg/m2 iv,
Adriamycin 45mg/m2 iv D1 followed by Paclitaxel
160mg/m2 repeat every 21 days OR carboplatin
and Paclitaxel as for Ovarian cancer

262
50Gy split course with
value above 4mg/mL
Classification
Majority are Squamous cell carcinomas
Adenocarcinomas arise commonly from the lower third
(gastro-oesophageal junction)
Symptoms and Signs

• Progressive dysphagia
• Pain
• Odynophagia (painful swallowing)
• Weight loss
• Regurgitation
• Vomiting
Diagnosis
• Barium swallow
• Oesophagoscopy and biopsy
• CXR
• FBC, U/Es, LFTs
• For lesions less than 5cm do CT chest and Abdominal
ultrasound
• Endoscopic ultrasound
Treatment
For lesions less than 5cm
• Surgery – oesophagectomy for primarily operable
tumours
• Preoperative chemo-radiation followed by surgery
for those requiring downsizing
Lesions 6 – 7cm
• Curative chemo-radiation
Chemotherapy
• Cisplatinum 40mg/m2 IV weekly concurrent with
radiotherapy at 1.8Gy per fraction to 50.4Gy
OR

272
Adjuvant treatment for colon cancer
• Stage I and II no further treatment after surgery but
require follow up with yearly colonoscopy
• Stage III and IV will require adjuvant chemotherapy
Adjuvant treatment for rectal carcinoma

• Preoperative short course radiotherapy: 5Gy daily
for 5 days followed by surgery one week later.
• Preoperative long course chemo-radiation
• Post-operative chemo-radiation
Chemotherapy
FL
• 5 Fluorouracil 425mg/m2 D1 – 5 IV
• Leucovorin 20mg/m2 D1 – 5 IV 30 minutes before
5 FU
Repeat every 28 days for 6 cycles

OR
FOLFOX
• 5 Fluorouracil as above
• Leucovorin as above
• Oxaliplatin 85mg/m2 D1 only IV

274
• Cloacogenic (transitional)
• Adenocarcinoma
• Others – pagets disease, basal cell, melanoma,
lymphoma
Symptoms and signs

• Bleeding
• Anal pain
• Pruritis
• Palpable mass
• Change in bowel habit
• Chronic anal condition- Haemorhoids,fistula,fissure
Diagnosis
• History and physical examination including DRE,
gynaecologic exam in women
• EUA, Proctoscopy, Biopsy of primary tumour
• FNA/biopsy of clinically suspicious inguinal nodes
• CXR
• Abdominal pelvic CT scan
• Ultrasound abdomen and pelvis if unable to do CT
scan
• FBC, U&Es, LFTs, HIV, CD4
Treatment
Surgery
• Wide local excision – Only in tumours <2cm which
are well differentiated, and preservation of anal
function assured
• Abdominal perineal resection – is reserved only
for salvage of patients who have failed
chemoradiotherapy
Combined modality therapy

• Chemoradiation is the standard primary treatment
option with doses of 45-60Gy
• 5 flourouracil 400mg/m2 Day1-4 and Day 22-25

278
Impairment of mental function
where possible for both low or high grade
• Low-grade astrocytomas
– Complete resection followed by observation
– In incomplete resection observation or adjuvant
chemotherapy and/or radiation therapy is
considered
• High-grade astrocytomas (anaplastic or glioblastoma
multiforme )
– complete surgical resection followed by
radiotherapy alone or concurrent with
temozolomide
Chemotherapy:
• Single agent regimens
– Carmustine (BCNU) 80 mg/m2 I.V D1-3 every
6-8 weeks
– Lomustine (CCNU ) 130 mg/m2 P.O D1 every 6-
8 weeks
Combination chemotherapeutic regimens

1. PCV
Procarbazine 60mg/m2 P.O D 8-21
Lomustine 110 mg/m2 P.O D1
Vincristine 1.4 mg/m2 I.V. D8 & D29
Repeat every 6-8 weeks (max 10 courses)
2. PE
Cisplatin 30 mg/m2 I.V. D 1-3
Etoposide 150 mg/m2 I.V. D 1-3
Repeat every 3 weeks 6-8 courses
Radiotherapy using 3D conformal radiation therapy

technique
Low-grade gliomas 1.8Gy per fraction to 50.4Gy

High grade gliomas 1.8Gy per fraction to a total of 54 –
59.9Gy

280
Classification
• Keratinising squamous cell carcinoma WHO type I
• Non keratinizing squamous cell carcinoma WHO type
II
• Undifferentiated squamous carcinoma or
lymphoepithelial carcinoma WHO type III
Symptoms and signs

• Nasal voice
• Nasal congestion and obstruction
• Nasal bleeding
• Neck swellings / lymphadenopathy
• Cranial nerve palsies
• Other CNS signs
• Bone pain and/or tenderness
Diagnosis
• CXR
• FBC, U/Es, LFTs
• CT Scan whole brain and Base of skull to clavicle
• Biopsy of nasopharynx
Treatment
The main stay of treatment of NPC is radiotherapy.
Stage I & II:

Curative radiation therapy to 70Gy at 1.8 – 2GY per fraction
Stage III:
Chemoradiation to 70Gy with cisplatinum 75–100mg/kg
IV 3 weekly starting with day 1 of radiation treatment
and currently this is followed with 4 cycles of cisplatinum
and 5 fluorouracil
Other Head and Neck Cancer

283
Symptoms and signs
• Thyroid nodule – found incidentally or during routine
physical examination
• Lump in the neck
• hoarseness of voice if recurrent laryngeal nerve
involved or extension to larynx,
• Dysphagia if oesophageal extension is present.
• Neck nodes
• Haemoptysis
• Cough
• Chest pain
• Bone pain
• Diarrhoea due to calcitonin, serotonin or prostaglandin
production in those with MTC
Diagnosis
• History and examination
• ENT exam
• Ultrasound of the neck FNAB is recommended at
this stage
• CXR
• FBC, CMP, U/E’s and LFT’s
• Preoperatively
– Routine use of CT scan, MRI and PET scan is not
recommended.
– Thyroglobulin level not recommended
• Postoperatively
– All patients with papillary and follicular cell
carcinoma must have an initial 131Iodine
diagnostic scan within 6 weeks post surgery
– Ultrasound of the neck with Tg levels
– CT scan with contrast is contraindicated.
– Non contrast CT chest can detect pulmonary
metastasis
– PET scan is useful in patients with:
– increased Tg levels and a negative 131 Iodine
uptake scan

285
Definition
Medulloblastoma is a primitive cerebellar tumour of
neuroectodermal origin that is the most common posterior
fossa malignant tumour in children. It accounts for 20%
of paediatric brain tumours.
Symptoms and Signs

• Headache
• Vomiting
• Convulsions
• Ataxia
• Cranial nerve palsies
• Coma and unconsciousness
• BP and pulse
Diagnosis
• CSF cytology
• MRI or CT scan of the brain and whole spine
• FBC, U/Es
• Audiometry
• Histological confirmation is done after craniotomy
and complete resection of the tumour
Treatment
Depends on the risk category
• Average Risk:
children older than 3 years, no metastasis, near to
total resection, with less than 1.5cm2 residual disease
on early post operative imaging (24-48hrs)
• High Risk:
overt metastatic disease based on CSF cytology or
imaging > 1.5cm2 residual disease, and all children
< 3 years of age.
1. Surgery:

287
Clinical features
Symptoms
i White papillary reflex
ii) (Leucokoria)
iii) Red painful eye
iv) Strabismus
v) Eye tumor
Signs
i) Creamy-pink mass projecting into vitreous
ii) A white avascular tumor
ii) Retinal detachment
iii) Vitreous haemorrhage
iv) Clouding of anterior chamber
Complications
I. Loss of vision
II. Local Pain
III. CNS disease
IV. Anaemia
Diagnosis
• History and Clinical Examination findings
• Investigations for Staging of Retinoblastoma
I. Intraocular extent of disease
Indirect ophthalmoscopy
Ultrasonography of globe
II. Orbital extent of disease
A. Plain X-ray of optic foramen, orbit, and skull

B. CT of orbit
III. Metastatic evaluation
A. LP: CSF for cytology

B. FBC
C. LFTs include ferritin and NSE
D. BM aspiration for histology and cytogenetics; BM

289
biopsy
E. Abdominal US (Liver/Spleen)
F. CT of brain, head and Abdomen
G. Bone Scan
H. Biopsy of extraoccular masses
I. Globe and optic nerve stump histopathology (if
enucleation done)
Added investigations to include ECG and as patient’s

condition dictates.
Reese-Ellsworth Intraocular staging:

Group I. Very favorable
A. Solitary tumor, less than 4 disc diameters in size at
or behind the equator
B. Multiple tumors, none over 4 disc diameters in size
at or behind the equator
Group II. Favorable

A. Solitary tumor, 4-10 disc diameters in size at or
behind the equator
B. Multiple tumors, 4-10 disc diameters in size behind
the equator
Group III. Doubtful

A. Any lesion anterior to the equator
B. Solitary tumors larger than 10 disc diameters in size
behind the equator
Group IV. Unfavorable

A. Multiple tumors larger than 10 disc diameters
B. Any lesion extending anterior to the ora serrata
Group V. Very unfavorable

A. Massive tumors involving more than one-half the
retina
B. Vitreous seeding

290
*Staging for probability of retaining useful vision rather
than survival.
Grabowski-Abramson Clinico-pathologic Staging

of Retinoblastoma
Stage Description
I. Intraocular disease
a. Retinal tumor, single or multiple
b. Extension to lamina cribrosa
c. Uveal extension
II. Orbital disease
a. Orbital tumor
1. Scattered episcleral cells
2. Tumor mass
b. Optic nerve
1. Distal nerve; line of resection and meninges
clear
2. Tumor at line of resection or in meninges
III. Intracranial metastasis
a. Positive CSF alone
b. Mass lesion in CNS
IV. Haematogenous metastasis
a. Positive BM alone
b. Focal bone lesions with or without positive marrow
c. Other organ involvement
Treatment
Stage/extent of disease determines choice of treatment
modality.
Treatment modalities for intraocular disease include:

1. External beam radiotherapy
2. Episcleral plaque therapy
3. Photocoagulation
4. Cryotherapy
5. Enucleation

291
6. A combination of the above modalities
Treatment modalities of extraocular disease:

Adjuvant chemotherapy improves survival in patients
with extraocular disease following enucleation. Patients
with overt CNS disease or with a high probability of
meningeal spread should receive intrathecal methotrexate
and cytosine arabinoside, and if possible cranial irradiation.
Stage II, III and IV all require multimodality therapy of
Enucleation, Radiation and Chemotherapy (plus intrathecal
chemotherapy).

292
Drugs Stage II and III
Phase Week Drug Dose
0 Cyclophosphamide 40 mg/kg IV, Day 1

Doxorubicin 0.67 mg/kg IV, Days 1, 2, 3
Vincristine 0.05 mg/kg IV, Day 1
3-21
(Repeat every 3rd week) Cyclophosphamide 20 mg/kg IV, Day 1
293

24-57 Cyclophosphamide 30 mg/kg IV, Day 1
(Repeat every 3rd week) Vincristine 0.05 mg/kg IV, Day 1
0, 1, 2, 3, 4, 5 Methotrexate IT
Cytarabine IT
Drugs Stage IV
0 Cyclophosphamide 40 mg/kg IV, Day 1

3, 9, 15, 21
294
Cisplatin 3 mg/kg IV, Day 1
Etoposide 3.3 mg/kg IV, Days 1, 2, 3

6, 12, 18, 24, 27, 30, 33 Cyclophosphamide 30 mg/kg IV, Day 1
36 – 105 Cyclophosphamide 30 mg/kg IV, Day 1

(Repeat every 3rd week) Vincristine 0.05 mg/kg IV, Day 1
0, 1, 2, 4, 5, 6 Methotrexate IT
Cytarabine IT
295
metanephric blastoma
adrenal carcinoma, hepatoblastoma, and
gonadoblastoma
• Genitourinary tract anomalies
Diagnosis
History and physical examination
Investigations
• FBC, U/E, LFT, Coagulation profile
• ECG and echocardiogram
• Abdominal US
• IVU
• CXR
• Abdominal and Chest CT scan
Staging
International Society for Paediatric Oncology (SIOP)
Nephroblastoma staging
Stage Description
I Tumour limited to the kidney,
complete excision
II tumour extending outside the kidney,
complete excision
a) invasion beyond the capsule,
perirenal/perihilar
b) invasion of the regional lymph nodes
(hilar nodes and/or periaortic nodes
at the origin of the renal artery
c) invasion of the extrarenal vessels
d) invasion of ureter
III Invasion beyond the capsule, incomplete
excision
a) preoperative or perioperative biopsy
b) preoperative/perioperative rapture
c) peritoneal metastasis
d) invasion of paraaortic lymph nodes

297
e) incomplete excision
IV Distant metastasis
V Bilateral renal tumours
Treatment
Multiple modality approach that is dependant on stage
and risk combining surgery, chemotherapy and radiation
Pre- nephrectomy Therapy
Pre OP 1, 2, 3, 4 Vincristine 1.5 mg/m2 IV,

Day 1
1, 3 Actinomycin D 0.015 mg/m2 IV,

Day 1, 2, 3
Post-operative Therapy
Stage I, Favourable histology: No therapy
Stage I, Standard histology and anaplastic WT
Drugs
Actinomycin D
Vincristine
Post OP 1, 2, 3, 4, Vincristine 1.5 mg/m2 IV,

10, 11, 17, Day 1
18
Day 1, 2, 3, 4, 5

298
Stage II Standard histology
Drugs
Actinomycin D
Vincristine
Doxorubicin
Radiation
Post OP 1, 2, 3, Vincristine 1.5 mg/m2 IV,

4, 5, 6, Day 1
7, 8
11, 12, &
14, 15
17, 18, &
20, 21
23, 24, &
26, 27

Day 1, 2, 3, 4, 5
4, 8, 14 Doxorubicin 50 mg/m2 IV,

Day 1
2–3 Radiation

299
Stage II and III anaplastic WT, I to III clear cell sarcoma
Drugs
Actinomycin D
Vincristine
Doxorubicin
Radiation
Post OP 1, 2, 3, Vincristine 1.5 mg/m2 IV,

5, 7 Day 1
10, 11, 12,
and 14, 15
17, 18, 19,
and 21, 22
24, 25, 26,
and 28, 29
31, 32, 33,
and 35, 36
5, 14, 21,
Day 1
1, 10 Doxorubicin 50 mg/m2 IV,

Day 1
3, 12 Ifosfamide 3000 mg/m2 IV,

Day 1
5-8 Radiation

300
Diagnosis
History and Clinical Examination findings
Investigations for Staging of Retinoblastoma

• Urinalysis
• FBC
• U/E
• LFTs
• Skeletal Xrays
• CT Scan
• Bone Scan
• BM aspiration and Biopsy
• Biopsy of tumor
Other special examinations and Investigations

• Head and Neck Tumor
• Ear, nose and
ane throat examination under anaesthesia
• Ophtalmologic examination
• LP and CSF cytology
• Abdominal Pelvic tumour
• Abdominal US
• Cystoscopy
Grouping
Group I. Definition
A. Localized, completely resected, confined
to site of origin
B. Localized, completely resected, infiltrated
beyond site of origin
Group II. A. Solitary tumor, 4-10 disc diameters in size

at or behind the equator
B. Regional disease, involved lymph nodes,
completely resected
C. Regional disease, involved lymph nodes,
completely resected with microscopic
residual

302
Group III. A. Local or regional grossly visible disease
after biopsy only
B. Grossly visible disease after >50% resection
of primary tumour
Group IV. Distant metastasis present at diagnosis
Staging
TNM staging system
Stages 1 to IV
Treatment
Multiple modality approach that is dependant on stage
combining surgery, chemotherapy and radiation

303
9
EYE DISEASES
9.1� THE RED EYE
This is characterised with the redning of the eye caused by:
With Pain Without Pain
Iritis Conjunctivitis
Corneal Foreign Body – Allergic
Acute Glaucoma – Viral epidemic Haemorrhagic
Chemical Conjuctivitis – Bacterial Conj. (ophthalmia
Neonatorum)
Corneal Ulcers
Penetrating and Perforating Eye Injuries
9.1.1� With Pain
9.1.1.1 Iritis
Definition
It is the inflammation of the Iris.
Clinical Features
Symptoms
• Deep seated eye pain
• Decreased vision
• Redness of the eye
• Light intolerance
• Watery eye
Signs
• Pink ring of blood vessels around the cornea – ciliary

304
flush
• Small white spots on the back of the cornea – keratic
precipitates
• Iris may be stuck to the lens – posterior synechiae
Treatment
• Atropine 1% Eye ointment twice daily
• Bethamethasone 1% eye drops, or
• Hydrocortisone 1% eye drops, or
• Dexamethosone 0.1% eye drops, or
Predinisolone 1% eye drops 1-2 times a day
9.1.1.2 Corneal Foreign Body
Definition
This is the presence of a foreign body on the cornea.
Clinical Features
Symptoms
• Red eye
• Watering eye discharge
• Difficulty to keep the eye open
• Pain
• Distorted vision
Sign
Foreign object may be seen on the cornea
Treatment
• Apply a drop of 2% Lignocaine onto the affected
eye
• Wipe away the foreign body with a wisp of sterile
cotton wool on an orange stick
• If foreign body does not come out easily refer to
nearest eye clinic where it may need surgical removal
(with a hypodermic needle)
• Chloramphenical
Chloramyphenical 0.5% eye drops 1 drop every 2

305
hours, then reduce frequency as infection is controlled.
Pad the eye for 24 hours
9.1.1.3 Acute Angle Closure Glaucoma
Definition
This is an acute increase in the intra ocular pressure
brought about solely by closure of the anterior chamber
angle by the peripheral Iris.
Predisposing Factor
• Small long sighted eye
• Anatomical shallow anterior chamber
Clinical features
Symptoms
• Impaired vision
• Red eye
• Severe Periocular pain
• Nausea
• Vomiting
• Severe headache
Signs
• Ciliary flush
• Very, very high Intraocular pressure (50 – 100mmltg)
• Hazy Cornea Bathroom window glass type of cornea
(middilated pupil)
• Bombe iris
• Flare
• Dilated Iris vessels
• Painful hard eye
Investigation
Tonometry with a schiotz or perkins tonometer will show
very high intraocular pressure

306
Treatment
The definitive treatment is surgical
Drugs
• Acetazolamide 500mg intravenously start, then
250mg 6 hourly
• Pilocarpine 4% 6 hourly
• Paracetamol 500 – 1gm orally 6 hourly
This is the initial treatment to relieve the angle closure
Definitive Treatment
Permanently keep the angle open surgically by:
(i) Peripheral laser iridotom
(ii) Peripheral Iridectomy
(iii) The surgery must be done to both eyes as the
predisposing condition affects both eyes
Other Hyperosmatic agents

Because of their speed of action and effectiveness,
hyperosmolar agents are of great value during the acute
crisis of acute glaucoma to reduce the intraocular pressure.
• Mannitol (1-2g/kg body wt of 20% solution in water,
given over 30 – 40 minutes, (60 drops per minute
as slow intravenous infusion) until intra-ocular
pressure has been satisfactory reduced
• Urea 1-2kg body wt of a 30% solution in 10% invert
sugar
9.1.1.4 Chemical Conjunctivitis
Definition
It is an inflammation of the eye caused by a chemical
substance.
Common Chemicals
• Car battery acid
• Snake venom

307
• Fluid from plants
• Household cleaning chemicals
• Alkali chemicals are more damaging to the eye than
acids
Clinical Features
Symptoms
• Pain
• Redness
• Watering
• Pus discharge if secondarily infected.
Emergency management
– Apply local anaesthetic – lignocaine 2% eye drops
– Wash the eye copiously with normal saline or
tap water for about 30 minutes
Investigation
Fluorescein staining will reveal area of conjunctival corneal
chemical erosion
Treatment
• Hydrocortisone 1% Eye Ointment. Apply 3-4 times
daily
• Atropine eye drops 1% 2 times a day
• Tetracycline 1% eye ointment three times daily if
infected
Note that the first line drug of choice is Hydrocortisone.
Use Tetracycline as second line, only if steroid is not

available.
Other Drugs Used In Chemical Burns

• Vitamin C (Sodium ascerbate) 10% drops and a daily
oral dose of ascorbic acid 1gm (assist in laying down
of the corneal collagen)

308
• Difficult to open eye in light (photophobia)
• Discharge, water or pus
• Disturbed vision
Signs
• Poor vision on snellen testing a white spot of the
eye may be seen
• On retinoscopy – irregular light refraction
Investigation
• Fluoresce in staining of the cornea, the wound stains
green
• Corneal swab for microscopy, culture and sensitivity
Treatment
Depends on the cause
For all types of ulcers, prevent ocular pain with atropine
1% once daily in the affected eye
Infections
• Bacteria Corneal Ulcers use tetracycline 1% eye
ointment, or chloramphenicol 1% eye ointment 3-
4 times a day
• If not resolving within 2 weeks, then refer
Fungal Ulcers
Typically see main ulcer, with riders, and satellite ulcers

around the main one. (This is seen occasionally. It may
not be seen at all)
Treatment
• Povidone Iodine, 2%, four times daily in the affected
eye
• Natamycin, 5% eye suspension given hourly for 7
days
• Econazole, 1% suspension for topical use
• Miconazole, 10mg/ml given subconjuctival or

310
intravitrial given as 10microgram per ml
• Amphoteracine, B 0.05-0.2% can be made from IV
injection and instill every 5 minutes first hour and
30-60minutes until clinical picture changes. (protect
from light- use umber coloured bottle)
Viral ulcers, Herpes simplex
Typical characteristic - on Fluorescein, 1 or 2% staining

a dendritic corneal ulcer (branching)
Treatment
• Acyclovir eye ointment (suspension) five times daily
in the affected eye for about 21 days.
Note: If has a very high association with HIV/AIDS
steroids are contra indicated
Ophthalmia neonatorum
Presents 2 – 4 days post partum
Clinical reactive
Hyperacute conjunctivitis with pus, with or without a
membrane
Severe swelling of both eyes
Treatment
• Penicillin G 50,0000 IU in 2 divided closes for 7 days
– systemic
• Penicillin eye drops 1 hourly both eyes – Topical
9.1.1.6 Penetrating and Perforating Eye Injuries
Definitions
Penetrating wounds are injuries of the eye ball that result
from a sharp object. They typically have a wound ofentry,
and a wound of exit. There may or may not have a

311
retained foreign body.
Perforating wounds are injuries of eye ball that have

only one wound of entry,. There also may have a retained
foreign body.
Clinical Features
Symptoms
• History injury present
• Red eye
• Painful eye
• Soft eye
Signs
• Eye maybe shrunken due to loss of volume
• There may be subconjuctival haemorrhage.
• Pigment discoloration of the conjunctiva in the area
of the wound
• Foreign Body may be seen.
Investigation
• X-ray orbit – to rule out intraocular foreign body.
• Ocular ultrasound
• Cranial CT scan
Treatment
• Tetanus toxoid
• I/V antibiotic preferably cefotaxime 1gm start
Or
• Gentamycin 80m IV start
Refer to the nearest eye unit promptly

312
9.1.2 Without Pain
The main cause of red eye without pain is conjunctivitis

of different types.
a) Infective
• Bacterial
• Viral
b) Allergic
c) Chemical
9.1.2.1 Bacterial Conjunctivitis
Definition
This is a bacterial infection of the conjunctiva
Clinical Features
Symptoms
• Ocular discomfort – gritty sensation in the eye
• Eye discharge (pus)
• Diffuse conjunctival redness
Signs
• Red conjunctiva with discharge
• Normal vision (clear cornea)
Investigation
Fluorescein staining is negative
Treatment
Tetracycline 1% eye ointment 3 – 6 times daily
Supportive
Good personal hygiene to prevent re-infection
Facial washing

313
9.1.2.2 Viral Epidermic heamorrhagic conjunctivitis
Definition
This is a viral infection of the conjunctiva and is associated
with bleeding. The condition is very infectious and difficult
to treat. It is often seen in families and epidemics.
Clinical Features
Symptoms
• Pain
• Watery discharge
• Ocular discomfort
• Photophobia
Signs
• Sub conjunctiva haemorrhage (severe rediness).
• Tender cervical lymphnodes, preauricular,submental
groups
• Swollen conjunctiva
• Water discharge
• Normal vision
Complication
• Secondary bacterial infection
Treatment
• Tetracycline 1% eye ointment 3 times daily for 7
days
Supportive
Patient hygiene – do not share face cloth
Wash face and eyes
9.1.2.3 Allergic conjunctivitis
Definition
An allergic inflammation of the conjunctiva. This condition

314
is common but very difficult to treat. A positive family
history of atopic disease may be present
Clinical Features
Symptoms
Itchy eyes
Signs
Ring of pale, fleshy, pink-grey tissue around the conea
Follicles on the tarsal conjunctiva (cobblestone type)
Treatment
Hydrocortisone 1% eye drops 3-4 times a day
Sodium chromoglycate 2% eye drops 5 times daily
9.2� TRACHOMA
Definition
Thiis is an infection of the eye caused by Chlamydia
Trachomatis. It is a disease of the under privileged
communities, with poor hygienic conditions. The common
fly is the major vector in the infection and re-infection
cycle. It is one of the leading causes of preventable
blindness in the world.
Characterized by an acute inflammation which appears

in the first decade of life, slowly progressing until the
disease becomes inactive during the 2nd decade of life.
Last sequelae may not appear for many years.
Stages
• Trachoma Follicular (TF): characterized by follicles
on the upper lid conjunctiva
• Trachoma intense (TI):, characterized by acute red
tarsal conjunctiva with obliteration of blood vessel
• Trachoma Scaring (TS): Tarsal conjunctiva starts
showing lines of scaring

315
• Trachoma Triachiasis (TT): – upper eye lid turns in,
because of extreme scaring and shortening of lid
conjunctiva causing corneal damage and ulceration
• Ulcerated Cornea (CO): starts scaring forming corneal
opacification
Clinical features
Symptoms
• None
• Red eyes
• Ocular discomfort
Signs
• Follicles on tarsal conjunctiva
• Eye lid conjunctional scaring
• In-turning of eyelids (entropion)
• Eye lashes rubbing on cornea (Trichiasis) heading to
corneal ulceration
• Corneal scars
Treatment
WHO recommends adopting the SAFE strategy in proven
endemic areas (after conducting survey).
S Surgery for stage 5

A Mass Antibiotic treatment. A single dose of
Azithromycin 500mg. In children 10mg/kg/bd/wt
as start dose (Donated by Pfizer free of charge once
results of the survey are made available proving
endemicity of the problem.
F Face washing (provision of clean and safe water –
multi-disciplinary approach where MOH partners
with other line Ministries responsible for safe water
as well as the some international NGOS that fund
this expensive aspect of Trachoma control.
E Environmental sanitation – Its a public health aspect
of management

316
9.3� LUMPS AND BUMPS ON AND AROUND �
THE EYE BALL
These are lumps and bumps on ana around the eye ball
and are divided into:
– Benign
– Malignant
Common ones
• Stye – KS (Kaposi Sarcoma)
• Chalazion (eye lid cyst)
– Squamous cell carcinoma of the
• Orbital dermoid cyst
– conjunctiva
• Pinguiculae Retinoblastoma
• Pterygia
9.3.1 Stye
Definition
This is a small abscess caused by an acute staphylococcus
infection of a lash follicle
Clinical Features
Symptom
Painful lump on the lid margin
Sign
Tender inflammed nodule or lump on lid margin
Treatment
• None – usually undergoes spontaneous resolution
• Hot compresses
• Removal of associated eye lash and drain the pus
• Tetracycline eye ointment may be applied to prevent
eye ball infection

317
9.3.2� Tarsal Cyst (Chalazion)
Definition:
This is a cyst on the eyelid that results from blockage of
the duct of tarsal glands. It is usually formed away from
the lid margin.
Treatment
Incision and curettage (I & C)
9.3.3� Orbital dermoid Cyst
Definition
These are round, localized nodules or lumps in the upper
temporal or upper nasal aspect of the orbit. They arise
from a displacement of epidermis to a subcutaneous
location.
Types
(a) Simple type – not associated with body defect, these
are superficially located
(b) Complicated – deeply seated, with deep intra-ocular
extension. Present later in life with displacement
of the eye ball
Investigation
• X-ray skull
• CT Scan to rule out intra orbital extension
Treatment
Surgery, total excision.
9.3.4 Pinguicula
Definition
This is a yellowish white growth on the bulbar conjunctiva
adjacent to the nasal or temporal aspect of the limbus.

318
This type does not involve the cornea.
Treatment
• Leave alone, if asymptomatic
• If inflamed – red – Tetracyline 1% eye ointment 2
times a day for 7 days.
9.3.5� Pterygium
Definition
These are conjunctival growths on the nasal or temporal
conjunctiva that enlarge and encroach on the cornea.
May cause a skin-like band over the cornea that may
cover the pupil.
Clinical features
Symptom
May not cause any problem
May be a discomfort of the eye ball if the pterygium is
inflamed.
Sign
Redness of the conjunctiva growth that lies within the
palpebral fissure.
Treatment
Local Excision in case of progression towards visual axis.
Tetracycline 1% eye ointment if inflamed, post excision
9.3.2. Malignant
9.3.2.1 Kaposi Sarcoma of the Conjunctiva and Eyelid
(See section on malignancies Page ------)
Definition
These are cancers arising from capillary endothelial cells.
In the eye, they present clinically as a patchy or patches
of elevated “haemorrhage” that do not resolve with

319
commonly affecting children. The typical lesion is a
pale, waxy elevated nodule on the eyelids.
Clinical Features
Complications
The shedding of cell laden with viral particles can
produce a chronic follicular conjunctivitis and superficial
keratitis.
Treatment
Expression of the contents of the nodule
Heat cauterisation of the lesions
9.4.2 � Herpes Zoster Ophthalmicus
Definition
This is infection caused by the varicella zoster affecting
the ophthalmic division of the trigeminal vein. It is
more common and more severe in patients with
lymphomas and in those being treated by radiotherapy
or immuno-suppressed individuals.
Clinical Features
Symptoms
• Severe pain along the ophthalmic division of
the trigeminal nerve VI)
• Maculo papular rash along the VI that obeys mid
facial line.
• Swelling of the affected part of the face
Signs
• Typical Herpes Zoster rash
Complications
• Anterior uveitis
• Neurological : cranial nerve palsies
• Optic neuritis

322
• Encephalitis
• Contra-lateral hemiplegia
• Severe facial skin scarring
• Corneal opacification
• Neuropathic keratopathy
• Disciform keratopathy
Diagnosis
Clinical – the typical distribution of the Herpes Zoster rash
Treatment
• Oral acyclovir 800mg 5 times daily
• Oxytetracyline 3%/hydrocortisone 1% eye drops or
• Betamethasone 0.1% neomycin 0.5% eye drops. or
• Dexamethasone 0.1% chloramphenical 1% eye
drops 4-6 times daily
• Calamine lotion to the skin or acyclovir 3% skin
ointment
• ± systemic steroids (x-ray to rule out PTB) may
activate TB in AIDS patients
• Acyclovir 3% eye ointment 5 times daily
9.4.3 Cytomegalovirus Retinitis (CMV)
Definition
This is a rare chronic diffuse exudative infection of the
retina caused by the CMV virus which occurs with rare
exception, in patients with an impaired immune system
caused by either AIDS, cytotoxic chemotherapy or long
term immuno suppression following organ transplantation
Clinical Features
Symptoms
• Poor vision
• Floaters

323
Signs
• Cotton wool spots
• Full thickness retinal necrosis and oedema which
starts peripherally or at the posterior pole
• Retinal bleeding
• Retinal vasculitis
• Whole retina eventually involved
Whoel
• Total retinal atrophy
• Retinal detachment
Treatment
• Dihydroxypropoxymethyl guanine i/v causes
regression
• Ganciclovir
Gancidovir IVIV infusion
infusion (induction) 5mg/kg 2 times
a day for 12-21 days maintenance dose 5
mg/kwbtwt daily until adequate recovery of
immunity
• Forscarnet IV infusion, induction 60mg/kg every 8
hours for 2-3 weeks, then maintenance dose
60mg/kg daily increased to 90-120mg/kg if
torerated. If CMW progresses while on maintenance
dose repeat the induction dose. Treatment is needed
for life
9.5 OPTICS & REFRACTION (REFRACTIVE �

ERRORS AND LOW VISION)
Definition
This is deficiency in the refracting mechanism of the eye
resulting into poor vision. The eye is designed to be able
to perceive light that falls within the visible part of the
electromagnetic spectrum. The two parts of the eye that
are responsible for image formation are:
a) The Cornea – accounts for 2/3 of the refractive

power of the eye.
b) The Crystalline Lens which accounts for 1/3 of the

324
refractive power of the eye as well as for the
1
accommodative capacity.
9.5.1 � Refractive Errors
Types of refractive error:

• Myopia:- “short sightedness”
• Hyperopia:- (Hypermetropia) : Long sightedness
• Aphakia:- Poor vision that results from absence of
the crystalline lens
• Presbyopia:-Difficult in reading in the elderly (above
40 years) that results from loss of the accommodative
power of the lens
• Astigmatism:- In this condition of the eye, the
meridians of the eye are not equal, resulting in
unequal refraction
Clinical Features
Symptom
Poor vision
Sign
Specific retinal reflex in line with the types of refractive
error mentioned above on retinoscopy.
Refractive errors should be managed by optometrists,

refractionists and opticians and sometimes ophthalmic
clinical officers, ophthalmic nurses and ophthalmologists.
After carrying out a visual acuity examination on a patient
complaining of poor vision, if the VA is found below 6/12
in the better eye with maximum correction, the patient
should be referred to the nearest eye specialist where
further assessment and management of such a patient
can be completed.
Treatment
• Glasses, contact lenses, or

325
• reflective surgery sometimes
9.5.2� Low Vision (VA range of 6/18 – 6/60)
Definition
This is failure to attain a visual improvement of more
than 6/18 in the better eye after being given the
maximum conventional treatment for poor vision. In
such a patient further improvement of vision can be
achieved by using low visual aids.
Treatment
The types of low visual aids available are:
• Optical – High power reading glasses, magnifies
(illuminating and non-illuminating), telescopes,
closed circuit television sets.
• Non-optical – Environmental modification aimed at
further enhancing the corrected residue vision such
as:
– improving lighting
– special reading stands
– painting of the stair cases to improve contrast
– painting kitchen utensils for ease of identification
– special cheque signing cards
– talking watches etc.
Refer such a patient to higher centers where appropriate

aid can be provided.
9.6 � STRABISMUS (SQUINT)
Definition
This is ocular misalignment resulting from either an
abnormality in binocular vision or anomalies of
neuromuscular control of ocular motor motility. When
eyes become dissociated (not aligned) then strabismus
(squint) is present.

326
Orthophoria:
This is when the ocular motor apparatus is in perfect
equilibrium, so that both eyes remain aligned (i.e. directed
on the fixation point) in all positions of gaze and at all
distances of the fixation point even when the fusion
mechanism is disrupted such as when one eye is occluded.
Orthophoria – describes “essentially straight eyes.
Phorias:
These are latent deviations (latent strabismus or squint)
or is a deviation kept latent by the fusion mechanisms.
Tropias:
Are manifest deviations. A deviation (squint) that is
manifest at all times and is not kept under control by the
fusion mechanisms
Types of Strabismus (squint)

• Esotropia:
eye is rotated so that the cornea is rotated nasally.
This is also known as convergent horizontal strabismus
• Exotropia:
Eye is rotated so that the cornea is rotated temporally
(i.e. on the temporal side). This is also known as
divergent horizontal strabismus
• Hypotropia:
Eye is rotated about a transverse X axis so that the
cornea is rotated inferiorly (down wards). This is
also known as vertical strabismus
• Hypertropia:
Eye is rotated about the transverse X axis so that
the cornea is rotated superiorly (upwards). This is
also known as vertical strabismus

327
• Incyclotropia:
Eye is rotated about the sagittal Y axis so that the
superior portion of the vertical meridian is rotated
nasally and the inferior portion of the vertical meridian
is rotated temporally.This is also known as torsional
strabismus
• Excyclotropia:
Eye is rotated about the sagittal Y axis so that the
superior portion of the vertical meridian is rotated
temporally (on the temporal side of the face) and
the inferior portion of the vertical meridian is rotated
nasally (This one is also a torsional strabismus)
Classification
Several methods of classifying eye alignments and motility
disorders are used:
(1) Classification according to fusional status
• Phoria – a latent deviation in which fusion control
is always present.
• Tropia – a manifest deviation in which fusion
control is not present
• Intermittent – Fusion control is present at times
(2) Classification according to variation of the deviation

with gaze position, or fixating eye.
• Comitant – a deviation does not vary with
direction of gaze or fixating gaze
• Incomitant – The deviation does vary with direction
of gaze or fixating eye. Most incomitant strabismus
is paralytic, indicating either neurological or orbital
disease.
(3) According to fixation :

• Alternating:
There is spontaneous alteration of fixation from
one eye to the other.

328
• Monocular – There is definite preference of fixation
with one eye.
(4) According to age of onset

• Congenital – a deviation noted (documented)
prior to age of 6months
• Acquired – an ocular deviation noted and
documented after the age of 6 months.
(5) According to type of deviation

• Horizontal – Exo deviation or Eso deviation
• Vertical – hyper deviation or hypo deviation
• Torsional – Incyclo deviation or excyclo deviation
or
• Combined
Treatment
This requires specialized assessment that starts with a
careful history, clinical examination and treatment.
Management requires the expertise of orthoptists working
hand in hand and under an ophthalmologists in order to
treat these unsightly ocular deviations.
A squinting child or an adult has an underlying problem
that is responsible for deviation. It could be an abnormality
of binocular vision, or anomalies of neuromuscular control
of ocular motility. Some, if not all are treatable provided
these patients are referred and corrected early in life.
specialist,
All squinting children should be referred to the spcialist,
preferably centers that have ophthalmologists.
9.7 SYSTEMIC EYE DISEASES AND THE �

EYE
9.7.1 � Eye Diseases associated with �

Hypertension
• Retinal vein occlusion
329
• Retinal artery occlusion
• Ocular motor palsies
9.7.1.1 Hypertensive Retinopathy
Definition
The primary response of retinal arterioles to hypertension
is narrowing. In sustained hypertension, there is a
disruption of the blood-retinal barrier resulting in increased
vascular permeability. The fundus picture of hypertensive
retinopathy is characterized by: Vasoconstriction, leakage
and arteriosclerosis.
Severe hypertension may lead to obstruction of the

precapillary arterioles leading to development of cotton
wool spots. Abnormal vascular permeability leads to
development of flame-shaped hemorrhage, retinal
oedema and hard exudates. The deposition of hard
exudates in the macular area may lead to their radial
distribution in form of a macular star. Swelling of the
optic nerve head is the hall mark of malignant
hypertension. Arteriolar sclerotic features are due to
thickening of the blood vessel wall. The single most
important clinical sign is presence of marked changes at
the arteriolar venous crossings.
Grading of Hypertensive retinopathy

Grade I: Mild generalized arteriolar constriction.
Broadening of the arteriolar light reflex and
vein concealment.
Grade II: More severe generalized as well as focal
arteriolar constriction and deflection of veins
at arteriolar/venous crossings.
Grade III: Flame-shaped hemorrhages, cotton wool spots,
hard exudates, copper-wiring of arterioles,
banking of veins distal to the arteriolar/venous
crossings and right-angled deflections of veins.

330
Grade VI: Disc swelling and silver wiring of arterioles.
Treatment
Medical, Control of hypertension
9.7.1.2. Retinal Vein Occlusion
Systemic hypertension is associated with an increased

risk of both branch retinal vein occlusion and central
retinal artery occlusion.
Treatment
• No effective treatment
• Control the hypertension
• refer to an ophthalmologists
• Some patients develop secondary retinal neo
vascularization which requires pan retinal laser
photocoagulation (Ischaemic type of central retinal
vein occlusion)
9.7.1.3 Retinal Artery Occlusions
Patient may suffer attacks of amourosis fugax (transient

absences of vision) or frank retinal artery occlusion as a
arteriosclerosis
result of the associated arteriosderosis
Treatment
Requires urgent management
• patient should lie flat
• Firm Ocular massage – to lower intraocular
pressure,and increase retinal blood flow
• Intravenous Acetazolamide 500mg start to further
lower the intraocular pressure
• Inhalation of a mixture of 5% Carbon dioxide and
95% Oxygen and anterior chamber paracentesis.
Unfortunately, the results of the treatment are usually

331
disappointing.
9.7.1.4. Ocular motor palsies
Ocular muscle palsies may be found in patients with

hypertension, even though hypertension is not the only
cause of ocular muscle palsies. There are other causes
like diabetes mellitus.
Treatment
Medical, control of hypertension
May undergo spontaneous resolution
9.7.2 Dysthroid Eye disease
Definition
Dysthyroid eye disease is a syndrome of clinical and
orbital imaging abnormalities caused by deposition of
mucopolysaccharides and infiltration with chronic
inflammatory cells of the orbital tissues, particularly the
extraocular muscles.
Clinical Features
In general, the ocular features of Grave’ disease and
ophthalmic euthyroid graves’ disease are similar, although
they tend to be more asymmetrical in the latter stages.
Signs
Eyelid signs:
• Lid retraction
• Lid lag
Signs resulting from infiltrative ophthalmopathy
• Conjunctival injection (redness)
• Chemosis (swelling)
• Superior limbic conjunctivitis
• Proptosis
• Optic neuropathy whose early sign is colour

332
desaturation
• Restrictive myopathy
Treatment
• Non-specific (reassurance, head elevation to reduce
the severity of peri orbital oedema, taping of eyelids
at night to protect the cornea, prismatic glasses to
reduce diplopia, diurectics such as cyclopenthiazide
.5mg at night to reduce morning periorbital oedema.
• Hypromellose 0.3mg (artificial tears) or SNO tears
• In severe cases, Prednisolone 80-100mg/day, enteric
coated and after 48hrs taper by 5mg every 5th day.
Treat for a maximum of 2-8 weeks and stop at 3
months
• Radiotherapy – used for patients who have systemic
contraindications to steroids, refuse steroids develop
serious steroids side effect or a steroid resistance.
• Dose – 20gy to the posterior orbit given for over a
10 day period
Response is usually evident within 6 weeks and
maximum improvement evident by 4 months.
• Orbital decompression; if patient develops severe
exposure keratopathy, optic neuropathy or
cosmetically unacceptable proptosis
• Surgery on Eyelids
– Tarsorrhaphy in uncontrolled exposure keratopathy
– To weaken muller’s muscle for patient with severe
lid retraction.
– Blepharoplasty

333
9.7.3� Diabetes Mellitus
Ocular complications
Diabetic Retinopathy
Background
• Maculopathy
• Preproliferative
• Proliferative
Advanced diabetic eye disease
• Cataract
• Accelerated senile
• True diabetic
• Ocular Motor nerve palsies
• Abnormal pupillary reactions
• Changes in refraction
a) Diabetic Retinopathy (DR)

The overall prevalence of retinopathy in diabetic patients
is about 25%. In none insulin depended diabetics
(NIDDs) the prevalence is 20% and in insulin dependent
diabetics it is about 40%.
Predisposing factors (risk factors)
• The incidence of diabetic retinopahy is closely related
to the duration of diabetes. (generally more likely
after 5 years onset of diabetes mellitus.
• Control of diabetes – poorly-controlled patients
develop the
develop thecomplication
complicationsooner thanthan
sooner thosewell
well those
controlled
controlled.
• Pregnancy
• Hypertension
• Renal disease
• Anemia

334
b) Background diabetic retinopathy (BDR)
Clinical Features
Signs
Mircroaneurysms at the posterior pole, temporal to the
macula.
• Dot and blot hemorrhage
• Hard exudates
• Diffuse retinal oedema
Treatment
• Treat associated high Blood pressure, anaemia, renal
failure
• Monitor patients annually by retinal examinations.
In some patients, spontaneous regression occurs
when diabetes is well controlled
c) Diabetic Maculopathy – results from macular

oedema and hard exudates
Clinical Features
Symptoms
Gradual impairment of central vision
Difficult in reading small print
Signs
BDR, plus
Features of BDR, plus foveal oedema, or foveal hard
foveal.oedema,
exudates
Treatment
Refer to Ophthalmologist
Laser macular grid

335
d) Preproliferative diabetic retinopathy (PPDR)
Clinical Features
Signs
• cotton wool spots
• Intra retinal microvascular angiopathies and
segmentation
• Arteriolar narrowing
• Large blot and dot hemorrhages
Treatment
Refer to specialist
e) Proliferative diabetic retinopathy (PDR)
Clinical features
Signs
• Early neovascularization is seen on the disc, or
elsewhere on retina
• Late elevated new vessels, associated with a white
fibrosis component.
Treatment
• Urgent referral to Ophthalmologist because they
require Pan retinal photocoagulation
f) Advanced Diabetic eye disease
Clinical Features
Symptoms
• Sudden onset of floaters
• Blurred vision from vitreous heamorrhage
Signs
• Dense vitreous Heamorrhage
• Tractional retinal detachment
• Neovascular glaucoma

336
Treatment
Surgery
• Vitrectomy with endolaser photocoagulation
9.8 � OCULAR EMERGENCIES
9.8.1 � Absolute
• Chemical injury to the eye

• Cornea Laceration
• Hyphaema (Traumatic) absolute
9.8.2 � Relative
• Peadiatric cataract
9.8.1.1. Chemical Injury to the Eye

Already discussed under Red eye with pain.
9.8.1.2 Cornea Laceration
Definition
Laceration if the Cornea
Clinical Features
Symptoms
• History of injury, Always ascertain mode of injury
• Loss of vision following trauma
• Bleeding from the eye
Signs
• Obvious corneal laceration visible on direct light
examination of the eye
• Prolapsed iris is seen plugging the laceration
• Anterior chamber is flat with blood
• Eye ball is soft
337
Diagnosis
• Examinine under local anaesthesia lignocaine 2%
eye drops, gently examine the eye under full aseptic
condition. The aceration will be visible.
Treatment
Early Management
• Tetanus Toxoid
• IM or IV Gentamycin 80mg start, or cefotaxime 1gm
stat.
• Chloromphenicol 1% eye drops or Gentamycin 0.3%
eye drops to affected eye start
• Light dressing (padding) of the affected eye
• Refer to specialist.
Specialist Management
• Under lignocaine 2% , examine the eye gently to
ascertain the wound shape.
• Exclude retained intraocular foreign body (x-ray or
ultra-sound)
• Arrange for emergency repair, preferably under
general anaesthesis.
• Suture the laceration under microscope
• Reform the anterior chamber
• Sub-conjunctival injection of gentamycin o.3ml +
atropine 0.3ml + dexamethasone, 0.3ml
• Gentamycin, 0.3% eye drops 2 drops 4 times a day,
or Chloramphenicol 1% eye drops 2 drops 4 times
a day and
• Keep eye padded
9.8.1. 3 Traumatic Hyphaema
Definition
This is blood in the anterior chamber as a result of trauma,
or very rarely spontaneous. If spontaneous, rule out
intraocular malignancy or juvenile xanthogranuloma.

338
Clinical Features
Symptoms
• History of injury, usually blunt type of trauma
• Poor vision
Signs
Blood clots visible in the anterior chamber.
Treatment
• If the patient is a child admit in hospital and keep
under observation. If left unattended, chances of a
re-bleed are high resulting in intraocular pressure
elevation and corneal staining
• If anterior chamber is 1/3 full in an adult, can treat
as an out patient
• If anterior chamber is full or 2/3 of it full, admit the
patient
• Bed rest
• Betamethasene, or Dexamethasene, 0.1% eye drops
four times a day
• Induce cycloplegia, with Tropicamide, 1% eye drop
twice daily or Atropine, 1% eye drop once daily
• If intraocular pressure is elevated, use antiglaucoma
drops, preferably Timolol 0.5% two drops or oral
Acetazolamide, 250mg tablets 4 times daily
• Use topical antibiotic to prevent or treat associated
infection
• Chloramphenical, 1% or Gentamycin, 0.3% eye drops
Relative Emergecies
• Congenital cataract
Refer to the specialists early.

339
9.9 � GLAUCOMA
Definition
This is a group of diseases in which the intraocular
pressure is sufficiently elevated to damage vision
Types
(i) Primary
(ii) Secondary
(iii) Congenital
1.9.1� Primary angle closure (congestive) �

Glaucoma
(see section on red eye with pain page)
1.9.2� Primary open angle glaucoma

(chronic simple glaucoma)
Definition
This is prolonged increase in the ocular pressure. The
result is complete damage of the optic nerve.
Clinical Features
Symptoms
• Usually asymptomatic
Signs
• Gonioscopy – normal angle
• on Tonometry, Intra-occular-pressure (IOP) will be
raised, above 25mmHg
• Optic nerve cupping
• Visual field – trachoma type of visual field loss
• Late - When blind – Optic atrophy
Investigations
• erimetry – Peripheral visual field analysis, either by
confrontation, or using Periferal visual field analyzer
• Tonometry – Perkins or Goldman

340
• Gonioscopy – Normal angle
• Fundoscopy – optic disc cupping
Treatment
1st Line
Timolol maleate 0.25% or 0.5% twice daily
Rule out underlining cardiac or pulmonary malfunction
2nd Line
Pilocarpine 2% or 4% eye drops 4 times daily
Dipivefrine 0.1% eye drops twice daily
3rd line
Latanoprost 50 micrograms/ml once or twice daily
Acetazdamide 250mg actazolamine sustate (slow release)
250mg once daily. use only for a short while
Treatment is for life as long as the compliance stays good

and as long as intra-ocular pressure is controlled.
Ocular association of Primary open angle glaucoma (POAG)
(recommend to rule out glaucoma in any of these
conditions:)
• High myopia
• Retinal vein occlusion
• Retinal detatchment
• Pigmentary Retinopaty of retinitis pigmentosa type
Systemic associations
• Dysthyroid ophthalmopathy
Current practice recommend surgery as 1st line

management because of poor compliance of treatment
for life. Traberculectomy (Filtration surgery) ± use
mitomycin C.
DO NOT DISCHARGE PATIENT. SEE AT LEAST TWICE YEARLY
TO SAFEGUARD AGAINST SECONDARY CLOSURE OF THE
FILTRATION BLEP
341
9.9.3 � Primary Congenital Glaucoma
Definition
This is intraocular pressure elevation in a child, that
manifest either at birth or a few years after birth due to
a developmental anomaly of the formation of the eye
anterior chamber angle.
Clinical Features
Symptoms
• Lacrimation (usually mistaken for lacrimal duct closure
• Light intolerance
Signs
• Large eye – Buphthalmos
• Misty looking cornea
• Haabs striae on the cornea (on slit lamp microscopy)
• Cuped disc
Investigation
• Corneal diameters (7 – 11mm) 16 over 11mm,
reason to be suspicious
• Refraction: myopic
• Tonometry – Intra ocular pressure will be high
• Fundoscopy – varying degrees of cupping
Treatment
• Surgical – Traberculectomy
• Goniotomy
1.9.1 Secondary glaucomas
Definition
These are glaucomas that are secondary to an underlying
cause.

342
Treatment
Refer to eye specialist services
References
Jack Kanski; Clinical Ophthalmology
Jack Kanski; Dafydd T. Thomas; The Eye in Systemic
Diseases
The American Academy of Ophthalmology; Basic and
Clinical Science Course
Peadiatric Ophthalmology and Strabismus

343
10
ANAEMIA AND NUTRITIONAL
CONDITIONS
10.1� ANAEMIA
Definition
This is a reduction in the haemoglobin concentration in
an individual to below the normal range for that individual’s
age and sex.
The normal haemoglobin concentration ranges are as

follows:
Male adults 130 – 180g/L
Female adults
(Non pregnant) 120 160g/L
Children
Birth (full term) 135 – 195g/L +/- 30
6 weeks 110 – 170g/L
2 - 6 months 115 – 155g/L
2 - 6 years 110 – 140g/L
7-12 years 110 – 150g/L
Anaemia is not a diagnosis in itself as there is always an

underlying cause, which must be determined before the
anaemia can be properly treated. Anaemia is most often
detected by measuring the haemoglobin (Hb)
concentration of the blood.
In the management of anaemia, one must obtain a

detailed history from the patient or care givers, examine
the anaemic patient carefully and perform the appropriate
investigations with a view of:
1. Establishing that the patient is anaemic

344
2. Establishing the type of anaemia the patient has
3. Determining the cause of the anaemia
4. Determining whether or not there are complications
arising from the anaemia, the cause of the anaemia
or both.
The history obtained from the patient or care givers often

gives very important information for making an appropriate
diagnosis.
Once the type of anaemia and its cause have been

established, appropriate treatment can be given and,
where possible, the underlying cause corrected or
removed.
One principle function of the red blood cells is to carry

oxygen from the lungs to all other areas of the body and
this function is performed by the haemoglobin. The
haemoglobin, found in the red blood cells, binds to
oxygen in the lungs and the haemoglobin bound oxygen
is transported to other organs where is it released. When
the haemoglobin concentration is low, the oxygen carrying
capacity of the blood is reduced and thus the amount of
oxygen reaching other organs is also reduced. In anaemic
states, the body will thus react in such a way as to try
to maintain the levels of oxygen reaching the organs.
Clinical features
The clinical features of anaemia are directly due to the
lowered haemoglobin concentration and are therefore
common to all types of anaemia irrespective of the cause.
Symptoms
• Tiredness, weakness, dizziness, shortness of breath
and headache, palpitations visual disturbances
Signs
• One general sign of anaemia is pallor of the mucous

345
membranes, and nail beds, However, this sign is
unrealiable as it can be masked by other conditions such
as jaundice and conjunctivitis.
• Other signs will be of either the underlying cause
e.g., bruising of the skin in aplastic anaemia or the
effects of anaemia such as heart failure.
Classification of Anaemia
There are several methods of classifying anaemia but
the most common is based upon the cause of the
anaemia. Anaemia can result from:
1. Poor production of red blood cells
2. Increased destruction of the red blood cells
3. Increased loss of red blood cells from the body
Anaemias that arise from poor production of red blood

cells include:
• Nutritional deficiency anaemias such as iron, folic
acid and vitamin B12 deficiency anaemias, anaemia
of chronic illness and bone marrow failure syndromes
such as aplastic anaemia, invasion of the bone
marrow by cancer, infection in the bone marrow
• Anaemias arising from increased red blood cell
destruction include sickle cell anaemia, infections
such as malaria, auto-immune haemolytic anaemia,
G-6-PD deficiency. Increased blood loss may result
from parasitic infestations such as hookworm, and
schistosomiasis, heavy menstrual loss and surgical
conditions such as bleeding peptic ulcers.
Nutritional anaemia
Iron deficiency anaemia

Iron deficiency anaemia is by far the most common type
of anaemia in the world. Hookworm infestation and
schistomiasis not only cause anaemia by whole blood
loss but they are also leading causes iron deficiency in

346
developing countries. Iron deficiency may also arise from
poor dietary intake, malabsorption or increased demands
as in pregnancy
Folic acid and Vitamin B12 deficiency

Deficiency of either or both of these micronutrients results
in anaemias characterised by larger than normal red
blood cells (megaloblastic anaemias). Megaloblastic
anaemias may arise from increased demands for the
micronutrients as may occur in pregnancy and lactation,
haemolysis, poor dietary intake particularly in absolute
vegetarians (Vit B 12) and malabsorption
Diagnosis
• FBC, peripheral smear
• Urinalysis + Microscopy
• Stool for occult blood, ova and parasites
• Other investigations will be dependent on the clinical
evaluation of the patient
10.1.1� Treatment of nutrititional anaemias
Drugs
Ferrous Sulphate, Adults 200mg 3 times a day after meals
until the Hb has reached the normal range. Continue
with 200mg daily for 6 months to build up iron stores.
Children up to 1 year:
Ferrous Sulphate 9-18mg of iron daily (0.75ml-1.5 ml
mixture).
1-5 years:
100-150mg daily (10-15ml mixture daily) in divided
doses. 6-12 years: 200mg 3 times a day.
For prophylaxis 200mg 3 times daily
Iron Dextran injection to be be used in a hospital under
the direct supervision of a doctor. It is not superior to oral

347
iron and is used only when patients cannot tolerate oral
therapy.
Folic Acid 5-10mg daily for as long as required.
Vitamin B12 (Hydroxycobalamin) injection, Initially 1mg
i.v. repeated 5 times at intervals of 2-3 days. Maintenance
dose 1mg every 2-3 months. Life long treatment may
be required.
10.2 MALNUTRITION
Definition
Malnutrition is a term that covers a wide range of clinical
conditions in children and adults causing an impairment
of health. It results from a deficiency or an excess of one
or more essential nutrients. Malnourished individuals are
prone to infections and in children it causes poor growth.
In pregnancy, poor nutrition results in the birth of low

weight babies.
Protein Energy Malnutrition (PEM)

This is the commonest form of malnutrition in children
below 5 years of age. It is a result of deficiencies in any
or all nutrients (macro and micronutrients) The first sign
is loss of weight or failure to gain weight. The children’s
under five card helps us to detect this form of malnutrition
at the clinic through growth monitoring.
There are three main clinical syndromes:

1. Kwashiorkor
2. Marasmic-kwashiorkor
3. Marasmus
Underweight represent the mildest form of malnutrition

while kwashiorkor, marasmus and marasmus-kwashiorkor
represent the severe forms and require admission in
health centre or hospital for treatment.

348
80-60% of normal Below 60% of normal without oedema.
Underweight Marasmus
Kwashiorkor 70-60% Marasmic-Kwashiorkor with oedema

Marasmus Below 60% without oedema
The child has gross muscle wasting, no subcutaneous fat,

has a hungry and anxious look.
Kwashiorkor 80-60%
The child shows oedema, flaky paint rash; thin, pale
sparse easily pluckable hair, apathetic, anorexic, moon-
faced. Big fstty liver on palpitation
Marasmic-kwashiorkor 60-70%
Wasted body but also has oedema. This is severe
malnutrition and usually requires admission in health
centre or hospital for treatment.
Treatment
For patients with very severe malnutrition, including its
complications, admit to hospital and treat with F75 and
F100 as nutritional replacement feeds. Patients with mild
or moderate disease can be treated at community level
using RUFT (plumpy nut).
Procedures on admission
1. Weigh the child
2. Record temperature (rectal), pulse, respiration rate
3. Check blood sugar (Dextrostix)
4. FBC/ESR, electrolytes, urea, serum protein/albumin,
sugar and MP
5. Stool and urine
6. Manitoux, CXR

349
Resuscitation
a) Resuscitation first 4-7 days. Most deaths occur in
this period.
b) Generally keep warm with heater and hot water
bottles.
– Do not give bath
– Nurse away from windows
– Adequate covering during the night (most
kwashiorkor babies die at night).
c) Start feeding immediately after admission with F75.
Oral:
Use a cup and spoon. For a very sick and anorexic child,
careful continuous nasogastric tube feeding can be used.
Milk Diet:
100ml/kg increasing to 150ml/kg in 7 divided doses.
The milk diet is made from:

Dried skimed milk 120g
Sugar 30g
Oil 35g
Electrolyte sol. 30 ml
Add cooled boiled water slowly up to 1 litre. Stir well.
Electrolyte Solution made up of:

Potassium chloride 90g
Magnesium hydroxide 9g
Cooled boiled water 100ml
Only 30ml of the Electrolyte solution is used for each litre

of milk diet made.
d) Rehydration, severe dehydration can be present

despite oedema!

350
Give half strength darrows with dextrose, 20ml/kg in
the first hour. 20ml/kg over the next 2 hours, followed
by 5 – 10ml/kg per hour depending on severity of the
dehydration.
In less severe dehydration and when an IV line is not

possible, give ORS, 50-80ml/kg over 4-6 hours followed
by milk diet.
f) Drugs
Potassium:
6 mEq/kg per day for 2 weeks or more, particularly in
a child with chronic diarrhoea. Give potassium as potassium
citrate, or potassium chloride.
Magnesium sulphate 25% IM 0.2g for 3-5 days,

Vitamin A 6 drops (30.000 IU) stat followed by one drop
(5.000 IU) daily given with water or milk. If there are
signs of keratomalacia give 1ml or 30 drops (150.000
IU) orally stat.
Folic Acid 5 mg daily

Vitamin K injection 5mg stat on admission
Antibiotics:
These should be all the time. Gentamycin
Multivitamin syrup
Note: Iron containing syrup should be avoided in the

acute phase of malnutrition.
Complications
1. Hypothermia:
With temperature below 35.50C, mortality doubles.
Warm up the child. Temperature monitor every hour
until the temperature reaches 370C, then take every
4 hours.

351
2. Hypoglycaemia:
If blood sugar is below 2.2mmol/l (or below
2.5mmol/1 by dextrostix) mortality increases by
about 4 times. May be asymptomatic.
Treatment
• IV dextrose 25% 2ml/kg or dextrose 50% 1ml/kg
followed by IV drip of 10% dextrose 75ml/kg/day.
Reduce gradually as the blood sugar stabilises.
• Monitor blood sugar with dextrostix 4 hourly until
normal and stable.
• Heart failure: May be precipitated by severe anaemia
or excessive fluids given IV or orally. This condition
is common in the second week of treatment.
Complications
3. Suspect heart failure if oedema disappears but
weight is constant, or sudden rapid weight gain, or
increase of pulse. Check size of liver.
10.2.1� Treatment (heart failure)
• Diuretic (Furosemide 1mg/kg).

• Blood transfusion to anaemic children (4-6 g%),
20ml/kg slowly. If CCF present, Hb below 4 g/dl
give 10ml/kg or packed cells slowly.
4. Convulsions: Diazepam to stop convulsions.
Do Lumbar Puncture, dextrostix, electrolytes and
Blood Slide.
5. Diarrhoea: Check stool for reducing sugars. If positive
change to lactose-free milk.
If there is no evidence of reducing sugars in stool continue

with milk diet.
Treat any parasites, e.g. giardiasis.
• Metronidazole 100mg 3 times daily for 5 days
• Bebendazole 100mg 2 times daily

352
Rehabilitation
2-6 weeks of gradually increasing the energy and protein
intake to 200-300 kcals/kg per day (normal requirement
100-110 kcals per day) and protein 4-5 g/kg per day
(normal requirement 2g/kg per day).
As soon as the child wants food put on normal diet in
addition to his full requirement of milk diet.
10.3 VITAMIN DEFICIENCIES
Vitamins are compounds needed in small quantities for

operation of normal bodily metabolism. The vitamin
requirements may be increased during disease and fevers.
Vitamin deficiency may appear as single or combined
conditions. Multivitamin preparations will cover mild
deficiencies of a combined nature. Vitamin B complex
preparations will often cover most of the vitamin B
deficiencies.
Note that a diet with sufficient fruit and vegetables will

prevent most vitamin deficiencies.
10.3.1� Vitamin A
Sources of Vitamin A: Mangoes, pawpaw, carrots, spinach,

cod liver oil. Deficiency leads to:
• Dryness of conjunctiva (Xerosi)
• Scaliness of the skin and sometimes acne
• Keratisation of the cornea, cortical opacity and
blindness
• Inability to see easily in the dark (night blindness),
• Softening of cornea (keratomalacia) often followed
by cortical perforation and panophthalmitis.
Treatment
• Children with severe malnutrition, give one age
specific dose (see under malnutrition above)

353
• Children with diarrhoea for more than 3 days and
children with measles give one dose
Prevention
• 6 - 11 months give 100,000 i.u. once
• 12 - 72 months give 200,000 i.u. once every six
months
10.3.2 Vitamin B group
a) Vitamin Bl.
May cause neuropathy in adults and cardiac failure
in babies (Beriberi)
b) Vitamin B2 (Riboflavin).
Deficiency causes mucocutaneous lesions such as
angular stomatitis, sore cracked lips, and glossitis
c) Nicotinic Acid.
Deficiency leads to pellagra, a disease common in
adults and recognisable by the so called 3 Ds:
Dermatitis:
Skin developing a cracked, pigmented scaliness in
the areas exposed to sun or mechanical irritation.
Diarrhoea:
Gastrointestinal symptoms of loose watery stools.
Dementia:
Neurological symptoms, usually severe in adults but
showing as apathy and irritability in children.
Treatment
• Vitamin B1 25 – 100mg i.m. or orally
• Vitamin B2: 5 – 10mg daily
• Nicotinamide 100-300mg daily
• Until symptoms disappear
10.3.3 Vitamin C (Ascorbic acid)
Sources of ascorbic acid: Oranges, lemons, green

354
vegetables. Deficiency leads to scurvy, a disease
recognised by:
Clinical features
Signs and Symptoms
• Periodontal haemorrhage
• Swelling and pain of long bones due to sub-
periodontal haemorrhage
• Loosening of teeth and lesions of the gums
• Leading to infections in the mouth.
Treatment
• Vitamin C tablets (Ascorbic acid) 200mg 4 times
daily.
• Until symptoms disappear .
10.3.4 Vitamin D
Sources of vitamin D: Milk, butter, eggs, cod liver oil. It

is normally formed in the skin from sunlight.
Clinical Features
Signs ans Symptoms
Deficiency leads to rickets, recognised by:
• Softening of bones resulting in bowing of legs or
knock-knees.
• Thickening of the ends of bones.
Treatment
• Vitamin D, 1000-5000 units/day orally for a period
of 6 weeks to 3 months.
• Exposure to sunlight
Prevention
• Prevention of malnutrition requires the administration
of a variety if foods providing a balanced or mixed
diet to satisfy the individual nutritional needs.

355
Guidance concerning locally produced foods of the
different food groups is important. People should
be educated on the importance of eating regular
nutritious meals including fruits and vegetables.
Pregnant women
Encouraged to:
• Eat a well balanced diet. (enough quantity of foods
daily to meet her daily energy and enough critical
nutrients needs, comply to the micronutrient
supplement – Essential nutrition)
• Have extra rest especially during third trimester.
• Space their pregnancies (child-spacing 3yrs)
adequately through the use of family planning
methods. And must know their HIV status to safely
breast feed her child
Infant and young Children

• Initiate breastfeeding within an hour of birth
• Exclusively breastfeed for the first 6 months
Timely introduction to Complementary feeding (from 6

months with continued breastfeeding up to 24 months
and beyond) and follow complementary feeding
guidelines ( Frequency of feeds according to the age
group, density, utilization of food by vitamins and active
feeding) after 6 months with continued breastfeed until
18-24 months. To the porridge should be added protein
foods e.g. legumes (beans, peas, groundnuts), fish, meat.
• Pre-school children should be fed 4-5 times a day
• Children should be fed even when they are sick

• Children should be given fruits and vegetables
regularly
• Encourage immunisation
For episodes of diarrhoea in breast fed young children
intensify breast feeding for and promote use of ORS

356
according to the severity of the diarrhoea. Early detection
of children developing malnutrition (not gaining weight
or loss of weight) and institutional high protein and high
calorie diet.
10.4 VULNERABLE GROUP FEEDING
The supplementary rations given to selected vulnerable

or at risk groups to make up for deficiencies in the diet
should be instituted on a temporary basis. Meanwhile
permanent home-based ways to make the diet adequate
should be sought.

357
11
SKIN CONDITIONS
These are classified according to the cause of infection or
infestation:
• Bacterial infections
• Fungal infections
• Viral infections
• Parasitic infestations
11.1 BACTERIAL INFECTIONS
Definition
This is a condition caused by blocked sebaceous glands. It
usually begins at or after puberty. The most affected parts
are the face, neck, back and chest.
Clinical features
Occurs in mild form as blackheads and whiteheads (closed
comedones and open comedones) and in more severe form
as nodular lesions, with or without infection
Treatment
Drugs
• Benzoyl peroxide gel 2.5-10%, topically 1- 2 times daily
• Doxycycline, 50-lOOmg orally daily for 6 weeks in severe
cases
Supportive
• Wash the affected parts with carbolic soap and water
2 to 3 times daily
• Avoid use of cosmetics
• Diet should include plenty of fruits and vegetables
• Avoid fatty foods

358
11.1.2� Abscess
Definition
This is a collection of pus in the dermis and subcutaneous
fat layer of the skin. It occurs as a result of infection of
the hair follicles commonly caused by Staphylococcus
aureus.
Clinical features
The skin surrounding the affected hair follicle becomes
red, hot, swollen and tender to touch. In severe cases
there will be fever and involvement of the local lymph
nodes
Treatment
Drugs
• Cloxacillin, adults; 250 - 500mg orally. 6 hourly for
5 days, children; 125 - 250mg orally 6 hourly five
days or
• Erythromycin, adults; 250 - 500mg orally 6 hourly
for 5 days, children; 125-250mg orally 6 hourly for
5 days
Surgery
• Incision and drainage
• In cases of multiple abscesses, non response to
antibiotic therapy or an abscess in a diabetic, refer
to specialist
Supportive
• Encourage patient to maintain good general hygiene
• Apply hot compression 3-4 times daily until abscess
is ready for draining

359
11.1.3� Impetigo
Definition
This is a superficial infection of the epidermal layer of
the skin by aureus commonly but Streptococcus species
may also be involved. Painful vesicles and pustules break
down to form scabs or crusts. Impetigo starts on the face
and may spread to the neck, hands and legs. It usually
occurs in children.
Treatment
Drugs
• Cloxacillin, orally, adults; 250 - 500mg 6 hourly for
5 days, children; 125 -250mg 6 hourly for 5 days or
• Erythromycin, orally, adults; 250 - 500mg 6 hourly
for 5 days, children; 125 -250mg 6 hourly for 5 days
Supportive
• Keep finger nails short
• Soak and clean pustules with water and soap
• Patient should be referred to the next level if there
is no improvement after 2 weeks
11.1.4� Eczema
Definition
Eczema is an inflammatory rash which may be due to
endogenous or exogenous factors.
Classification of Eczema:
• Endogenous
– Atopic (inherited disposition)
– Seborrhoeic
– asteatotic
– discoid(nummular)
– unclassified
• Exogenous
– allergic contact dermatitis

360
– primary irritant dermatitis
– photodermatitis
11.1.4.1 Atopic eczema
Definition
This is a condition characterised by an itchy, rough, dry
skin. In babies it occurs mainly in the areas surrounding
the knees, elbows and neck whereas in older children
and adults it can occur on any part of the body. The
itching is intense at night and could become chronic and
infected. Where possible the causative factor should be
determined before commencing treatment.
Treatment
Drugs
• Aqueous cream, topically 1-3 times daily after bathing
or
• Zinc oxide cream, topically 1-3 times daily after
bathing
• Bethamethasone 1%, topically twice daily for 7 days
(for severe or non- responsive cases) or
• Hydrocortisone in, topically twice daily for 7 days
• Zinc and Coal Tar Paste, topically 1 -2 times daily (in
chronic cases)
• Chlorpheniramine 4mg 2 times a day
• Erythromycin 500mg 4 times a day for 7 days
Supportive
• Keep fingernails short
• Keep skin hydrated with Oil bath
• Patient should avoid scratching
• Avoid exposure of affected parts to sunlight
• Avoid known irritants e.g. soap, woolen clothing
If there is no improvement of acute condition after 2
weeks refer to specialist.

361
11.1.4.2 Seborrhoeic eczema
Definition
This is a condition characterized by thick adherent scales
presenting as a diffuse scaly scalp (dandruff). It may also
affect other parts of the body which tend to be oily e.g.
facial skin nasolabial folds, eyebrows, eyelashes, external
ears, and centre of back. Variable pruritis and vesicular
or scaly lesions may be present.
Infantile seborrhoiec eczema occurs in early infancy 2-

4 weeks after birth. Begins with cradle cap (scaly scalp
surrounding the anterior fontanelle), spreads to face,
axilla, neck and nappy area. The rash is non itchy and
gets better without leaving marks.
Treatment
Drugs
• Hydrocortisone 1% cream, topically twice daily
• Maintenance; once or twice a week as required
• Zinc oxide cream, topically 1-3 times daily after
• bathing specially in the nappy area or
• Aqueous cream, topically 1-3 times daily after
bathing
To reduce scaling and itching of the scalp use keratolytic

or antifungal containing shampoos once or twice weekly.
Refer patients who do not respond to treatment or have
acute oozing eczema to a specialist.
11.2� FUNGAL INFECTIONS
Superficial fungi live in the stratum corneum and feed

on the keratin. They are called dermatophytes and belong
to 3; genera microsporum, trichophyton, and
epidermophyton. More than 40 species are currently
recognized with 10 causing human infection. They are

362
transmitted from person to person by direct body contact
or by formites e.g. combs. They can also be transmitted
from animals such as cats and dogs( zoophilic) or from
the soil and plants ( geophillic) The infections are named
according to the body parts affected
• Tinea pedis – feet
• Tinea corporis – body
• Tinea capitis – scalp and hair
• Tineamanus – hands
• Tineaunguium – nails
• Tineacruris – groin area covering the T of the genital
area extending behind
• along the gluteal cleft
• Tinea facialis – face
• Tinea barbae – beard area
• Tineaversicolor
• Cutaneous candidiasis
11.2.1� Tinea pedis (athletes foot)
Definition
This is a contagious fungal infection of the foot caused
by Trichophyton mentagrophytes and T. rubrum most
commonly.
Clinical features
• Itching of the foot
• Burning or stinging lesions with scaling borders
between the toes
• Vesicular eruptions with white scaling between the
4th or 5th toes or the instep of the sole
• May be accompanied by vesicles on the palms and
sides of fingers called ‘id’ reaction. The vesicles do
not contain fungus and gets better when the fungus
is treate

363
Diagnosis
Scrape the scales from the infected site and put on a
glass slide with a drop of 20% KOH. On microscopy
branching fungal hyphae are seen.
Treatment
Drugs
Miconazole 2% cream, topically twice daily
Continue treatment for 2 weeks after the symptoms have
cleared.
Supportive
• Keep feet dry all the time
• Wear open footwear
• Wear cotton socks, if need be
• Change socks daily
11. 2.2 Tinea corporis (ringworm of body, trunk and

limbs)
Definition
This is a condition which can be acquired from animal
(Trichophyton verrucossum, Microsporon canis) or human
contact (T. rubrum). It is characterised by itchy lesions
appearing as scaly grayish patches with raised borders.
It can affect any part of the body, with the most commonly
affected parts being the arms, groin, buttocks, waist and
the area under the breasts.
Treatment
Drugs
• Miconazole cream 2%, topically twice daily for 2 to
6 weeks.
• Ketoconazole 200mgs O.D. oral for 6 wks
• Griseofulvin 500mgs O.D. oral up to 2 weeks after
lesions disappear

364
Supportive
• Maintenance of general hygiene
• Avoid sharing of personal items such as towels and
clothes
11.2.3 Tinea capitis (scalp ringworm)
This is a fungal infection of the scalp which is especially

common in children. It is caused by Trichophyton species
– violaceum in Africa and Asia, T. rubrum in Europe. Non
inflammatory invasion of the hair shaft can occur due to
Microsporum audouiini transferred by contact wih barber
shears, hats or m.canis from pets.
Clinical features
• Diffuse scaling of scalp with no hair loss
• Circular scaly patches in the scalp with associated
alopecia (hair loss)
• In severe cases, a boggy swollen mass with
discharging pus and exudates called Kerion is due
to animal fungus.
Diagnosis
Remove scales and broken hairs with a blunt scalpel and
put it on a slide with KOH (Pottassium Hydroxide 20%).
The hair shaft is seen under the microscope full of fungal
spores.
Treatment
Drugs
• Griseofulvin, adults; 500mg orally daily as a single
dose or in divided doses (in severe infection dose
may be doubled, reducing when response occurs),
children; l0mg/kg body weight daily as a single
dose or in divided doses continue till two weeks
after the lesions disappear and hair is growing

365
Supportive
• Maintenance of good general hygiene
• Avoid sharing of personal items such as, towels and
clothes
• Keep hair short
11.2.4 Cutaneous Candidiasis
Definition
This is an infection of the skin caused by Candida albicans
a yeast fungus which is a normal commensal occupying
the gut. Under certain circumstances such as diabetes or
other endocrine diseases or immunosuppressive states
it becomes pathogenic. The infection usually occurs in
the skin folds such as, around the groin area, under the
breasts, in the nail folds and axilla. In chronic or severe
cases suspect HIV/AIDS.
Clinical features
Moist, white curdlike papules and plaques form which
are easily scrapped off leaving red and raw-looking
patches with clear edges.
Diagnosis
Scrape off white patch and place on glass slide with a
drop of KOH. Hyphae and yeast are seen.
Treatment
Drugs
• Miconazole cream 2%, topically twice daily.
Continue treatment for 14 days after lesions have healed.
For nail infections apply under occlusive dressing.
Supportive
• Patient should be advised to keep the skin dry
• Long-term antibiotic use should be avoided

366
Patients not responding to topical applications should be
referred to a specialist.
11.3� VIRAL SKIN INFECTIONS
These include:
• Chickenpox
• Herpes zoster
• Herpes simplex
11.3.1� Chickenpox
Definition
This is a condition caused by the Varicella zoster virus

(VZV). It is a common childhood infection. It is characterized
by an itchy rash, which appears first on the trunk and
spreads out to other parts of the body. Papules and crusts
form within a few days. Fever may be present. When
the blisters occur they are in crops. The rash lasts 2 to
4 weeks. The condition is usually more severe in the
elderly.
Diagnosis
Diagnosis is usually done clinically.
Treatment
Drugs
• Calamine lotion, topically twice daily or
• Chlorpheniramine, adults; 4mg orally twice daily,
children up to 10 years; 2mg orally twice daily
• Acyclovir, 800mg orally 5 times daily for 7 days
• Paracetamol, adults; 500mg-lg orally 3-4 times daily,
children; 10-20mg/kg orally 3-4 times daily

367
11.3.2� Herpes Zoster
Definition
This is condition caused by the resurgence of the Varicella-
zoster virus. It is characterised by burning pain before
vesicular rash appears. The rash is always unilateral and
does not cross the midline (see section 8.8, malignancies).
Treatment
Drugs
• Paracetamol, 500mg-lg orally 3-4 times daily.
• Gentian violet maybe applied
• Acyclovir 5%, topically 4 hourly for 10 days.
• Acyclovir, 800mg orally 5 times daily for 7 days.
• Carbamazepine, 200-400mg orally 3 times daily.
(for post herpetic neuralgia)
Treat secondary bacterial infection with appropriate

antibiotics.
Severe neuralgia should be referred to a neurologist.
11.3.3� Herpes Simplex
Definition
This is a condition caused by Herpes simplex virus (HSV)
type 1 characterised by a vesicular rash around the mouth
or genitalia.
Treatment
Drugs
• Usually no drugs are required
• Wash lesions with saline water
• Paracetamol, adults; 500mg-1 g orally 3-4 times
daily, children; 10- 20mg/kg orally 3-4 times daily
• Acyclovir cream, 4 hourly

368
11.4 PARASITIC INFESTATIONS
Definition
Parasitic infestations of the body include:
• Pediculosis
• Scabies
11.4.1 � Pediculosis (lice)
Definition
This is the infestation of the hair or body with lice. Hair
infestation (Pediculus humanus var capitis) is characterised
by eggs (nits) which appear as small white specks
attached to the hair. Body infestation ( P. humanus
corporis) is characterised by bite marks. Both hair and
body infestations cause itching. Eczema may be present.
The lice usually live in cloth folds. Infestation of the
pubic area called pediculosis pubis is caused by the crab
or pubic louse Pthirus pubis transmitted during close
physical contact which may be sexual in nature.
Treatment
Drugs
• Malathion 0.5% lotion. Apply to affected parts.
Let it dry naturally and remove by washing after 12
hours.
• Permethrin 1% cream. Apply to clean damp hair.
• Rinse after 10 minutes and dry.
Supportive
• The whole family should be examined and treated
if possible
• Bed linen and clothes should be washed in warm
water and dried in the sun
• Maintenance of good personal hygiene

369
11.4.2 � Scabies
Definition
This is an infestation of the skin by mites, Sarcoptes
scabie, which burrow the skin causing lesions where the
female rests and lays eggs. The most common sites are
skin folds, wrists, in between fingers and axilla. The main
characteristic is intense itching which worsens at night.
Treatment
Drugs
• Benzyl Benzoate 25%, applied all over the body
from the neck downwards. Leave to dry and repeat
without bathing after 24 hours. Wash off on the
third day. A third application may be required. (Not
recommended in children, pregnancy and
breastfeeding mothers) or
• Permethrin cream 5%, applied all over the body
from the neck down to the feet. Wash off after 8 to
24 hours
• For children apply all over the body including the
face, neck, scalp and ears
• If hands are washed with soap within 8 hours of
application, cream should be re-applied or
• Malathion 0.5% lotion. Apply all over the body and
wash off after 24 hours
Supportive
• All members of the family should be examined and
treated ( if possible)
• Clothes and bedding should be washed in warm
water and dried in the sun
• After treatment only clothes washed as above should
be worn
• Dicourage scratching
• Keep fingernails short and clean

370
12
CONDITIONS OF THE EAR,
NOSE AND OROPHARYNX
These include:
• Oral diseases
• Pharyngeal diseases
• Nasal diseases
• Ear conditions
12.1 ORAL DISEASES
These include:
• Dental caries
• Periodontal disease
• Oral candidiasis
• Herpes simplex stomatitis
• Mouth ulcers
12.1.1� Dental caries
Definition
This is a sugar-dependent disease, which by a combination
of chemical and bacterial action, progressively destroys
the enamel of the tooth. Many bacteria ferment sugar
to produce acid, which in turn causes lesions on the
enamel of the tooth.
Clinical features
•Chalky white spots on the chewing surface of the tooth
• Sensitivity of tooth to cold or hot drinks and foods
• Cavity on the tooth
• Pain
• Swelling at the base of the tooth if pulp nerve roots
are involved
• Fever

371
Treatment
The aim of treatment is to preserve the tooth as far as
possible.
Drugs use in infections, complicated extractions or

prophylaxis:
• Phenoxymethyl penicillin, adults; 250-750mg orally
6 hourly, children; 1 – 5 years; 125mg orally 6 hourly,
6 – 12 years; 250mg orally 6 hourly
• Paracetamol, adults; 500mg -1g orally 3 times daily,
children; 10-20mg/kg orally 3 times daily or
• Aspirin, adults; 600mg orally 3 times daily (Not
recommended for children)
Conservation
• Tooth filling
• Root canal treatment if pulp is affected
Surgical
• Extraction
• Apicectomy
Prevention
• Encourage maintenance of good oral hygiene
• Reduce intake of sugary foods
• Use of fluoride containing toothpaste
• Use of mouth rinses containing fluoride
• Use of topical fluoride applications
• Use of sealants in children, where available
• Dental check at least twice a year
12.1.2� Periodontal disease
Definition
This is a pathological condition of the periodontium and
refers to inflammatory diseases which are plaque-induced.
These fall into two groups:

372
• Gingivitis
• Periodontitis
12.1.2.1 Gingivitis
Definition
This is an inflammatory condition of the free gingivae.
It is caused by dental plaque and supragingival calculus
or tartar. In this condition there is no destruction of the
supporting tissue.
Clinical features
• Red mucosa
• Loss of gum texture
• Gums bleed easily
Treatment
Scaling and prophylaxis
Drugs
• Metronidazole, adults; 200mg orally 3 times daily
for 5 days, children; 7.5mg/kg orally 8 hourly for 5
days
6 hourly for 5 days, children; 12.5 -25mg/kg orally
6 hourly for 5 days or
• Erythromycin, adults; 250-500mg orally 6 hourly for
5 days, children; 2-8 years; 12.5 - 25mg/kg orally
6 hourly, 8-12 years; 25 – 50mg/kg 6 hourly for 5
days
Preventive
• Gargle warm salty water or mouthwash after every
meal
• Brush teeth at least twice daily
• Flossing

373
12.1.2.2 Periodontitis
Definition
This is an inflammatory response of the free gingivae
affecting all the periodontal structures. It is caused by
plaque and supra or sub gingival calculus. It results in the
destruction of the attachment apparatus and the
development of a periodontal pocket. Halitosis is usually
present.
Treatment
• Scaling and prophylaxis
• Sub gingival curettage
Drugs
Metronidazole, 200mg orally 3 times daily for 5 days
Refer patient to next level
Prevention
• Use of mouthwash containing fluoride
12.1.3� Oral candidiasis
Definition
This is an infection of the mouth caused by Candida
albicans. It is commonly known as oral thrush. The infection
sometimes also affects the pharynx.
The predisposing factors include: trauma, denture wearing,

dryness of the mouth, inhaled steroids, radiotherapy,
diabetes mellitus, antibiotic therapy, HIV/AIDS.
Clinical features
• Creamy white or yellow plaques on normal mucosa
• Patches on the palatal and buccal mucosa and dorsum
of the tongue and gums.

374
• Removal of plaques reveals bleeding surface.
Treatment
Drugs
• Gentian violet solution, topically 2 times daily for 7
days or
• Nystatin oral suspension or lozenges, 2 times daily
for up to 10 days or
• Miconazole oral gel, applied 2 times daily for 10
days or
Refer to specialist in case of:
• No improvement
• Painful or difficulty in swallowing or
• Affected pharynx
Supportive
• Remove or treat predisposing factor.
• Use snuggly-fitting dentures
• Good oral hygiene.
• Gargle warm salty water after every meal.
12.1.4� Herpes simplex stomatitis
Definition
This is inflammation of the mucosal area due to infection
by the herpes simplex virus. It is usually a self-limiting
condition clearing up after 7 - 10 days. It is characterised
by painful, shallow ulcers around the lip area, gums and
tongue. It is common in small children who usually
present with high fever and refusal of food because it
is too painful to eat.
Treatment
• Debridement
• Mouthwash with tetracycline

375
Drugs
• Paracetamol, adults; 500-1g orally 3 times daily,
• children; 10-20mg / kg orally 3 times daily for 5
days.
• * Metronidazole, adults; 200-400mg orally 3 times
daily, children; 100-200mg orally 3 times daily for
5 days or
• *Phenoxymethyl penicillin, adults; 250-500mg orally
4 times daily, children; 125-250mg orally 4 times
daily for 5 days
*In case of secondary infection only
Supportive
• Increase fluid intake
• In severe cases, a nasogastric tube may be necessary
until
• the child can feed again.
• Saline mouthwash and gargle
Avoid acidic foods and drinks
Refer to a specialist if the condition is severe or does

not heal within 7-10 days
12.1.5� Mouth Ulcers
Definition
This is a condition in which there is damage to the
mucosal lining of the mouth, including the tongue. These
are similar to ulcers due to the herpes simplex virus.
They are painful and may occur singly or in groups. They
frequently recur and can be very troublesome.
Treatment
• Paracetamol, adults; 500-1g orally 3 times daily,
children; 10-20mg/kg orally 3 times daily
• Aspirin, 600mg orally 3 times daily for adults only
• Chlorhexidene gluconate, 10-15ml as a mouthwash

376
kept in the mouth for about 30 seconds to 1 minute 2-
3 times daily
Ulcers that do not heal rapidly should be referred to a
specialist.
12.2� PHARYNGEAL DISEASES
These are conditions affecting the pharynx. They include:

• Tonsillitis and pharyngitis
• Peri-tonsillar abscess
• Epiglottitis
12.2.1� Tonsillitis and Pharyngitis
Definition
This is an inflammation of the pharynx and tonsils. There
are two types of pharyngitis; viral and bacterial. The vast
majority of pharyngitis is viral, which is self-limiting. In
clinical practice, it is difficult to distinguish between viral
and bacterial pharyngitis. It is important to diagnose and
treat streptococcal throat infections to prevent Rheumatic
fever and other complications.
Acute tonsillitis is most frequent in childhood. However,

it is very rare in adults. Untreated acute tonsillitis will
subside over the course of one week. Appropriate
treatment will make the illness shorter.
Diphtheria infection is an important differential diagnosis.
Clinical features
Symptoms
• Sore throat
• Pain on swallowing
• Headache
• Fever
• Voice change

377
Signs of streptococcal pharyngitis
• High fever
• White pharyngeal exudates
• Tender enlarged anterior cervical lymph nodes
• Grossly enlarged painful tonsils which are
asymmetrical
• Absence of signs suggesting a viral pharyngitis
Signs of viral pharyngitis
• Nasal stuffiness
• Coryza
• Irritating cough
• Conjunctivitis
Signs of tonsillitis:
• Hyperaemic tonsils
• Enlarged tonsils
• Pus in the crypts
Treatment
Viral pharyngitis
• No antibiotics should be given
• Analgesia for pain and fever relief
Streptococcal pharyngitis and tonsillitis

Drugs
6 hourly at least 30 minutes before food, children,
up to 1 year; 62.5mg orally 6 hourly,
1-5 years; 125mg orally 6 hourly, 6-12 years; 250mg
orally 6 hourly for 7 days or
• Erythromycin, adults; 250mg-500mg orally 6 hourly,
children, up to 2 years; 125mg orally 6 hourly,
2-8 years; 250mg orally 6 hourly for 7 days
• Paracetamol, adults; 500mg-1g orally 3-4 times
daily, children; 10-20mg/kg orally 3-4 times daily

378
Complications of streptococcal pharyngitis
• Peritonsillar and parapharyngeal abscesses
• Rheumatic fever
Refer for specialist treatment
12.2.2� Peri-tonsillar abscess
Definition
This is an abscess around the tonsils
Clinical features
It presents with signs of acute tonsillitis but with more
pain on one side and almost always a large, very tender
lymph node on that side. The patient may be unable to
swallow fluids. It is always difficult to see into the mouth
because the mouth cannot be opened widely. Use a
good light and gently depress the tongue on the painful
side to look for bulging of the tonsil and the palate above
the tonsil.
Treatment
Drugs
• Pethidine (if needed) , adults; 50-100mg
intramuscularly repeated 4 hourly, children; 0.5-
1mg/kg intramuscularly repeated 4 hourly
• Dextrose solution or Normal Saline intravenously
• Benzyl Penicillin, adults; 1 MU intravenously 6 hourly,
children; 50,000-100,000 IU kg/day intravenously
in 4 divided doses for 5 days or
• Phenoxymethyl penicillin, adults; 500-750 mg orally
6 hourly, children; 20-50 mg/kg orally daily in 4
divided doses for 5 days
• Metronidazole, adults; 500mg intravenously or 400
mg orally 8 hourly for 5 days, children; 20-30 mg/kg
orally or 7.5 mg/kg intravenously in divided doses
8 hourly

379
Surgical
• Incision and drainage, if necessary
Patients should be nursed in a place where surgery can

be done urgently.
12.2.3� Epiglottitis
Definition
This is an acute inflammation of the epiglottis due to
Haemophilus influenzae type B. The condition can be life
threatening.
Clinical features
• Acute onset, usually within 6 hours
• High fever
• Toxic patient
• Drooling of saliva
• Respiratory stridor
Diagnosis
Diagnosis should be suspected from clinical features.
Avoid throat examination as the patient's airway may
become completely obstructed.
Treatment
Refer immediately for specialised treatment
Drugs
• Chloramphenicol, adults; 500mg-1g intravenously
4 times daily, children; 50-100mg/kg daily in 4
divided doses for 5 days.
• Cefotaxime, adults; 1g intramuscularly/ intravenously
12 hourly, increased in severe infection to 8 - 12 g
in 3-4 divided doses, children; 100-150mg/kg daily
in 2-4 divided doses increased up to 200mg/kg
daily in very severe infections.

380
12.3 NASAL DISEASES
These include:
• Acute sinusitis
• Allergic rhinitis
12.3.1� Acute sinusitis
Definition
This is inflammation of one or more sinuses. This condition
usually occurs after suffering from a cold or allergic rhinitis.
Clinical features
• Tenderness over the affected sinuses
• Headache
• Blocked nose
• Copious mucopurulent discharge
• Fever
Treatment
Drugs
• Amoxicillin, adults; 250 - 500mg orally 3 times daily,
children over 20kg; 250mg orally 3 times daily, 10
- 20 kg; 125mg orally 3 times daily, below 10kg;
62.5mg orally 3 times daily for 5 days or
• Cotrimoxazole, adults and children over 12 years
old; 960mg orally 2 times daily, children 5 - 12 years;
480mg orally 2 times daily, 6 months to 5 years;
240mg orally 2 times daily
Supportive
• Steam inhalation
• Saline nasal drops

381
Complications
• Dental abscess
• Periorbital swelling
Patients with complications need referral to a specialist.
12.3.1.2 Allergic rhinitis
Definition
This is inflammation of the nasal mucosa due to
hypersensitivity to allergens. The common allergens
include pollen, dust, animals, or food.
Clinical features
• Recurrent nasal blockage
• Irritation
• Watery nasal discharge
• Sneezing
• Watery and itchy eyes
Treatment
Drugs
• Chlorpheniramine, adults and children over 12 years;
4mg orally 2 times daily, children 5 - 12 years old;
2mg orally 2 times daily, 6 months to 1 year 1mg
orally 2 times daily
• Loratidine, adults; 10mg orally once daily, children
2-5 years; 2-5mg orally once daily
Supportive
• Saline nasal drops used at night. But these should
not be used for too long periods, as rebound blockage
is likely to occur
• Avoid causative allergens
Persistent attacks with severe symptoms should be

referred to the specialist.

382
12.4� EAR CONDITIONS
These include:
• Acute otitis media
• Chronic suppurative otitis media�
12.4.1 Acute otitis media
Definition
This is inflammation of the middle ear. It usually follows
an upper respiratory tract infection.
Clinical features
• Fever
• Severe pain in the ear, worse at night
• Babies cry, rub or pull the ear
• Red bulging eardrum
• Blood and/or pus discharg
Treatment
Drugs
• Amoxicillin, adults; 250-500mg orally 8 hourly,
children; 12.5-25mg/kg orally 8 hourly for 5 days
• Aspirin (adults only); 600mg orally 3 times daily
6 hourly, children up to 1 year; 62.5 orally 6 hourly,
1-5 years; 125mg orally 6 hourly, 6-12 years; 250mg
every 6 hours for 7-10 days or
• Erythromycin, adults; 250-500mg orally 4 times daily,
children; 125-250mg orally 4 times daily for 5 days
Supportive
• Avoid wetting the inside of the ear

383
Complications
• Mastoiditis
• Hearing loss
• Acquired cholesteatoma
12.4.2� Chronic suppurative otitis media
This is a condition in which there is an ear discharge

lasting more than two weeks and results from inadequately
treating or neglecting acute otitis media.
Clinical features
• Painless discharge from one or both ears
• Perforation of the eardrum
• Discharge may be thin, clear, mucoid to thick, pasty,
• offensive mucopus
• Presence of multiple organism infection
• Red and swollen middle ear mucosa
• Mucosa may bulge if blocked
Treatment
• Wick dry with a cotton cloth
• Keep the ear as dry as possible
• Antibiotics are not usually indicated
• The patient should be referred if:
• Pain is present
• There is swelling behind the ear
• There is poor response to treatment

384
13
SURGICAL CONDITIONS
This chapter discusses the following conditions:
• Injuries
• Animal bites
• Testicular torsion
• Strangulated hernia
• Hydrocele
• Varicocele
13.1 INJURIES
Definition
Injuries refers to harm that occurs to the body. They may
be intentional or due to accidents. The cause may be physical,
chemical, burns, or traffic accidents.
Injuries may cause temporary or permanent disability. Injuries

may be divided into minor and major injuries.
13.1.1� Minor injuries
These include cuts and blunt injuries. Cuts are usually from
sharp objects, especially household implements. Blunt injuries
usually follow assault.
Clinical features
Cuts may bleed and if seen late may have developed

infection with pus formation.
Blunt injuries will cause bruises or haematomas or more
serious deeper injuries, such as bone fractures.
Treatment
• Clean open wounds thoroughly with soap and water

385
or a disinfectant
• Remove foreign matter and dead tissue
• Suture fresh superficial wounds
• Do not suture open wounds after 6 hours of injury
• Cover the wound with dressing
Drugs
• Tetanus toxoid, 0.5ml intramuscularly as a single
dose
• Anti-tetanus serum, 250 IU as a single dose ( for
non-immunised patients)
• Paracetamol, adults; 500mg-1g orally 3 times daily,
• Aspirin, (adults only) 600 mg orally 3 times daily
Haematomas usually resolve on their own
13.1.2� Major injuries
These are multiple injuries or serious injuries to specific

body parts.
13.1.2.1 Multiple injuries
These may be characterised by fractures, bruises, internal

injuries, head injuries, spinal injuries, and chest trauma
or eye injuries. The patient will present with two or more
of such injuries. They may result from traffic accidents,
assault or war.
Treatment
Initially a quick history and examination should be carried
out to establish the severity of the injuries.
• Establish a clear airway
• Remove any debris in the mouth
• Insert airway breathing, if necessary
• Ensure good circulation
• Set up an intravenous line with the largest gauge

386
possible
• Control bleeding
• Resuscitate, if necessary
• Treat shock
• Look for signs of internal haemorrhage
• Group and cross match blood
• Clean and debride wounds before suturing
• Immobilize fractures immediately
Drugs
dose
Refer patient to the nearest hospital in case of head or
chest injuries, suspected internal haemorrhage, loss of
consciousness or need of additional care.
13.1.3� Specific injuries
13.1.3.1 Head injuries
The patient may present with a laceration, fracture, a

history of altered consciousness or amnesia
General Management
• An accurate history is needed, especially to find out
if the patient was unconscious at any time after the
head injury. A careful examination is needed. Head
injuries may be associated with a fracture or
dislocation of the cervical spine
• Brainstem compression causes hypertension and
bradycardia, with irregular respiration
• Assess the conscious level using the Glasgow Coma
Scale (GCS). The face and head should be examined
carefully for blood or cerebrospinal fluid draining
from the nose or ears, suggesting a fractured base
of the skull
• Examination of the eyes is needed as a unilateral

387
fixed and dilated pupil may indicate a haematoma
on the same side
Investigations
• X-ray of the cervical spine (lateral view)
• X-ray of the skull (antero-posterior, lateral and
Townes’ views)
Specific treatment
Patient should be admitted to hospital for observation
for at least 24 hours, even if it is apparently a trivial
injury, if there is:
• History of loss of consciousness
• Loss of consciousness on arrival in hospital
• Focal neurological signs
• Post traumatic amnesia
• Significant drowsiness
• Severe headache or vomiting
• Blurred vision
• Other associated injuries
• Skull fracture
Management
• Do hourly observation of GCS, breathing pattern,
vital signs, and pupil reaction
• The airway must be safe and patients nursed with
the head propped up at 150
• Severe injuries need specialised management by a
neurological centre
• Restrict intravenous fluids to minimise cerebral
oedema. Sufficient fluid to maintain a urine output
of 0.5 – 1ml/kg/hour should be given
1.1.3.2 Facial injuries
Treatment
• Maintain the airway as swelling may be severe

388
• Intubation or tracheostomy may be performed, if
necessary
• Prophylatic antibiotics should be given for facial
fractures
13.1.3.3 Spinal injuries
This should always be suspected in patients with head

injury or multiple trauma(s). There may be numbness,
parasthesia, weakness of the limbs or pain radiating
down a limb.
Diagnosis
Lateral view X-ray of the cervical spine, including all
cervical vertebrae and first thoracic vertebra.
Treatment
• The patient should be moved very carefully
• Avoid rotation and extremes of flexion and extension
• The attendants should work as a team to move the
patient. One assumes responsibility for the neck and
places the fingers under the angle of the mandible
with palms over the ears and parietal region and
maintaining gentle traction. Keep the neck straight
and in line with the body. The neck can be splinted
with a sandbag on either side or a cervical collar
Refer for specialised management, which will be needed

for specific injuries.
13.1.3.4 Eye injuries
For penetrating or blunt trauma refer patient for specialised

treatment at higher level of care. (See also chapter 9)

389
13.1.3.5 Chest injuries
Clinical features
• Pain on breathing
• Dyspnoea
• Unequal movement of chest wall
• Surgical emphysema of neck and chest
• Palpable rib fractures
• Bruising
• Tracheal deviation
• Restlessness
• Central cyanosis
• Tachycardia
• Hypotension
• Sweating
Diagnosis
• Bruising over the lower left ribs may indicate a
ruptured spleen
• Bruising over the right lower ribs may indicate a
ruptured liver
• Chest X-ray (antero-posterior view)
Treatment
• Rib fractures do not require any specific management
apart from analgesia
• Large flail chest may require mechanical ventilation
for 10-14 days and stronger analgesia
Pneumothorax
There are two types: open and tension.

Open
• Conservative management
• Refer for appropriate treatment if patient’s condition
deteriorates

390
Tension
• This is an emergency
• Convert to open pneumothorax by pushing a large
bore needle into the 2nd intercostal space along the
midclavicular line
• Insert an intercostal under water seal drainage
Haemothorax
There are two types: asymptomatic and symptomatic.
Asymptomatic
• Conservative management
Refer for appropriate treatment if patient’s condition
deteriorates
Symptomatic
• Insert an intercostal under water seal drainage
• Patient should be referred to higher level or specialist
Flail chest
• Patient needs oxygen or mechanical ventilation
• Ribs may need to be fixed.
• Refer to higher level or specialist
13.1.3.6 Abdominal injuries
Penetrating injuries are usually due to stab and bullet

wounds. The patient may present with a metal protrusion
or disembowelment. The injuries may result in
haemoperitoneum. Haemoperitoneum may be present
with pain, abdominal distension, rigidity or tenderness.
Diagnosis
Peritoneal aspiration for haemoperitonerium should be
done

391
Treatment
All abdominal bullet or stab wounds should be explored
by laparatomy
13.1.3.7 Renal injuries
There is usually microscopic or macroscopic haematuria.
Diagnosis
• Abdominal ultra sound
• Intravenous urogram
Clinical features
• Swelling in the loin area
• Bruising in the loin area
• Tenderness in the loin area
Treatment
• Catheterise patient
Refer patient to a specialist for specific treatment
13.1.3.8 Burns
A burn is an injury occurring after exposure of the body

surface to friction, chemicals, electricity or extreme
temperature.
Clinical Features
Burns may result in damage to the dermis. Such damage
may be partial or full thickness.
Partial thickness burns

• Some of the dermis is alive
• Heals in 10-14 days without scarring
• Blisters may be present
• Pain
• Shock may be present

392
Full thickness burns
• Damage to all of the dermis
• Usually heal after 21 days with scarring
• Painless
• Shock may be present
Complications
• Infection
• Anaemia
• Contractures
• Pulmonary oedema may occur after inhalation of
smoke
• Acute peptic ulcers
• Acute renal failure
Management
Assessment
• Examine for shock and loss of fluids
• Assess the extent and depth of the burn
• Look for signs of infection
Treatment
Drugs
• Paracetamol, adults; 500mg-1g orally 3 times daily,
• Pethidine, 0.5-1mg/kg intramuscularly 4-6 hourly
for severe burns
• Tetanus toxoid 0.5ml intramuscularly as a single
dose, if necessary
• Topical antibacterial agents – silver nitrate, and silver
sulphadiazine cream. Others used are povidone-
iodine, chlorhexidine
Supportive
• High calorie, high proteins diet
• Physiotherapy for burns affecting joints as soon as
patient is resuscitated and pain has been controlled

393
Specific Care
• Superficial burns should be cleaned with water, dried
and left open
• Fluid replacement. Suggested fluids are normal
saline, ringer’s lactate or hartmann’s solution. 50ml
of 50% dextrose per litre can be added
• Do not open blisters
• Dress burns with vaseline gauze but exposure method
is preferred
• Wash burns every 4-6 hours with salt water
• Use showers. Avoid baths which may allow cross-
infection
• Slough is removed using wet to dry dressings
• Dressings should not be allowed to dry and stick
• Specific areas such as the eyes, eyelids, ears,
perineum and hands need specific care
• The haemoglobin should be checked once a week
and transfusion given, if necessary
• Monitor urine output. It should be at least 1ml/kg
/hour
All patients with deep and extensive burns should be
referred to a specialist
Determination of burn size

The burn size in adults is determined using the rule of
nines in which the following body areas are taken to
represent 9% or 18%:
Whole of each upper limb = 9%

Whole of each lower limb = 18%
Front of trunk =18%
Back of trunk =18%
Whole of head and neck =9%
Perineum =1%
The above formula is not applicable to children. In children

the burn size can be determined by considering the area

394
of one palm surface of the patient’s hand as 1% of body
surface area. This palm surface formula is also applicable
to adults.
Fluid therapy in burns
Fluid requirements
a) Maintenance requirements
Age group Weight (kg) ml/kg/ ml/kg

24hours /hour
Neonates
(<3months) 3 150 6
Infants
(>3months) 3-10 10-20 5
120 80 3
Children >20 60 2.5
Adults 35 1.5
b) Extra requirements
Age under 6
One ration = 2 x burn size x weight
Age 6 or over
One ration = 1 x burn size x weight
Note:
On top of the maintenance fluid requirement which is
given at a constant rate, one ration of extra fluid is given
during the first 8 hours from the time of the burn, a
second ration during the next

395
8 hours and a third ration during the next 24 hours.
Prevention of injuries
• Public education on supervision of young children
• Household chemicals, insecticides, sharp objects
should be kept out of reach of children.
• Teach road safety measures at an early age
• Safety standards in places of work should be
maintained
13.2 BITES
These are bites which are inflicted by animals or humans.
Clinical features
A wound may sometimes be associated with fractures
or amputations if inflicted by large animals. There may
be bleeding.
Complications
Infection with both aerobic and anaerobic bacteria or
viruses.
Treatment
• Clean,debride the wound
• Excise dead tissue
• Leave the wound open for delayed primary or
secondary suture
Drugs
• Phenoxymethyl penicillin , adults; 250 -500mg orally
4 times daily, children; 125-250mg orally 4 times
daily for 5 days
• Metronidazole, adults; 200-400mg orally 3 times
daily, children; 100mg -200mg orally 3 times daily
for 5 days

396
dose.
If bite is from suspected rabid animal, administer post-

exposure rabies treatment. (Refer to chapter 2.7).
13.3� TESTICULAR TORSION
Definition
This is the twisting of the testis along its vertical axis,
resulting in compromised blood supply to the testis and
the adjoining spermatic cord. It may be spontaneous or
following strenuous activity. It may also result from
anomalies in the development of the tunica vaginalis
and the spermatic cord.
Clinical Features
Symptoms
• Severe local pain
• Nausea
• Vomiting
• Scrotal swelling
• Dark discoloration of the scrotum
• Fever
Diagnosis
This is clinical and confirmed on surgical exploration
Treatment
• Immediate surgical intervention is advised if torsion
is suspected. Surgical exploration of the scrotum
within a few hours offers the only hope of testicular
salvage. Fixation of the contra lateral testis is
performed to prevent torsion on that side.
• Appropriate antibiotic cover is required.

397
13.4� STRANGULATED HERNIA
Definition
This is a condition in which the blood flow to an abnormally
protruding viscus is compromised. The strangulation can
occur in any type of hernia.
Clinical Features
• Abdominal pain
• Fever
• Vomiting
• Irritability
• Restlessness
• Abdominal distension
• Guarding of the abdomen
• Rebound tenderness
Diagnosis
• History and examination is very important in making
a diagnosis
• Abdominal X-rays
Treatment
The basic line of management is immediate surgical
intervention and relieving the obstruction. It is mandatory
to inspect the bowel if gangrenous resection is done and
anastomose the viable segments.
Drugs
• Benzyl penicillin, adults; 2MU intravenously 4 times
daily, children; 50,000-100,000 IU/kg intravenously
in 4 divided doses for 5 days
• Metronidazole, adults; 500mg intravenously 3 times
daily, children; 7. 5mg/kg 8 hourly for 5 days
• Gentamicin, adults; 80mg intravenously 3 times
daily, children; 2-3mg/kg intravenously in three
divided doses for 5 days
• Intravenous fluids

398
13.5� HYDROCELE
Definition
This is a condition characterised by the accumulation of
fluid in the tunica vaginalis and it presents as a cystic
scrotal mass.
Clinical Features
• Intrinsic, often cystic and painless scrotal mass
• May be painful when severely distended
• Mass is unilateral
• Transluminable mass
• Spermatic cord is palpable above the cystic mass
Treatment
• Hydrocelectomy
• Appropriate antibiotic cover is required
13.6� VARICOCELE
Definition
This is a collection of large veins, usually occurring in the
left scrotum. It feels like a “bag of worms”. It is present
when the patient is in the upright position and should
empty in the supine position.
Clinical Features
• Pain
• Feeling of scrotal fullness
Treatment
• Varicoceletomy
• Appropriate antibiotics cover is required

399
14
POISONING
Definition
This is the exposure by ingestion, inhalation or other
means of a substance capable of causing harm to the
body.
Clinical features
The patient may present a variety of symptoms ranging
from mild to serious ones like the loss of consciousness.
Diagnosis
• Assess for vital signs
• Ascertain as far as possible, the nature and quantity
of the poison and when it was taken.
14.1� MANAGEMENT
Management depends on the type of poison taken and

the clinical condition of the patient. Treatment is aimed
at slowing down, reducing or preventing further absorption
of the poison and to counteract the effects of the poison
already absorbed.
All patients with poisoning should be referred to a specialist

after emergency treatment.
Emergency resuscitation measures should be taken in

the following circumstances:
a) Obstructed airway
• Pull the tongue forward
• Remove dentures, foreign bodies (e.g. food) and
oral secretions
• Hold the jaw forward and insert an oropharyngeal
airway if possible

400
• Put the patient in a semi-prone position with
head down to minimise the risk of inhaling vomit
b) Inadequate respiration
• Give continuous oxygen
• Apply assisted ventilation with an ambu bag or
mouth to mouth or intubate and do mouth to
tube respiration.
• Do not use respiratory stimulants as they cause
harm
c) Hypotension
• Keep patient in a position with his head
downwards by elevating the foot of the bed
• Administer 0.9% sodium chloride intravenously
d) Recurrent fits
Control with diazepam, adults; 5-10mg intravenously
stat, children; 0.2-0.3mg/kg intravenously stat.
Repeat as necessary
e) Removal of poison from the stomach
Gastric emptying carries the risk of the victim inhaling

gastric contents. The benefit of the procedure should
therefore be weighed against this risk. The procedure
should not be performed in the following circumstances:
• When corrosive substances (e.g. acids, alkalis and
petroleum products) have been swallowed.
• When there is marked hypothermia (less than 300C)
• When the amount of poison swallowed is minimal
• If poison was ingested more than 2 hours earlier
(except in the case of poisoning with salicylates, tri-
cyclic anti-depressants and beta-blockers)
Procedure
To remove poison from the stomach, two methods may
be used:
• Inducing vomiting by giving:
– Ipecacuanha syrup, adults; 30ml, children above
1 year; 15ml, children below 1 year;

401
10ml followed by a glass of water. Repeat after 20
minutes if necessary.
• Gastric lavage
If done in an unconscious patient, a cuffed
endotracheal tube should be passed to prevent
aspiration of stomach contents into the lungs.
Reduction of absorption of poison
After vomiting has occurred:

• Activated charcoal; 50g mixed with 400ml water in
a bottle and shaken well. Administer the suspension
in a dose of 5ml/kg. Repeat every 4 hours. Total
dose of 100g for adults, if necessary
• Magnesium sulphate mixture or magnesium
hydroxide mixture; 50ml to avoid constipation
• Milk, cooking oil or beaten raw egg may also be
given in the absence of activated charcoal, to delay
absorption of the poison
14.2� TREATMENT OF SPECIFIC �

COMMON POISONING
14.2.1� Aspirin and other salicylates
Treatment
• Induce emesis with ipecacuanha, unless respiration
is depressed
• Give activated charcoal
• If respiration is depressed, do airway-protected
gastric lavage
• Gastric emptying is effective up to 4 hours after
ingestion of poison
14.2.2� Carbon monoxide
Treatment
• Remove patient from further exposure

402
• Give oxygen for several hours
• Maintain blood pressure and normal body
temperature
• To reduce cerebral oedema, give 20% mannitol,
intravenously 5ml/kg body weight over 20 minutes
and a corticosteroid intravenously or intramuscularly
4 hourly (e.g. prednisolone, 1mg/kg body weight
dexamethasone, 0.15mg/kg body weight or
hydrocortisone, 4mg/kg body weight)
• Control convulsions or hyperactivity with diazepam,
0.1mg/kg body weight by slow intravenous or per
rectum
14.2.3� Ethanol�
Treatment
• Remove unabsorbed ethanol by gastric lavage or
inducing emesis with ipecacuanha syrup
• Maintain adequate airway
• Maintain normal body temperature
• If patient is hypoglycaemic give dextrose 50%,
followed by 5% intravenously
• May need Vitamin B compound, if chronic alcohol
abuser
14.2.4� Insecticides
14.2.4.1 Organochlorine
Treatment
• Remove patient from source of poisoning and remove
contaminated clothing
• Give ipecacuanha syrup
• After vomiting give activated charcoal followed by
gastric lavage with 2 – 4 litres water (adult dose)

403
• Give a laxative such as magnesium hydroxide
• Do not give milk, fats or oils as they will increase
absorption of the poison
• Scrub the skin with soap and cold water to remove
skin contamination
• Give artificial respiration with oxygen if there is
respiratory depression
• Give diazepam, 10mg slow intravenous or
phenobarbitone, 100mg intramuscularly to control
convulsions, hyperactivity or tremors
Organophosphates and carbamate
Treatment
• Remove patient from source of poisoning and remove
contaminated clothing
• Establish airway and give artificial respiration if
necessary
• Remove excess bronchial secretions by suction
• Give ipecacuanha syrup or start gastric lavage
Give atropine, adults; 2mg intravenously/
intramuscularly stat , children; 100-200mcg
intravenously/intramuscularly/orally every 3 – 8
minutes until signs of atropinisation appear (hot dry
skin, dry mouth, widely dilated pupils and fast pulse)
14.2.5� Paraffin, petrol and other petroleum �

products
Treatment
• Prevent the substance from entering the lungs to
avoid damage to tissue
• Do not induce vomiting
• Do not do gastric lavage
• Look out for pulmonary oedema and chemical
pneumonitis and treat accordingly

404
14.2.6� Paracetamol poisoning
Clinical features
Liver damage may result in paracetamol overdosage.
The damage occurs within a few hours of ingestion.
Treatment
• Keep the patient quiet and warm
• Induce emesis with ipecacuanha syrup
• Where there is depressed respiration use airway-
protected gastric lavage
• N-acetylcysteine, 20% solution, orally 140mg/kg
as a loading dose, followed by 70mg/kg every 4
hours for 3 days. It may be necessary to administer
through a nasogastric tube
• Dextrose, 5% intravenously for the first 48 hours
• Phytomenadione, 1– 10mg intramuscularly if the
prothrombin time ratio exceeds 2.0
• Do not force dieresis
14.2.7� Chloroquine poisoning
Clinical features
Characterised by blurred vision, tinnitis, weakness,
haemoglobinuria, oliguria, low blood pressure, shock,
convulsions, cardiac arrest
Treatment
• Induce emesis
• Stomach wash (air-way protected gastric lavage, if
respiration is depressed)
• Treat symptomatically

405
14.2.8� Mushroom or other foods poisoning
Clinical Features
There will be abdominal pain, nausea, vomiting, and
diarrhoea.
Shock, in severe cases
Treatment
Symptomatic:
• Bed rest
• Keep patient warm
• Stomach wash using normal saline
• Give Oral Rehydration Salts (ORS) or intravenous
fluids to re-hydrate
• If no improvement refer to specialist
14.2.9� Snake Bites
Treat all snake bites an emergency
Clinical features
• Pain
• Swelling
• Tisuue necrosis
• Regional lymph node swelling
• Haemorrhagic symptoms; bleeding at wounds site
• And other parts of the body
Danger signs
• Drowsiness
• Slurred speech
• Excessive oral secretions
• Dificulty in breathing
• Neurological signs
Treatment
• Immobilse limb And keep slightly elevated

406
• Administer tetanus toxoid
• Dextrose 5% in saline intravenously
• Treat shock
• Vitamin K, 1-10mg intramuscularly
• Anti-snake venom, if available
• Transfer patient to specialist
Prevention
• Wear protective shoes
• Clear bushes near dwelling places
• Avoid walking on dark paths

407
15
DISORDERS OF THE RENAL
SYSTEM
15.1 � METABOLIC DISORDERS
15.1.1 � Hyperkalemia
Definition
This is serum Potassium > 5.5mmol/L
Clinical features
Symptoms
Muscle weakness
Signs
• Ascending paralysis with respiratory failure
• Cardiac instability, ventricular fibrillation, cardiac arrest
• May have signs of acute kidney injury or metabolic
acidosis
Investigations
• Serum Potassium
• ECG – tall, peaked symmetrical T wave, flat P,
increased PR interval, wide QRS , bradycardia, AV block
Therapy
• Stop source of K+ ( oranges, bananas, ACEI, K+ sparing
diuretics, septrin, heparin, NSAIDS,B-blockers)
1. Severe Hyperkalemia (K > 6.5) and ECG changes

a. Protect the heart- 10mls 10% Calcium Gluconate over
10mins.
b. Push K+ into cell
– 0mls of 8.5% NaHCO3 over 5minutes if patient is
also acidotic. Another dose after 5 -10mins. Can then

408
infuse 100mls over 1-2 hrs ( DONT USE or INFUSE
WITH RL OR with CALCIUM- PPT but YOU CAN USE
5% Dextrose for infusion)
– 50mls 50% Dextrose with 10iu soluble insulin

over 15-20mins. May given 2-4 hourly as required.
Monitor serum glucose 2-4 hourly
– 10-20mg nebulised salbutamol
c. Push K+ out of the body

– Frusemide 1mg/kg IV ( Please hydrate patient
first if dehydrated)
– Kayexalate/sodium Resonium 15-30g in 50-
100mls 20% Sorbitol or with lactulose PO/PR
– Consider Hemodialysis if refractory
2. Moderate Hyperkalemia (K+ 6.0 – 6.5)

a. Push K+ into cell
b. Push K+ out of the body
3. Mild Hyperkalemia (K+5.5 – 5.9)

Push K+ out of the body
15.1.2� Hypokalemia
Definition
Serum K+ < 3.5, maybe associated with
hypomagnesaemia and hypocalcaemia
Clinical features
Symptoms
Muscle weakness, fatique, constipation, muscle cramps
Signs
• Paralytic ileus, ascending paralysis, reduced reflexes.

409
Tetany when associated with alkalosis
• Arrthymias
Causes
• GIT and Renal losses
Management
Investigations
• check K+, other electrolytes and serum pH
• ECG- flat or inverted T wave, prominent U wave
Therapy
• 20mmol KCL in 250-500mls Normal saline over one
hour. Check K+ before repeating dose and ECG
monitoring.
• Consider 6-12mls (5-10mml/l) 20% MgSO4 or 2mls
50% diluted in 50mls over one hour.
• If cardiac arrhythmia or arrest give 2mmol KCl per
minute iv for 5mins. Repeat ONCE only if necessary
• Oral K+ supplements if K+>3.0
15.1.2� Hypernatremia
Definition
serum Na+ > 150mmol/ L
Clinical features
Symptoms
• thirsty, nausea, vomitting, weakness, malaise
• muscle tremor, weakness
Signs
Drowsiness, stupor, coma, convulsions, tremors,
ataxia
Causes
• water loss more than electrolyte

410
– GIT losses,
– Renal losses (osmotic diuresis, DI)
• increase in Na+
– Hyperaldosteronism, cushings
– Excessive saline or sodium bicarbonate infusion
Management
• Investigate and treat cause
• Please do urine Na+ as well
Therapy
• Correct water deficit – rehydrate first if patient is
dehydrated
• Stable/asymptomatic patients
– take it easy
– replace fluids orally
• unstable/symptomatic patients
– IV fluids with NS, DNS, avoid 5%Dextrose as Na+
may drop too fast
– rate of lowering serum Na+ 0.5-1mmol/hr, aim
for 12mmol/l in 24hrs and not more than this
– ESTIMATE THE EFFECT OF 1 LITRE OF ANY INFUSATE
ON SERUM Na+
– Change in serum Na+ = ( infusate Na+ _ serum
Na) divided by (total body water + 1)
– The answer is in mmol/L. the formular helps to
calculate the infusion rate so that you do not
exceed 1 mmol/min.
15.1.3� Hyponatremia
Definition
Low serum Na but treatment warranted with severe
(<120mmol/l) or acute
Clinical features
• asymptomatic unless severe or acute

411
• nausea, vomitting, seizues, coma
Causes
• hypovolemic
• GI losses, renal losses
Euvolemic
• SIADH
• Hypothyroidism
• Adrenal insuffiency
Hypervolemic
• CCF
• cirrhosis
• Nephrotic syndrome
Management
• Investigate and treat cause
• Urine Na+ should be ordered, urine and serum
osmolarity should be measured
Therapy
• CNS manifestations
– 200mls 5% NaCl over 6 hours. Monitor serum
Na+ hourly
– Aim to increase Na+ to 120mmol/l at a rate of
0.5 – 1.0mmol/l per hour
– If no CNS symptoms, do not use Hypertonic saline.
– Once serum sodium is around 12ommol/l, stop
active therapy and restrict fluid intake to approx.
500mls/day.
• Asymptomatic
– Can use conservative measures like fluid restriction
may be enough.
• SIADH
– restrict fluid intake to 50-60% of estimated
maintenance fluid requirements(±1L/day).

412
15.1.5 Hypercalcaemia
Definition
Corrected serum Ca 2+ > 2.65mmol/l
Clinical features
Symptoms Polyuria, polydipsia, dysphagia, bone
pain, renal colicky
• Muscle weakness
Signs
• Confusion, hypotonia, dysarthria, coma, seizures
Causes
Hyperparathyroidism, malignancy, sarcoidosis, drugs,
Vitamin D intoxication esp in renal patients
Investigations
• ECG- short QT interval, wide QRS complex, flat T, AV
block, may have fatal arrhythmias
• Serum Calcium U+Es, albumin, Mg2+, Phosphate,
ALP, Serum electrophoresis
• PTH
• X-RAYS
Frequent association with hypokalemia increasing risk of
arrhythmias.
Therapy
• Hydrate with Normal Saline 500mls/hr untill Urine
out > 200mls/hr then reduce 100-200mls per hour.
• Furosemide 1mg/kg only when patient has been
hydrated or if in cardiac failure
• Hemodialysis or peritoneal Dialysis with low Calcium
dialysate. Hemodialysis prefered
• Prednisolone 40mg daily esp for Vit D intoxication,
sarcoidosis, multiple myeloma, metastasis
• Pamidronate 60-90mg in 500-1000mls NS infusion

413
over 4-6hrs. should be effective within 48hrs
• Monitor and replace K+ and Mg2+
15.4 � CATHETER RELATED BLOOD �

STREAM INFECTIONS (CRBSI)
Intravenous catheters inserted into central veins such as

the internal jugular vein, subclavian vein or femoral vein
provide the only and vital access for hemodialysis for
patients with no arterio-venous fistulas. Introduction of
catheters including venous and urinary catheters increases
the risk of blood stream infections.
In most cases CRBSI can be prevented by simple

interventions:
• Hand hygiene
• Using full barrier precautions during the insertion of
central venous catheters,
• Cleaning the skin with chlorhexidine,
• Avoiding the femoral site if possible
• Removing unnecessary catheters including urinary
catheters as soon as possible
Management of CRBSI
Patients with central venous accesses and new fevers
should be evaluated for CRBSI, with the catheter as the
source of the infection unless otherwise excluded by
patient examination and investigations. The following
minimum evaluations should be done.
• Thorough patient history and examination including
the central line insertion sites to assess for superficial
thrombophlebitis and insertion site abscess
• Two sets of blood cultures obtained from two different
sites and another drawn from the central venous
access site
• If you suspect bacteremia/sepsis remove catheters
and culture the tip to guide antibiotic treatment

414
required.
• Other investigations as determined from history and
physical examination of the patient
• Empiric antibiotics guided by local microbiology and
susceptibility of organisms
• Vancomycin 1gm IV Stat dose and thereafter dosed
according to renal function for empiric treatment of
Methicillin Resistant Staphylococcus aureus, Coagulase
Negative Staph, Enterococci species
• For patients unable to tolerate Vancomycin due to
deteriorating renal function, switch to Linezolid for
the treatment of MRSA and resistant Enterococcus
• Fourth Generation Cephalosporins (Cefepime 2gm
IV Stat) or Carbepenems (Doripenem or Meropenem)
should be initiated for empiric gram negative
bacteremia such as Pseudomonas that may be
resistant to routinely used gram negative antibiotics.
• If cultures are positive for fungal elements particularly
Candida albicans, initiate Caspofungin until sensitivity
results are available and switch to Fluconazole if
susceptible. Remove the central line immediately in
the case of candidemia.
15.5 GLOMERULAR DISORDERS
Five clinical syndromes

• Nephrotic syndrome
• Nephritic syndrome
• Rapid progressive glomerulonephritis
• Asymptomatic Hematuria or and proteinuria
• Chronic glomerulonephritis
15.5.1 Nephrotic syndrome
Definition
• At least 3.5g proteinuria in 24hrs
• Generalised edema

415
• Low serum albumin
• Hypercholesteronaemia
Causes
• Minimal change disease Membranous
• Membranous
• Focal segmental glomerulosclerosis (FSGS)
Membranoproliferative glomerulonephritis (MPGN)
• Lupus Nephritis
• Diabetic nephropathy
• Amylodosis
Clinical features
Symptoms
• Facial swelling worse in the morning
• froth urine
Signs
• Edema
• Usually normal BP
• Urine dipstick >2 + proteinuria, rare hematuria except
in FSGS
Diagnosis
• Renal biopsy needed for light microscopy, IF and EM
• Thus early referral to Nephrologist important
General Management
• Salt restriction
• No need for protein restriction in our setting
• Furosemide 80-120mg/day (aim 0.5-1L/day)
• Proteinuria lowering drugs
– Titrate dose depending on proteinuria
– ACEI- enapril 2.5 – 20mg/day or Perindopril 4-
16mg daily
– ARB- Lorsatan 25-100mg/day or Micardis 40-
160mg/day

416
• Lipid lowering
– Simvastatin 10-40mg daily or atavostatin 10-
20mg daily
• Anti-coagulation (INR 2-3).
– Only if albumin < 20g/l, bedridden, very rapid
diuresis, otherwise dont use routinely
– Warfarin daily
Pathological classification
a. Minimal change disease
Definition
Pathologically no glomerular changes on light microscopy
but podocytes are effaced on electron microscopy
Presents with nephrotic syndrome
Causes
• Idiopathic
• NSAIDS, bee sting, lymphomas
Therapy
Idiopathic MCD
• ACEI/ARB are not used initially in MCD
• Prednisone, 1 mg/kg daily or 2 mg/kg qod in am
for a minimum of 8 weeks. (If response is after 8
weeks, treat 2 weeks after response)
• Taper 5 mg/day every 3-4 days to 30, then use
QOD, taper 5 mg/dose/week to 0.
• If relapse while tapering (steroid dependent) retreat
with 4 week course.
• If relapse off steroids, retreat with 4 week course.
• If pt remains steroid dependent or has > 3
relapses/year can use low dose prednisone (10-15
mg) for a year to maintain remission,
• If using more than 0.3-0.4 mg/day of prednisone
long term, treat with cyclophosphamide 2 mg/kg
po for 12 weeks.

417
• Steroid resistance is usually defined as no response
after 4 mos of 1 mg/kg.
b. Membranous
Pathologically immune deposits are visible just above or
within the glomerular basement membrane
Presents with nephrotic syndrome
Definition
Immune
Causes
• Idiopathic – 80%
• Infections -HBV, HCV, ?syphillis,? schistosomiasis,
malaria
• Drugs- penicillamine, NSAIDS, Captopril, Gold
• Malignancies- lung, breast, thyroid, GI
• Autoimmune- SLE, Thyroid disease

418
Management
Membranous nephropathy: Approach to therapy based
on risk of progression (6 mos observation
Feature/risk Low risk Medium risk High risk
Urine protein <4 >4 but <8 >8
GFR (onset) Normal Normal Normal or low
GFR (6 mos) Stable Stable Stable or declining
Risk ESRD
(10 yrs) < 10% 55% 66-80%
Therapy ACEI/ARB Steroids, Steroids,

Conservative, MMF*** CTX*, CSA**, MMF***
CTX*, CSA**
CTX* - cyclophosphamide, CSA** - cyclosporine, MMF*** -

Mycophenolate
• Prednisone (0.5 mg/kg/day) and Cyclophosphamide

(1.5-2.0 mg/kg/day) po for 6 months or
• Cyclosporine 3.5 mg/kg for 12-24 months (keep
levels 110-170 mgL) (or FK .05 mg/kg in bid dose
to level 3-5 mg/L) (plus pred 0.15 mg/kg to max
15)
• Prophylaxis
– INH 300mg od po
– Co-trimoxazole( single dose) 2tab od po
– Fluconacozole 100-200mg od po
– At least for 3 months
IF NO RESPONSE IN 6 MONTHS
• Methylpred 1.1 g/IV x 3 and then prednisolone
0.5 mg/kg x 27 days;

419
• Chlorambucil 0.2 mg/kg (or Cyclophosphamide, 2
mg/kg)daily x 30 days,
• Alternate these monthly for 6 months Do not initiate
immunosuppression if sepsis suspected or present
• Do not initiate immunosuppression if sepsis
suspected or present
a. Focal Segmental Glomerulosclerosis (FSGS)

Definition; pathologically < 50% of all glomeruli affected
and of the affected glomeruli, < 50% of their tuft is
affected. Presents commonly with Nephrotic syndrome,
asymptomatic hematuriaand proteinuria
Causes
• Idiopathic
• collapsing (HIV), collapsing (non-HIV)
• Low birth weight. prematurity
• Obesity
• Sickle cell anemia,
• Anabolic steroids, Heroin, Lithium, pamidronate
Therapy
• General measures for Nephrotic syndrome
Idiopathic FSGS
• Conservative therapy (ACEI/ARB/aldo blocker)
• Exclude secondary causes
• Prednisone, 1 mg/kg daily (or 2 mg/kg alt days)
for 12-16 weeks (20% CPR at 8 wks, 50% at 16)
• May go to 6 months if no steroid contraindication
and/or bad prognostic signs are present.
• If CR continue for 2 weeks and taper over 2-3 mos
using qod regimen. If Up increases to >2.0 gms,
start CSA.
• If no reponse at all by 16 weeks, taper and start
CSA.
• Steroid resistance is usually defined as no response

420
after 4 mos of 1 mg/kg.
• If the disease is non-immunologic (eg genetic, drug-
induced, etc) use only low dose steroids (.15 mg/kg)
with a calcineurin inhibitor)
Guidelines for use of cyclosporine

• Do not use if GFR <40 or severe interstitial or vascular
disease on biopsy.
• Use 3-5 mg/kg in divided doses and monitor trough
levels (100-200 ng/ml).
• Use concomitant low dose prednisone (0.15
mg/kg,maximum 15mg) until remission.
• Treat for 6 mos after a CR or 12 mos after a PR
occurs and taper slowly over several months. relapse
rate is determined by duration of therapy
• Tacrolimus is an alternative to cyclosporine
Indications for use of Cyclosporine

• Steroids are contra-indicated
• Proteinuria does not diminish by 50% or more after
4 mos of steroids.
• Patient is steroid-dependent
• Relapse in < 1 yr after CR or PR
• There is a significant increase in proteinuria during
steroid taper after CR or PR
• GFR must be >40 ml/min and interstitial/ vascular
disease on biopsy minimal
• The cause of FGS is not immunologic
FSGS due to HIVAN

• General measures
• HAART
• May add prednisolone after six months if maximum
dose of ACEI reached but still proteinuric.
b. MPGN
Glomerular disease with sudendothelial immune deposts

421
forming a double basement membrane or a dense
basement membrane
Causes
• Idiopathic
• HCV, HBV, Infective endocarditis, Shunts, abdomino-
pelvic sepsis
Clinical features
• Nephrotic syndrome – see definition above
• Nephritic syndrome – see definition below
Therapy
• General measures for treatment of Nephrotic
syndrome
• Treat secondary cause
c. LUPUS Nephritis
Definition
Glomerular disease as a result of chronic autoimmune,
multisystem, inflammatory connective tissue disorder of
unknown cause( SLE)
Clinical presentation
• Nephrotic syndrome – see definition above
• Nephritic syndrome – see definition below
• Rapid progressive glomerulonephritis – see definition
below
• Asymptomatic proteinuria or and hematuria
• Proteinuria or hematuria without any other renal
symptoms
• Chronic glomerulonephritis
• Disease with irreversible damage to the kidney. GFR
will not improve despite intervention but may delay
further drop in GFR

422
Diagnosis
• Should meet criteria for diagnosis of Lupus and look
for systemic features; CNS(psychosis, fits), Cardiac
(pericarditis) ,Respiratory (pleuritis), hematologic
(Thrombotic microangiopathy, leukopenia),
rheumatologic (arthritis), dermatologic( malar rash,
discoid rash, photosensivity, mucosal ulcers) renal(
hematuria, proteinuria) immunologic (low C3/C4),
GIT( serositis), ANA, ds DNA, anti-Sm
• Should have 4 of the 11 manifestations
• Biopsy needed for LUPUS as histological diagnosis
defines treatment
Therapy
• Depends on histological staging (stage 1-6)
• 1 and 2 do not need immunosuppression
– Stage 2 may need treatment if 24hr protein >
1g.then give prednisolone 20-40mg/day for 1-
3months and taper to 5-10mg/day
• Stage 5 follow guidelines for membranous
• Stage 6 damage already done and do not need active
immunosuppression but follow measures for
management of CKD
Stage 3 and stage 4

• Induction phase treatment for 24 weeks with:
– Mycophenolate Mofetil (MMF) 1- 1.5g b.d. or
– IV Cyclophosphamide 0.5-1.0g/m2 monthly
– Plus oral prednisolone 60mg/day (1mg/kg) with
taper
– Do not initiate immunosuppression if sepsis
suspected or present
• Prophylaxis
– INH 300mg od po
– Co-trimoxazole( single dose) 2tab od po
– Fluconacozole 100-200mg od po

423
ß At least for 3months
• Maintenance upto at least 18 months
– MMF 1 – 1.5g bd PO or
– Azathioprine 1-3mg/kg/day po
– IV cyclophosphamide 0.5-1.0g/m2 every 3
months
– Plus prednisolone 5-10mg/day
d. Diabetes Nephropathy
Definition
Persistent microalbuminuria or proteinuria on albustix or
dipstick respectively and or urine albumin:creatinine ratio.
Persistent means tests should be done three months
apart.
Clinical presentation
Symptoms
• Asymptomatic proteinuria, microalbuminuria
• Body swelling
Signs
• No clinical signs on general examination
• Pedal Edema, facial puffyness
• Presence of Diabetic neuropathy and retinopathy
makes the diagnosis of nephropathy more likely
• Classical presentation of diabetic nephropathy does
not require renal biopsy but atypical presentation
need renal biopsy. These include
– Rapid drop in GFR over few days to weeks
– Diabetic with hematuria
– Proteinuria in presence of HIV, Hepatitis B, SLE,
small vessel vasculitis (ANCA positive)
Management
• General Measures of managing Nephrotic syndrome
• Target BP < 125/75
• Target HBAc1 < 6.5%

424
• Low dose aspirin 75-150mg daily
e. Amylodosis
AL-primary
AA- secondary
15.5.2 Nephritic syndrome
Definition and clinical presentation

• mild proteinuria
• Hematuria
• High blood pressure
• Acute reduction in GRF
• Some edema
Causes
Reduced compliment
• Post streptococal Glomerulonephritis
• Shunt Nephritis
• Endocarditis
• SLE
• HCV
• Athero-emboli GN
Normal compliment
• IgA
• HSP
• Anti-GBM
• ANCA positive GN
Clinical features
History of sore throat esp children, features of lupus,
purpura(HSP,HCV), peripheral neuropathy (HSP,HCV),
pulmonary hemorrhage(ANCA ), chronic sinusitis( ANCA),
associated asthma (ANCA)

425
Diagnosis
• ANA, ANCA, ds-DNA, ASOT, DNAse, HBsAg, Anti-
HCV, anti-GBM, RPR, C3, C4
• Renal biopsy except for post streptococcal
Therapy
a. Post streptococcal
• Supportive
• BP control
• Antibiotic
• Fluid management Dialysis
• Dialysis
• Prognosis good
b. ANCA positive/Anti-GBM
• See under Rapid progressive Glomerulonephritis
c. Systemic Lupus Erythromatosis

• See Nephrotic syndrome
d. Others (HBsAg, HCV, IgA, HSP, Shunt)

• Treat cause
15.5.3 Asymptomatic hematuria/proteinuria
Definition/Features
• Isolated proteinuria/hematuria with no other features
like hypertension, Edema etc
• Common Causes in our setting
• SLE
• HIVAN
• FSGS
• UTI
• IgA/HSP
Therapy
See under specific conditions

426
15.5.4 Rapid progressive Glomerulonephritis
Definition
• Sub acute reduction in renal function as opposed to
acute nephritis that is rapid.
• Takes few weeks to few months for renal function
to deteriorate
Clinical features
Similar to acute nephritis except this is more insidious,
Hemoptysis, asthma, sinusitis, epistaxis, abdominal pain,
peripheral neuropathy, petechiae, purpura.
Causes
• Type 1
– Anti-Glomerular basement disease (Anti-GBM)
• Type 2
– Immune complex disease
– SLE
– Post streptococcal
– IgA/HSP
• Type 3
– ANCA positive (Wegners, Churg strass,
microscopic polyangitis)
Management
• Serum p-ANCA and C-ANCA
• Renal biopsy mandatory for light, Immunoflourence,
electron microscopy
1. Anti-GBM
a. Prednisolone 60 mg/day and reducing
b. Cyclophosphamide 2mg/kg/day and adjusted
for white cell count
c. Plasma exchange (50ml/kg to a maximum of 4L
daily for 14 days or until anti-GBM antibodies
undetectable)
d. Treat for 6 months

427
2. Immune complex
a. except for Streptococcal, treat as in 3 except
plasma exchange may not be indicated
3. ANCA positive
a. Methyprednisolone 7mg/kg for 3days and then
prednisolone 1mg/kg/day for 4 weeks then
taper with either
b. IV cyclophosphamide 0.5g/m2 monthly for 6
months or
c. Oral cyclophosphamide 2mg/kg for 6-12months
d. Plasma exchange for patients with lung
hemorrhage and renal dysfunction
e. Co-trimoxazole prophylaxis
15.5 HYPERTENSION
Check detail on hypertension under CVS
15.5.1 Malignant hypertension
Definition
a. BP 180/120
b. Fundal changes/encephalopathy
c. Proteinuria or increased urea/creatinine
d. Thrombotic microangiopathy
Common causes
a. Chronic kidney disease (small kidney on U/S)
b. Acute Nephritis
c. Renal vascular disease (one kidney 1.5cm than
the other kidney on US)
Scleroderma
d. Cocaine
e. Other endocrine disease- conns, cushings etc

428
Clinical features
a. Above but look for signs of possible etiology
b. Suspect in elderly Diabetics (atherosclerotic) and
young women (fibromyoplasia)
Management
a. FBC- thrombocytopenia
b. Peripheral smear – RBC fragments
c. Urinalysis
d. U+Es
e. Specific tests to rule out etiology like kidney sonar,
MRI angiogram to rule out renovascular disease
Therapy
a. Check under cardiovascular disorders
b. ACEI should be given if scleroderma
c. Renal vascular disease needs referral to specialist
if suspected and BP unresponsive
Increase of serum creatinine <30µmol/l from
baseline should not prompt withdraw of ACEI but
monitor closely
d. If dialysis needed peritoneal dialysis preferred to
allow possible recovery. Recovery may take up to
several months.
15.52 Hypertension or kidney disease in pregnancy
PLEASE CHECK HYPERTENSION IN PREGNANCY FOR OTHER

DETAILS
• Effects of Pregnancy on kidney

i. Hemodynamic changes leads to hyperfiltration
ii. Presence of HTN, Uremia
iii. Facts that may predict deterioration
iv. Proteinuria
v. Intercurrent pregnancy related illnesses e.g Pre-
eclampsia

429
vi. Possibilty of permanent loss of function Kidney on
pregnancy
Effects of Kidney disease on pregnancy

vii. Risk of pre-eclampsia
viii. Prematurity
ix. IUGR
LUPUS Versus Pre-Eclampsia/Eclampsia

Other conditions that may present like pre-eclampsia or
eclampsia or HELLP need to be considered.
LUPUS
Lupus flare PRE-ECLAMPSIA
PROTEINURIA + +
HTN + +
RBC CASTS + -
AZOTEMIA + +
C3/C4 + -
ABNORMAL LETs - +-
LOW PLTS + +-
LOW WBC + -
• Thrombotic microangiopathic disorders

– Thrombotic thrombocytopenic purpura
– Hemolytic Ureamic syndrome
• Acute Fatty Liver of Pregnancy

430
Other conditions that my mimmick HELLP in pregnancy
HELLP/ AELP TIP HUS

ECLAMPSIA
Hypertension 80% 25-50% Occasional present
Renal Mild to Moderate Mild to

Dysfn moderate moderate Severe
Fever,
neurological
signs ++ 0 ++ 0
Onset 3rd Trimester 3rd Trimester Anytime Post partum
Platelet
count Low Low Low low
LFTS High Very high Usually Usually

normal normal
PTT Normal to high High Normal Normal

Anti-
thrombin III Low Low Normal normal
LUPUS and PREGNANCY
Poor Outcomes
• Active disease at conception
• Disease first appearing in pregnancy
• HTN, Azotemia 1st trimester
• High titres of lupus anticoagualant,
• antiphospholipid antibodies
Antiphospholipid antibody in pregnancy

• Increase fetal loss
• Venous and arterial thrombosis
• Renal vasculitis

431
• Thrombotic microangiopathy
• Pre-eclampsia
• Treatment- ASA, Heparin
15.6 � RENAL AND PANCREATIC �

TRANSPLANT
15.6.1 � ESKD patients who meet the following �

criteria will be suitable for � � � �
recommendation for Renal or/and �
Pancreatic Transplant
• No malignancy or free of malignancy for at least 5

years
• No serious cardiovascular disease or ischemic heart
disease (minimum Ejection Fraction of 40%)
• No Major pulmonary disease
– No major restriction or obstruction
• No major urological disease
• No major psychiatric illness
• BMI< 35
• Low preformed antibodies (PRAs). High PRAs are
associated with the following
– Multiple pregnancies
– Multiple blood transfusions
– Prior failed transplant
• GI disorders should have been addressed
• PUD
• Pancreatitis
• Diverticulitis
• Infections
• HIV patients can be transplanted as long as they
meet the following:
– CD4 >200
– On HAART for at least 6 months
– VL undetectable
– Adherence with HAART

432
• All other active infections should be treated first
– Special considerations should be taken for HBV
and HVC
• Should not a smoker or chronic alcoholic
15.62 � The basic work-work up for a recipient �

should include the following;
A. Serum/blood
• HIV test
• HBsAg
• Anti-HCV
• Anti-CMV
• Anti-EBV
• Anti-HTLV-1
• RPR
• Blood group
• PRAs
• X match for CDC and flow cytometry
B. Imaging/Invasive
• CXR
• Doppler US of femoral/iliac veins
• ECG
• VCU
• Gastroscopy
• Doppler of carotids for Diabetics
• Other tests will be dependent on condition of patients
C. Other aspects that patient need to meet which are

dependent on dialysis adequacy
• CaPO4 product should be acceptable
• PTH within recommended levels
• Hb 11-12g/dl
• Potassium normal
A check list should be done the day before transplant to

make sure candidate is ready if possible do the tests.

433
Repeat HIV test as well unless already HIV positive
Patients should be fully examined the day before transplant
and ensure no comobidity
D. Stop-or-go Strategy for Evaluation of a Potential

Living Donor
• Blood group determination: Stop if incompatible with
recipient blood group….
• Plasma Urea, creatinine; proteinuria; urinary sediment:
Stop if abnormal
• Viral tests: HBV, HCV, HIV Stop if positive
• Renal ultrasound: stop if solitary kidney
• HLA A, B, DR, DP and DQ typing
• CDC Cross match; FC cross match: Stop if positive (T
cell-positive Xmatch with IgG)
E. Full medical evaluation of the potential donor

• BMI, blood pressure, cardiac evaluation (at least EKG
and ultrasound)
• Aorto-iliac CT scan, and renal angiography; urography
• Measurement of GFR: Cr51-EDTA, iohexol, or other
method
• Blood glucose, HbA1c, cholesterol, microalbuminuria
• Liver enzymes, alkalin phosphatases, gGT
• Gynecologic evaluation: mammography, uterine
cervix smear
• Prostate evaluation, clinical and PSA
• Evaluation of skin, lung, thyroïd, infectious diseases,
etc…
• Psychologic/ psychiatric evaluation
• Validation by urologist and anaesthesiologist
f. The best kidney donor

• Iso blood group and HLA identical
• Less than 50 y
• Normal BP (< 140/90 mmHg)

434
• BMI < 25 Kg/m2
• GFR > 80 ml/min/ 1,73m2
• Proteinuria < 300 mg/d ; microalbuminuria <30
mg/d
• No hematuria
• No diabetes nor dyslipidemia
• No cardiac disease nor past history of cancer
• No infectious (viral) disease
15.6.3 � Immunosuppression in live-donor Kidney � �

Transplant patients
• Immunosuppression can be started PRIOR to

transplantation, e.g. one week before; this aims at
achieving efficient immunosuppression.
• This might result in avoiding induction therapy with
antilymphocyte preparations or monoclonal anti-IL2
receptor antibody
• The HLA matching (D/R) can sometimes be very
good, thereby allowing “lighter” immunosuppression,
e.g. avoiding the use of calcineurin inhibitors
• There is no cold ischemia time: thus the risk of
delayed graft function is almost nil, decreasing the
risk of acute rejection
15.6.4 Immunosuppression protocols
• Calcineurin inhibitors (ciclosporine OR tacrolimus)

plus antiproliferative agent (azathioprine-AZA- OR
mycophenolate mofetil –MMF) with OR without
steroids
• With or without induction therapy: antilymphocyte
agents –ATG- OR anti-IL2 receptor monoclonal
antibodies, e.g. basiliximab, daclizumab
• Calcineurin inhibitors can be avoided (from the
beginning or after a few months) provided the use
of mTOR-inhibitors such as sirolimus or everolimus

435
Induction
• Simulect 20 mg (baxiliximab) pre-operative, day 4
• Methyl prednisolone 500mg-1000mg day 0 (in
operating theatre)
• MMF or Azathioprine 1.5g or 1-3mg/kg/day
respectively
• 4. Cyclosporine 8-12mg/kg start or Tacrolimus 0.15-
0.30mg/kg/day bd
Maintenance
• MMF 1.5g BD PO or Azathioprine 1-3mg/kg/day
• Cyclosporine or Tacrolimus (dose adjusted according
to C-2 levels or Tacrolimus levels)
• Prednisolone 60mg first day and taper down fast as
long as creatinine remain stable. By end of month
dose should be 20mg or less
Prophylaxis
• INH 300mg od for 6 months
• Valcyclovir 450 bd PO (depending on CMV status of
donor and receipient) for 3 months
• Nystatin suspension 10mls od po for 3months
• Amphoterin B oral suspension for 3 months
• Co-trimoxazole 960mg od po for 6 months
Tacrolimus or Cyclosporine levels to be done daily till

discharge then twice weekly then weekly , fortnightly
and so on.
Kidney US sound and renogram will be routine within 5

days of transplant
Acute rejection will be defined on the basis of an increase

in serum creatinine or amylase (urine as well) and renal
biopsy. Rejection will be managed on protocols to be
developed but will require induction agents like ATG or
methylprednisolone or and modification of maintainance

436
regimen
Fertility and Pregnancy

• Fertility restored
• Pregnancy outcomes improve if renal fn normal and
hypertension absent
• Pregnancy accelerates graft loss???
• Advisable to wait for 2 years
– So that renal fn stabilises
– Lowest doses of Immunosuppressive
– Cyclosporine, prednisolone, Azathioprine safe,
MMF no experience

437
16� INFECTIVE ENDOCARDITIS
Definition
This is microbial infection of the endocardium, which may

result in valvular damage, myocardial abscess, or mycotic
aneurysm.
Causes
Streptococcal species (especially Streptococcus viridans),
Staphylococci, HACEK group, Enterococci
Predisposing factors
Preexisting valvular disease, congenital heart disease, dental
and surgical procedures, intracardiac devices ( prosthetic
valves, pacemaker), intravascular catheters, intravenous
drug abuse.
Can be acute and subacute
Clinical features
Symptoms
• Fever
• Night sweats
• Arthralgia
• Malaise
• Weight loss
• Dyspnea
Signs
• Fever
• Peripheral stigmata ( splinter hemorrhages, Osler’s
nodes, Janeway lesion, Roth’s spots)
• Pallor and jaundice
• Heart murmurs
• Features of heart failure
• Embolic phenomena

439
• Splenomegaly
• Hematuria
Diagnosis
Duke’s criteria:
1. Criteria for Infective Endocarditis
A. Two major criteria or
B. One major and three minor or
C. Five minor criteria
2. Major criteria
A. Positive blood culture X > 2 (typical
microorganisms for infective endocarditis)
B. Positive Echocardiographic study ( vegetations
on the valves, wall abscess, new valve
regurgitation)
3. Minor criteria
A. Predisposing heart condition or injected drug user
B. Febrile syndrome
C. Vascular phenomena (embolism, CNS
hemorrhage, conjunctival hemorrhage, Janeway
lesion)
D. Immunologic phenomena ( glomerulonephritis,
Rheumatoid factor, Osler’s nodes, Roth’s spots,
false positive VDRL test)
E. Microbiologic evidence (positive blood culture,
but not typical microorganisms)
F. Echocardiography : suggestive but not positive
for infective endocarditis
Management
Investigations
• Blood culture
• FBC
• Urinalysis and microscopy

440
• U/E, LFTs
Treatment
1. Appropriate antibiotics: Penicillin G 10-20 MU /day
IV in divided doses ( 4 times)or Ampicillin 8-12
g/day IV for 4 weeks and Gentamycin 1 mg/kg (
up to 80 mg) 3 times IV daily 2-4 week. If
Staphylococcus aureus: Oxacillin or Vancomycin IV
2. Bed rest
3. Treat heart failure and arrhythmias
4. Surgery - valvular replacement (indications : refractory
heart failure, uncontrolled infection, fungal infections
with large vegetations > 10 mm in size, recurrent
systemic embolism, suppurative pericarditis, mycotic
aneurysm or rupture of sinus of Valsalva)
Prophylaxis
Conditions in which prophylaxis is recommended:
1. Prosthetic cardiac valves
2. Previous infective endocarditis
3. Certain types of Congenital Heart Diseases
(unrepaired cyanotic CHD, complete repair of CHD
with prosthetic material or device for first 6 months;
repaired CHD with the residual defects at the site of
prosthetic valve or patch)
4. Cardiac transplantation with valvulopathy
No prophylaxis is recommended for most dental,
GIT and GUT procedures, with acquired valve disease,
hypertrophic cardiomyopathy, pacemaker or coronary
by-pass surgery.
Prevention
Good oral hygiene, regular dental review
Antibiotics for prophylaxis, 1 hour before procedure:
Oral:
Amoxycillin 2 g ( adult), 50 mg/kg ( children) or
Cephalexin 2g (adult), 50 mg/kg (children) or

441
Azithromycin 500 mg (adult), 15 mg/kg (children)
Parenteral
Amoxycillin 2 g IM/IV ( adult), 50 mg/kg ( children)
Cefazolin or Ceftriaxone 1 g IM/IV (adult), 50 mg/kg
(children)
Clindamycin 600 mg IM/IV (adult), 20 mg/kg (children)

442
Drug Presentation Level VEN
1 Drugs used in anaesthesia
1.1. Drugs used in general anaesthesia

1.1.1 Intravenous and intramuscular anaesthetics
1.1.1.1 Ketamine injection 10mg/ml (10 ml) II-IV V
1.1.1.2 Thiopentone sodium powder for reconstitution 1g and 5g vials II-IV V
1.1.2 Inhalation anaesthetics
1.1.2.1 Halothane inhalation II-IV V
1.1.2.2 Nitrous oxide medical gas II-IV E
1.1.3 Muscle relaxants
445
1.1.3.1 Suxamethonium chloride injection 50mg/ml, (2ml) II-IV V
1.1.4 Anticholinesterases
1.1.4.1 Neostigmine injection 2.5mg/ml, (1ml) II-IV V
1.2 Drugs used in local anaesthesia

1.2.1. Lignocaine injection 1% (10ml, 50ml) I-IV V
1.2.2 Lignocaine + adrenaline dental cartridge injection 2% (1 in 80,000) II-IV V
1.3 Drugs used in spinal anaesthesia

1.3.1 Bupivacaine/glucose injection 0.5%, (4ml) IV E
2. Drugs acting on the gastrointestinal system
2.1 Antacids
2.1.1 Aluminium hydroxide gel, chewable tablets I-IV E
2.12 Magnesium trisilicate Compound chewable tablets, mixture I-IV E
2.2. Antispasmodics
2.2.1 Hyoscine butyl bromide injection 20mg/ml, (1ml) II-IV E
2.2.2 Propantheline bromide tablets 15mg I-IV E
446
2.3 Ulcer healing drugs
2.3.1 Cimetidine tablets 200mg II-IV E
2.3.2 Omeprazole tablets 10mg, II-IV E
2.3.3 Ranitidine tablets 150mg II-IV E
2.3.4 Tripotassium dicitratobismuthate tablets 120mg II-IV E
2.3.5 Clarithromycin tablets 250mg II-IV E
2.4. Antidiarrhoeals
2.4.1 Codeine phosphate tablets15mg II-IV E
2.4.2 Loperamide tablets 2mg IV E
2.4.3 Nitazoxanide suspension 100mg III-IV E
2.5. Laxatives
2.5.1 Glycerol suppository 1g,4g I-IV E
2.5.2 Senna tablets 7.5mg II-IV E
2.6 Drugs used for treating haemorrhoids

2.6.1 Bismuth subgallate and zinc oxide suppository, cream II-IV E
3 Drugs acting on the central nervous system
3.1 Anxiolytics and Antipsychotic drugs
447
3.1.1 Alprazolum tablets 0.25 microgram III-IV E
3.1.2 Lorazepam tablets 2mg tablets III-IV E
3.1.3 Diazepam tablets 2mg, injection 5mg/ml (2ml) II-IV V
3.1.4 Medazolam injection 1mg/ml III E
3.1.5 Selective serotonin reuptake inhibitors
3.1.5.1 Sertraline tablets 50mg IV E
3.2 Tricyclic Antidressants

3.2.1 Clomipramine tablets 25mg III E
3.3 Anti-depressant drugs

3.3.2 Fluoxetine tablets 20mg IV E
3.3.4 Lithium carbonate tablets 300mg IV E

3.3.5 Sodium valproate tablets 200mg, II-IV E
3.4 Antiepileptic drugs

3.4.1 Carbamazepine tablets 200mg II-IV V
injection 5mg/ml I-IV V
3.4.2 Lamotrigine tablets 25mg, 50mg I-IV V
3.4.3 Ethosuximide capsules 250mg III-IV V
3.4.4 Phenobarbitone tablets 30mg, injection 200mg/ml II-IV V
3.4.5 Phenytoin tablets 100mg II-IV V
448
3.4.6 Sodium valproate tablets 200mg, syrup 200mg/5ml II-IV V
3.4.7 Clonazepam tablets 0.5mg, 2mg II-IV V
3.4.8 Acetazolamide tablets 250mg IV E
3.4.9 Gabapentin tablets 600mg IV E
3.5 Drugs used in Parkinsonism and related disorders

3.5.1 Benzhexol tablets 5mg II-IV V
3.5.2 Bromocriptine tablets 2.5mg III-IV E
3.5.3 Procyclidine tablets 5mg, injection 5mg/ml,(2ml) I-IV E
3.5.4 Selegiline tablets 5mg, 10mg III-IV E
3.5.5 Levodopa tablets 125mg, 250mg, 500g III-IV E
3.6 Drugs used in nausea

3.6.1 Cyclizine tablets 50mg, injection 50mg/ml IV E
3.6.2 Domperidone tablets 10mg II-IV E
3.6.3 Metoclopramide tablets 10mg, injection 5mg/ml (2ml) II-IV E
3.6.4 Prochlorperazine tablets 5mg III-IV E
3.6.5 Promethazine tablet 25mg, injection 25mg/ml(2ml) I-IV V
3.6.6 Triuoperazine tablets 1mg, injection 1mg/ml II-IV E
3.7 Analgesics
3.7.1 Non-opiod analgesics
449
3.7.1.1 Acetyl salicylic acid (aspirin) tablets 300mg I-IV V
3.7.1.2 Paracetamol (acetaminophen) tablets 100mg, 500mg, mixture 120mg/5ml I-IV V
3.7.2 Opioid analgesics
3.7.2.1 Dihydrocodeine tablets 30mg II-IV E
3.7.2.2 Morphine sulphate tablets 10mg, injection 10mg/ml II-IV V
3.7.2.3 Pethidine tablets 50mg, injection 50mg/ml II-IV V
3.8 Anti-migraine drugs

3.8.1 Ergotamine tartrate tablets 1mg II-IV E
3.9 Stimulants
3.9.1 Methylphenidate tablets 5mg IV E
3.10 Non-steroidal anti-inflammatory drugs

3.10.1. Ibuprofen tablets 200mg, 400mg I-IV E
4 Drugs used in the treatment of infections
4.1 Antibacterial drugs

4.1.1 Penicillins
4.1.1.1 Benzathine penicillin injection 2.4 MU vial I-IV E
4.1.1.2 Benzyl penicillin injection 5MU vial I-IV V
4.1.1.3 Phenoxymethyl penicillin tablets 250mg, suspension 125mg/5ml I-IV E
450
4.1.1.4 Procaine penicillin injection 3MU vial I-IV E
4.1.2 Broad-spectrum penicillins
4.1.2.1 Amoxycillin tablets/capsules 250mg, syrup 125mg/5ml I-IV V
4.1.2.2 Ampicillin injection 500mg vial II-IV V
4.1.3 Penicillinase-resistant penicillins
4.1.3.1 Amoxycillin+clavulanic acid tablets 375mg(250mg+125mg) III-IV E
4.1.3.2 Cloxacillin capsules 250mg injection 500mg II-IV V
4.1.3.3 Flucloxacillin capsules 250mg injection 250mg III-IV E
4.1.4 Aminoglycosides
4.1.4.1 Gentamicin injection 40mg/ml, (2ml) I-IV V
4.1.4.2 Kanamycin injection 1g vial I-IV E
4.1.5 Aminocyclitol
4.1.5.1 Spectinomycin injection 2g vial III-IV E
4.1.6 Sulphonamides and trimethoprim
4.1.6.1 Co-trimoxazole tablets 120mg, 480mg, (sulfamethoxazole + I-IV V
trimethoprim)mixture 240mg/5ml
4.1.6.2 Trimethoprim tablets 200mg I-IV E
4.1.7 quinolones
4.1.7.1 Ciprooxacin tablets 250mg III-IV E
I.V 2mg/ml 50ml,100ml bottle IV E
4.1.7.2 Nalidixic acid tablets 500mg, suspension 30mg/5ml I-IV V
451
4.1.7.3 Ooxacin tablets 400mg, I.V 2mg/ml IV E
4.1.8 Nitro-furan drugs
4.1.8.1 Nitrofurantoin tablets 50mg I-IV E
4.1.9 Macrolides
4.1.9.1 Erythromycin tablets 250mg, injection 500mg vial, I-IV V
syrup 125mg/5ml
4.1.9.2 Azithromycin capsules/tablets 250mg, Suspension 200mg/5ml II-IV V
4.1.9.10 Clindamycin capsule 75mg, suspension III-IV E
75mg/5ml, injection 150mg/ml
4.1.10 Cephalosporins and cephamycins
4.1.11.1 Cefotaxime injection 500mg vial III-IV E
4.1.11.2 Cefoxitine injection 1g, 2g vial II-IV E
4.1.11.3 Ceftriaxone injection 250mg,500mg,1g vial II-IV E

4.1.11.4 Cephalexin tablets or capsules 250mg III-IV E
4.1.12 Tetracyclines
4.1.12.1 Doxycycline tablets 100mg I-IV E
4.1.12.2 Tetracycline tablets 250mg I-IV E
4.1.13 Metronidazole tablets 200mg I-IV V
IV infusion 5mg/ml, (100ml) III-IV V
Other antibacterials
452
4.1.14 Chloramphenicol capsules 250mg, suspension II-IV V
125mg/5ml, injection 1g vial
4.2 Anti-tuberculosis drugs
4.2.1 Rifampicin + Isoniazid Tablets 150 mg + 75 mg I-IV V
4.2.2 Rifampicin + Isoniazid Tablets 60 mg + 30 mg I-IV V
4.2.3 Rifampicin + Isoniazid + Ethambutol Tablets 150 mg + 75 mg + 275 mg I-IV V
4.2.4 Rifampicin + Isoniazid + Pyrazinamide Tablets 60 mg + 30 mg + 150 mg I-IV V
4.2.5 Rifampicin + Isoniazid + Ethambutol + Pyrazinamide Tablets 150 mg + 75 mg + 275 mg+ 400mg I-IV V
4.2.6 Ethambutol Tablets 400 mg I-IV V
4.2.7 Pyrazinamide Tablets 400 mg I-IV V
4.2.8 Streptomycin Injection 1 g, 5 g vial I-IV V
4.3 Anti-leprosy drugs

4.3.1 Clofazimine capsules 50mg,100mg II-IV V
4.3.2 Dapsone tablets 10mg,25mg,50mg II-IV V
4.3.3 Rifampicin capsules 150mg, 300mg, syrup 100mg/5ml II-IV V
4.4 Antifungal drugs (also see section 12.3 and 13.3)

4.4.1 Amphotericin B injection 50mg III-IV E
4.4.2 Clotrimazole vaginal tablet 500mg II-IV E
4.4.3 Fluconazole 50mg, 150mg, 299mg, IV 2mg/ml III-IV V
4.4.4 Flucytosine Injection 10mg/ml III-IV E
453
4.4.5 Griseofulvin tablets 125mg III-IV E
4.4.6 Ketoconazole tablets 200mg II-IV E
4.4.7 Nystatin vaginal tablets 100,000 IU II-IV V
4.5 Anti-protozoal drugs

4.5.1 Antimalarials
4.5.1.1. Artemether-lumefantrine tablets 20mg/120mg I-IV V
4.5.1.2 Pyrimethamine + sulphadoxine tablets 25mg/500mg I-IV V
4.5.1.3 Quinine tablets 300mg, injection 300mg/1ml (2ml) I-IV V
4.5.2 Amoebocides
4.5.2.1 Metronidazole tablets 200mg I-IV V
4.5.2.2 Tinidazole tablets 500mg III-IV E
4.6 Trypanocides
4.6.1 Melarsoprol injection 3.6% III-IV V
4.6.2 Suramin sodium injection 1g vial III-IV V
4.7 Drugs used in pneumocystis pneumonia

4.7.1 Co-trimoxazole (sulfamethoxazole + trimethoprim) tablets 120mg, 480mg, mixture 240mg/5ml II-IV V
4.8 Herpes zoster and varicella zoster drugs

4.8.1 Acyclovir cream II-IV E
4.8.2 Acyclovir tablets 200mg, 400mg II-IV E
454
4.9 Antiretrovirals
4.9.1 Nucleoside Reverse Transcriptase Inhibitors
4.9.1.1 Abacavir tablets 300mg II-IV E
4.9.1.3 Lamivudine, 3TC tablets 150mg II-IV E
4.9.1.4 Lamivudine + zidovudine tablets 150/250mg II-IV E
4.9.1.5 Lamivudine + Stavudine tablets 150/30mg II-IV E
4.9.1.6 Lamivudine + Stavudine + Nevirapine tablets 150/30/200mg II-IV E
4.9.1.7 Stavudine, D4T tablets 30mg II-IV E
4.9.1.8 Zidovudine, ZDV, AZT tablets 100mg, 250mg II-IV E
4.9.1.9 Tenofovir tablets 245mg II-IV E
4.9.1.10 Emitricitabine tablets 200mg II-IV E
4.9.1.11 Tenofovir/Emitricitabine tablets 300/200mg II-IV E

4.9.2 Non-nucleoside Reverse Transcriptase inhibitors
4.9.2.1 Efavirenz tablets 600mg II-IV E
4.9.2.2 Nevirapine tablets 200mg II-IV E
4.9.3 Protease inhibitors
4.9.3.2 Ritonavir tablets 600mg II-IV E
4.9.3.3 Lopinavir/Ritonavir tablets 133.3/33.3mg II-IV E
4.9.3.4 Nelnavir tablets 750mg II-IV E
4.10 Anthelmintics
455
4.10.1 Mebendazole chewable tablets 100mg I-IV V
4.10.2 Niclosamide tablets 500mg I-IV E
4.10.3 Pyrantel tablets 125mg, suspension 250mg/5ml I-IV E
4.10.4 Thiabendazole tablets 500mg II-IV E
4.10.5 Albendazole tablets 400mg II-IV E
4.11 Schistosomicides
4.11.1 Praziquantel tablets 600mg I-IV V
4.12 Anti-filarials
4.12.1 Diethylcarbamazine tablets 50mg III-IV E
4.12.2 Ivermectin tablets III-IV E
4.12.3 Suramin sodium injection 1g vial III-IV V
5. Drugs acting on the endocrine system and obstetrics, gynaecology and contraception
5.1 Drugs used in diabetes

5.1.1 Insulin
5.1.1.1 Short acting (soluble) injection 100 IU/ml 10ml II-IV V
5.1.1.2 Isophane Insulin, Biphasic Insulin Injection 100IU/ml 10ml II-IV V
5.1.1.3 Actraphane or mixtard (30/70)Intermediate-and long acting Injection 100IU/ml 10ml II-IV V
5.1.2 Oral hypoglycaemics
456
5.1.2.1 Chlorpropamide tablets 100,250mg II-IV V
5.1.2.2 Glibenclamide tablets 5mg II-IV V
5.1.2.3 Metformin tablets 500mg II-IV V
Other Antidiabetics
5.1.4.1 Glucagon Injection II-IV V
5.2 Preparations acting on the thyroid

5.2.1 Carbimazole tablets 5mg III-IV E
5.2.2 Iodine aqueous solution III-IV E
5.2.3 Thyroxin tablets 100mcg III-IV V
5.3 Corticosteroids
5.3.1 Dexamethasone tablets 500mcg, injection 5mg/ml (5ml) III-IV V

5.3.2 Hydrocortisone sodium succinate injection 100mg vial I-IV V
5.3.3 Prednisolone tablets 5mg I-IV V
5.4 Oestrogens and progestogens

5.4.1 Norethisterone tablets 5mg III-IV E
5.4.2 Conjugated oestrogens tablets 625micrograms III-IV E
5.5 Androgens and anti androgens

5.5.1 Cyproterone tablets 50mg III-IV E
457
5.5.2 Stilboestrol tablets 1mg III-IV E
5.5.3 Testosterone capsules 40mg, injection oily depot 250mg/ml,(1ml) III-IV E
5.6 Other endocrine drugs

5.6.1 Bromocriptine tablets 2.5mg III-IV E
5.6.2 Clomiphene citrate tablets 50mg III-IV E
5.6.3 Danazol capsules 100mg III-IV E
5.7 Drugs used in obstetrics and gynaecology

5.7.1 Drugs acting on smooth muscle
5.7.1.1 Anticonvulsants
5.7.1.1.1 Magnesium sulphate injection 50% II-IV E
5.7.1.2 Prostaglandins and oxytocics

5.7.1.2.1 Dinoprostone tablets 500mcg, injection 1mg/ml III-IV E
5.7.1.2.2 Ergometrine maleate tablets 250mcg,500mcg, injection 200mcg/ml I-IV V
5.7.1.2.3 Ergometrine/ oxytocin injection II-IV E
5.7.1.2.4 Oxytocin injection 10IU/ml,1ml II-IV V
5.7.1.2.5 Misoprostol Tablet 200microgram I-IV V
5.7.1.3 Myometrial relaxants
5.7.1.3.1 Salbutamol injection 500mcg/ml (1ml) II-IV V
5.8 Contraceptives
458
5.8.1 Combined oral contraceptives
5.8.1.1 Ethinyloestradiol/levonorgestrel tablet 30mg/150mcg I-IV V
5.8.2 Emergency contraception
5.8.2.1 Levonorgestrel tablet 750mcg I-IV V
5.8.3 Progesterone-only oral contraceptives
5.8.3.1 Levonorgestrel tablet 30mcg I-IV V
5.8.4 Progesterone-only injectable contraceptives
5.8.4.1 Medroxyprogesterone acetate injection 150mg/ml,1ml I-IV V
5.8.4.2 Norethisterone enanthate injection, oily 200mg/ml,1ml I-IV V
5.8.5 Barrier methods
5.8.5.1 Female condoms articial plastic sheath I-IV V
5.8.5.2 Intrauterine device (IUD) copper long coil type (Copper T 380A) II-IV V
5.8.5.3 Male condoms latex sheath with/without spermicide I-IV V

5.8.5.4 Menefegol vaginal foaming tablets I-IV E
5.8.6 Implants
5.8.6.1 Levonorgestrel implant 38mg in silicone capsule IV V
6 Drugs used in the treatment of diseases of the respiratory system and allergy
6.1 Bronchodilators
6.1.1 Adrenaline 1 in 1000, (1ml) I-IV V
6.1.2 Aminophylline tablets 100mg, injection 25mg/ml (10ml) I-IV V
459
suppositories 50mg,360mg I-IV E
6.1.3 Salbutamol tablets 2mg, syrup 2mg/5ml, I-IV V
inhaler 100mcg/dose I-IV E
6.2 Corticosteroids
6.2.1 Hydrocortisone sodium succinate injection 100mg vial I-IV V
6.2.2 Prednisolone tablets 5mg II-IV V
6.3 Asthma prophylaxis therapy

6.3.1 Beclomethasone inhaler 5mgcg/dose II-IV E
6.3.2 Sodium chromoglicate inhaler 5mg/dose II-IV E
6.4 Antihistamines
6.4.1 Chlorpheniramine tablets 4mg I-IV E

6.4.2 Promethazine tablets 10mg, 25mg I-IV E
6.5 Oxygen
6.5.1 Oxygen medical gas I-IV V
7 Drugs used in the treatment of diseases of the cardiovascular system
7.1 Cardiac glycosides

7.1.1 Digoxin tablets 250mcg,injection 250mcg/ml, (2ml), elixir II-IV V
460
7.2 Diuretics
7.2.1 Thiazides
7.2.1.2 Bendrouazide tablets 5mg II-IV E
7.2.1.3 Hydrochlorthiazide tablets 50mg II-IV E
7.2.2 Loop diuretics
7.2.2.1 Frusemide tablets 40mg, injection 10mg/ml, (2ml) II-IV V
7.2.3 Potassium sparing diuretics

7.2.3.1 Amiloride + hydrochlorthiazide tablets 5mg/50mg II-IV E
7.2.4 Osmotic diuretics
7.2.4.1 Mannitol injection 20% 250ml bottle II-IV V
7.3 Antiarrhythmic drugs

7.3.1 Amiodarone tablets 100mg III-IV E
7.3.2 Atenolol tablets 50mg II-IV E
7.3.3 Digoxin tablets 250mcg, injection 250mcg/ml,(2ml) II-IV V
7.3.4 Lignocaine injection 1%, (10ml, 25ml) II-IV V
7.3.5 Quinidine tablets 200mg, 300mg IV V
7.4 Anti-angina drugs

7.4.1 Atenolol tablets 50mg III-IV E
7.4.2 Glyceryl trinitrate sub-lingual tablets 500mcg II-IV E
461
7.4.3 Isosorbide mononitrate tablets 10mg II-IV E
7.4.4 Nifedipine tablets or capsules 10mg Antihypertensive drugs II-IV E
7.5 Diuretics
7.5.1 Thiazide diuretics
7.5.1.1 Hydrochlorthiazide tablets 50mg II-IV E
7.5.1.2 Potassium sparing diuretics
7.5.1.2.1 Amiloride + hydrochlorthiazide tablets 5mg/50mg II-IV E
7.5.1.2.2 Spironolactone tablets 25mg II-IV E
7.5.2 Beta blockers
7.5.2.1 Atenolol tablets 50mg II-IV E
7.5.2.2 Propranolol tablets 10mg, 40mg II-IV E
7.5.2.3 Carvedilol tablets 3.125mg IV E

7.5.2.4 Labetalol tablets 100mg III-IV E
7.5.2.5 Metoprolol tablets 50mg, 100mg III-IV E
7.5.3 Vasodilators
7.5.3.1 Hydralazine tablets 25mg, injection 20mg ampoule II-IV E
7.5.4 ACE inhibitors
7.5.4.1 Captopril tablets25mg III-IV E
7.5.4.2 Lisinopril tablets 5mg, 10mg, 25mg III-IV E
7.5.4.3 Enalapril tablets 5mg, 10mg, 20mg III-IV E
ACE inhibitors II
462
7.5.4.4 Losartan tablets 25mg, 50mg IV E
7.5.5 Calcium channel blockers
7.5.5.1 Nifedipine tablets or capsules10mg, 20mg III-IV E
7.5.5.2 Verapamil tablets 40mg III-IV E
7.5.5.3 Amlodipine tablets 5mg, 10mg III-IV E
7.6 Drugs used in shock - sympathomimetics

7.6.1 Adrenaline injection 1 in 1000 (1mg/ml) I-IV V
7.7 Alpha-adrenoceptor blocking agents

7.7.1 Prazosin tablets 500 mcg, 1mg III-IV E
7.8 Lipid-regulating drugs
7.8.1 Statins
7.8.1.1 Simvastatin tablets 20mg, 40mg IV E
7.9. Inotropic sympathomimetics

7.9.1 Dopamine injection 40mg/ml IV E
8 Drugs used in the treatment of malignant disease: anti-neoplastic drugs
8.1 Actinomycin D injection 500mcg III-IV V

8.2 Asparaginase injection 1000 IU
463
8.3 Azathioprine tablets 50mg, injection 50mg vial IV V
8.4 Bleomycin injection 15 unit ampoule IV V
8.5 Busulphan tablets 500mcg IV V
8.6 Calcium folinate tablets 15mg IV V
8.7 Carboplatin injection 10mg/ml
8.8 Carmustine vial 100mg IV V
8.9 Chlorambucil tablets 2mg IV V
8.11 Cisplatin injection 1mg/ml IV V
8.12 Cyclophosphamide tablets 50mg, injection 100mg IV V
8.13 Cytarabine injection 100mg,500mg,1g vial IV V
8.14 Cytosine arabinosate injection100mg IV V
8.15 Cyproteron acetate tablets 50mg, 100mg IV V
8.16 Darcabazine injection 200mg IV V

8.17 Daunorubicin injection 20mg IV V
8.18 Doxorubicin injection 10mg,50mg IV V
8.19 Etoposide IV infusion 20mg/ml IV V
8.20 Fludarabine my mouth 40mg/m2, injection, infusion IV V
8.21 Filgastrin injection 300mcg/ml IV V
8.22 Fluorouracil injection 25mg/ml IV V
8.23 Hydroxyurea capsules 500mg IV V
8.24 Ifosfamide injection, 1g, 2g vial IV V
2.29 Imatinib tablets 100mg IV V
464
8.25 Interferon injection 300mg IV V
8.26 Lomustine capsules 40mg IV V
8.27 Melphalan tablets 2mg, injection 100mg IV V
8.28 Mercaptopurine tablets 50mg IV V
8.29 Methotrexate tablets 2.5mg, injection 50mg IV V
8.30 Mitomycin injection 40mg IV V
8.31 Mustine injection 10mg IV V
2.32 Paclitaxel IV infusion 6mg/ml IV V
8.33 Procarbazine capsules 50mg IV V
8.34 Stilboeastrol tablets 1mg IV V
8.35 Tamoxifen tablets 20mg IV V
8.36 Temozolmide capsules 5mg IV V
8.37 Thioguanine tablets 40mg IV V

8.38 Vinblastine injection 1mg/ml
8.39 Vincristine injection 1mg, 5mg III-IV V
9 Drugs acting on the eye
9.1 Ophthalmic diagnosis

9.1.1 Fluorescein sodium eye drops, strips III-IV E
9.2 Anti-infective preparations
465
9.2.1 Antibacterial
9.2.1.1 Chloramphenicol eye drops 0.5% eye ointment 1% II-IV E
9.2.1.2 Chloramphenicol/dexamethasone eye drops 15/0.1% III-IV E
9.2.1.3 Framycetin eye drops, eye ointment III-IV E
9.2.1.4 Tetracycline eye ointment 1% I-IV E
9.2.1.5 Oxy-tetracycline/Hydrocortisone eye drops 3%/1% III-IV E
9.2.1.6 Neomycin/betamethasone eye drops 0.5%/o.1% III-IV E
9.2.1.7 Gentamicin eye drops 0.3% II-IV E
9.2.1.8 Cefotaxime injection 500mg, Ig vial III-IV E
9.2.2 Antifungals – Preparations are not generally available
and could be made extemporaneously
9.2.2.1 Pivodine Iodine eye drops 2% III-IV E
9.2.2.2 Natamycin eye suspension 5% IV E

9.2.2.3 Econazole eye suspension 1% IV E
9.2.2.4 Miconazole eye suspension 10mgg/ml IV E
9.2.2.5 Amphoteracine B eye solution 0.05% -0.2% IV E
9.2.3 Antiviral
9.2.3.1 Aciclovir eye ointment III-IV E
9.2.3.2 Ganciclovir IV infusion 500mg vial IV E
9.2.3.3 Forscarnet IV infusion 24mg/ml IV E
9.3 Anti-inflammatory preparations
466
9.3.1 Betamethasone eye drops, eye ointment III-IV E
9.3.2 Hydrocortisone acetate eye drops, eye ointment II-IV E
9.3.3 Dexamethasone eye drops 0.1% III-IV E
9.3.4 Prednisolone eye drops 0.5%, 1% III-IV E
9.3.5 Tropicamide eye drop 1% III-IV E
9.3.6 Sodium chromoglycate eye drops 2% III-IV E
9.4 Miotics and anti-glaucoma drugs

9.4.1 Pilocarpine eye drops 2%, 4% III-IV E
9.5 Mydriatic drugs

9.5.1 Atropine sulphate eye drops 1% III-IV E
9.6 Systemic preparations

9.6.1 Acetazolamide sodium tablets 250mg III-IV V
9.7 Local anaesthetics

9.7.1 Lignocaine hydrochloride eye drops 4% III-IV E
9.8 Postaglandin Analogue

9.8.1 Latanoprost eye drops 50mcg/ml IV E
9.9 Sympathomimetics
467
9.9.1 Dipivefrine eye drops 0.1% IV E
9.10 Beta-blocker
9.10.1 Timolol maleate eye drops 0.25% or 0.5% III-IV E
9.11 Diuretics
9.11.1 Cyclopenthiazide tablets 0.5mg IV E
9.12 Artificial tears

9.12.1 Hypromellose eye drops 0.3mg III-IV E
9.13 Hyperosmatic agents

9.13.1 Mannitol solution in water 20% III-IV E
9.13.2 Urea solution 30% in 10% invert sugar III-IV E
10 Blood
10.1 Anti-coagulants
10.1.1 Heparin injection 5000IU/ml,1ml II-IV V
10.1.2 Warfarin tablets 1mg,5mg II-IV V
468
10.2 Anti-haemorrhagic
10.2.1 Amino caproic acid Effervescent powder 3g III-IV E
Oral suspension 10mg/5ml
10.2.2 Fibrinogen dry or freeze dried powder III-IV V
10.2.3 Human anti-haemophiliac fraction(dried) 3 units/ml IV E
10.2.4 Phytomenadione (vitamin K) injection 10mg/ml,(1ml) II-IV V
10.3 Haemopoetics
10.3.1 Ferrous sulphate tablets 50mg,200mg I-IV V
10.3.2 Folic acid tablets 5mg I-IV V
10.3.3 Hydroxocobalamin (vitamin B12) injection 1mg/ml,1ml II-IV E
10.3.4 Iron dextran injection 50mg iron in 2ml ampoule II-IV E
11 Nutrition
11.1 Vitamins, minerals and dietary supplements

11.1.1 Ascorbic acid (vitamin C) tablets 50mg,200mg I-IV E
11.1.2 Calcium gluconate injection 10%, (5ml,10ml) III-IV E
11.1.3 Ergocalciferol (vitamin D) tablets 50,000 IU, solution 3000 IU/ml II-IV E
11.1.4 Nicotinamide tablets 50mg II-IV E
11.1.5 Pyridoxine (vitamin B6) tablets 50mg I-IV E
11.1.6 Retinol (vitamin A) capsules/tablets 200,000IU I-IV E
11.1.7 Riboavine (vitamin B2) tablets 5mg III-IV E
469
11.1.8 Thiamine (vitamin B1) tablets 50mg III-IV E
11.2 Electrolyte and water replacement

11.2.1 Oral administration
11.2.1.1 Oral rehydration salts sachet 27.9g powder to make 1 litre I-IV V
11.2.1.2 Potassium chloride tablets slow-release 600mg II-IV E
11.2.2 Infusions
11.2.2.1 Dextrose (glucose) solution 5%, 20, 50% I-IV V
11.2.2.2 Potassium chloride solution 11.2% II-IV E
11.2.2.3 Sodium bicarbonate solution 4.2% III-IV V
11.2.2.4 Sodium chloride (normal saline) solution 0.9% I-IV V
11.2.2.5 Sodium lactate and glucose (Darrows) solution, full and half strength I-IV V
11.2.2.6 Sodium lactate compound (Ringers lactate) solution I-IV V

11.2.2.7 Water for injection 2ml, 5ml, 10 ml I-IV V
11.2.3 Plasma substitutes
11.2.3.1 Dextran 40 solution 10% III-IV V
11.2.3.2 Gelatin (as polygeline) solution III-IV E
12 Drugs acting on the skin
12.1 Topical corticosteroids

12.1.1 Betamethasone cream/ointment 0.1% III-IV E
470
12.1.2 Hydrocortisone cream/ointment 1% I-IV E
12.2 Soothing preparations

12.2.1 Aqueous lotion I-IV E
12.2.2 Calamine lotion I-IV E
12.2.3 Zinc oxide cream I-IV E
12.3 Antifungal preparations

12.3.1 Miconazole nitrate cream 2% III-IV E
12.3.2 Ketokonazole tablets 200mg III-IV E
12.3.3 Griseofulvin tablets 500mg II-IV E
12.4 Anti-bacterial preparations

12.4.1 Tetracycline ointment I-IV E
12.5 Antiseptic preparations

12.5.1 Gentian violet solution I-IV E
12.5.2 Potassium permanganate solution I-IV E
12.6 Anti-parasitic preparations

12.6.1 Benzyl benzoate application 25% I-IV E
12.6.2 Malathion lotion 0.5% I-IV E
471
12.6.3 Permethrin cream 1% I-IV E
12.7 Keratoplastics and keratolytics

12.7.1 Coal tar solution 5% I-IV E
12.7.2 Dithranol ointment 1% III-IV E
12.7.3 Podophylline paint 15% in compound benzoin tincture II-IV E
12.7.4 Salicylic acid ointment 5%, 10%, 20% I-IV E
12.8 Acne preparations

12.8.1 Salicylic acid lotion I-IV E
12.8.2 Benzyl peroxide lotion I-IV E
12.9 Surgical disinfectants

12.9.1 Cetrimide solution 1% I-IV E
12.9.2 Chlorhexidine + cetrimide concentrated solution (1.5%/15%) I-IV E
12.9.3 Chlorhexidine gluconate concentrated solution 5% I-IV V
12.9.4 Chloroxylenol concentrated solution 4.8% I-IV E
12.9.5 Povidone iodine solution 10% I-IV V
12.9.6 Sodium hypochlorite 0.1% available chlorine I-IV V
12.10. Antivirus 12.10.1 Acyclovir cream 5% II-IV E

Tablets 50mg II-IV E
472
13 Drugs used in the treatment of diseases of the ear, nose and throat
13.1 Drugs acting on the ear

13.1.1 Betamethasone eye/ear drops III-IV E
13.1.2 Gentamicin + hydrocortisone ear drops II-IV E
13.1.3 Sodium bicarbonate ear drops III-IV E
13.1.4 Vegetable oil ear drops I-IV E
13.2 Drugs acting on the nose: topical nasal decongestants

13.2.1 Normal saline nasal drops II-IV E
13.3 Drugs acting on the throat

13.3.1 Chlorhexidine mouth wash 0.2% I-IV E
13.3.2 Ketaconazole tablets 200mg, suspension 100mg/5ml I-IV E
13.3.3 Miconazole oral gel I-IV E
13.3.4 Nystatin oral suspension I-IV E
14 Drugs used in the treatment of musco-skeletal disorder
14.1 Drugs used in rheumatic diseases

14.1.1 Acetyl salicylic acid tablets 300mg I-IV V
473
14.1.2 Ibuprofen tablets 200mg I-IV E
14.2 Drugs used in gout

14.2.1 Allopurinol tablets 100mg III-IV E
14.2.2. Colchicine tablets 500mcg IV E
15 Immunological products
15.1 Antisera, immunoglobulins and anti-toxins

15.1.1 Anti-D immunglobulin injection II-IV V
15.1.2 Diphtheria antitoxin injection II-IV V
15.1.3. Mamba anti-sera injection II-IV V
15.1.4 Polyvalent snake anti-sera injection II-IV V

15.1.5 Tetanus antitoxin injection I-IV V
15.2 Vaccines
15.2.1 BCG injection I-IV V
15.2.3 Diptheria-pertussis injection I-IV V
tetanus, heamophilia inuenza B
and heapatitis B (Pentavalent,) I-IV V
15.2.4 Hepatitis B injection II-IV E
15.2.5 Measles injection I-IV V
474
15.2.6 Poliomyelitis injection I-IV V
15.2.7 Rabies injection I-IV V
15.2.8 Tetanus toxoid (TT) injection I-IV V
15.2.9 Typhoid injection III-IV E
15.2.10 Yellow fever injection III-IV E
16 Antidotes and other substances used in poisoning
16.1 General treatment of poisoning

16.1.1 Activated charcoal powder I-IV V
16.1.2 Ipecacuanha syrup 0.14% ipecacuanha alkaloids I-IV V
16.2 Specific treatment of poisoning

16.2.1 Atropine injection 1mg/ml, (1ml) III-IV V
16.2.2 Naloxone injection 400mcg/1ml III-IV V
16.2.3 Pralidoxine mesylate injection 200mg/ml, (5ml) III-IV V
16..2.3. N-acetylcysteine 20% solution IV E
475
Essential Laboratory Supplies List
476
TEST REAGENT UNIT PACK
CD4 estimation BD FACSCalibur
BD Tritest CD3/CD4/CD45 with TruCount Tubes Kit of 50 tests
BD Calibrate 3 Beads Kit of 25 tests
BD FACS Lysing Solution 100 ml
True Count Control Kit of 30 test
BD FACSCount
BD FACS Count CD4/CD8 Reagents Kit of 50 tests
BD FACS Count Controls Kit of 25 tests
BD FACS Rinse Solution 5L
BD FACS Clean Solution 5L
BD FACS Flow Sheath Fluid 20 L
477
BD FACSCount Thermal Paper Roll
Guava
Guava Auto CD4/CD4 % reagent kit 100 tests
Guava easy CD4 microcentrifuge tube 500 x 1.5 ml
Guava check kit 50 tests
Guava cleaning fluid 100 ml
Full Blood count Sysmex PocH 100i
Eight Check-H 1.5 ml
Eight Check-N 1.5 ml
Eight Check-L 1.5 mL
PocH pack 65 Pack of 2.7L pack D and 50ml pack L
Sysmex Clean 50ml
Sysmex Thermal Paper Roll
ABX Micros 60/80
ABX Minotrol 16 Twin Pack Low 2 x 2.5 ML
ABX Minotrol 16 Twin Pack Normal 2 x 2.5 ML
ABX Minotrol 16 Twin Pack High 2 x 2.5 ML
ABX Miniclean 1L
478
ABX Minilyse 1L
ABX Minidil 20 L
ABX Pentra 60C+/80XL
ABX Difftrol Twin Pack Low 2 x 3ML
ABX Difftrol Twin Pack Normal 2 x 3ML
ABX Difftrol Twin Pack High 2 x 3ML
ABX Lysebio 400 ml
ABX Basolyse 1L
ABX Cleaner 1L
Full Blood count ABX Diluent 20 L
ABX Eosinofix 1L
Sysmex XS 800i/XS1800i/XT 2000i
Sysmex control e-Check Low 8 x 4.5ML
eCheck Sysmex control e-Check Normal 8 x 4.5ML
Sysmex control e-Check High 8 x 4.5ML
Sysmex Cell pack 20L
Sysmex Stromatolyser 4DL 5L
Sysmex Stromatolyser 4DS 3 x 42 ML
Sysmex Sulfolyser 5L
Sysmex Cell clean 50ML
Sysmex Retsearch Diluent/Dye 1L
Sysmex Stromatolyser FB 5L
479
Clotting profile Coagulation
Activated Partial thromboplastin time (APTT) test kit each
Prothrombin Time (PT) test kit each
Thrombin Time (TT) test each
CaCl 0.025mmol/L 10 ml
Factor VIII deficient plasma vial
Factor IX deficient plasma vial
Fibrin degradation products kit
Peripheral smear HAEMATEK slide stainer
Blood film stain pack pack
Bone marrow stain pack pack
Special Stains Cytochemistry
Glucose 6 phosphate dehydrogenase (G6PD) kit
Sudan black B stain kit
Myeloperoxidase kit
Antinuclear antibody test by indirect method kit
Clotting profile Coagulation

Activated Partial thromboplastin time (APTT) test kit each
Prothrombin Time (PT) test kit each
480
Thrombin Time (TT) test each
CaCl 0.025mmol/L 10 ml
Factor VIII deficient plasma vial
Factor IX deficient plasma vial
Fibrin degradation products kit
Peripheral smear HAEMATEK slide stainer
Blood film stain pack pack
Bone marrow stain pack pack
Special Stains Cytochemistry
Glucose 6 phosphate dehydrogenase (G6PD) kit
Sudan black B stain kit
Myeloperoxidase kit
Antinuclear antibody test by indirect method kit
Clinical chemistry Cobas Integra 400

Cobas ALT/ GPT 500 test cassette
Cobas AST/ GOT 500 test cassette
Cobas Creatinine 700 test cassette
Cobas Urea 500 test cassette
Cobas Cholesterol 400 test cassette
Cobas Glucose 800 test cassette
481
Cobas Triglycerides 250 test cassette
Cobas Bilirubin Total 500 test cassette
Cobas Bilirubin Direct 500 test cassette
Cobas Total Protein 400 test cassette
Cobas Albumin 300 test cassette
Cobas Cfas 36 ml
Cobas Precinorm U 4 X 5 ml
Cobas Precipath U 4 X 5 ml
Cobas Deproteinizer 23 ml
Clinical chemistry Cobas Amylase 300 test cassette
Cobas Lipase 200 test cassette
Cobas Lactate 300 test cassette
Cobas Cuvettes Pack of 2000 cuvettes
Cobas Sample cups (white) Pack of 1000 cups
Cobas Control cups (brown) Pack of 1000 cups
Cobas Waste container Each
Cobas Cleaner 1L
Cobas c 111
Cobas ALT/ GPT 4 x 100 test
Cobas AST/ GOT 4 x 100 test
Cobas Creatinine 2 x 200 test
Cobas ALP 4 x 50 test
482
Cobas Urea 4 x 100 test
Cobas Cholesterol 4 x 100 test
Cobas Glucose 4 x 100 test
Cobas Triglycerides 4 x 50 test
Cobas Bilirubin Total 4 x 100 test
Cobas Bilirubin Direct 4 x 50 test
Cobas Total Protein 4 x 100 test
Cobas Albumin 4 x 100 test
Clinical chemistry Cobas Bicabonate 4 x 100 test
Cobas HbA1C 400 test
Cobas LDH 4 X 50 tests
Cobas Uric 4 x 100 tests
Cobas Amylase 4 x 100 tests
Cobas Lipase 4 x 50 tests
Cobas Lactate 4 x 50 tests
Cobas Cuvettes Pack of 2000 cuvettes
Cobas Sample cups (white) Pack of 1000 cups
Cobas Control cups (brown) Pack of 1000 cups
Cobas Waste container Each
Cobas Cleaner 1L
483
Humalyzer 2000
Human ALT(GPT) Liquicolor UV 10 X 10 ml
Human AST(GOT) Liquicolor UV 10 X 10 ml
Human Creatinine Liquicolor 200 ml
Human Glucose Liquicolor 1L
Human Urea Liquicolor 2 X 100 ml
Human Bilirubin Direct 100 ml
Human Bilirubin Total 100 ml
Humatrol Normal (N19) 6 X 5 ml
Clinical chemistry Humatrol Pathological (P17) 6 X 5 ml
Humalyzer 2000 Thermal Printing Paper Roll
Humalyzer 2000 Cuvettes Pack of 1000
Humalyte
Na ISE
Cl ISE
K ISE
Olympus AU400
Olympus ALT 4x12, 4x6 ml
Olympus AST 4x6, 4x4 ml
Olympus Cholesterol 4 X 22.5 ml
484
Olympus Cholesterol HDL 4 X 22.5 ml
Olympus Bilirubin Direct 4 X 25 ml / 4 X 25 ml
Olympus Bilirubin Total 2 X 100 ml
Olympus Electrode Na+ Each
Olympus Electrode K+ Each
Olympus Electrode Cl Each
Olympus ISE Buffer 1L
Olympus Mid ISE Standard 2L
Olympus Electrode Cleaning Solution 2 X 50 ml
Olympus Control Serum 1 20 X 5 ml
Clinical chemistry Olympus Control Serum 2 20 X 5 ml
Olympus Creatinine 4 X 60 ml
Olympus Glucose 4x25 ml/ 4x12.5 ml
Olympus System Calibrator 20 X 5 ml
Olympus Triglyceride 4x50 ml/ 4x12.5 ml
Olympus Urea 2x4x25 ml
Olympus Wash Solution 5L
Olympus Total Protein 500 test cassette
Olympus Albumin 500 test cassette
Olympus Amylase ?
Olympus Lipase ?
485
Olympus Lactate ?
Pentra 200/400
Alanine Aminotransferase (ALT/GPT) 1*70ml
AST (Cobas III) 1*90ml
Creatinine 1*90ml
Urea 1*90ml
Cholesterol 1*90ml
Glucose 1*90ml
Total Protien 1*90ml
Bilirubin Total 1*90ml
Clinical chemistry Cuvette Segements Rack 1*90ml
Control Pathological 1*90ml
Control Normal 1*90ml
Amylase 1*90ml
Lipase 1*90ml
Lactate 1*90ml
Deproteinizer 1*30ml
Standard 1 100ml
Standard 2 100ml
Reference 100ml
HIV Viral load and Cobas Taqman 48 analyser
486
qualitative tests CAP/CTM HIV - version 2.0
COBAS TaqMan K Tubes
CAP - G Wash Buffer
CAP SPU Flapless
CAP S Tubes (input)
CAP K tips
DNA PCR - Pediatric
DNA, PCR AMPLICOR HIV-/ Monitor Test Kit of 96 tests
PCR Consumables Kits, for 960 Tests Kit for 960 tests
DBS Bundles for 50 tests Bundles for 50 tests
Bacteriology Acetone L
Ammonium Oxalate g
Bacitracin 0.04units 250 discs
Basic Fuchsin Powder g
Blood Culture Media Adult Bottle
Blood Culture Media Pediatric Bottle
Blood Agar Base g
MacConkey agar with crystal violet
Campylobacter Karmali Agar g
Bacitracin 0.04units 250 discs
Basic Fuchsin Powder g
Cary Blair g
Simmon Citrate Agar g
487
Crystal Violet Powder g
Cystine Lactose Electrolytes Deficient Agar (CLED medium) g
Mueller Hinton Agar g
N,N,N,N Tetramethyl-P-Phenylene Diamine (Oxidase Reagent) g
Orange G 6 Solution L
Glucose test Accucheck active Glucometer Strips Strips

Hepatitis tests Hepatitis B Test Kit Strips
Hepatitis C Test kit strips
Histolopathology Ethanol Absolute (99.9%) L
Methanol Absolute L
Formalin L
General laboratory Hydrochloric Acid L
use
Kovacs Reagent ml
Syphilis RPR (syphilis reagent kit) Tests
Meningitis Cryptococcus antigen Test Kit Tests
investigation
Pregnancy Pregnancy Test Kit (Latex) Tests
Stool Microscopy Salmonella Typhi Hd antisera 2ml
488
culture and Salmonella Typhi Vi antisera 2ml
identification Salmonella Typhi O-9 antisera 2ml
Salmonella Paratyphi A antisera 5 ml
Salmonella Paratyphi B antisera 5 ml
Salmonella Paratyphi C antisera 5 ml
Salmonella Polyvalent H Phase 1 and 2 Antisera 5 ml
Salmonella Polyvalent O groups A - S Antisera 5 ml
Selenite F Broth g
Shigella boydii types 1 - 6 5 ml
Shigella boydii types 12 - 15
Stool Microscopy Shigella boydii types 7 - 11
culture and Shigella disenteriae type 1 -10 antisera 5 ml
identification Shigella disenteriae type 1 antisera
Shigella flexneri types 1-6, x,y Antisera 5 ml
Shigella sonnei Phase 1 and 2 antisera 5 ml
General laboratory Sodium Chloride (Analar grade) g

use
Bacteriology (MCS) Sulphide Indole Motility (SIM) medium g
Triple Sugar Iron Agar (TSI) g
Urea Agar g
Urea (analar grade) g
Urinalysis Urine Multistix Pack of 100 Strips
489
Bacteriology (MCS) Deoxycholate citrate agar (DCA) agar g
Ampicillin 10 µg 250 discs
Cefotaxime 30µg 250 discs
Chloramphenicol 30 µg 250 discs
Ciprofloxacin 5 µg 250 discs
Cotrimoxazole 25 µg 250 discs
Erythromycin 15 µg 250 discs
Gentamicin 10 µg 250 discs
Nalidixic Acid 30 µg 250 discs
Bacteriology (MCS) Nitrofurantoin 300 µg 250 discs
Penicillin 10 units 250 discs
Oxacillin 1 µg 250 discs
Nofloxacin 10 µg 250 discs
Histopathology Chloroform L
Haematoxyllin (Harris Alum Haematoxyllin) ml
DPX Mountant ml
EA 50 ml
Acetic acid
Malaria Giemsa powder g
490
Glycerol 5L
Aesculine-bile agar
Peptone water
Lysine Iron agar
Sabourauds agar
Thiosulphate citrate bile-salt sucrose (TCBS) medium
Tryptone soy broth
0.5 McFarland standard (Latex)
Amyl alcohol
Chlamydia test kit
Malaria Coagulase test (Commercially prepared kit e.g. StaphAurex kit or equivalent)
diSodium hydrogen phosphate (Na2HPO4) Anhydrous
Eosin powder
General laboratoru Hydrogen peroxide
use Iodine
Methylene blue
Nigrosin
p-dimethyaminobenzaldehyde powder
Phenol crystals
Potassium hydroxide
Potassium iodide
491
Potassium permanganet
Sodium biselenite powder
Sodium hydroxide crystals
Sodium dihydrogen phosphate (NaH2PO4.2H2O) hydrated
Bacteriology (MCS) Streptococcus Lancefield typing kit (e.g. Streptex kit or equivalent)
General Laboratory Sulphuric acid
use
Special stains Toluidine blue O stain
Toxoplasmosis Toxoplasma antigen detection test
General Xylene
Formic Acid
Bacteriology (MCS) Cefoxitin 30 µg (Disc)
Ceftazidime30 µg (Disc)
Ceftriazone 30 µg (Disc)
Colistin 10 µg (Disc)
Polymyxin B 300 Units (Disc)
E-test strips
Cefotaxime (E-test)
Penicillin (E-test)
492
Diagnostic discs
Colistin 10 µg (Disc)
Furazolidone 100 µg (Disc)
Indole test discs
Nitrocefin discs
Novobiocin 5 µg (Disc)
Optochin disc
Polymyxin B 300 units (Disc)
Pyrrolidonyl arylamidase test (PYR) discs
V factor (Disc)
Bacteriology (MCS) X factor (Disc)
XV factor (Disc)
Bacteriology (MCS) Antisera
Vibrio cholerae O1 polyvalent antisera
Vibrio cholerae O139 antisera
Vibrio cholerae Inaba antisera
Vibrio cholerae Ogawa antisera
E.coli O 157:H7 antisera
Clavulanic Acid Powder
Streptococcus pyogenes group A Rapid test strips
Streptococcus agalactiae group B Latex agglutination antigen detection kit
493
Gonorrhoae Rapid test strips
Endocrinology Thyroid Hormones
TSH
T3
T4
Cancer Tumor Makers
CEA
PSA
AFP
Heart/cardiac Cardic Markers
CK MB
CKNAC
Troponin T
Troponin I
General laboratoru General Consumables
use Applicator Sticks, Orange Pack of 1000 sticks
Cotton Wool g
Filter Paper, Medium Pack of 100 pieces
Filter Paper, Large Pack of 100 pieces
Examination Gloves, Medium Pack of 100 gloves
494
Examination Gloves, Large Pack of 100 gloves
Sodium Hypochlorite (Jik) Bottle (750mls)
Lancets Pack of 100
Kimwipes Pack of 140
Lens Tissue Book of 25 pieces
Microcapillary Tubes, Non-Heparinized Pack of 100 tubes
Microcapillary Tubes, Heparinized Pack of 100 tubes
Microscope Cover Slips 22 X 22mm Pack of 100 slips
Microscope Cover Slips 22 X 40mm Pack of 10 boxes
Microscope Slides Pack of 50
General laboratoru CD4 Stabilization tubes pack of 100
use Microtube, 2 ml Screw Cap Pack of 500
Plastic transfer Pasteur Pipettes, 3 ml Pack of 500
Petri Dish, Plastic Box of 500
Pipette Tips, Blue Pack of 500
Pipette Tips, Yellow Pack of 1000
Spirit, Methylated 2.5 L
Sputum Containers Pack of 1000
Sterile Swab Pack of 1000
Swabs (sterile cotton swabs with activated charcoal in Amies transport Pack of 1000
medium)
495
Stool Containers, 28 ml, Screw Cap, with Scoop Pack of 1000
Blood collection Universal Container, 20 ml Screw Cap Pack of 200
Vacutainer, 4ml, Plain Red Top Pack of 100
Vacutainer Needle, 21G X 1 Pack of 100
Vacutainer, 4 ml, EDTA Pack of 100
Vacutainer, Flouride Oxalate Pack of 100
Vacutainer, L.Heparin Pack of 100
Vacutainer Holders Pack of 250
General Disposable Biohazard Bags Pack of 100
laboratoryuse Autoclavable Bags Pack of 100
Histopathology Histopathology Cassettes Pack of 100
Histopathology Paraffin wax 25Kg
Haemoglobin Haemacue cuvettes Pack of 100
496
Children Less than 5 yrs
497
Children age 5-12 yrs
498
499
500
501
502
503

Final Standard Treatment Guidelines Booklet 04

Uploaded by

Copyright:

Available Formats

Final Standard Treatment Guidelines Booklet 04

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Final Standard Treatment Guidelines Booklet 04

Uploaded by

Copyright:

Available Formats

REPUBLIC OF ZAMBIA

STANDARD TREATMENT GUIDELINES,

ESSENTIAL MEDICINES LIST

ESSENTIAL LABORATORY SUPPLIES LIST

Standard Treatment Guidelines

I commend the European Union under HSSP for technical and

The first edition proved to be a very popular reference document

Dr. Jabbin Mulwanda

Standard Treatment Guidelines

It is the spirit of the physicians’ workshop on the

Finally we thank the untiring efforts and commitment

Standard Treatment Guidelines

We also thank individuals and groups of professionals

Zambia National Formulary Committee 2014-2017

3. Dr. Owen Ngalamika - Dermatologist, UTH

4. Mr. Pious Hachizo - Senior Pharmacist - Cancer Diseases Hospital

7. Dr. Sally Trollip - Physician UTH

8. Dr. Maureen Chisembele - Obstetrician/Gynaecologist

9. Mr. Enock Chikatula - Pharmaceutical Services Manager, UTH

10. Dr. Pauline Musukwa Sambo - Oncologist, UTH

Standard Treatment Guidelines

21. Ms. Anne Zulu - Director, Pharmaceuticals Standards,

Other Technical Reviewers

Design and print

2. Mr. Boyd Mwanashimbala - Principal Pharmacist

3. Mr. Luke Alutuli - Principal Pharmacist Logistics Management

4. Mrs. Elis Mwanza - Secretary, DCCDs, MOH

5. Mr. Nyambe Sitali - Office Assistant

Standard Treatment Guidelines

The essential medicines and laboratory supplies listed in

Standard Treatment Guidelines

The Medicines and Therapeutic Committees and hospital

Standard Treatment Guidelines

Chapters are divided into sections providing introductory

Descriptive information about the disease or condition

• Definition of disease or condition

Standard Treatment Guidelines

REVISION OF STANDARD TREATMENT GUIDELINES

Dr. Kor Chiyenu

Standard Treatment Guidelines

1.1� ABDOMINAL PAINS

Abdominal pains include gastritis and peptic ulcer disease

This is divided into acute and chronic gastritis. In acute

Chronic gastritis is divided into 3 categories:

Type B (bacterial) gastritis, which is associated with

Type C (chemical) gastritis, which is due to repeated

Most chronic gastritis is asymptomatic

1.1.2� Chronic Peptic Ulcer Disease

Most peptic ulcers occur in the stomach or proximal

Many patients, particularly the young presenting with

Standard Treatment Guidelines

• Magnesium trisilicate compound, 250-500mg to

Ulcer healing drugs

Cimetidine 400mg 4 times daily for 4 – 8 weeks.

Ranitidine 150mg tablets twice daily (with

Standard Treatment Guidelines

b) Proton pump inhibitors

c) Tripotassium dicitratobismuthate (Bismuth chelate)

Tablets 120mg. 2 tablets twice daily or 1 tablet 4

d) Triple therapy regimens