Diagnosis

Diagnosis & Management
Handbook for Family Physicians
Ministry Of Health November 2010
EGYPT
Diagnosis & Management

Handbook for Family Physicians
Ministry of Health November 2010
Contents
Contents
1- Emergency Medicine 2- Basic Surgical Skills 3- Cardiovascular System 4- Adult Medicine 5- Gastro-intestinal System 6- Pregnancy 7- Labor 8- Gynaecology 9- Contraception 10- Pediatrics 11- Laboratory Standards 12- Annexes
Disclaimer
DISCLAIMER The authors views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development of the United States Government.
Index
Index
Subject Page
List of Tables .................................................................................................. List of Figures ............................................................................................... 1- Emergency Medicine .............................................................................. Toxins ............................................................................................................... Trauma ............................................................................................................. Animal Bite ...................................................................................................... Foreign body aspiration ................................................................................ Burns ................................................................................................................ Electrical Injury ................................................................................................ Heat Exhaustion .............................................................................................. Anaphylaxis ..................................................................................................... Adult Immunization ....................................................................................... Hypotension, Shock and Pulmonary Edema ............................................... Cardiac Arrest ................................................................................................ Cardio-Pulmonary Resuscitation (CPR) ..................................................... Basic Life Support ......................................................................................... 2- Basic Surgical Skills ............................................................................... Suturing Technique ........................................................................................ Abscess Drainage .......................................................................................... 3- Cardiovascular System .......................................................................... Hypertension (HTN) ........................................................................................ Chest Pain Evaluation .................................................................................... Dyspnea & palpitation .................................................................................... 4-Adult Medicine .......................................................................................... Anemia ............................................................................................................. Microcytic Anemia .......................................................................................... Macrocytic Anemia ......................................................................................... 5
11 13 15 17 22 24 25 27 28 28 29 30 32 33 33 33 37 41 42 45 47 54 56 57 59 60 60
Index
Megaloblastic Anemia ................................................................................... Normocytic Normochromic Anemia ............................................................. Microangiopathic Hemolytic Anemia ........................................................... Sickle Cell Anemia ......................................................................................... Deep Vein Thrombosis (DVT) ....................................................................... Pulmonary Embolism (PE) ............................................................................ Diabetes Mellitus ........................................................................................... Diabetic Nephropathy .................................................................................... Diabetic Hypoglycemia .................................................................................. Diabetic Keto-Acidosis (DKA) ...................................................................... Hyperglycemic Non-Ketotic State ................................................................ Foot care for people with diabetes .............................................................. TB suspect ....................................................................................................... Hemoptysis ...................................................................................................... Cough ............................................................................................................... Weight loss ..................................................................................................... Severe respiratory symptoms and signs .................................................... Pyelonephritis ................................................................................................. Hematurea ....................................................................................................... Chronic Renal Diseases ............................................................................... Benign Prostatic Hypertrophy (BPH) ........................................................... Erectile Dysfunction (ED) .............................................................................. Cancer Screening ........................................................................................... Breast Mass .................................................................................................... Nipple Discharge ............................................................................................ Bladder Carcinoma ........................................................................................ Colorectal Carcinoma .................................................................................... Hyperthermia and Fever ............................................................................... Service for General Population 65 Years and Older ................................ Domains of Geriatric Assessment ............................................................... Osteoporosis ................................................................................................... Fatigue ............................................................................................................. 5-GIT ................................................................................................................ 6
61 61 61 62 62 63 64 61 72 73 73 74 77 78 79 80 81 90 91 92 95 95 96 97 98 98 98 99 100 101 102 102 107
Index
Peptic ulcer disease ........................................................................................ Acute appendicitis ........................................................................................... Acute hepatitis ................................................................................................ Chronic hepatitis ........................................................................................... Viral hepatitis subtypes ................................................................................. Upper GIT bleeding ........................................................................................ Lower GIT bleeding ........................................................................................ Ascitis ............................................................................................................... Acute diarrhea ................................................................................................ E. Coli infection .............................................................................................. Salmonella infection ....................................................................................... Shigellosis ........................................................................................................ IBS .................................................................................................................... Unconsciousness and coma ........................................................................ Convulsions ..................................................................................................... Stridor ............................................................................................................... Acute abdominal pain .................................................................................... 6-Pregnancy ................................................................................................... Diagnosis of Pregnancy ................................................................................. Antenatal Care (ANC) .................................................................................... High-Risk Pregnancy ...................................................................................... Bleeding in Early Pregnancy ......................................................................... Abortion ............................................................................................................ Ectopic Pregnancy ......................................................................................... Vesicular Moles (Molar pregnancy) ............................................................. Vaginal Bleeding <20 weeks ....................................................................... Suspected Ectopic Pregnancy .................................................................... Septic Shock ................................................................................................... Antepartum Hemorrhage .............................................................................. Diabetes Mellitus (DM) With Pregnancy .................................................... Hyperemesis Gravidarum ............................................................................. Heart Disease with Pregnancy .................................................................... Hypertension with Pregnancy ...................................................................... 7
109 109 111 111 112 114 115 115 116 116 117 117 117 119 124 126 129 131 133 134 142 144 145 147 148 149 150 150 151 154 157 158 158
Index
Pre-Eclampsia ................................................................................................. Eclampsia ........................................................................................................ Chronic Hypertension .................................................................................... Essential drugs for managing complications in pregnancy and child birth ... Rh Isoimmunization ...................................................................................... Teratogenicity and drug effects upon fetus ................................................ 7-Labor ............................................................................................................ Clinical Conduct of Normal Labor ................................................................. Cord Prolapse ................................................................................................. Partogram ........................................................................................................ Multiple Pregnancies ...................................................................................... Retained Placenta .......................................................................................... Perineal Trauma: Assessment and Repair ................................................ Rupture Uterus ............................................................................................... Preparation for home birth checklist ........................................................... Referral guideline for the pregnant patient .............................................. Postpartum Hemorrhage (PPH) .................................................................. Preterm Labor ................................................................................................. Premature Rupture of Membranes (PROM) .............................................. Routine Postpartum Care ............................................................................. Immediately After Labor ................................................................................ The First Few Days ........................................................................................ Post-partum Patient Education ................................................................... Lactational Mastitis ....................................................................................... 8-Gynaecology .............................................................................................. Infertility ............................................................................................................ Premenstrual syndrome (PMS) ................................................................... Menstrual abnormalities ................................................................................ Dysfunctional uterine bleeding (DUB) ......................................................... Postmenopausal bleeding ............................................................................ Acute pelvic pain ............................................................................................. Chronic pelvic pain .......................................................................................... Genital tract infections ................................................................................... 8
159 161 162 165 167 169 171 173 177 179 180 180 181 181 182 184 185 187 188 192 192 193 194 195 197 199 203 203 204 204 205 206 208
Index
Pelvic inflammatory disease (PID) ............................................................... Sexually transmitted diseases (STDs) ........................................................ Treatment of scrotal swelling ....................................................................... Treatment of genital ulcers ............................................................................. HIV .................................................................................................................... Pelvic and pelvi-abdominal masses ............................................................ Menopause ..................................................................................................... Womens health .............................................................................................. Domestic violence .......................................................................................... Female Genital Mutilation (FGM) ................................................................ 9-Contraception ............................................................................................ Methods of Contraception ............................................................................. Natural Contraception .................................................................................... Barrier Contraception ..................................................................................... Oral Contraceptive Pills ................................................................................ Injectable Hormonal Contraception ............................................................. Hormonal Implants ......................................................................................... Intrauterine Device (IUD) .............................................................................. Emergency Contraception ........................................................................... Contraception for special groups ................................................................. 10-Pediatrics .................................................................................................. Infant care in delivery room ......................................................................... Referral guidelines for the neonate ............................................................. Young infant age up to 2 months ................................................................. Diarrhea ........................................................................................................... Jaundice ........................................................................................................... Feeding problem or low weight ................................................................... Treat the young infant .................................................................................... Early detection and congenital hypothyroidism ......................................... Neonatal conjunctivitis .................................................................................. Congenital infections ..................................................................................... Child development ......................................................................................... Compulsory childhood immunization schedule ......................................... 9
211 212 217 219 221 221 223 224 226 226 229 231 231 235 236 242 243 243 246 247 251 253 254 256 258 260 260 262 263 264 265 267 268
Index
Child age 2 months up to 5 years ................................................................ Danger signs ................................................................................................... Breathing difficulty .......................................................................................... Diarrhea ........................................................................................................... Throat or ear problem .................................................................................... Malnutrition and anaemia ............................................................................. Bacterial meningitis ........................................................................................ 11-Laboratory standards ............................................................................ Sex Steroids, Plasma .................................................................................... Thyroid Function Tests .................................................................................. Glucose, Plasma - Fasting Level ................................................................ Glucose Tolerance Test 2Hour Postprandial Plasma Glucose ............ Insulin, Plasma ............................................................................................... Total Cholesterol ............................................................................................ HighDensity Lipoprotein (HDL) Cholesterol ........................................... Low-Density Lipoprotein (LDL) Cholesterol .............................................. Triglycerides, Plasma .................................................................................... Serum Electrolytes ......................................................................................... Others Lab Tests ............................................................................................ 11- Anexes ..................................................................................................... Hepatotoxic drugs ......................................................................................... Drugs Induced toxic renal syndrome ......................................................... National Disease survillance ........................................................................ Diet Regimen for chronic diseases ............................................................
269 269 270 272 274 276 284 285 287 288 289 289 289 289 290 290 290 290 291 293 295 300 302 304
10
List of Tables
List of Tables
Table No. )1-1( )1-2( )1-3( )1-4( )1-5( )3-1( )3-2( )3-3( )4-1( )4-2( )4-3( )4-4( )4-5( )4-6( )4-7( )4-8( )4-9( )4-10( )4-11( )4-12( )4-13( )4-14( )4-15( )4-16( )4-17( )4-18( )4-19( )4-20( )4-21( )4-22( )4-23( Title Drug toxicity Methods of Gastrointestinal Decontamination: Estimate the Body Surface Area (BSA) Determine the depth of the burn Adult immunization Assessment of Severity of the blood pressure Adverse effects of common antihypertensive Drugs (Page 28 Vol 5 Clinical Practice Guidline) Doses of common antihypertensive drugs Deep vein thrombosis (DVT) Diabetes Mellitus Plasma Glucose Diagnostic Criteria for Diabetes Mellitus Estimated total daily insulin requirement Types of insulin in clinical use Side effects of Oral Hypoglycemics Oral hypoglycemic combination for Type 2 Diabetes Mellitus Currently available antidiabetic drugs for type 2 DM Comparison between antidiabetic drug classes Hypoglycemia Clinical Picture Commonly available sources of 10 g. of Glucose Ketoacidosis Hyperglycemic Hyperosmolar Coma (HHC): Foot care for people with Diabetes Severe respiratory symptoms and signs that necessitate urgent referral Management of upper respiratory tract conditions Staging and management of COPD whether at the first time or during follow up Staging of asthma whether at the first time or during follow up Clinical classification of asthma Stages Of CKD Imaging Studies Used in Evaluating Patients with Renal Disease Types, characteristics and treatment of urinary inccontnence Cancer Screening Page No. 18 20 25 25 30 47 50 51 62 64 65 66 67 67 68 68 70 72 72 73 73 74 81 85 87 88 89 92 92 93 96
11
List of Tables
)4-24( )4-25( )5-1( )6-1( )6-2( )6-3( )6-4( )6-5( )6-6( )6-7( )6-8( )6-9( )7-1( )8-1( )8-2( )8-3( )8-4( )8-5( )8-6( )8-7( )8-8( )8-9( )9-1( )10-1( )10-2( )10-3( )10-4( )10-5( )11-1( )11-2( )11-3( )11-4( )11-5( )11-6( )11-7( )11-8( )11-9( )11-10(
Preventive Services Recommended for the General Population 65 Years of Age and Older Domains of Geriatric Assessment Glasgow Coma Scale Diagnosis of pregnancy Antenatal Care (ANC) Visits Antenatal Care Immunizations during pregnancy Tetanus Toxoid vaccination (TT) Glucose Challenge Test Assessment of Hyperemesis Gravidarum Essential Drugs For Managing Complications In Pregnanacy And Child Birth A-1 Teratogenicity and drug effects upon fetus Initial evaluation of the infant Etiology of Infertility: Incidence of Infertility The Role of The Family Physician in Infertility Causes of referral of Infertile Couple Semen analysis - WHO Standard Differential diagnosis of vaginal discharge: Differential diagnosis of pelvic & abdominal masses: Sex-steroid hormonal changes Types of Female Genital Mutilation (FGM) Management of common side - effects of oral contraceptive pills Classification & treatment the Sick Young Infant Age Up To 2 Months TORCH Infection Child Development The compulsory childhood immunizations schedule in Egypt Classification & Treatment The Sick Child Age 2 Months Up To 5 Years Plasma levels of sex steroids Thyroid function tests Glucose, plasma - Fasting level Glucose tolerance test 2hour postprandial plasma glucose Insulin, plasma Total cholesterol Highdensity lipoprotein (HDL) cholesterol Low-density lipoprotein (LDL) cholesterol Triglycerides levels in plasma Serum Electrolytes
100 101 119 133 134 138 140 140 155 157 165 169 177 199 200 200 200 201 209 222 223 227 239 256 266 267 268 269 287 288 289 289 289 289 290 290 290 290
12
List of Figures
List of Figures
Figure No. )1-1( )1-2( )1-3( )1-4( )1-5( )1-6( )3-1( )3-2( )3-3( )3-4( )3-5( )4-1( )4-2( )4-3( )4-4( )4-5( )4-6( )4-7( )4-8( )4-9( )4-10( )4-11( )4-12( )4-13( )4-14( )4-15( )4-16( )4-17( )5-1( )5-2( )5-3( )5-4( Title Toxin Exposure Patient with trauma Burn Anaphylaxis Hypotension, shock and acute pulmonary edema Basic Life Support Hypertension Management Of Rapid Severe Hypertension DD of chest pain Management of Chest pain Dyspnea or Palpitations Anemia Target for acceptable control Management of type 2 DM Hypoglycemic Therapy Diabetics Follow up at home Suspecting TB Standardized Management Plan of TB Suspects (WHO) Standardized Management Plan of TB Suspects (WHO) Standardized Management Plan of TB Suspects (WHO) Patient coming with acute problem with cough with or without dyspnea and/or wheezing Pyelonephritis Hematuria Begnin prostatic hypertrophy Breast mass Hyperthermia and Fever Fatigue Chronic fatigue syndrome Upper GIT Bleeding Lower GIT Bleeding Acute Diahrrea Disturbed level of consciousness (Coma or stupor) Page No. 21 23 26 31 32 36 52 53 54 55 56 59 66 71 72 75 77 78 79 80 83 90 91 95 95 99 104 105 114 115 116 120
13
List of Figures
)5-5( )5-6( )5-7( )5-8( )5-9( )6-1( )6-2( )6-3( )6-4( )6-5( )6-6( )6-7( )7-1( )7-2( )7-3( )7-4( )8-1( )8-2( )8-3( )8-4( )8-5( )8-6( )9-1( )9-2( )10-1( )10-2(
Syncope Convulsions Stridor in Children Stridor in Adults Acute Abdominal Pain Antenatal care Vaginal bleeding <20 weels Suspected ectopic pregnancy Antepartum Hemorrhage Diabetes Mellitus (DM) with pregnancy Pregnant woman >20 weeks, Diastolic blood pressure >90 mmHg Eclampsia Partogarm Post-partum hemorrhage Preterm labor Premature Rupture of Membranes (PROM) Infertility Protocol Pelvic Pain Treatment of vaginal infection Flow-chart for Scrotal Swelling Flow-chart for Genital Ulcer Syndrome Flow-chart for Inguinal Bubo Lactational Amenorrhea Method ( LAM ) Mechanism Management of Lost threads of IUD Infant care in delivery room Neonatal Conjunctivitis
122 124 126 127 128 141 149 150 153 156 163 164 179 186 190 191 202 207 210 216 218 220 234 245 253 264
14
Chapter 1
Emergency Medicine
Chapter 1: Emergency Medicine
Toxins
N.B: Contact a Poison Control Center for urgent information in the management of all acute poisoning 23640402-23643129 : Determine: Type of toxin the patient exposed to (by relatives, friends, etc.). Method of toxin exposure i.e., through ingestion (most common), inhalation, injection, and absorption. Determine the amount and time since exposure. If any other toxic or non-toxic substances were involved. If exposure was intentional (suicidal, criminal) or accidental. Diagnosis: Vital signs give an idea about the type of ingestion: 1. Hyperthermia: Thyroid medication, nicotine, aspirin, anticholinergics, amphetamines, cocaine, neuroleptics. 2. Hypothermia: Carbon monoxide, alcohol, sedative, hypnotics, barbiturates. 3. Tachycardia: Cocaine, amphetamines, thyroid medication, anticholinergics. 4. Bradycardia: -blockers, calcium channel blockers, clonidine, digitalis, opioids. 5. Tachypnea: Salicylates, organic phosphates. 6. Hypertension: Amphetamines, cocaine, anticholinergics. 7. Hypotension: Sedative, hypnotics, organic phosphates, opioids, digitalis, -blockers, and calcium channel blockers. 8. Other diagnostics based on symptoms and signs: Breath odor: Bitter almonds: Cyanide. Garlic: Organic phosphates. Pear: Chloral hydrate. Pupils: Constricted: Clonidine, opiates, sedatives and hypnotics. Dilated: Amphetamines, anticholinergics. Pulmonary edema: Opioids, salicylates, toxic inhalations
17
(chlorine, nitric oxide), cocaine, organic phosphates, ethylene glycol. Bowel sounds: : Opiate withdrawal, sympathomimetics. : Anticholinergics, opiate toxicity. Skin findings: Needle tracks: Opioids injection. Alopecia: chemotherapeutic agents, arsenic, thallium. Cyanosis: Drugs methemoglobinemia (e.g., nitrates or nitrites, caine anesthetics, aniline dyes, chlorates, sulfonamides). Findings
Hypoventilation (elevated Pco2) Hyperventilation Hyperkalemia
Table (1-1): Drug toxicity Test

Arterial blood gases
Selected Causes
CNS depressants (e.g., opioids, sedative-hypnotic, phenothiazines) Salicylates; carbon monoxide; other asphyxiants Digitalis; fluoride; potassium Theophylline; caffeine; beta-adrenergic agents (e.g., albuterol) Oral hypoglycemic agents; insulin Quinidine and antiarrhythmic drugs, tricyclic antidepressants; Quinidine and related antiarrhythmic agents Calcium antagonists; digitalis glycosides Iron; lead; potassium; calcium; chloral hydrate; foreign bodies
Electrolytes
Hypokalemia Hypoglycemia Wide QRS complex
Glucose
ECG
Prolongation of the QT interval Atrioventricular block
Plain abdominal x-ray
Radiopaque pills or objects
18
The ABCDs of Emergency Stabilization of Poisoned Patient: 1. Airway: a. Position the patient to open the airway. b. Suction or any secretions or vomitus. c. Endotracheal intubation, if needed. 2. Breathing: a. Monitor respiratory rate. b. Administer supplemental 100% oxygen. 3. Circulation: a. Evaluate perfusion, blood pressure, pulse. b. ECG Determine QRS complex. c. Continuous cardiac monitor, if available. 4. Dextrose: a. Determine blood glucose by finger-stick test. b. Hypoglycemia Give dextrose by I.V line. 5. Decontamination: Skin cleaning, and gastric decontamination to limit absorption of poisons. Referral guidelines: Insert two wide bore IV cannulae (size 16 or 18). IV Ringers infusion at a fast drip (1 liter/ hour). Provide 100% oxygen via mask. Warm the patient, if needed (hypothermic). Insert a Foleys catheter. Referral should be in an equipped ambulance. A physician should accompany the patient. Further management for removal of absorbed toxins: Alkalization methods: Involves mixing dextrose 5% with 2-3 amps of NaHCO3. Alkalization of blood: improves clearance of heterocyclic antidepressants. Alkalization of urine: to pH >8 ionize weak acids into ionized molecules excretion of salicylates, phenobarbital, and chlorpropamide.
19
Table (1-2): Methods of Gastrointestinal Decontamination: 1. Emesis: Give syrup of pecac, 30 ml orally in adults (15 ml in children), with 1-2 glasses of water; may repeat after 30-min if no emesis occurs; alternatively, give 1-2 teaspoon of liquid hand washing or dishwashing machine soap. N.B: Dont use Ipecac in certain poisoning including ingestion of calcium channel blokers, beta- blokers, digitalis, or when there has been an ingestion of corrosive agent. Ipecac is contraindicated for ingestions that can produce changes in levels of alertness because of aspiration risk. Specific complications of pecac may include aspiration, diarrhea, ileus, arrythmia during vomiting, dystonia from treatment for vomiting and hematemesis from vomiting. 2. Gastric lavage: Insert large-bore naso-gastric or oro-gastric tube, empty stomach contents, and lavage with 100-200 ml of water or saline until clear 3. Activated charcoal: Treatment of choice for GIT decontamination Give 5060 g of charcoal slowly orally or by gastric tube gastric absorption absorption of toxic substances in the blood. Usually given with one dose of a cathartic agent 4. Whole bowel irrigation: Done with bowel cleansing solutions of polyethylene glycol and electrolytes (e.g. Ringer), rather than with normal saline, which may cause fluid overload and hypokalemia. 1-2 L/hr orally or by gastric tube, until rectal effluent is clear or x-ray is negative for radiopaque materials
20
Figure (1-1): Toxin Exposure

Toxin Exposure
A. Medical history B. Physical examination C. Immediate management: 1. IV line (Ringer or saline) 2. Provide O2 by mask 3. Fix Follys catheter
Patient Conscious?
Yes GIT Decontamination: 1. Emesis by ipecac 2. Gastric lavage by water 3. Activated charcoal 4. Whole bowel irrigation Patient improved?
No
Do not waste time Refer to toxic center by equipped ambulance with life support
Yes 1.Continue first aid management 2. Toxin Antidote if available
No
Follow the referral guidelines No
Yes Continue management and
21
Trauma
Begin with the ABCs then Survey progress System assessment Patient management. (I) ABCs to start trauma management as follows: A: Airway maintenance with cervical spine control. B: Breathing maintenance with ventilation. C: Circulation maintenance with hemorrhage control. D: Disability: Do either of the neurological examination: AVPU system: A = Alert; V = responds to Vocal stimuli; P = responds to Painful stimuli; U = Unresponsive. Glasgow Coma Scale (GCS): Based on the best response of E +V+M Other neurological exam: Examine for unequal pupils, depressed skull fracture, focal weakness, and posturing. E: Exposure / Environmental control, completely undress the patient, but prevent hypothermia. R: Resuscitation: IV access: insert IV lines e.g., 2 large-bore, 18-gauge antecubital lines. Estimate and replace fluid and blood loss.
Musculoskeletal:
Assessment: Look for evidence of trauma, including contusions, lacerations, and deformities. Inspect the extremities for tenderness, pain, crepitus, abnormal range of motion, and sensation. Management: Obtain radiographs as needed. Maintain immobilization of the patients thoracic and lumbar spine. Apply a splint if indicated. Open fractures require urgent orthopedic consultation. Tetanus immunization
22
Figure (1-2): Patient with trauma

Patient with trauma A- Medical history B- Physical examination C- System assessment D- Immediate management: 1. IV line (Ringer or saline) 2. Provide O2 by mask 3. Fix Follys catheter Severe or multiple trauma
No
Yes
Patient Conscious?
Do not waste time Refer to hospital by equipped ambulance with life support
Yes
No
ABCS and Survey
Patient improved?
Yes
No
Continue first aid management and
23
Animal bite
Do first aid for the wound (clean the wound by water and soap) Do not suture the wound Give empirical antibiotics to prevent secondary infection Active immunization by human diploid vaccine at 0, 3, 7 ,14 and 28 days Passive immunization by human rabies immunoglobulin for dangerous wounds or wound near the brain. The dose is 20-40 IU/ kg body weight If the animal is wild, immediate treatment is indicated: Active immunization with human diploid cell vaccine (HDCV). Passive immunization with human rabies immune globulin (HRIG).
Scorpion bite: 1- Analgesic 2- Antivenom Snakes bite : 1- observation for 12-24h 2- no excision of bite area 3- no arterial tourniquet 4- diazepam for anxiety 5- I.V fluids & volume expander for hypotension 6- Antivenoms as early as possible by slow IV 7- usually this is allergic ! adrenalin ( 1 in 1000) & continue antivenoms 8- antibiotic of wound is infected 9- antitetanous prophylaxis Tetanus: 1- clean wound & debridment 2- give tetanus Ig 250u + tetanus toxoid booster 3- if not vaccinated before : give tetanus toxoid : Day zero 0.5ml IM 8 wks 0.5ml IM 6-12 m 0.5ml IM Booster every 5 years
24
Foreign body aspiration

Most foreign body aspirations occur in children under the age of 4 years Physcial finding may include stridor, wheezing, tachypnea, cough or apnea, air traping may leads to hyperinflation, do the Heilmlich manouvre ( subdiaphragmatic abdominal thrusts), if not successful , Rapid referal with airway support, O2 mask. Burns Determine if the victim is in closed or an open space: Any toxic products of combustion? Any respiratory symptoms? Carbon monoxide poisoning? Examination: 1. Estimate the Body Surface Area (BSA) involved. Rule of 9s: Table (1-3): Estimate the Body Surface Area (BSA)
Adult Child Head 9% 18% Arm 9% 9% Back 18% 18% Front 18% 18% Leg 18% 14%
2. Determine the depth of the burn: Table (1-4): Determine the depth of the burn
Degree First degree Second degree (superficial) Second degree (deep) Third degree Fourth degree Tissue involvement Epidermis only. Epidermis and superficial dermis. Epidermis and deep dermis. Epidermis and entire dermis. Below dermis to bone, muscle, and fascia. 25 Findings Red and painful. Red, wet, and painful with blisters. White, dry, and tender. Charred, pearly white, and nontender. Red and painful.
Treatment: 1. Pre-hospital: IV fluid and high flow 100% oxygen. Remove patients clothes and cover with clean dressing. Place under cold running water for 10 minutes or until pain is relived. Dont burst blisters. Administer pain medications. Check tetanus immunity , give immunization and/or prophylaxis as necessary. Apply silver sulfadiazine or sterile Vaseline impregnated gauze and non adherent dressing and follow up , every 1-2 days ( for healing & infection ). Refer the following cases: 1- Cases of more than 10% children or 15 % adults. 2- Burns affecting face ( eyes & ears ), neck, both hands, both feet and perineum. 3- Electric , chemical and smoking inhalation. 4- Presence of associated injuries : soft tissue truma, fractures & head injuries. 5- Presence of medical problems: diabetes, heart disease , pulmonary disease & ulcer history. 6- Social problems such as suspected child abuse or neglect , self inflicted burns and psychological problem.
26
Figure (1-3): Burn

Burn
A- Take history cause of burn B- Physical examination C- Estimate the Body Surface Area (BSA) involved. Rule of 9s D- Pre-hospital: 1. IV fluid and high-flow O2. 2. Remove patients clothes and cover with clean dressings. 3. Administer pain medications
Determine the depth of burn
1. First degree 2. Second degree (superficial)
1. Second degree (deep) 2. Third degree 3. Fourth degree
Manage as outpatient
1- Irrigate the wound with saline 2- Use swab and gently clean the wound. 3- Apply local antibiotic ointment on burn. 4- Close the wound by Vaseline based dressing 5- Broad spectrum antibiotics 6- Close the wound for 2 weeks unless infected.
27
Electrical injury Electrical current flows easily through tissues of low resistance
Symptoms: 1. Alternating current AC- (household and commercial): a. Explosive exit wounds. b. Effects are worse with AC than with DC current at the same voltage. c. Ventricular fibrillation is common. 2. Direct current DC- (industrial, batteries, lightning): a. Discrete exit wounds. b. Asystole is common. Treatment: ABCs (see trauma). Treate burns. IV fluids for severe burns. Pain control. Treate myoglobinuria by IV fluids to maintain urine output of 1.5-2 cc/kg/hr. Tetanus prophylaxis. Asymptomatic low-voltage (<1000 V) burn can go home. (nerves, blood vessels, mucous membranes, and muscles).
The current pathway determines which organs are affected.
Heat Exhaustion The patient presents with extreme fatigue with profuse sweating, Body temperature is normal or slightly increased. Patients are tachypneic, tachycardic, and hypotensive. Treat with IV saline and a cool environment.
A true emergency! Body temperature; altered mental status. Hot, dry skin, often with no sweating Ataxia.
28
with nausea or vomiting and dull headache.
Heat Stroke
Treat with rapid and aggressive cooling. Remove from the heat Anaphylaxis
source and undress. Atomized tap water spray; ice packs to the groin and axilla.
Anaphylaxis is a generalized immunological condition of sudden onset which develops after exposure to a foreign substance in a previously sensitized person. Common causes of anaphylaxis Drugs (antibiotics especially penicillins, streptokinase, aspirin, and nonsteroidal anti-inflammatory [NSAI]) Foods (nuts, shellfish, strawberry) Vaccines Clinical features: The speed of onset (minutes to hour) and severity vary according to the nature and amount of the stimulus. A prodromal stage, or feeling of impending death may present. Patients with history of asthma may have severe features. Respiratory system: Swelling of lips, tongue, pharynx and epiglottis upper airway occlusion. Lower airway involvement similar to severe acute asthma, dyspnea, wheeze, chest tightness, hypoxia and hypercapnia. Skin: Pruritus, erythema, urticaria and angio-oedema. Cardiovascular: Peripheral vasodilation and vascular permeability plasma leakage from circulation hypotension and shock. Arrhythmias, ischaemic chest pain and ECG changes may be present. GI tract: Nausea, vomiting, diarrhea, abdominal cramps. Treatments: Resuscitation guidelines: Discontinue further administration of suspected agent as drug.
29
Remove stings using forceps or by scraping from skin. Give 100% Oxygen. If hypotention , rapidly administer large volumes of crystalloid Epinephrin ( 0.3 to 0>5 ml of 1: 1000 q 5 to 10 min ) may be administered IV , SC, or by Nebulizer Antihistamines are helpful , including H1 blokers such as IV or IM diphenhydramine . H2 blokers have also proved helpful such as the administation of Famotidine 20 mg PO or IV Steroid are used to control presistent allergic reactions such as : - Methylprednisolone 125 mg IV is ordered for severe cases - In less severe cases, prednisone 60 mg PO , either in a pulse dose or tapering dose , is prescribed over several days Patient with less severe reactions can be observed for several hours Refer all patients with a severe reaction to Intensive care Unit. Provide all patients with serious reactions with Med- Alert Bracelets , consider refer all to an allergist for further testing and desensitization therapy
Table (1-5): Adult immunization Influenza Hepatitis A Hepatitis B Given to Visitors to Haj and Omra High risk patients Health care workers Given to food handlers High risk patients Health care workers Given to Visitors to Haj and Omra High risk groups (military and police recruits) Travelers to endemic areas Given to travelers to endemic areas
30
Meningococcal Yellow Fever
Figure (1-4): Anaphylaxis

Anaphylaxis 1- History of severe allergic reaction 2- Respiratory difficulty or hypotension 3- Skin changes 4- System assessment 100% oxygen by mask Striders, wheeze, respiratory distress or clinical signs of shock Adrenaline (Epinephrine) 1:100 solution 0.5 ml IM Repeat in 5 min if no response Antihistaminic (Chlorphenarmin) 10-20 mg IM
In Addition
For all severe or recurrent reaction and the patient with Asthma Hydrocortisone 100-50 mg IM
If clinical manifestion of shock not respond to drug treatment 1-2 IV fluid by rapid infusion
Refer to hospital by equipped ambulance with life support
31
Figure (1-5): Hypotension, shock and acute pulmonary edema

Hypotension, shock and acute pulmonary edema
1. Quick history review. Check vital signs and examine the patient. 2. Signs and symptoms of congestive heart failure, acute pulmonary edema. 3. Assess ABCDs, secure airways, administer oxygen, secure I.V. access. 4. Monitor ECG, pulse, blood pressure, protable chest x-ray. 5. Determine differential diagnosis. Determine underlying cause
Hypovolemia
Heart Failure
Bradycardia or Tachycardia
1. 2. 3. 4.
Administer fluids/blood Consider vasopressors Apply hemostatis Treat underlying problem
Determine blood pressure
Be ready for CPR
Refer to hospital by equipped ambulance with life support accompanied by physician

32
Cardiac arrest
The appropriate and timely management of patients with cardiac arrest is one of the most challenging to confront the doctor. Obtain the following information from ambulance crew or relatives: 1. Time of collapse. 2. Patient information, including age, medical history, current medication, chest pain before event. 3. Clinical features. Cardiac arrest is a clinical diagnosis: 1. Any unconscious patient that does not have a major arterial pulse (carotid or femoral) = Pulseless is in cardiac arrest. 2. The time taken to check for a pulse or other signs of a circulation should not exceed 10 sec. 3. Other clinical features (e.g. color, pupil size and response) do not waste time but continue with the diagnosis. 4. Some respiratory efforts such as gasping, may persist for several minutes after the onset of cardiac arrest. 5. Occasionally, cardiac arrest may present as a grand mal fit of short duration. Management: Cardio-Pulmonary Resuscitaion (CPR) Basic life support guidelines: 1. Confirm the patient unresponsiveness 2. Call the emergency medical assistance and Ambulance. 3. Refer once ambulance arrived and complete the steps in the ambulance. 4. Open airway 5. Check breathing if no breathing, make 2 initial breaths 6. Check carotid pulse if pulseless, do the following: a. Begin chest compressions at the rate of 100 compressions per min, depressing sternum 3.5-5 cm per compression in patients older than 8 years b. In between chest compressions:
33
In non-intubated patients deliver 15 compressions, pause for 2 breaths, then repeat In intubated patients deliver 1 breath every 5 sec, with no pause in compressions 7. Reassess for spontaneous circulation every 1-3 minutes 8. Call the emergency medical assistance Airway and ventilation Mouth to mouth ventilation: With the patient on his back, open the airway by tilting the patients head and lifting the chin. (Avoid head tilt if trauma to the neck is suspected). Remove any visible obstructions from the mouth. Give breaths lasting 2 secs. Each should make the chest rise. After each breath, maintain the head tilt/chin lift, take your mouth away from the patients and watch for the chest to fall as the air comes out. Use a ratio of 15 chest compressions to 2 ventilations (15:2). Chest compression:
Place the heel of one hand over the lower half of the patients Extend or interlock the fingers of both hands and lift them to avoid With yourself above the patients chest and your arms straight, Release all the pressure and repeat at a rate of 100/min. Compression and release phases should take the same time.
press down to depress the sternum 4-5 cm. applying pressure to the patients ribs. sternum, with the other hand on top of the first.
34
35
Figure (1-6): Basic Life Support
Basic Life Support

Check Responsiveness Shake and Shout
Open Airway
Head tilt / chin lift
Check Breathing
Look, Listen and Feel
Breathe
2 effective breaths
Assess 10 sec only
Signs of circulation
Circulation present Continue rescue breathing
No circulation Compress chest
100 per min Check circulation every min
Call for help as soon as possible according to guidelines

36
Chapter 2
Basic Surgical Skills
Chapter 2: Basic Surgical Skills
Basic Surgical Skills

Location and equipment: A suitable room, adequate lighting and appropriate equipment are needed for successful minor surgery. An experienced assistant is of great help. Sterile instruments and gloves and aseptic technique. Basic minor surgery sets: Scalpel; several sizes of blade (e.g. size 11 and 15); toothed forceps; needle holder, fine scissors; artery forceps; skin hook; curette. Additional equipment required: Skin preparation liquid (e.g. Betadine) Local anesthetic (e.g. lignocaine 1%) Suitable sized needles and syringes Sterile towels and swabs Sterile specimen pots Suture materials and dressings for the wound. Basic techniques: Local anesthesia: 0.5-2% lidocaine, and xylocaine, is the most commonly used preparations. Epinephrine (1:200,000) in local anesthesia bleeding and prolongs anesthesia, but do not use epinephrine in areas supplied by end-arteries (i.e. fingers, toes, penis, ear, nose). The safe maximum dose of local anesthetic in adults is 20-ml of 1% solution (less in elderly and children); overdose causes fits or cardiac arrhythmias. Administering local anesthetic: Pre-warn patients that local anesthetic causes numbness but the patient is still able to feel pressure but not pain. If pain is felt, more anesthetic is needed. Clean the skin, insert a small needle intradermally, and raise a small bleb before infusing more deeply. Always pull back the syringe plunger before injecting site to be
39
Anesthetic must be infused all around the excision site. This may
require several needle insertions so try to do this through an already numb area to comfort the patient. Allow time for the anesthetic to take effect (5-min) before proceeding.
sure that you are not in a blood vessel.
Suturing: Various techniques for suturing and knot tying can be used (e.g. interrupted, continuous, sub-cuticular). Always make a careful record of the number of stitches and when they should be removed. Usually stitches need removal after 3-5 days, on the face, 7-10 days on the back and legs, and 5-7 days elsewhere. Sterile dressing is used after stitches to protect the wound from contamination. Suture types: Absorbable: e.g. catgut, dexon, and vicryl are used to stitch deep layers to decrease wound tension. Non-absorbable: e.g. silk, prolene, and nylon are used for closure of skin wounds after minor surgery. Needle types: Straight, curved, cutting, or round bodied. Surgical site and personal preference dictate which to use; a cutting needle is usually used for skin. Suture thickness (gauge): Indicated by a number (10/0 is fine and 2/0 thick). For skin closure: 6/0 or 5/0 is usually used for the face, 3/0 on legs and back, and 4/0 elsewhere. Skin wound closure: Close the wound by carefully apposing the edges (slightly everted) using cutting needle by interrupted non-absorbable sutures (e.g. silk). Avoid tension in the sutures and knot securely. Large wounds may benefit from the use of deep absorbable
40
sutures (by rounded needle) to reduce skin tension. Wound management: Use a systematic approach, starting at the centre of the wound out to the periphery. Gently sweep the debris and dirts away from the wound. Any foreign bodies should be removed using the forceps; this should prevent any infection. A solid object embedded within the wound such as a piece of broken glass may be removed using forceps when performing this procedure. Irrigate the wound with saline. A swab is then used to gently to clear the wound.
Suturing Technique
Loading needle onto Needle Holder
After opening the suture pack, the needle is presented ready for Grasp the needle with the tip of the needle holder. When removing the suture from the pack, it is often useful to use The needle can be held two thirds away from the tip and When using a half curved needle, it can be held half way along It is important that the needle is grasped at the tip of the jaws of
the needle holder. the shaft at a right angle. perpendicular to the needle holder. your little finger to take up the slack in the suture. mounting in the needle holder.
41
Interrupted Suturing:
To make a bite through the skin, start with the needle point
perpendicular to the surface.As the needle is advanced, turn your wrist so that the needle follows a curved path and will emerge at an equal distance from the opposite wound edge. The suture is then tied.The knot is made on the side of the wound so that it does not interfere with the healing process. To estimate the next bite placement, consider the distance of the first bite from the wound edge. The next bite should be placed at a point that is double this distance.The needle is again introduced at 90 degrees to the surface and driven along a curved path, with counter pressure applied. Further sutures are placed at equal distances until the wound is closed.Ensure that the knots are sitting at the side of the wound and not directly above the incision site.
Removal of sutures: The suture is divided just below the knot, and the tail pulled so that the external part of the suture does not pass through the deeper tissues. Abscess Drainage
When an abscess forms, there is overlying skin erythema and a
central area of thin and necrotic skin tissue.The area is gently palpated to find the maximum point of fluctuation. The first step is to make a generous incision at this point.This will result in an immediate release of pus, which should be cleared away using swabs. There will be a cavity, which still contains pus and an overlying linear skin incision.It is vital to ensure that the skin incision cannot close over.Making a generous skin incision can do this.Usually, an elliptical incision should be made. A swab is taken, placed in a container and sent for culture and sensitivity tests at the bacteriology lab. The next step is to express the remaining pus usingtwo handed
42
pressure and plentiful swabs to clear away the exudates.Now there will be a cavity and an overlying cruciate incision. It is sometimes necessary to excise the edges of necrotic skin tissue. A finger is then inserted into the cavity to break down any loculi, leaving one continuous space.If necessary, the cavity can be irrigated with saline using standard syringe. 3% hydrogen peroxide can be used to help clean out the cavity. A pack must be inserted into the cavity to keep the osteum open and to absorb any further exudates. The pack is loosely inserted, leaving a small tail for subsequent removal. The pack will remain in place for about 24 hours and will then be replaced by clean dressing. When removing the pack, make sure that it is moist, as pulling out a dry dressing will disturb the granulation tissue forming at the base of the cavity.If a dressing is used, it is important to match with the size of the cavity, as a larger dressing may cause maceration of the surrounding normal tissue.
N.B : Abscess at Dangerous areas ( breast , face, Diabetic foot, preanal abscesses ) need to be referred.
43
Chapter 3
Cardiovascular System
Chapter 3: Cardiovascular System
Introduction: - The prevalence of hypertension increases with age. Morbidity and mortality of hypertension increase with higher systolic and diastolic blood pressures. Hypertension is usually asymptomatic and occurs in 20-40% of population. - Before blood pressure measurement, the patient should be seated, arm exposed, supported, and at heart level. No smoking, caffeine, or exercise for 30 minutes before measurement. - Hypertension should be confirmed in at least 2 subsequent visits (unless severely elevated). Table (3-1): Assessment of Severity of the blood pressure
Category Normal Prehypertension Blood Pressure mmHg Systolic < 120 120139 Diastolic < 80 8089 2-5 years In 2 years Any risk factor Any risk factor Follow-up Treat
Hypertension (HTN)
Hypertension Stage 1 (Mild) Stage 2 (Moderate) Stage 3 (Severe) Stage 4 (Very Severe) 140159 160-179 180-209 210 9099 100-109 110-119 120 Evaluate within 2 months Evaluate within 1 month Evaluate within 1 week Evaluate daily
Diagnosis: Medical History: 1. The duration of hypertnesion, if known. 2. Appearance of symptoms, e.g. headache 3. Drugs used to control blood pressure and its side effects. 4. Hypertension risk factors: e.g. a. Smoking, diabetes, and hypercholesterolemia b. Family history of hypertension. 5. Exclude secondary causes:
47
a. Renal: Renal infections, stoness, hematuria, and proteinuria. b. Pheochromocytoma: Paroxysms of headache, pallor, and/or palpitations. c. Cushings syndrome: Central fat distribution, muscle weakness, purple striae, amenorrhea, and diabetes. d. Hyperparathyroidism: Proximal muscle weakness, psychological disturbances, abdominal symptoms. Family history: Polycystic kidney, collagen vascular disease, thyroid and parathyroid diseases, and hypertension Medication history: The use of anabolic steroids, smoking, oral contraceptive pills, appetite suppressants, non-steroidal anti-inflammatory drugs (NSAIDs), and tricyclic antidepressants. General physical Examination: 1. Height and weight and record. 2. Observe body habitus (hypercortisolism). 3. Estimate blood pressure from both arms. 4. Fundoscopy: To asses hypertensive retinopathy. 5. Neck: Carotid bruits, and neck veins distension. 6. Heart: Size, Point of maximal intensity (PMI) displaced laterally, clicks, murmurs, and gallops. 7. Lungs: Rales [congestive heart failure (CHF)], and wheezes (avoid -blockers). 8. Abdomen: masses, and enlarged kidneys. 9. Extremities: Edema, decreased peripheral pulses. 10. Neurologic: Paresthesias, and weakness; previous cerebrovascular accident (CVA)). 11. Endocrinologic: Diabetes mellitus, hyperthyroidism. Classic Features of Essential Hypertension: 1. Onset of hypertension in the 4th or 5th decade of life 2. Family history of hypertension 3. Usually asymptomatic 4. BP <180 systolic or <110 mmHg diastolic at diagnosis 5. History, examination, and laboratory studies are normal 6. BP control achieved with lifestyle changes and 1 or 2 drugs
48
7. BP control is maintained once achieved Laboratory Evaluation: 1. Urinalysis: Protein, blood, and glucose. Microscopic for red blood cell (RBC), and casts 2. Hematocrit: Increased in polycythemia, decreased in renal insufficiency. 3. Blood sugar: For diabetes, Cushings, pheochromocytoma, hyperaldosteronism. 4. Potassium: in mineralocorticoid induced hypertension . 5. Blood urea nitrogen (BUN) and creatinine: for renal failure. 6. Cholesterol, triglycerides, high density lipoprotein (HDL) for Cronary Artery Disease (CAD) risk status. 7. Calcium: for hyperparathyroidism. 8. Uric acid: with renal disease and HTN. 9. Chest x-ray (CXR): cardiomegaly, left ventricular hypertrophy (LVH), congestive heart failure (CHF) and aortic coarctation. 10. Electrocardiogram (ECG): LVH and left atrial enlargement (LAE) of HTN, and/or previous myocardial infarction (MI). Management: It aims at maintaining blood pressure below 140/90 mmHg (for nondiabetic; non-renal diseased patients) and below 130/80 (for diabetic OR renal diseased patients). A. Non-pharmacologic therapy: Lifestyle modifications for prevention and management: 1. Weight reduction if overweight, discontinue tobacco use 2. Increase aerobic exercise walking (30-45 min/day for 5 days a week ) 3. Reduce sodium intake (2.4 g sodium OR 6 g salt/day) 4. Maintain adequate intake of potassium (Banana & Orange fruits) 5. Diet rich in fruits and vegetables with reduced fat intake. B. Pharmacologic therapy: - Start therapy with a drug from any of the following drug classes (unless there is a contraindication OR compelling indication to a certain class): thiazides calcium antagonists ACE inhibitors or.. ARBs. - Start by single drug therapy If inadequate response Increase the
49
drug dosage, substitute another drug If inadequate response Consider adding a second drug from a different class or diuretic, if not prescribed. Table (3-2): Adverse effects of common antihypertensive Drugs (Page 28 Vol 5 Clinical Practice Guidline)
Drug Dosage Form Side-effects CVD: postural hypotension Digestive: jaundice, diarrhea, vomiting, constipation, gastric irritation, nausea, anorexia. Hematologic: leucopenia, hemolytic anemia, thrombocytopenia. Hypersensitivity Metabolic: Electrolyte imbalance Digestive: Gastric bleeding, gastritis, diarrhea nausea and vomiting. Endocrine: Gynecomastia Hematologic: Agranulocytosis Hypersensitivity - Cough, Rash - Renal Failure - Neutropenia - Angioedema - Taste impairment - - - - Bradycardia Cold extremities Tiredness Impotence Contraindication
Hydrochlorothiazide
Tablets 25 mg
- Severe renal & hepatic impairment - Anuria
Furosemide
Tablets 40mg Injection 40mg
- Liver cirrhosis - Hypokalaemia - Anuria
Spirolactone
Tablets 25mg
- Renal impairment - Anuria - Hyperkalemia
Captopril
Tablets 25mg
- Bilateral renal artery stenosis - Hyperkalaemia - Neutropenia - Sinus bradycardia - Heart block greater than first degree - Cardiogenic shock
Atenolol Propranolol
Tablets 50mg Tablets 10mg & 40mg
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Nifedipine
Tablets 20mg
- - - -
Flushing Oedema Postural hypotension Headache
- Hypersensitivity
Deltiazem
Tablets 60mg Capsules 90 mg, 120mg, 180mg
- Bradycardia/heart block
- Heart failure, heart block - Severe hypotension (less than 90mm Hg systolic)
Methyldopa
Tablets 250mg
- Drowsiness during the first few weeks of therapy - Fluid retention - Headache - Weakness
- Liver disease or cirrhosis - Hypersensitivity
Table (3-3): Doses of common antihypertensive drugs

Drug class and types Diuretics: Hydrochlorothiazide Furosemide Beta-blockers: Atenolol Metoprolol bisoprolol Calcium Channel antagonists: Diltiazem Verapamil Nifedepine ACE Inhibitors: Benzapril Lisinopril 10 - 40 mg 10 - 40 mg Once a day Once a day 90-360 mg 80-480 mg 30-120 mg 3 times a day Twice daily Twice daily 25-100 mg 50-200 mg 5-10 mg Once daily 1 or 2 daily Once daily 12.5-50 mg/day 20-100 mg Once daily Twice daily Dosage Range Frequency
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Figure (3-1): Hypertension
Hypertension
1. Lifestyle modifications + or 2. Start with lowest recommended dose once-daily drug. Combination therapy if BP > 20/10 mm Hg above desired level.
Not at goal blood pressure (2-4 wk)
No response or significant side effects
Partial response and well tolerated
Substitute another drug from a different class
Increase dose of initial drug, or add agent from a different class (diuretic if not chosen initially)
Not at goal blood pressure (2-4 wk)
Continue titrating doses and adding agents from other classes at regular follow-up visits
Not at goal blood pressure
1. Consider resistant hypertension & 2. Refer to higher level of health care
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Figure (3-2): Management Of Rapid Severe Hypertension
Rapid BP >220/130
Severe symptoms of acute TOD
Yes
No
Sublingual Captopril Tablet (12.5 mg)
Retinal hge / exudates/ papilloedema (malignant HTN)
Refer immediately to emergency unit Combination of rapid acting oral hypertensive drugs Start oral antihypertensive drugs
- Never use sublingual nifedipine.or IV Lasix ( severe organ hypoperfusion and leads to more damage ) - Routine follow up for 3 weeks after Referal When to refer? Suspecting 2 ry hypertension Complicated hypertension Multiple risk factors Difficult or resistant to treatment Pregnancy
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Figure (3-3): DD of chest pain
DD of chest pain
Constant Intermittent
Without significant HTN
With significant HTN
Precipitated or increased by breathing
Not affected by breathing & relieved by nitroglycerine
Dissecting aneurysm Myocardial infarction
Pleurisy, fractured rib, costochondritis, pneumothorax
Lasting 10-20 min. or <
Relieved by antacids
Not relieved by antacids
Esophagitis & hiatal hernia
With hemoptysis
Without hemoptysis
Angina pectoris
Pulmonary Embolism
With fever & sputum
Without fever or sputum
Coronary insufficiency
Aggravated by movement
Not aggravated by movement
Pneumonia
Pericarditis Muscular
Myocardial Infarction
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Figure (3-4): Management of Chest pain
Management of Chest pain
1.History: Details and description of chest pain (anginal versus non-anginal or atypical) 2.Cardiovascular risk factors. 3.Physical examination.
Suspicion of CAD
Low
Intermediate
High
No additional diagnostic testing
Refer to higher level of health care for evaluation and management initiation
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Figure (3-5): Dyspnea or Palpitations
Dyspnea or Palpitations
History Physical examination
Diagnosis established
Diagnosis not established
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Chapter 4
Adult Medicine
Chapter 4: Adult Medicine
Definition: Hemoglobin level less than 13gm/dl.in adult males or less than 12gm/ dl.in adult females. Figure (4-1): Anemia
Anemia
Anemia
Microcytic
Normocytic
Macrocytic
- Iron Deficiency - Anemia of chronic disease - Thalassemias - Hemoglobinpathies - Sideroblastic anemia
- Anemia of chronic disease - Early iron deficiency - Hemoglobinpathies - Primary marrow disorders - Combined deficiencies - Increased destruction
- Megaloblastic anemias - Liver disease / alcohol - Hemoglobinpathies - Metabolic disorders - Primary marrow disorders - Increased destruction
Anemia is classified by the size of the mean corpuscular volume (MCV) to microcytic, normocytic, or macrocytic. Diagnosis: 1. Start by CBC, MCV, blood smear, reticulocyte count. 2. According to type of anemia you may request: iron studies (ferritin, serum iron), serum folate, TSH, serum B12, hemolysis labs (LDH, unconjugated bilirubin, haptoglobin, Coombs test), DIC panel (D-dimer, fibrinogen). 3. Look for a bleeding source. Consider blood typing and cross match if the patient is in active bleeding. 4. Look for pancytopenia: Causes include systemic lupus, toxins, drugs, infection, myelodysplasia, malignancy, radiation, and vitamin B12/ folate deficiency.
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Treatment: 1. Severe anemia requires packed RBC transfusion. 2. Transfuse to keep serum hemoglobin >8 gm/dL, or >9g/dL for CAD patients. 3. Identify the cause of the anemia and treat the underlying disorder Anemia with an MCV <80 fL Clinical presentation: - Patients with Iron deficiency anemia may have eating disorder (Pica). Ask about history of blood in the stools. - In females, ask about heavy menstrual periods. Diagnosis: 1. Lab studies of iron(serum iron; TIBC;&serum ferritin), and CBC to identify the cause of the microcytic anemia. 2. Suspect colorectal cancer in elderly patients with microcytic anemia, and refer these patients for a colonoscopy. 3. Suspect gynecological cause in females and refer to a specialist. D.D.of microcytic anemia: 1. Iron deficiency. 2. Anemia of chronic disease. 3. Thalssemia. 4. Sideroblastic anemia. Treatment: 1. If iron-deficiency anemia is the cause identify the site and cause of blood loss and start oral iron supplementation. 2. Patients with anemia of chronic disease EPO may be administered e.g: in patients with CKD. 3. Patients with thalassemia treat with blood transfusions. Anemia with MCV >100 fL Diagnosis: 1. Estimate serum B12 level, serum folate level, and CBCto look for megaloblastic anemia. 2. Hemolysis: reticulocyte, LDH, unconjugated bilirubin, haptoglobin.
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Microcytic Anemia
Macrocytic Anemia
Characterized by: Hypersegmented neutrophils. Causes: 1. B12 or folate deficiency and drugs (e.g. azathioprine, AZT, hydroxyurea, chemotherapeutic agents). 2. Others include liver disease, alcohol abuse, and myelodysplasia. Treatment: 1. B12 deficiency with monthly B12 shots; treat folate deficiency with oral replacement. 2. Discontinue medications that cause megaloblastic anemia Anemia with MCV of 80100 fL Clinical diagnosis: - Evidence of acute bleeding by history and examination. - Hemolytic anemia may present with jaundice from unconjugated hyperbilirubinemia as well as with dark urine on standing in test tube. Diagnosis Laboratory blood tests reticulocyte count, creatinine, and blood hemolysis indicators: 1. Decreased reticulocyte count: Anemia of chronic disease or chronic renal failure (CRF). 2. Increased reticulocyte count with normal hemolysis labs (= hemorrhage. 3. Increased reticulocyte count, LDH, unconjugated bilirubin, haptoglobin (= hemolysis). Causes include the following: a. Microangiopathic hemolytic anemia: Schistocytes or helmet cells on blood smear. b. Hereditary spherocytosis: Spherocytes and Coombs test. c. Autoimmune hemolytic anemia: Spherocytes with Coombs test. d. Sickle cell anemia. Treatment: - Patients with chronic hemorrhaging may need packed RBC transfusions.
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Megaloblastic anemia
Normocytic normochromic anemia
- -
The cause of the bleeding must be identified and treated. Anemia from CRF treated with Epo and iron.
Sickle Cell Anemia

An autosomal-recessive disease resulting from the substitution of valine for glutamic acid at the 6th position in the goblin chain Clinical presentation: 1. Sickle cell patients often have a family history. 2. More common in black races. 3. May be history of gallstones and poorly healing leg ulcers. 4. Exam: may be jaundice, splenomegaly (usually during childhood but in adulthood: autosplenectomy), or CHF. Diagnosis: 1. Hemoglobin electrophoresis is the definitive diagnostic test. 2. Sickled cells by blood tests Treatment: 1. Patients should be vaccinated for Streptococcus pneumonia, Hemophilus influenza, and hepatitis B. 2. Blood transfusion for severe anemia. 3. Folic acid. 4. Avoid dehydration, hypoxia, intense exercise, and high altitudes(e.g.: flight in aeroplane). Deep vein thrombosis may be proximal (involving veins above the knee) or isolated to the calf veins. Predisposing factors: Table (4-1): Deep vein thrombosis (DVT)
Age >40 years Smoking Obesity Immobility Recent long distance travel Pregnancy Puerperium Contraceptive pill/HRT 62 Surgery Recent trauma Malignancy Heart failure Nephrotic syndrome Inflammatory bowel disease Chronic illness as Diabetes Burns
Deep vein thrombosis (DVT)
Clinical presentation: Unilateral leg pain, swelling and or tenderness mild fever, pitting edema, warmth, and distended collateral superficial veins Differential diagnosis: 1. Cellulites 2. Hematoma 3. Ruptured tendons. 4. Superficial thrombophlebitis 5. Chronic venous insufficiency 6. Venous obstruction 7. Post-thrombotic syndrome 8. Acute arterial ischemia Immediate action: Clinical diagnosis is unreliable. Only 50% of clinically suspected DVT have a diagnosis confirmed on diagnostic imaging. Refer all suspected DVT for further specialist assessment. Remember Virchows triad when thinking of risk factors for deep venous thrombosis (DVT) and PE: 1. Stasis: Immobility, CHF, obesity, central venous pressure (CVP). 2. Endothelial injury: Trauma, surgery, recent fracture, prior DVT. 3. Hypercoagulable state: Pregnancy, oral contraceptive pills (OCP), coagulation disorder, malignancy, burns. Symptoms: Any patient with risk factors and complaints of leg pain or swelling, followed by acute-onset of chest pain (pleuritic), shortness of breath, or syncope should be suspected as having PE. Examination: - Tachypnea, tachycardia, cyanosis, loud P2 or S2, jugular vein distension (JVD), and signs of right heart failure.
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Pulmonary Embolism (PE)
Patients may have hemoptysis or low-grade fever.
Differential diagnosis: Most signs and symptoms of PE are non-specific Other causes, as acute myocardial infarction, pneumonia, congestive heart failure, and aortic dissection Refer all suspected cases of Pulmonary Embolism for further assessment and treatment. Table (4-2): Diabetes Mellitus
Characteristic Type 1 Failure of the pancreas to secrete insulin as a result of autoimmune destruction of -cells Usually Under age 30 years Usually not Insulin dependent 15 % Usually negative Type 2 Insulin resistance and inadequate insulin secretion by the pancreas. Usually Over age 30 years Usually yes Insulin may be required 85 % Usually positive
Pathophysiology Age at onset Obesity Treatment Percentage Family history
Symptoms: - Classic symptoms: as Polyuria (including nocturia), Polydipsia, and Polyphagia - Rapid or unexplained weight loss, blurry vision, or recurrent infections (e.g., moniliasis). Differential Diagnosis: Pancreatic disease (chronic pancreatitis), Cushings disease, iatrogenic factors (e.g., corticosteroids), gestational diabetes, diabetes insipidus (DI) Diagnosis: 1 of the following is needed 1. Random plasma glucose 200 mg/dL + classic symptoms.
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2. Fasting plasma glucose 126 mg/dL (in 2 occasions) 3. 2-hour postprandial glucose 200 mg/dL after a 75-g oral glucose tolerance test. 4. Glycosylated hemoglobin (HA1C): > 6.5%. - Patients with a clinical picture suggestive of diabetes should be screened with fasting blood glucose. - Screening every 3 years if the patient: 1. >45 years of age 2. Fasting glucose level of 110126 mg/dL. 3. Obese. 4. Physically inactive. 5. Has delivered a baby weighing >4 kg 6. Family history of diabetes in a first-degree relative. 7. History: gestational diabetes, hypertension, dyslipidemia, or polycystic ovarian disease. Table (4-3): Plasma Glucose Diagnostic Criteria for Diabetes Mellitus
Plasma Glucose Diagnostic Criteria for Diabetes Mellitus

Diagnosis Normal Impaired glucose tolerance (IGT) Impaired fasting glucose (IFG) Diabetes mellitus: Diabetes mellitus: Fasting 8 hr <110 <126 >110 - <126 >126 <126 Fasting Gestational diabetes mellitus (GDM): (2 glucose values are diagnostic) 2 hr after 75 g Oral Glucose <140 >140 - <200 <200 >200 After 100g oral glucose 1 hr >180 >97 2 hr >155 3 hr >140
Diabetes mellitus: (Classic symptoms + plasma glucose 200 mg/dl)
Management: Type (1) diabetics: started on insulin. The most popular regimen for insulin therapy is as follows: a. Estimated total daily insulin requirement: 0.5 U/kg. b. Divide the total dose as:
65
Table (4-4): Estimated total daily insulin requirement

2/3 Pre-Breakfast 2/3 NPH insulin 1/3 regular insulin 1/3 Pre-Dinner 2/3 NPH insulin 1/3 regular insulin
Many type(1) diabetics will need more intensified insulin regimens e.g. regular insulin injection before each meal and a longer acting insulin(NPH or glargine)before bedtime or pre-dinner. Type (2) diabetics: started on life style measures and oral anti-diabetic drugs: a. Stepwise management includes metformin Cidophage, and a sulfonylurea (e.g., glimeperide). b. If the patient continues to have inadequate control on 3 oral antidiabetic drugs from different classes , glimeperide should be replaced with NPH insulin at bedtime. Figure (4-2): Target for acceptable control
FPG < 140 mg/dL PPG < 180 mg/dL Bedtime < 160 mg/dL HbA1c < 7% Cholesterol <200 mg/dL LDL < 100 mg/dL HDL < 40 mg/dL TG < 150 mg/dL BMI < 25 BP < 130-80
Maintenance: Blood glucose monitoring by a glucometer Type (1): 1. Pre-breakfast glucose level reflects pre-dinner NPH dose. 2. Pre-lunch glucose level reflects pre-breakfast regular insulin doses. 3. Pre-dinner glucose level reflects pre-breakfast NPH dose. 4. Bedtime glucose level reflects pre-dinner regular insulin doses. 5. Screen for thyroid disease in newly diagnosed type 1 Type (2): 1. Check fasting glucose level once a day. 2. Check hemoglobin A1c level every 3 months. 3. Maintain HbA1c < 7. 4. Maintain a low-fat, reduced-carbohydrate diet. 5. Manage CAD risk factors hypertension, smoking, obesity, and hyperlipidemia.
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6. Obtain a baseline ECG, if the patient has heart disease or >35 years of age. 7. Check eyes annually for retinopathy or cataracts. 8. Annual BUN/creatinine; urinalysis and urine alb/cr ratio for diabetic nephropathy. 9. Check the feet annually and during every visit for neuropathy, ulcers, and peripheral vascular disease. Patients should inspect feet daily and wear comfortable shoes. Table (4-5): Types of insulin in clinical use
Insulin Type Rapid acting: (Regular, crystalline zinc insulin [CZI]) Very rapid acting: 1. Lispro 2. Insulin aspart Intermediate acting: Lente, neutral protamine Hagedorn (NPH) Long acting: 1. Ultralente 2. Glargine Onset (hr) 0.51.0 Duration (hrs) 6-8 Peak (hrs) 2-3
0.250.5 0.250.5 1 1 1.5
4-6 4-6 10-14
1-2 1-2 4-8 10-14 Non
Adverse Effect & C/I Of Common Oral Antidiabtics
18-24
Table (4-6): Side effects of Oral Hypoglycemics Drug Metformin Side effect 1. GI upset 2. Anemia 3. Lactic acidosis 1. Hepatotoxicity 2. Lower limb edema 3. Weight gain Hypoglycemia.
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Contraindication Renal failure
Glitazone Glyburide or glipizide
CHF
Table (4-7): Oral hypoglycemic combination for Type 2 Diabetes Mellitus Combinations: 1. Sulfonylurea + metformin 2. Sulfonylurea + thiazolidinedione 3. Metformin + thiazolidinedione 4. Metformin + repaglinide 5. Miglitol + sulfonylurea Insulin + any other drug Potentially useful combination: 1. Repaglinide + metformin + thiazolidinedione 2. Nateglinide + metformin + thiazolidinedione Table (4-8): Currently available antidiabetic drugs for type 2 DM Second generation sulphonylurea Glyburide (gilbernclamide) Diabeta Micronase Glynase 2.5-10mg q.d or b.i.d 2.5-10mg q.d or b.i.d 0.75-12mg q.d or b.i.d 10 mg q.d. or b.i.d 5-10 mg q.d. 1-4 mg q.d.
Glipizide
Glucotrol Glucotrol XL
Glimepiride Meglitinids Repaglinide
Amaryl
Prandin
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1.5-2mg t.i.d
Nateglnide Biguaride Metformin
Starlix
60-120mg t.i.d
Glucophage Glucophage XR
500-2.500mg q.d t.i.d. dosing 500-2.000mg q.d.
Thiazolidinediones Rosiglitazone Pioglitazone Glucosidose inhibitors Acarbose Migitol GLP-1 receptor agonists Extenatide Liraglutide DPP-4 inhibitors Sitagliptin Vildagliptin Sythetic analogues Pramlinide Smylin
69
Avandia Actos
4-8mg q.d., 2-4mg b.i.d 15-45mg q.d.
Precose/ Glucobay Glyset
50-100mg t.i.d 50-100mg t.i.d
Byetta
5-10 b.i.d. 0.65-1.9mg/day
Januvia Galvus
100mg q.d 25-50mg b.i.d.
60-120g/day
Table (4-9): Comparison between antidiabetic drug classes

Agent class Secretagogues Sulfonulureas Meglitinides Biguanide (Metformin) 0.5-1.5 0.5-1.5 1-1.5 No effect No effect TG LDL HDL TG LDLHDL TG LDLHDL Increase Increase Hypoglycemia Hypoglycemia Efficacy range (A1c) Lipids Body weight Major side effects
Decrease Gl disturbances Increase Fluid retention; decreased Hb
Thiazolidinediones 0.5-1.5 Piglitazone Rosiglitazone Glucosidase inhibitors GLP-1 receptor agonists DPP-4 inhibitors Pramlintide 0.4-1.0 0.5-1.5 0.6-1.5 0.5-1.0
No effect TG HDL Neutral
Neutral
Gl disturbances
Decrease Gl disturbances Neutral Headaches
Decrease Gl disturbances
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Figure (4-3): Management of type 2 DM Level 1: Well-validated core therapies
At diagnosis: Lifestyle + Metformin
Lifestyle + Metformin + Basal insulin
Lifestyle + Metformin + Salfunylurea
Lifestyle + Metformin + Intensive insulin
STEP 1
STEP 2
STEP 3
Level 2: Less well - validated therapies

Lifestyle + Metformin + Pioglitazone No hypoglycemia edema/CHF Bone loss Lifestyle + Metformin + Pioglitazone + Sulfonylurea
Lifestyle + Metformin + GLP-1 agonist No hypoglycemia Weight loss Nausea/vomitting
Lifestyle + Metformin + Basal insulin
71
Hypoglycemia: Etiology: (Predisposing factors) a) Inappropriate therapy b) Kidney failure c) Liver disease d) Alcohol intake e) Long acting oral hypoglycemic agent Table (4-10): Hypoglycemia Clinical Picture
Adrenergic Tremulousness Palpitations Anxiety Nervousness Hunger Pallor Flushing Cholinergic Parasthesias Sweating Neuroglycopenic Headache Dizziness Confusion Amnesia Blurred vision Aggressiveness Neuronal damage Babinsky sign Transient hemiplegia Seizure
Figure (4-4): Hypoglycemic Therapy

Mild
Hypoglycemia
Severe
Give oral glucose
Glucagon IM
IV glucose 25%
Table (4-11): Commonly available sources of 10 g. of Glucose Commonly available sources of 10 g. of Glucose Orange juice Grape juice Table sugar Honey
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1 cup cup 4 teaspoons 3 teaspoons
1 cup =8 ounces (fluid) 1 tablespoon=3teaspoons Table (4-12): Ketoacidosis

Precipitating events Infections Withdrawal of insulin therapy Type1 at onset Acute myocardial infarction Stroke Unknown causes Clinical manifestations Thirst Polydipsia Nausea and vomiting Acetone in breath Dry skin Polyuria Asthenia Tachypnea and /or Kussmaul breathing Dehydration Hyporeflexia Tachycardia and hypotension Abdominal pain Laboratory signs Blood glucose rarely > 600 mg/dL Urine ketone :intense positive
Therapy: 0.9% Na Cl. IV+ regular insulin 0.4U/Kg, as IV bolus& IM & refer to emergency unit. Table (4-13): Hyperglycemic Hyperosmolar Coma (HHC):
Etiology Onset of type 2 Diabetes Mellitus (Type2DM) Inappropriate treatment Type 2DM Infections Acute myocardial infarction Stroke Thrombophlebitis Drugs Exaggerated food intake Trauma Clinical manifestations Laboratory signs The majority of patients Blood glucose > 800 > 60 year old mg/dL Signs and symptoms of No ketonuria (or mild) intercurrent disease are often present The presence of a severe dehydration (1012 liters) is the rule Elevated mortality (around 10-20%) Neurological alterations Fever 73
Therapy: Administer 0.9% Na Cl & regular insulin 0.15U/Kg, as IV bolus &refer to emergency unit. Table (4-14): Foot care for people with Diabetes For the doctor 1. Ulcer detersion 2. Microbiologic examination 3. Metabolic control 4. Antibiotics Fluoroquinolone Amoxicillin-clavulanic acid Erythromycin/ Clarithromycin Cefoxitin Metronidazole(anaerobes) Imipemen-cilastatin Aminoglycosides 5. Decrease edema 6. No weight bearing 7. Improve circulation 8. Optimize nutritional intake 9. Hyperbaric oxygen therapy 10. Surgical correction Peripheral bypass graft Transluminal balloon angioplasty Minor amputation Major amputation For the patient 1. Do not smoke 2. Inspect feet daily 3. Wash feet daily and dry carefully 4. Avoid temperature extremes 5. Do not walk barefoot 6. Do not use adhesive tapes 7. Do not soak feet 8. For dry skin, use cream 9. Wear properly fitting stockings 10. Do not cut corns and calluses 11. Shoes should be comfortable 12. Cut nails straight across 13. Notify your physician of blisters or sores on foot
74
Figure (4-5): Diabetics Follow up at home
Blood glucose level
Urine
Type 1 Frequent premeal testing
Type 2 3-4/wk
During If Blood sugar Stress & infection > 350 mg/dL
If you Suspect DKA
If you Suspect hypoglycemia
Figure (4-7): Diabetics Follow up at clinic
Every 3 months
Every 6 months
Every 1 yr.
Check self-monitoring & drugs History & clinical examination Feet examination Blood sugar Urine Health education
HbA1c Creatinine
Fundus Microalbuminuria Blood lipid
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Referral: Type 1 diabetes. Seriously out of control Persistent morning hyperglycemia Switching from oral hypoglycemic drugs to insulin Foot ulcer Ketoacidosis or Hyperglycemic Hyperosmolar coma Presence of micro vascular complications: o Neuropathy o Nephropathy o Retinopathy TB : When to suspect TB: Persistent cough > 2 weeks Blood stained sputum Breathlessness and chest pain General symptoms: loss appetite & loss weight Malaise &tiredness Night sweat & night fever History of contact with TB patient Sharp angular deformity of the spine Chronic diarrhea .
76
Figure (4-6): Suspecting TB
AFB Micorscopy
(Acid Fast Bacilli) AFB +++ ++X-ray & physicians judgement AFB ---
Broad spectrum antibiotics
Yes TB
Repeat AFB microscopy
No improvement
Improved (not TB)
AFB +++
AFB ---
X-ray & physicians judgement
Yes TB Treat as Smear positive PTB
No TB
Treat as Consider other Smear negative diagnosis PTB
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Figure (4-7): Standardized Management Plan of TB Suspects (WHO)
Hemoptysis
Chest pain
No chest pain
Pulmonary Embolism
Fever, purulent Sputum
No fever
Pneumonia Lung abscess Tuberculosis Bronchiectasis
Dyspnea Cardiomegaly or murmur
No Dyspnea Cardiomegaly or murmur
Congestive heart failure Mitral stenosis
Carcinoma of lung Bronchiectasis Tuberculosis Parasitic infection Fungal infection Bronchial adenoma
Haemoptysis: Coughing of blood
Refer for further evaluation
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Figure (4-8): Standardized Management Plan of TB Suspects (WHO)
Cough
Sputum
Little or No Sputum
Purulent
Non-purulent
Dyspnea
Emphysema Chronic Pulmonary Fibrosis Pulmonary Embolism Congestive Heart Failure Mediastinal Tumours Asthma
No dyspnea
With fever Pneumonia Abscess Tuberculosis
No fever Chronic Bronchitis Bronchiectasis Foreign Body Cancer of Lung Tuberculosis
Viral upper Respiratory Infection Lung Tumour Reflux Esophagitis with Aspiration Smoking, toxic fumes Hay fever & Asthma Primary Atypical Pneumonia Silicosis
Bloody See Haemoptysis
Mucoid Asthma
Foamy Congestive heart Failure
Refer cases if persistent > 2 weeks

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Figure (4-9): Standardized Management Plan of TB Suspects (WHO) Weight Loss
Anorexia
Normal or increased Appetite
Fever Tuberculosis Other febrile Illnesses AIDS Collagen Disease Lymphoma
No fever
Enlarged Thyroid Hyperthyroidism
Thyroid Not Enlarged
Diabetes mellitus Iatrogenic Normal physical Hyperthyroidism, bulimia exam
Abnormal physical exam Hyperpigmentation Lymphadenopathy
Normal Chest X-Ray
Abnormal Chest X-Ray Carcinoma of stomach, intestine or pancreas, colon
Abdominal Mass Anorexia nervosa Simmonds disease Drugs, scurvy Malabsorption Addisons Leukemia Syndrome Uremia disease Sarcoidosis Lymphoma
Splenomegaly Leukemia Lymphosarcoma, Hodgkins disease Collagen Disease
Midepigastrum Carcinoma of lung tuberculosis, congestive heart failure, pulmonary
Hepatomegaly Liver cirrhosis Liver carcinoma Metastatic cancer
Renal Mass Hypernephroma Wilms tumor Hydronephrosis Polycystic Kidney
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Table (4-15): Severe respiratory symptoms and signs that necessitate urgent referral
Signs and Symptoms Clinical criteria for diagnosis - Temperature more than 39oC - Respiratory rate > 30 per minute - Pulse more than 140 per minute - Arterial systolic tension < 90 mm Hg and / or diastolic tension < 60 mm Hg - Mental confusion or lethargy (drowsiness, or being lazy or sluggish) or Agitation(excitement or restlessness) - Patient seated, hunched forward, speaks only with isolated words - Sub-sternal chest retraction - Pulse more than 140 per minute - Permanent cyanosis - Edema of both legs - Patient sleepy or confused - Unable to speak - No wheeze - Paradoxical respiratory movements - Bradycardia Retro-sternal chest pain, radiating to the upper left arm and / or the neck Sharp latero-thoracic pain Latero-thoracic pain and Clinical context (post-surgery, postpartum) Reasons for urgent referral
Signs of toxic infectious syndrome
Suspicion of severe pneumonia or TB Pre-referral injectable antibiotic if transportation takes more than 4 hours.
Acute respiratory Insufficiency Suspicion of COPD with severe exacerbation or severe attack of bronchial asthma. Right heart failure Suspicion of very severe asthma attack or COPD deterioration with imminent respiratory arrest Suspicion of myocardial infarction Suspicion of spontaneous pneumothorax Suspicion of pulmonary thromboembolism
Signs of severe dyspnea without pain and without fever
Signs of imminent respiratory arrest
Sudden acute localized chest pain With Intense dyspnea
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Severe hemoptysis Abundant pink and frothy expectoration
Signs of shock (pallor, hypotension, confusion, weak pulse)
Need for intensive care
Suspicion of acute pulmonary edema Crepitantions and rales spread over both hemithorax Urgent treatment before referral: IV furosemide, O2 2 liters /minute through nasal prongs Acute obstructive laryngitis- give steroid IV + subcutaneous adrenaline if there are no contraindications. Presumptive diphtheria
Croupy cough, hoarseness, fever Inspiratory stridor Extensive adhesive white membrane on the throat, painful and large cervical lymph nodes, fever Accidental inhalation of foreign body
Foreign body
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Figure (4-10): Patient coming with acute problem with cough with or without dyspnea and/or wheezing Classification of dyspnea or wheezing severity NB. You have to be sure first of the cause of Dyspnea: e.g. asthmatic, COPD, Pneumothorax, Pleural effusion, Cardiac, severe hypertension. .etc
Give oxygen 2 liters/minute through N. prongs Do x-ray and ECG to exclude pneumothorax and cardiac asthma. Position for greatest ease in breathing Immediately prepare for urgent referral to hospital with oxygen and salbutamol after exclusion of cardiac asthma. Inhaled salbutamol and repeat every 20 minutes, if no response, for one hour max.. Give IV corticosteroids If feverish (>37.2 C), give IM antibiotic Refer urgently to hospital with oxygen and continue salbutamol inhalation.
calssify as severe If there is Breathlessness at rest And / or Speaks in single words or cant at all And / or Confused, agitated plus
83
calssify as severe If there is Breathlessness at rest And / or Speaks in single words or cant at all And / or Confused, agitated plus
Salbutamol inhaler or by nebulizer with oxygen, if no contra-indication. If no response, repeat Salbutamol inhalation every 20 minutes for one hour maximum Give oxygen Position for greatest ease in breathing Give prednisone IV if known asthma or COPD. If no response, immediately prepare for urgent referral to hospital with oxygen and salbutamol If patient improved, prepare for non-urgent referral.
calssify as MILD If there is Breathlessness only on walking. And Comfortable lying down. And Speaks in full sentences.
If known as asthma or COPD patient, give Salbutamol inhaler or by nebulizer. . If no response, repeat Salbutamol inhalation every 20 minutes for one hour maximum If patient improved, treat at home. If no improvement for one hour: Give prednisone IV, do chest x-ray to exclude pneumothorax and non-urgent referral for assessment
84
Table (4-16): Management of upper respiratory tract conditions

Presenting symptoms Criteria for diagnosis If less than 2 weeks, consider Coryza, acute rhinitis. If more than 2 weeks, consider allergic or vasomotor rhinitis If without fever, without purulent nasal discharge, consider non-purulent sinusitis Pain when para-nasal sinuses are pressed Treatment Just observation, soothing remedies and advise when to return. Oral antihistaminic Analgesic, 5 days
Blocked nose or Non purulent runny nose
If with fever or purulent nasal discharge, consider purulent sinusitis If red throat and/or red tonsils & temperature less than 38 C, consider non-streptococcal pharyngitis or tonsillitis
Amoxicillin or cotrimoxazole, 7 days. Refer to a specialized service if symptoms persist more than 2 weeks. Paracetamol If symptoms > 3 days, give oral Penicillin or Amoxicillin for 5 days. If there is history of allergy to penicillin, Erythromycin, 5 days. Oral Amoxicillin or, Erythromycin for 7 days
Sore throat
Enlarged tonsils with at least white spots & temperature more than 38C, consider streptococcal tonsillitis. Malaise, white-grayish, extensive membranes attached firmly to the throat, large and painful cervical lymph nodes, fever more than 39 C, Suspected diphtheria
Refer urgently to fever hospital. Procaine Penicillin If allergy to penicillin, Erythromycin.
85
Normal otoscopy in a patient with acute rhino-pharyngitis, consider Otalgia
Analgesic for 5 days Analgesic. If boil (furuncle) or pus in the external ear canal use Dicloxacillin for 5 days. Local application of pack with antibiotic, antifungal and corticosteroid combination rapidly relieve the pain. Analgesic, Amoxicillin or cotrimoxazole for 7 days+ nasal decongestant. Consult to specialist. As previous.
Ear pain
Pain when pulling ear lobe, Painful otoscopy with normal ear drum, consider Otitis externa
Otoscopy shows bulging red drum without discharge, consider Otitis media With discharge, Purulent Otitis media Hoarseness and/or aphonia and/or dysphonia for less than a week Without dyspnoea, Acute Laryngitis. With stridor, Oedematous Laryngitis History of foreign body aspiration. Foreign Body With cough and fever, consider laryngo-trachitis.
86
Table (4-17): Staging and management of COPD whether at the first time or during follow up
Stage IV
Stage 0 No obstruction but at risk of COPD
Stage I
Stage II
Stage III
History of predisposing Smoking, asthma, chronic respiratory infection, occupational dust inhalation factors Chronic cough Chronic cough (>3 months) (>3 months) + expectoration expectoration Little or no May be present dyspnea Cough expectoration Breathlessness on moderate exertion breath sounds Wheezes hypoxemia (ABG or Pulse oximeter) Breathlessness on any exertion or at rest, prominent cough and wheezes.
Symptoms
Signs
No abnormal signs
No abnormal signs
Cyanosis, lower limb oedema
Spirometry
FEV1> 80% of predicted & FEV1/FVC>70%
FEV1 80 % of predicted & FEV1/ FVC<70% Mild COPD
80>FEV1> 50 30 <FEV1<50% FEV1 < 30 % of predicted of predicted of predicted & & & FEV1/ FEV1/ FEV1/FVC<70% FVC<70% FVC<70% Moderate COPD Severe COPD Very severe COPD
Salbutamol, 3-4 puffs/day as needed + Ipratropium bromide 2- 4 puffs/6 hours + Corticosteroids oral trial Inhalation Low dose of Sustained released theophylline
Chronic Classification bronchitis without obstruction
Intervention
Avoid risk factors e.g. smoking
Salbutamol, 3-4 puffs/day as needed
Salbutamol, 3-4 puffs/day as needed Salbutamol, 3-4 + puffs/day Ipratropium as needed bromide 2- 4 + puffs/6 hours Ipratropium + bromide 2- 4 Corticosteroids puffs/6 hours oral trial Inhalation
87
Table (4-18): Staging of asthma whether at the first time or during follow up

Step IV Step III Step II Step I 2 puffs salbutamol when needed - 2 puffs salbutamol when needed. - inhaled daily low dose corticosteroids e.g. Beclomethasone* 500 mcg/day (divided on two doses) - Inhaled daily corticosteroid (Beclomethasone 1000 mcg/day on divided 2 doses). - SR thiophylline 200 mg/12 hours. - 2 puffs salbutamol when needed. - Inhaled corticosteroid (Beclomethasone 2000 mcg/day on two divided doses). - SR Theophylline 200 mg/12 hours. - For uncontrolled asthma oral corticosteroids: prednisone 0.5 mgm/km/day. - Inhaled salbutamol as needed.
88
Table (4-19): Clinical classification of asthma

Classification Clinical characteristics Mild Intermittent Mild Persistent Moderate Persistent Severe persistent - Continual symptoms - Limited physical activity - Frequent exacerbations - Frequent nighttime symptoms.
- Symptoms - Symptoms 2 - Daily 2 episode per episodes per symptoms week. week, but 1 - Exacerbation - Free between per day. affects exacerbations. - Night-time activity - Brief symptoms 2 & >2 / week, exacerbation, a month. may last days few hours to - Exacerbation - Night-time few days may affect symptoms >1 - Night-time activities. time a week symptoms 2per month.
Measurement of peak expiratory flow- PEF or FVC1
80% 80% 60-80% of predicted or of predicted or of predicted or personal best personal best personal best (if known) (if known) (if known)
<60% of predicted or personal best (if known)
Epistaxis Treatment: 1. Patient Leaning forward with Direct nasal pressure; topical nasal vasoconstrictors (phenylephrine or oxymetazoline). 2. If bleeding does not stop cauterize with silver nitrate or insert nasal packing (with antibiotics to prevent infection, covering for S. aureus). 3. Define the cause of bleeding 4. I.V line access in severe uncontrolled bleeding and transfer to hospital.
89
Figure (4-11): Pyelonephritis

Healthy individual with fever and back pain, with or without symptoms of cysitis
1. 2. 3. 4.
History and physical examination Suprapubic and renal angles for tenderness Urine for urinalysis, culture and sensitivity Blood cultures if patient has signs of sepsis
1. 2. 3. 4. 5.
No morbid conditions Non-pregnant woman Vital signs stable Fever <38.9oC No nausea or vomiting
1. Complicating medical examination 2. Signs of sepsis 3. Not tolerating oral intake
Treat as outpatient
Refer to higher level of health care for evaluation and Hospital admission
1. Fluoroquinolone x 7-14 days; first dose may be I.V. 2. TMP-SMS x 14 days;first dose may be I.V. 3. Ceftriaxone or amoxicillinclavulanate x 14 days (grampositive pathogens)
I.V.antibodies: 1. Fluoroquinolone or Aminoglycoside + ampicillin or cephalosporin 2. Ampicillin-sulbactam aminoglycoside
90
Figure (4-12): Hematuria

Dark urine Dipstick for blood Positive
Urine microscopy for red blood cells
Negative
Drugs, food dyes, melanin

Positive
Investigate
Negative Myoglobin, hemoglobin
91
No RBC casts, no dysmorphic RBCs, no proteinuria, no bacteria RBC casts, dysmorphic RBCs, proteinuria Glomerular disease For Renal biopsy Ultrasonography, urologic exam
Pyuria, leukocyte casts, bacteria
Urinary tract infection
Treatment
Resolution
Persistent hematuria
Refer to higher level of health care and Hospital admission
Differentiation between Acute and Chronic Renal Disease: 1. Old medical and hospital records 2. Determination of kidney size (normal, small or large) 3. Radiographic evidence of renal or ureteric stones 4. Renal biopsy Note: Degree of anemia, if present, and serum phosphate measurement are not useful for this purpose Table (4-20): Stages Of CKD
Chronic renal diseases
Based on estimated GFR

Stage 1 2 3 4 5 Description Kidney damage with normal or GFR Kidney damage with mild GFR Moderate GFR Severe GFR Kidney failure Disease GFR (ml/min./1.73m2) 90 60-89 30-59 15-29 < 15 (or dialysis)
Table (4-21): Imaging Studies Used in Evaluating Patients with Renal

Imaging Study Plain X-ray abdomen (kidneys, ureters, and bladder Ultrasound scanning and CT Use - - - Determining kidney size and shape Detection of stones Calcifications
- Determining kidney size and shape - Detecting urinary obstruction and radiolucent stones - Distinguishing between simple and complex cysts - Early evaluation of polycystic kidney disease - Evaluation of renal mass
Refer for further investigation 92
Table (4-22): Types, characteristics and treatment of urinary inccontnence

Types Characteristics - Associated with urethral hypermobility or intrinsic sphincter deficiency (ISD) - Urinary leakage with an increase in intra-abdominal pressure resulting from coughing, sneezing or physical exertion Continuous leakage with ISD Treatments Non-drug Behavioral: -Pelvic muscle exercises (repeated contraction of pelvic muscles) -Scheduled toileting (urinate at defined intervals) -Bladder training (interrupt urination, avoid straining) Surgical: -Needle bladder neck suspension for urethral hypermobility; -Vaginal sling or periurethral (collagen) injections for ISD -Bladder training (scheduled or prompted voiding) -Pelvic muscle rehabilitation (contraction and relaxation of pelvic muscles) -Biofeedback (reduction of intensity of uninhibited contractions) Drug
Stress
Refer
Urge
-Urinary urgency and frequency (small to moderate volumes) -Overactive bladder caused by detrusor instability
Refer
Overflow
-Associated with either an acontractile bladder or bladder outlet obstruction (BPH, stricture or bladder neck constriction) -Bladder distention with frequent or constant dribbling, with or without urgency Behavioral: Toileting schedule and prompted
Refer
Associated with inability or unwillingness to Functional perform
Change treatments ( diuretic and vasodilator dosages)
93
- Hyperplasia of the prostate bladder outlet obstruction. - Incidence increase with age, common in patients >45 years. Symptoms: Frequency, urgency, nocturia, force and size of stream, and incomplete emptying, overflow incontinence Examination: Presents with a firm, rubbery, smooth surface (in contrary to the rockhard areas that suggest cancer prostate). Diagnosis: 1. History and physical examination. 2. Urinalysis for infection or hematuria, both need further evaluation. 3. PSA is in 50% of patients but is not diagnostically useful. Treatment: 1. -blockers (terazosin), 5-reductase inhibitors (finasteride). 2. Avoid anticholinergics, antihistamines, or narcotics. 3. If no good responce, Refer Screening: 1. Prostate cancer screening, ranging from no screening to a yearly rectal exam and PSA testing. 2. If an abnormality is found on exam Refer
94
Figure (4-13): Begnin prostatic hypertrophy

Initial evaluation: 1-History 2-Physical exam and PR 3-Urine analysis 4-PSA (Optional) Symptoms assessment 1-Urine retention 2-Recurrent UTI 3-Recurrent or persistent hematurea 4-Bladder stone 5-Renal insufficiency
Mild Follow-up
Moderate/severe Refer to higher level
- Inability to achieve or maintain erection sufficient to effect vaginal penetration and ejaculation. - Affects 30 million men. Associated with age; some degree of ED is seen in 40% of 40-year and in 70% of 70-year olds. Examination: 1. Check for organic cause e.g., small testes, perineal sensation, cremaster reflex, evidence of peripheral neuropathy, or galactorrhea. 2. Assess peripheral pulses; look for skin atrophy, hair loss, and low skin temperature. Differential diagnosis: Psychological: 1. Symptoms often have a sudden onset. 2. Patient unable to sustain or obtain an erection. 3. Patients have normal nocturnal penile tumescence (those with organic causes do not). Organic: 1. Endocrine: Hypothyroidism or thyrotoxicosis, pituitary or gonadal
95
Erectile Dysfunction (ED)
disorder,Hyprprolactinemia. 2. Vascular disease: Atherosclerosis of penile arteries or venous leaks. 3. Neurologic disease: Stroke, temporal lobe seizure, multiple sclerosis, spinal surgery, neuropathy. 4. Exogenous: Drugs that cause ED include -blockers, clonidine, CNS depressants, anticholinergics, and tricyclic antidepressant. Diagnosis & Treatment: Refer Table (4-23): Cancer Screening Cervical cancer - An annual Pap smear is recommended starting at age 18 or at the onset of sexual activity. - After three normal Pap smears, the screening interval can be every three years. - Monthly self-examination and an annual exam by a physician. - Mammography done annually after age 4050 (Start earlier if there is family history at young age). - Hemoccult annually (especially in patients >50y); flex sigmoidoscopy (every 3-5 years in patients >50y) or colonoscopy (every 10 years in those >50y). - If a first-degree relative has colon cancer, begin screening at age 40 or when the patient is 10 years younger than the age at which that relative was diagnosed, whichever comes first. - Controversial. Either no screening - Others recommend a yearly rectal exam and PSA beginning at age 45 for patients with a strong family history, and at the age of 50y for all others.
96
Breast cancer
Colon cancer
Prostate cancer
Figure (4-14): Breast mass

Breast mass
Clinically malignant
No Mammogram and Ultrasound
Yes Mammogram
97
Biopsy and re-examine after next menses and 1-4 months Biopsy No bloody fluid and completely resolved cyst Appears malignant Recurrence Excision No Recurrence Routine follow-up
Cystic mass
Biopsy
Aspirate
Pre-operative evaluation and counseling
No bloody fluid and completely resolved cyst
Surgical intervention
Recurrence
No Recurrence
Excision
Routine follow-up
The most common causes of nipple discharge in the non-lactating breast are duct ectasia, intraductal papilloma, and carcinoma. Diagnosis: 1. Nature of the discharge (serous, bloody, or other) 2. Association with a mass 3. Unilateral or bilateral 4. Single or multiple duct discharge 5. Discharge is spontaneous (persistent or intermittent) or must be expressed by pressure 6. Discharge produced by pressure at a single site or by general pressure on the breast 7. Relation to menses 8. Premenopausal or postmenopausal 9. Patient taking contraceptive pills or estrogen Refer for Investigations: - The most common malignant tumor of urinary tract in Egypt. - Most cases are transitional cell carcinoma. - Risk factors include smoking, aniline dyes, and chronic bladder infections (e.g., Bilharziasis) Clinical presentation: 1. Terminal hematuria is the most common presenting symptom. 2. Other urinary symptoms, as frequency, urgency, and dysuria 3. Most patients are asymptomatic during early stages. Diagnosis: 1. Urine analysis which shows hematuria (macro- or microscopic) Refer for Confirmatory Diagnosis and treatment
Nipple discharge
Urinary Bladder Carcinoma
Refer all suspected cases for urgent surgical assessment: 1. Palpable right-sided mass 2. Rectal bleeding with change in bowel habit to more frequent defecation or looser stools (or both) 3. Iron deficiency anemia (Hb <11gm/dl in men; <10gm/dl in postmenopausal women >50 years) without obvious cause
98
Colorectal Carcinoma
Younger patients with 1st degree relative who had colorectal cancer age <55 years 5. Rectal bleeding persistently without anal symptoms High risk Factors: Require regular screening 1. Familial adenomatous polyposis 2. Juvenile polyposis 3. Hereditary non-polyposis colorectal cancer 4. More than 2 in the first degree relatives with history of colorectal cancer - Abnormal elevation of body temperature, or pyrexia, can occur in one of two ways: hyperthermia or fever. - In hyperthermia, thermal control mechanisms fail, so that heat production exceeds heat dissipation. - In fever, the hypothalamic thermal mechanism is intact, so thermal control mechanisms bring body temperature up to the new high level. Treatment: 1. Hyperthermia: Treated by physical cooling methods that promote heat dissipation 2. Fever: Treated by drugs that lower the thermal set point, as aspirin, cyclooxygenase inhibitors, or acetaminophen. Figure (4-15): Hyperthermia and Fever
Fever 1. Toxins 2. Microorganisms 3. Microbial products & toxins 4. Immune complexes 5. Tissue injury Activation Autonomic and somatic nerve activation 1. Increase Muscle tone 2. Decrease sweating 3. Increase cutaneous vasoconstriction Pyrexia Hyperthermia Failure of thermoregulatory homeostasis: 1. Increase heat production 2. Decrease heat dissipation, or hypothalamic insult
4.
Hyperthermia and fever
99
Table (4-24): Preventive Services Recommended for the General Population 65 Years of Age and Older
Frequency Annually Every 2-3 yr Annually Every 3-5 yr Every 3 yr Annually Annually Annually Annually Annually Annually Annually With visits Annually Each fall Epidemics Every 10 yr With visits Daily Obesity, CAD Osteoporosis Immobility, CAD, osteoporosis Falls, car accidents, burns, other injuries COPD, many cancers, CAD Malnutrition, oral cancers, endentulism Influenza Pneumococcal disease Tetanus Osteoporosis Additional MI, TIA, or stroke Risk factor for CAD Visual impairment Obesity, malnutrition Cervical cancer Colorectal cancer Breast cancer Hypertesion Condition to Detect or Prevent
Service
Activity
Screening
Blood pressure
Mammography
Fecal occult blood testing
Pap smear
Height and weight
Serum lipids in persons with angina, prior MI, DM
Vision testing
Hearing testing
100
Counseling
Low-fat, well-balanced diet
Adequate calcium intake
Physical activity
Injury prevention
Smoking cessation
Regular dental visits
Immunization
Influenza vaccination
Pneumococcal vaccination
Tetanus booster
Chemoprophylaxis
Discussion, implementation of HRT in women
Aspirin therapy after MI
Table (4-25): Domains of Geriatric Assessment

Physical health 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 1. 2. 3. 4. 1. 2. 3. 1. 2. 3. 4. 5. 6. 1. 2. Prevention of diseases Illness Balance and gait Falls Nutrition Incontinence Dental Hearing Vision Polypharmacy Cognition Depression Anxiety Psychosis Basic activities of daily living Instrumental activities of daily living Advanced activities of daily living Caregiver burden Finances Service needs Values and advance directives Communication and emergency support Elder abuse and neglect Safety Impact of climate
Mental health
Functioning
Social support
Environmental adequacy
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- A common metabolic bone disease characterized by osteopenia with normal bone mineralization. - Common in inactive, postmenopausal white women. Causes Risk factors: Old age, prolonged inactivity, smoking, alcoholism, renal failure, hyperthyroidism, multiple myeloma, heparin, and chronic steroid use Clinical presentation: 1. Commonly asymptomatic. 2. Patients may present with hip fractures, vertebral compression fractures (resulting in loss of height and progressive thoracic kyphosis), and/or distal radius fractures after minimal trauma. Differential diagnosis: Osteomalacia (inadequate bone mineralization), multiple myeloma, hyperparathyroidism, metastatic carcinoma (pathologic fracture) Diagnosis: 1. All patients >65 years and patients between 4060 years with 1 risk factors for osteoporotic fractures should be Refered for screening with a dual-energy X-ray absorptiometry (DEXA) scan of the spine and hip. 2. Take the lowest T-score between the hip and the spine: a. Osteopenia: T-score from 1 to 2.5. b. Osteoporosis: T-score 2.5. Treatment: 1. health education . 2. Eliminate or treat the causes. 3. Weight-bearing exercise, calcium and vitamin D. 4. DEXA scan should be repeated 12 years after initiation of drug therapy.
Osteoporosis
Fatigue or lassitude: A complaint of weakness, tiredness, and lethargy attributed to

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Fatigue
overexertion, poor physical conditioning, sleep disturbance, obesity, under nutrition, and emotional problems. Fatigue is composed of 3 major components: 1. Generalized weakness (difficulty in initiating activities) 2. Easy fatiguability (difficulty in completing activities); and 3. Mental fatigue (difficulty with concentration and memory) Causes: 1. Hyperthyroidism and hypothyroidism 2. Congestive heart failure (CHF) 3. Infections (endocarditis, hepatitis) 4. Chronic obstructive airway diseases (COPD) 5. Sleep apnea 6. Anemia 7. Autoimmune disorders 8. Cancer 9. Alcoholism, 10. Drug side effects, as sedatives and b-blockers 11. Psychological conditions (as insomnia, depression, and somatization disorder) Fatigue of unknown cause or related to psychiatric illness exceeds that due to physical illness, injury, medications and drugs.
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Figure (4-16): Fatigue

Weight loss. Fever. Sleep-disordered breathing. Medications. Substance use. A. History and physical examination; B. Mental status examination (psychological, neurologic exam) C. Tests: 1. CBC, ESR, ALT, total protein, albumin, globulin, alkaline phosphatase, Ca, P02, glucose, BUN, electrolytes, creatinine, TSH and urinalysis. 2. Additional tests as clinically indicated to exclude other diagnoses
Fatigue
Reject diagnosis if another cause for chronic fatigue is found. Classify as idiopathic chronic fatigue if fatigue severity or symptom criteria for chronic fatigue syndrome are not met.
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Classify as chronic fatigue syndrome if: 1. Criteria for severity of fatigue are met 2. 4 or more of the following symptoms are present for 6 months: Impaired memory or concentration Tender cervical or axillary lymph nodes Muscle pain Multi-point pain New headaches Un-refreshing sleep Post-exertion malaise
Classify case as: 1. Chronic fatigue syndrome or 2. Idiopathic chronic fatigue if fatigue persists or relapses for 6 months.
Figure (4-17): Chronic fatigue syndrome
1. Un-refreshed sleep 2. Headaches
Depression: 1-Loss of motivation 2-Loss of pleasure
Prolonged fatigue status 1-Fatigue 2-Pain 3-Poor concentration 4-Irritable mode
Fibromyalgia: 1.Myalgia 2.Arthralgia 3.Tender points
Anxiety: 1.Panic attacks 2.Avoidant behavior
Irritable bowel syndrome 1.Diarrhea/ constipation 2.Abdominal pain 3.Bloating
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Chapter 5
Gastro-intestinal System & Medical Emergencies

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Chapter 5: Gastro-intestinal System & Medical Emergencies
Peptic ulcer disease (PUD)

- - The most common sites are the stomach and duodenum. H. pylori infection,smoking and NSAIDs/aspirin are the major causes.
Clinical presentation: Epigastric pain: aching pain comes in waves: a.Duodenal ulcers: Pain relieved by food, and occurs few hours after eating. b.Stomach ulcers: Pain worsened by eating and occurs during eating. Dyspepsia and upper GIT bleeding. Diagnosis: 1. Peptic ulcer: Endoscopy and urease testCLO test for H.pylori; biopsy from any peptic ulcers. 2. H. pylori infection: a. Urease testing of biopsy from ulcer by gastroscopy. b. Serum H pylori antibody: but may not indicates active infection. c. Urea breath test: Detect active infection, the patient must stop proton pump inhibitor (PPI), antibiotics, or bismuth for several weeks before the test. d. Fecal antigen test: detect H. pylori. Treatment: 1. Discontinue aspirin/NSAIDs; stop smoking. 2. PPI or H2 receptors antagonist (Zantac) to control symptoms and acid secretion. 3. H. pylori infection Start multiple drugs using 2 drugs of the following 3: Amoxicillin 1-g BID, Clarithromycin 500-mg 2/day, or metronidazole 500-mg 2/day, plus a PPI (omeprazole20mg po bid, lansoprazole 30mg po bid) for 2 weeks.
Acute Appendicitis
- Acute appendicitis is the most common surgical emergency of the abdomen.
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- Rapid diagnosis and treatment before rupture is the aim. - Perforation occurs in >20% of patients, and in 50% of patients at the extremes of life (<3 years and >50 years). Clinical presentation: 1. Children <5 years and adults >50 years will typically present later in the disease with vague symptoms and signs. 2. Early symptoms Dull ache vague epigastric and periumbilical pain. Anorexia in 90% of patients. 3. Later symptoms pain in the right lower quadrant at McBurney's point; however, the variability of anatomic locations of appendix (retrocecal, etc.) may cause pain to be localized in any region. 4. Once the pain localizes, it is common to find the patient with voluntary guarding. 5. Low-grade leukocytosis is commonly present (WBC of 12,000 to 16,000). A WBC greater than 18,000 is not generally seen and suggest another possible diagnosis. Differential Diagnosis: - Up to 40% of young women explored for appendicitis had a negative surgical exploration of the appendix. - Viral gastroenteritis or ovarian cyst are commonly found when acute appendicitis is excluded. - Abdominal pain similar to acute appendicitis: 1. Gastroenteritis (viral or bacterial) 2. Acute regional ileitis (crohns disease) 3. Ureteral colic 4. Salpingitis 5. Ruptured ovarian follicle 6. Ovarian torsion 7. Ectopic pregnancy 8. Diverticulitis 9. Perforated peptic ulcer 10. Cholecystitis Treatment: Early referral to hospital for Appendicectomy
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Viral Hepatitis
May be acute and self-limited or chronic and symptomatic. May be detected after years of initial infection. Clinical presentation: 1. Patient presents with anorexia, nausea, vomiting, malaise, and fever. 2. Examination: Enlarged tender liver, dark urine, and jaundice. Differential diagnosis: 1. High level of transaminase (>10-20 times normal): D.D.: Infection (acute viral), ischemia (shock liver), or toxins. 2. Moderate level of transaminase elevation: Chronic viral, autoimmune, or non-alcoholic fatty liver disease (NAFLD). Others as mononucleosis, Cytomegalovirus (CMV), drug-induced illness, and autoimmune disease. Diagnosis: 1. Clinical presentation and transaminases. 2. Serology and/or PCR testing confirming a specific virus. 3. Abdominal Ultrasound Enlarged liver in acute hepatitis. Treatment: 1. Treat according to subtype. 2. Additional guidelines are as follows: Rest during the acute phase. Avoid hepatotoxic agents; avoid morphine. Most symptoms resolve in 3-16 weeks, but Liver function tests (LFTs) remain for much longer.
Acute Hepatitis
Chronic Hepatits
- Vague ill health;anorexia &fatigue. - Asymptomatic high liver enzymes.
Fulminant Hepatitis
- rapid deterioration in general health culminating in coma with very high levels of liver enzymes.
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Viral Hepatitis Subtypes

Hepatitis A virus (HAV): Transmission: - Transmition from contaminated food, water, milk, and shellfish by fecal-oral transmission - Incubation period: 2-4 week , and the virus is excreted in stool till jundice appears Clinical findings: 1. Clinical symptoms and signs of acute hepatic viral infection 2. IgM antibody to HAV (acute infection). 3. IgG antibody to HAV (past exposure). 4. Chronic infection does not occur. Treatment: 1. Supportive; usually resolves without complications. 2. Immunoglobulin to close contacts. Hepatitis B virus (HBV) Transmission: - Transmitted by infected blood, sexual contact, or perinatally. - Incubation period: From 6 weeks to 6 months. Clinical findings&diagnosis: 1. Clinical symptoms and signs of acute hepatic viral infection 2. Surface antigen (HBsAg) indicates active infection; but it is positive also in chronic hepatitis and asymptomatic carriers. 3. <1% of patients pass to fulminant hepatitis. 4. Adult-acquired infection usually does not become chronic. Treatment: Interferon, lamivudine, and other nucleotide / nucleoside analogs. (Aiming at reducing the viral load and improving liver functions; however cure is not common.) Prevention: vaccination against HBV. Hepatitis C virus (HCV) Transmission: - Transmitted by blood transfusion, IV drugs or body piercing. - Incubation period: 6-7 weeks.
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Clinical findings&diagnosis: 1. Mild or asymptomatic clinical symptoms and signs of acute hepatic viral infection. 2. Up and down aminotransferases enzymes changes. 3. Antibody appears 3-15 weeks after infection 4. Diagnosis of acute infection by PCR testing which detects the virus1-3 weeks after infection. 5. Most infections become chronic. 6. HCV antibody is not protective (Recurrent infection may occur). Treatment : Refer General principles of referral: 1. First Aid Management always provided before transport to stabilize the patient 2. History, physical examination and investigations, should be documented and records sent with the patient 3. Communicat with the referred hospital to ensure immediate care as the patient arrives 4. Transfer by equipped ambulance (If not available provide any other form of transport immediately and ensure the procedures needed for safe transport. 5. A physician accompany the patient during transport. Referral guidelines: Insert two wide bore IV cannulae (size 16 or 18). IV Ringers infusion at a fast drip (1 liter/ hour). Provide 100% oxygen via mask Warm the patient, if needed (hypothermic) Insert a Foleys catheter. Referral should be in an equipped ambulance. A physician should accompany the patient
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Figure (5-1): Upper GIT Bleeding
Upper GIT Bleeding
Medical history Physical examination Amount of blood loss assessment Immediate management: 1. IV line (Ringer or saline) 2. Provide 02 by mask 3. Fix Follys catheter Patient is hemodynamically Stable
Yes
No
1. Check coagulation defects 2. Ultrasound Liver cirrhosis 3. X-Ray abdomen perforating ulcer
Do not waste time Refer to higher level of health care
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Figure (5-2): Lower GIT Bleeding

Lower GIT Bleeding
History of Drug Ingestion
No history of drug ingestion
1. Aspirin 2. Anticoagulants 3. Caffeine etc.
Hematemesis
No
Yes
1. Duodenal ulcer 2. Gastric Ulcer 3. Esophagitis 4. Esophogeal No
Abdominal Pain
Yes
1. Gastric malignancy 2. Goagulation defects 3. Esophageal verices
4. Peptic Ulcer 5. Gastritis
Ascites - Ascites is accumulation of fluid in peritoneal cavity Ascites may be: - Part of generalized edema: CHF , Liver Cirrhosis , Renal , Nutritional deficiencies Due to local cause: - TB peritonitis , Peritoneal carcinomatosis , Chylous ascites
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Ascites
Treatment: - Bed rest , Dietary sodium restriction - Fluid restriction , Diuretics: spironolactone 100 mg/day - You can add frusemide 20-40 mg/day - Treatment of underlying conditions - If response is poor (< 0.7 kg weight loss in 24 hours), refer for further evaluation & further treatment.
Figure (5-3): Acute Diahrrea Acute Diahrrea
Blood in stool
No blood in stool
Fever
No Fever
Severe vomitting
1. Toxic staphylococcal 2. Gastroenteritis 3. Travelers diarrhea 4. Contaminated food 5. Viral gastroenteritis
Little or no vomitting
1. Salmonella 2. Shigella 3. Campylobacter 4. Ulcerative colitis
Amoebic Dysentery
Giardiasis
Escherichia coli (E-Coli) infection

Management: Fluid replacement; fluoroquinolone can be used alone or in combination with loperamide
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Entamoeba Histolytica (Amebiasis)

Treatment: 1. Metronidazole (Flagyl): 500 mg orally tds for 10 days OR 2. Tinidazole: 2-gm/day orally for 3 days .
Giardia lamblia, a type of protozoan that causes intestinal infection Diagnosis: As intestinal amebiasis, and differentiated by stool analysis Treatment: 1. Metronidazole: 250 mg PO tid for 7 days
Giardia Lamblia
Treatment : - Ciprofloxacin 500 mg twice daily
Salmonella
*Not to be given in children under 12 years
Shigellosis
Treatment: The first aim of treatment is to keep up nutrition and avoid dehydration. 1. The Oral Rehydration Solution (ORS) includes salt, baking powder, sugar, orange juice, and water. Commercial preparations, as Rehydran is available. 2. Antibiotics: Ampicillin, Trimethoprim-Sulfamethoxazole (TMPSMX) (Bactrim), or fluoroquinolones (Ciprofloxacin, not for use in children).
Irritable Bowel Syndrome (IBS)

Abdominal pain or discomfort associated with alteration in bowel habits with no organic cause. It is the commonest functional GI disease
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Symptoms supporting diagnosis of IBS: - 3/d or < 3/week stool frequency - Stools: lumps/hard or loose /watery stool - Passage of mucus - Bloating or abdominal distension Management: - Explore dietary triggers - High fiber diet for constipation - Antidiarrheal drugs for bowel frequency - Smooth muscle relaxant for pain - Reassurance - Psychotherapy - Antidepressant
Management of Medical Emergencies Unconsciousness and coma

- - - - - - - Glasgow coma scale Disturbed level of consciousness Delirium Syncope Convulsions Stridor Abdominal pain: Acute
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- Consciousness means a state of wakefulness with awareness of self and surroundings. - Clouding of consciousness means reduced wakefulness and/or self-awareness. - Confusion is the state of altered consciousness in which the subject is bewildered and misinterprets his or her surroundings. - Sleep is the state of normal mental and physical inactivity from which the subject can be aroused. - Stupor is an abnormal, sleepy state from which the subject can be aroused by stimuli, applied vigorously or repeatedly. - Delirium is a state of high arousal in which there is confusion and often visual hallucination. - Coma is a state of unarousable unresponsiveness (The Glasgow coma Scale for grading coma). - Syncope (drop attack) is a transient loss of consciousness (fall to ground) for less than 2 minutes and recovered when patient lies down. Table (5-1): Glasgow Coma Scale
Score Eye opening (E)
Spontaneous To speech To pain No response 4 3 2 1
Unconsciousness and coma
Score Verbal response (V)

Orientated Confused conversation Inappropriate words Incomprehensible sounds No response 5 4 3 2 1
Motor response (M)

Obeys Localizes Withdraws Flexion Extension No response 6 5 4 3 2 1
Glasgow Coma Scale = E + M + V (GCS minimum = 3 : maximum = 15)
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Figure (5-4): Disturbed level of consciousness (Coma or stupor) - First you have to exclude hypoglycemia. - If you suspect hypoglycemia give oral or IV glucose
Epilepsy, chronic elicit drug use, transient ischemic, attacks migraine, insulinoma
Intermittent
NotIntermittent
Positive drug or alcohol history
Cocaine, Barbiturates, Alcohol morphine, LSD
Negative drug or alcohol history
Focal neurological signs No focal neurological signs
With nuchal rigidity Without nuchal rigidity
Subarachnoid hemorrhage, meningitis
Specific odor to breath
No Specific odor to breath
1. Cerebo vascular accident, 2. Advanced brain tumor, 3. Cerebral abscess 4. encephalitis, 5. Subdural hematoma, 6. Central nervous system lupus, 7. Cerebral arteriosclerosis, 8. Werinckles encephalopathy
1. Uremia, 2.Diabetic acidosis
1. Concussion, 2. Schizophrenia, 3. Depressive states, 4. Hysteria, 5. Advanced dementia, 6. Metabolic or inflammatory, Encephalopathy, 7. Shock, 8. Myxoedema
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After exclusion of hypoglycemia, in all patients examine & assess Glasgow Coma Scale Ensure patent airway Put IV line with 5% glucose to keep veins open Refer to emergency unit
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Figure (5-5): Syncope
According to pulse:
Slow pulse < 45 heart block < 60: vaso vagal or carroted sinus syncope Aortic stenosis Normal pulse with murmur Normal pulse with -out murmur No Pallor Aortic regurgition Syanotic congenital heart disease Pallor Severe anemia or bleeding 1. Cardiovascular. insufficiency 2. Hypoglycemia 3. Transient ischemic attacks 1. Hysteria, 2. Hypoglycemia, 3. Orthostatic hypotension, 4. Hyperventilation syndrome, 5. Migraine, 6. Epilepsy, 7. Addisons disease, 8. micturition syncope, 9. Myocardial infarction, 10. Tussive syncope
Focal neurological signs
No focal neurological signs Rapid irregular pulse
A.F.
Supraventicular Tachycardia Rapid regular pulse Ventricular Tachycardia Heat exhaustion Heat storke
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- Syncope (drop attack) is a transient loss of consciousness (fall to ground) for less than 2 minutes and recovered when patient lies down. Immediate management: lay patient down & lift legs, Patient will recover consciousness Then refer for further evaluation
Delirium
Is a state of high arousal in which there is confusion and often visual hallucination. After exclusion of hypoglycemia, in all patients examine & assess Glasgow Coma Scale Ensure patent airway Put IV line with 5% glucose to keep veins open Refer to emergency unit
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Figure (5-6): Convulsions
Convulsions
With Incontinence and/or tongue biting
Without Incontinence or tongue biting
No history of drugs or alcohol
History of drugs or alcohol
Hysterical seizures
With fever
No fever
Febrile convulsions Encephalitis Cerebral Abscess Meningitis
No focal neurological signs
Focal neurological signs
Idiopathic Epilepsy Metabolic Encephalopathy
Space-occupying Lesion
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In case of epilepsy: Emergency measures: Maintain airway patent - Avoid tongue biting - Exclude hypoglycemia - If prolonged seizure >3 min give IV diazepam Avoid precipitating factors: - - - - - - Pyrexia: in children <5 yrs. Sleep deprivation Photosensitivity: flashing lights or flickering Drugs: Tricyclic antidepressants, Phenothiazines Withdrawal of anticonvulsant drugs Metabolic abnormalities
Refer for EEG & CT In case of hysterical seizures: Reassure and refer to a psychiatrist
In the other cases refer for proper diagnosis.
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Figure (5-7): Stridor in Children
Stridor
Stridor in Children
Acute onset
Gradual Onset
With Drooling and Dysphagia
Without Significant Drooling and or Dysphagia
Foreign Body in Trachea or Bronchus Laryngismus Stridulus Retropharyngeal Abscess
Acute Epiglottitis
Fever
No Fever
Diphtheria Acute Laryngotracheitis
Foreign Body Congenital Laryngeal Stridor
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Figure (5-8): Stridor in Adults Stridor in Adults
Abnormal Neurological Exam
Normal Neurological Exam
Myasthenia Gravis Bulbar Pseudo bulbar Palsy Bilateral Recurrent Laryngeal Palsy Coma
Abnormal Ear, Nose and throat exam including Bronchoscopy
Normal Ear, Nose and Throat Exam including Bronchoscopy
Pharyngitis Laryngotracheitis Carcinoma of Larynx or trachea Angioneurotic Edema Foreign Body
Thyroiditis Carcinoma of Esophagus Aortic Aneurysm Mediastinitis Hodgkins disease
Stridor: is difficulty in respiration (inspiratory) or due to pathology in upper respiratory tract. Management: - Give oxygen - Insert IV line - Give IV Corticosteroid - Refer immediately to emergency unit
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Figure (5-9): Acute Abdominal Pain

Right Upper Quadrant Acute Cholecystitis
Focal Tenderness and rebound
Persistent Pain
Lower Quadrant
Appendicitis Salpingitis Ectopic Pregnancy Diverticulitis Regional Ileitis Perforated Ulcer
Board like rigidity Generalized tenderness with rebound
Shock
Acute Pancreatitis Mesentericc thrombosis or embolism
Bloody stool
Intermittent Colicky Pain
Hyperactive bowel sounds tympany
Intestinal obstruction
Right upper quadrant with slight jaundice or dark urine
Cholelithiasis
Frank hematuria
Nephrolithiasis
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Acute Abdominal Pain

In medical causes of acute abdomen there is NO rigidity or rebound tenderness. N.B. Familial Mediterranean Fever is characterized by recurrent attacks of - Fever - Arthritis: monoarticular - Serositis: abdominal pain due to peritonitis or pleurisy - Attacks last for up to 1 week - Refer to confirm diagnosis Appendicitis produces more gradual onset of pain and pain may be made worse by movement. Vomiting may accompany any acute abdominal pain but, if persistent, it suggests an obstructive lesion of the gut. All other cases with rigidity and /or rebound tenderness should be referred to surgical emergency unit. Other rate medical Cause of Acute Abdomen are acute propheria and familial hypertriglyceridemia . A sudden onset of severe pain suggests: - Perforation e.g.doudenal ulcer - Rupture e.g. of an aneurysm - Torsion e.g. of an ovarian cyst - Acute pancreatitis Refer immediately to emergency unit Colicky pain can be due to an obstruction of gut - Biliary system - Urogenital system - Or uterus. These will probably initially require conservative management along
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with analgesics and antispasmodic. If colicky pain changed into constant pain inflammation supervene. This will be supported by: - Raised temperature. - Tachycardia - And/or raised white cell count Add broad spectrum antibiotics, IV line and transfer to emergency unit Back pain suggests: - Pancreatitis - Rupture of an aortic aneurysm - Renal tract disease Diabetic Ketoacidosis (refer to Diabetic section) Myocardial infarction: refer to chest pain & IHD section - Give sublingual nitrate tablet every 5 min for 3 tablets - Chew aspirin tablet - Refer to emergency unit Sickle cell crisis: - IV fluid - Oxygen - Antibiotics - Adequate analgesia - After attack give pneumococcal vaccine - Hemophilis influenza vaccine - Refer to further evaluation
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Chapter 6
Pregnancy and related problems
Chapter 6: Pregnancy and related problems
Table (6-1): Diagnosis of pregnancy Amenorrhea from the first day of menstrual period until delivery Fundal height during pregnancy Weeks Fundal Height 12 Just above symphysis pubis 16 6 cm above the symphysis pubis 20 6 cm below the umbilicus 24 At the umbilicus 28 6 cm above the umbilicus 32 6 cm below the xyphoid process 36 2 cm below xyphoid process 40 4 cm below xiphoid process Serum b-hCG (pregnancy test): Beta human chorionic gonadotropin (bhCG) detected in maternal serum or urine. (3.5 weeks after the LMP) Fetal Heart Sounds (FHS): The electronic Doppler device (Sonicade) can detect fetal heart sounds (FHS) as early as 14 weeks. Ultrasonic Scanning (US): Once a gestation sac is present within the uterus diagnose pregnancy, but not generally used to do so. Why? Confirm an intra-uterine pregnancy (exclude ectopic) Confirm fetal heart beat (patient with history of abortion) Diagnose multiple pregnancy Estimate gestational age Screen for fetal structural anomalies Limitations? Estimation of gestational age becomes less accurate after 24th gestational weeks. US measure the size of the fetus, not the gestational age. Biologic variation in size increases as gestation advances.
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Table (6-2): Antenatal Care (ANC) Visits When and How Often: Routine antenatal visits First 28 weeks every 4 weeks 28 to 36 weeks every 2 weeks 36 weeks to delivery once weekly until delivery And at anytime when medical care is needed Minimum Required Visits First visit as early as possible in early first trimester (<12 weeks) - Second visit - Third visit - Fourth visit - Fifth visit - 22-26 weeks - 30-32 weeks - 34-36 weeks - 38-40 weeks
First antenatal visit includes the following: Registration: Complete Pregnancy follow-up form included in the family folder Complete the ANC card if available Check for Women Health Card and complete the relevant information. If none, issue a new card. Register the mother in the New Pregnant Registry With repeated visits: Complete the ANC form. Complete the data in the womens card Register data in the repeated visits
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History taking: Date of last menstrual period (LMP): to calculate the expected date of delivery (EDD) by adding 9 months +7 day Obstetric history: All deliveries and abortion details Record any complaint Past-medical history: Diabetes mellitus Hypertension Urinary tract troubles Heart diseases Viral infections Drugs and/or allergies Blood transfusion Past-surgical history: Any operation especially abdominal History of contraception: types, duration of usage and complications Current medications used by patient Family history for diabetes, twins, and any hereditary diseases or congenital anomalies Patient education about pregnancy and give client an idea about the important warning signs (vaginal bleeding, sudden gush of watery fluid from vagina, persistant regular abdominal pain, persistant frontal headache) Examination: Weight and height measurement Pulse Temperature Blood pressure Lower limb edema Complete system check-up e.g. chest, heart, ect. Fundal level: See fundal height (page 2)
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Obstetric palpation if pregnancy more than 32 weeks: Fundal grip: part of the fetus occupying fundus Umbilical grip: palpate fetal back (right or left) Pelvic grip: part of fetus occupying lower uterine segment Auscultation: Fetal Heart Sounds (FHS) after 12 weeks by Sonicade Laboratory tests: Hemoglobin Blood type Rh factor Urine analysis (glucose, proteins, ketones) and microscopic exam for pus cells and RBCs Special lab test for any associated diseases, e.g. blood glucose for diabetes and liver functions for liver disease Repeat Visits: During each visit Update the record for any complaint or problem Assess weight increase by the 20th week; the pregnant mother usually has gained 3.5 kg. After that date she is not allowed more than 0.5 kg per week as a maximum. The total weight gain during pregnancy is between 9-11 kg. Examination: General and systematic examination. Weight Blood pressure (Blood pressure more than 140/90 is a risk) Assess the fundal height. Fundal level; and Fetal Heart Sounds (FHS) if pregnancy is after 20 weeks. Pelvic examination at the 36th week to estimate the pelvic capacity and test for cephalopelvic disproportion. Laboratory tests: Hemoglobin
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Blood group (ABO) Rh factor Urine analysis (glucose, proteins, ketones), microscopic Special lab test for any associated diseases, e.g. blood glucose In repeated visits: Urine analysis (glucose, proteins)
Nutrition needed for pregnant woman: Weight Gain: Weight gain for normal pregnancy 9 to 12 kg Diet: for diabetes and liver functions for liver disease. examination.
Calories = 2500 cal/day. The average woman must consume an Protein:

additional 300 kcal/day beyond baseline needs. Animal: Meat, fish, cheese, milk, and eggs Plant: Peas, beans and lentils Calcium: Milk, cheese, and youghart Iron: Animal: Date palm , molasses, Liver, and red meat Plant: Green leafy vegetables Vitamins: 400-g folic acid /day is required. Elemental iron supplements with 3060 mg/day in the second half of pregnancy to prevent anemia. Calcium is increased in pregnancy to 1200 mg/day that may be adequately met with diet alone. Zinc is increased from 15 to 20 mg/day.
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Table (6-3): Antenatal Care

First Visit Booking or Registration Timing Early First Trimester (<12 weeks) Hight, Wt., BP, F.L Physical Examination Nutrition, Personal Hygiene, Dental care, Breast care Smoking Second Visit Third Visit Fourth Visit Fifth Visit
22-26 weeks Hight, Wt., BP, F.L Fetal Heart Sound When to seek medcal care, Nutrition, Personal Hygiene & Fetal movement awarness
30-32 weeks Hight, Wt., BP, F.L Fetal Heart Sound When to seek medical care, Nutrition, Personal Hygiene Fetal movement awarness, Warning of symptoms of PE
34-36 weeks Hight, Wt., BP, F.L Fetal Heart Sound& Fetal presentation When to seek medical care, Nutrition Personal Hygiene Fetal movement awarness Warning of symptoms of PE PP care and FP
38-40 weeks Hight, Wt., BP, F.L Fetal Heart Sound& Fetal presentation When to seek medical care, Nutrition Personal Hygiene Fetal movement awarness Warning of symptoms of PE Breast care
Councelling & Health Education
Urine analysis Stool analysis for ova and parasites Complete blood count ABO group and Rh typing Wasserman Reaction Investigations Arrange for pelvic ultrasound
Urine analysis Urine analysis by Urine analysis by Urine analysis by dipstick dipstick dipstick by dipstick
Arrange for pelvic ultrasound Screen for DM
Arrange for pelvic ultrasound
Immunization
Tetanus Toxoid Tetanus Toxoid
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Physical activity: Physical activity may relieve stress, decrease anxiety, and shorten labor. Contraindications to exercise include: Evidence of IUGR Vaginal bleeding Incompetent cervix Risk factors for preterm labor Rupture of membrane Pregnancy-induced hypertension Common complaints with pregnancy: 1. Nausea and Vomiting : a. Recurrent nausea and vomiting occur in 50% of pregnancies. b. Management of mild cases includes: o Avoidance of fatty or spicy foods o Eating small, frequent meals 2. Heartburn: a. Common in pregnancy b. Treatment consists of: o Elimination of spicy and acidic foods o Small and frequent light meals o Decrease amount of liquid consumed with each meal o Limit food and liquid intake a few hours prior to bedtime o Antacids (suspension) and H2-receptor inhibitors 3. Constipation: a. Common in pregnancy b. Management includes: o Increase intake of high-fiber foods o Increase liquids 4. Varicose veins: a. Common in pregnancy, particularly in lower limbs and vulva b. Can cause chronic pain and superficial thrombophlebitis c. Management includes: o Support elastic stockings o Increased periods of rest with elevation of the legs
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5. Hemorrhoids: a. Varicosities of the rectal veins are common in pregnancy b. Management includes: o Cool baths o Stool softeners o Increase fluid and fiber intake to prevent constipation 6. Sexual Relations: a. No restrictions during the normal pregnancy. b. Nipple stimulation, vaginal penetration, and orgasm Release oxytocin and prostaglandins Uterine contractions c. Contraindications: o If membranes have ruptured o If placenta previa is suspected or diagnosed Table (6-4): Immunizations during pregnancy There is no evidence of fetal risk from inactivated virus and bacterial vaccines, toxoids, or tetanus immunoglobulin, and all can be administered when needed. Safe vaccines: 1. Yellow fever 2. Hepatitis B 3. Diphtheria 4. Tetanus Vaccines should be avoided during pregnancy 1. Measles 2. Mumps 3. Rubella 4. Polio
No live attenuated vaccines administered during pregnancy like (Polio, MMR and BCG) Children of pregnant women are safely given viral vaccines. Immune globulin for pregnant women exposed to measles, hepatitis A and B, tetanus, chickenpox, or rabies is given. Table (6-5): Tetanus Toxoid vaccination (TT) TT1 TT2 TT3 TT4 TT5 After the first trimester At least 4 weeks after TT1 or during subsequent pregnancy At least 6 months after TT2 or during subsequent pregnancy At least one year after TT3 or during subsequent pregnancy At least one year after TT4 or during subsequent pregnancy
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Figure (6-1): Antenatal care Antenatal care
1. Medical history 2. Physical examination 3. Investigations Are their risk factors for pregnancy? No Is patient potentially diabetic? No Yes Yes
Continue antenatal care: 1. Scheduled visits 2. Iron supplementation 3. Tetanus immunization At 24 to 28 weeks 50 gm oral one hour glucose challenge test
Refer to a higher level of health care facility
Is the blood glucose level >140 mg/dl? No
Yes
Continue routine antenatal care
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High-risk pregnancy
Conditions associated with child bearing that may jeopardize maternal or fetal wellbeing: Pregnancy and childbirth are normal physiological processes. Problems can occur during pregnancy, labor or puerperium. Skilled obstetrician should follow up high-risk pregnant women. A. Personal Factors Less than 18 years old More than 35 years old Lives far from health facility Positive consanguinity Long duration of marriage with infertility B. Obstetric history Primigravida >30 years Parity of >5 No spacing Previous intrauterine fetal death (IUFD) or neonatal death Previous small for gestational age Previous large for gestational age Previous fetal malformation Previous recurrent 1st trimester abortion Previous spontaneous 2nd trimester abortion, premature labor Previous hypertensive disorders during pregnancy Previous cesarean section delivery Previous retained placenta or post-partum hemorrhage Previous Rh-isoimmunization or hydrops-fetalis Previous instrument delivery C. Past history Hypertension Heart disease or heart murmur
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Tuberculosis or anti-tuberculosis drugs Epilepsy or anti-epileptic drugs Uterine anomalies as uterine fibroid or other pelvic masses Previous myomectomy Previous cervical circulage Previous successful classical repair Previous successful repair of fistula D. Current situation affecting obstetric outcome History Changes in frequency or intensity of fetal movements Vaginal bleeding in early pregnancy Premature uterine contractions Third trimester vaginal bleeding Rubella exposure Examination: Gait: limping Color: Pallor and or jaundice Maternal weight > 90 kg= Morbid obesity Maternal weight < 45 kg Maternal height > 150 cm Excessive weight gain: > 2 kg 1st trimester > 7 kg 2nd trimester > 4 kg 3rd trimester Poor weight gain < 8 kg Smaller uterine size than gestational age Larger uterine size than gestational age Blood pressure >160/100 mmHg Non-engagement of fetal head at 40 weeks Malpresentation. Investigation: Excess or diminished amniotic fluid Hemoglobin <11-g% Proteinuria >+1 Glucosuria Bacteriuria
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Management of high-risk pregnancy: A conscious service provider should refer these women to a higher-level health facility equipped to manage their conditions. Patient needs: investigations, monitoring and timely interventions. Patient should receive antenatal care in a well equipped antenatal clinic Warn patient against home delivery
Bleeding in early pregnancy

Uterine bleeding in the first 20 weeks of pregnancy Causes: Abortion Ectopic pregnancy Vesicular mole Gynecological causes; such as cervical erosion Note: Always take a careful history, always think of ectopic pregnancy Clinical Evaluation: Vital signs (rule out shock, sepsis, and illness) Pelvic exam (look at cervix for source of bleeding) Diagnostic Evaluation: hCG level (to help interpretation of ultrasound results) Ultrasound (US) (assess fetal viability; abdominal US detects fetal heart motion 7 weeks gestational age Complete blood count (CBC) Blood group and Rh type Urine analysis (to screen for urinary tract infection) Remember: Emergency pelvic ultrasound helps to reach the diagnosis and to guide in subsequent treatment line. Patients with a visualized intrauterine pregnancy by sonar, and closed cervix are considered as a threatened abortion. Correlation of ultrasound results with the patients history and physical findings will identify the type of abortion.
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Definition of Abortion Abortion is the interruption or termination of pregnancy before the fetus is viable, i.e. sufficiently developed to survive (<20 weeks gestation or fetal weight <500 gm). Types of Abortion Inevitable Abortion: Uterine bleeding without passage of tissue but with a dilated cervical os Incomplete Abortion: Uterine bleeding with a dilated cervical os and only partial expulsion of the Products Of Conception (POC). Complete abortion: Expulsion of all products of conception. Missed abortion: The embryo or fetus dies but is retained in utero. Recurrent abortions: Three or more consecutive abortions. Septic abortion: Abortion complicated by infection, bacteria and their toxins are disseminated into the maternal systemic circulation. Abortion may be spontaneous or induced: Induced abortion is illegal in Egypt; however, it can be self- induced for unwanted pregnancies. Threatened Abortion: Mild vaginal bleeding with or without uterine colic, with closed cervix, and without expulsion of products of conception. Fetal cardiac activity is reassuring. 95% of pregnancies continue beyond the first trimester once cardiac activity is visualized by ultrasound No evidence that any treatment could influence the outcome: Rest is the most helpful (mental and physical) Observe for amount of vaginal bleeding Repeat hCG and ultrasound every 2-3 days and after stoppage of bleeding No sexual activity Empirical progesterone, anti-spasmodic may be given Poor outcome predicted by: Falling hCG titers Progressive bleeding and or cramping
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Abortion
All other types of abortion should be referred to hospital: General principles: First aid management before transport to stabilize the patient History, physical examination and investigations should be documented and record sent with the patient Communication with the referred to hospital to ensure immediate care as the patient arrives Transfer with equipped ambulance (if not available provide any other form of transport immediately and ensure the procedures needed for safe transport). Septic Abortion: Signs and symptoms: Fever, abdominal pain, and uterine tenderness with foul vaginal discharge Prompt transfer to hospital by ambulance is essential Polymicrobial infection can progress to septic shock Urinary catheter and monitor urine output Fluid replacement through wide-bore IV line Administer tetanus prophylaxis: Immunized patient: 0.5 ml. Tetanus toxoid SC None immunized: 250U tetanus immune globulin IM Antibiotic Regimens for Septic Abortion: A. Gram-negative anaerobic organism coverage: 1. Clindamycin: 600-mg IV / 6 hr or 900-mg / 8 hr; or 2. Metronidazole: 1g IV loading dose followed by 500-mg / 6 hr B. Gram-positive anaerobe and aerobic coverage: 1. Aqueous penicillin G: 4-5 million units IV / 4-6 h (20-30 million U/ 24 hr); or 2. Ampicillin: 2-g IV / 6 hr; or 3. Clindamycin: 600-mg IV / 6 hr or 900-mg / 8 hr; or 4. Cephalosporin: 2-g IV / 4-6 hr (penicillin-allergic patient)
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Recurrent pregnancy loss (Habitual abortion): Suggested Routine Evaluation: a. History: Determine pattern and trimester of pregnancy losses Does the patient have a live child? Evidence of autoimmune disease (lupus anticoagulant) Exposure to environmental toxins, drugs, and infections Previous gynecologic disorders or surgery including DandC Previous diagnostic tests and treatments Definition Pregnancy outside the normal uterine cavity Location 95% of all ectopic pregnancies occur in the fallopian tubes with 5% being ovarian or abdominal pregnancies. Risk factors: Previous history of ectopic pregnancy Pelvic inflammatory disease (PID) Previous tubal or pelvic surgery Assisted reproduction techniques (ART) Intrauterine contraceptive devices (IUD) Diagnosis: 50% of women are usually asymptomatic before tubal rupture Suspected when woman presents with any combined 3 of the following: History of short period amenorrhea (usually < 8 weeks) Positive pregnancy test (urine or serum) Empty uterus by ultrasound Pelvic pain and or abnormal bleeding in first trimester Failure of doubling hCG level every 48 hours Differential diagnosis of ectopic pregnancy Appendicitis Salpingitis Ovarian torsion
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Ectopic Pregnancy
Rupture of ectopic pregnancy Acute disturbed ectopic Syncope Sudden onset of severe pelvic and/or abdominal pain Hypotension Ultrasound findings in ectopic pregnancy (1 or more present) Empty uterus Decidual reaction = thick endometrium Free fluid in Doglas pouch (behind uterus) Cystic or complex adnexal mass Live embryo may be visualized in the adnexa Laboratory evaluation of ectopic pregnancy: Complete Blood Count (CBC) Hemoglobin and hematocrit Blood group (ABO) and Rh factor Ultrasound hCG
Threatened abortion Normal intrauterine pregnancy Corpus luteum cyst
Vesicular Moles (Molar pregnancy)
Clinical presentations: Symptoms of early pregnancy e.g. amenorrhea Vomiting which is usually severe (hyperemesis gravidarum) Symptoms of pre-eclampsia in early pregnancy The uterus is larger than period of amenorrhea Uterus is soft and doughy in consistency Pregnancy test is positive in high dilution >1/300 Sonar: Snowstorm or honeycomb appearance 1st aid management and referral: Refer to hospital for termination of pregnancy Remember: In all cases of bleeding in early pregnancy (abortion, ectopic and vesicular moles), even if the patient is still clinically stable and showing symptoms and signs of internal or external bleeding refer to hospital by an equipped ambulance following the referral protocol.
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Figure (6-2): Vaginal bleeding <20 weels

Vaginal bleeding <20 weels Severe A. Medical history B. Physical examination C. Immediate management: 1. IV line (Ringer or saline) 2. Provide O2 by mask 3. Blood sample and cross match (ABO & Rh) Ultrasound Intra-uterine pregnancy Empty uterus
Mild
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Cervix Closed Severe bleeding Cervix Closed mild bleeding Threatened abortion Conservative
Molar pregnancy
Cervix Opened
High hCG Yes No Asses other causes of bleeding Ectopic
Refer to Hospital for termination
Figure (6-3): Suspected ectopic pregnancy

Suspected ectopic pregnancy Clinical Status of the patient) First aid management Refer to hospital by equipped ambulance Positive Ultrasonography
Cliniclly stable -HCG
Cliniclly unstable?
Negative Diagnosis excluded
Intra-uterine Sac Diagnosis excluded
No Sac Refer to hospital
Not diagnostic Repeat -HCG after 2 days with ultrasound
Normal -HCG and sonar
Subnormal increase -HCG
Falling -HCG
Diagnosis excluded
Refer to hospital
Septic Shock
Pregnancy may predispose to septic shock (septic abortions, chorioamnionitis, and pyelonephritis) Early septic shock is a classic example of distributive shock: Hypotension, fever, and chills Increased pulse rate, high normal or elevated cardiac output
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Progressive Septic Shock: Myocardial dysfunction and ventricular failure First aid management and referral guidelines: 1. Insert two wide bore IV cannulae (size 16 or 18). 2. IV Ringers or saline infusion at a fast drip (1 liter/ hour). 3. Provide 100% oxygen via mask and warm the patient. 4. Blood sample for type and cross match (ABO, Rh, Hb). 5. Insert a Foleys catheter. 6. Referral should be in an equipped ambulance. 7. A physician should accompany the patient
Antepartum hemorrhage
Bleeding after 20 weeks of pregnancy. It is a complicated clinical situation, which puts both the mother and fetus in jeopardy. Causes: Abruption placenta: Bleeding after 20 weeks pregnancy from normally situated placenta Placenta previa: Bleeding after 20 weeks pregnancy from abnormally situated placenta (low laying placenta) Local gynecologic causes: e.g. Cervical polyp or erosion Medical History: History taking, including the last menstrual period The pattern, color and amount of vaginal bleeding The presence and type of pain Symptoms and signs of hypovolemia (nausea, vomiting, dizziness, pallor, perspiration) The presence or absence of fetal movement and fetal heart sounds Physical Examination: Record blood pressure, pulse and temperature. Observe the amount of bleeding in the pad No vaginal examination Examine the external genitalia for lesions, signs of trauma or infection. Abruption placenta Severe pain with hard and tender uterus
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Placenta previa No pain with soft uterus Determine whether blood is maternal or fetal or both: Apt test: Put blood from vagina in tube with KOH (potassium hydroxide): Turns brown if from maternal Turns pink if from fetus
Remember: Pregnant woman + trauma history + back pain = Abruption. Pregnant woman + Painless bleeding = Placenta Previa First aid management: Insert two wide bore IV cannulae, (size 16 or 18). Immediately start I.V crystalloid (Ringers or Saline) infusion at a fast drip (1 liter/hour). Provide 100% oxygen by mask and warm the patient. Obtain a blood sample to type and cross-match (ABO, Rh, Hb). Insert a Foleys catheter to monitor urine output Referral guidelines: Refer to a higher level of health care facility; should be in an equipped ambulance. A physician should accompany the patient. Continue I.V fluids (Ringers or Saline) Continue 100% oxygen Monitor blood pressure and pulse every 5 minutes and monitor the urine output every 30 minutes
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Figure (6-4): Antepartum Hemorrhage

Antepartum Hemorrhage
1. Immediate management: 1. IV line (Ringer or saline) 2. Provide O2 by mask 3. Blood sample and cross match (ABO & Rh)
NO PV
Placenta previa
Ultrasound
Abruption Placenta Living Fetus
1. Sever bleeding OR 2. In labor NO Yes Minor or placenta previa Anti-Shock Refer to Hospital by equipped ambulance Sever Abruption
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Yes
NO
Fetal maturity
Mild to moderate abruption
NO
Yes
Minor placenta previa
Major placenta previa
Conservative
Diabetes Mellitus (DM) with pregnancy

Types:
Pre-gestational
diabetes: diabetes develops before pregnancy Gestational diabetes: diabetes that develops during pregnancy and disappears after delivery. Usually in the second half of pregnancy, particularly in the third trimester.
Screening: Glucose challenge test at 26 to 28 weeks: Give 50-mg glucose load (non-fasting state). Draw glucose blood level 1 hour later. Risk factors of Diabetes in pregnancy Maternal: Adverse effects on existing retinopathy, nephropathy and neuropathy Increased incidence of urinary, and other infections Obstetric complications: pre-eclampsia, polyhydraminos, and preterm labor Trauma to the genital tract e.g. hematomas and tears due to difficult delivery of large birth weight baby (macrosomia >4500 gm) Fetal:
Congenital malformations, prematurity associated with preterm

labor, Intrauterine death
Glucose Challenge Test: If the patient has symptoms suggestive of diabetes mellitus, order the one-hour random oral 50gm glucose challenge test If the blood glucose is >140 mg/dl, a 3-hour oral glucose tolerance test should be done to confirm the diagnosis of diabetes mellitus, and the patient should be referred.
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Table (6-6): Glucose Challenge Test Time of test Fasting One hour Two hours Three hours Management: Refer Serum glucose concentration (must exceed 2 or more values for diagnosis) > 95 mg/dL > 180 mg/dL > 155 mg/ dL > 140 mg/ dL
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Figure (6-5): Diabetes Mellitus (DM) with pregnancy
Diabetes Mellitus (DM) with pregnancy

1. History taking 2. Physical examination 3. Investigations: a) Urine analysis b) Renal function tests c) Ultrasound d) Blood Glucse level 2 hours post-prandial blood glucose <140 mg/dl
Yes
No
Manage in the outpatient Clinic
Refer to hospital for admission and control of blood glucose Controlled blood glucose
Yes
No Refer to higher level of health care
Out-patient management till 37 weeks refer to hospital for delivery
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Hyperemesis Gravidarum Emesis gravidarum is present in up to 85% of early normal Nausea and vomiting commonly occurs between 6-16 weeks
gestation; 20% persist beyond this time. Table (6-7): Assessment of Hyperemesis Gravidarum Severity Mild and Moderate 1. Vomiting 2 / day 2. +1 ketones 3. Requiring anti-emetics 3. May require IV rehydration 4. Managed in outpatient Severe 1. Vomiting >2 / day 2. >+2 ketones 3. Progressive weight loss 4. Require IV rehydration 5. Require hospitalization pregnancies.
Management: History and examination: Exclude other causes as hepatitis, gastrointestinal problems, peptic ulcer, and thyroid disease Investigations include: Exclude urinary tract infection Electrolytes (low chloride and high potassium in severe cases) Changes in renal and liver functions Ultrasound to exclude trophoblastic disease or multiple pregnancy TSH level if clinical suggestion of hyperthyroidism Dietary advice: Small frequent meals; avoid tea, coffee and fatty foods Stress on the importance of adequate oral fluid intake Drug Guidelines: Pyridoxine: 25-mg oral tds/day or 200-mg orally at night Metochlopromide (Pramin, Maxolon): 10-mg orally tds/day Add sedating, antihistamine, and promethazine (Phenergan)
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Moderate and Severe Hyperemesis Gravidarum: Not relieved by the above measures Refer to a higher level of health care facility for hospital admission and further management (Require I.V therapy and close renal and liver monitoring).
Heart Disease with Pregnancy

Interpretation is difficult, but certain findings increase the suspicion that the pregnant woman has a significant cardiac anomaly. Clinical presentation: Medical History: Dyspnea with ordinary effort Dyspnea at rest Paroxysmal nocturnal dyspnea Dyspnea on lying flat Physical Examination: Blood pressure and pulse Orthopnea Congested neck veins Lower limb edema Enlarged tender liver The presence of a diastolic murmur Bubbling crepitation when complicated by pulmonary edema Antenatal Care: Antenatal care for those patients who are not in labor should be performed in a hospital for combined obstetric and cardiac management.
Hypertension with pregnancy

Three criteria for diagnosis of hypertension in pregnancy: Increased SBP >30 mmhg above non-pregnant level Increased DBP >15 mmhg above non-pregnant level Systolic and Diastolic blood pressure >140/90 mmHg These changes must be present on two occasions separated by 4 hours apart under basal conditions
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1. Pre-Eclampsia
Definition: A disease specific to pregnancy occuring in the last trimester (usually after the 24th weeks) and characterized by: 1) Hypertension 2) Proteinurea and/or 3) Edema Clinical presentation: During antenatal care and after 20 weeks gestation, the following symptoms should alert that pre-eclampsia may exist or develop: Nulliparous woman Maternal age <18 years or >35 years Headache and/or dizziness Blurring of vision Epigastric pain Abnormal weight gain Edema of the lower limbs reaching above the knees or present early in the morning before getting out of bed Physical examination: Routine measurement of blood pressure during regular antenatal care visits is very important for early diagnosis of cases of pre-eclampsia. Classification of pre-eclampsia: Range from mild or severe, including the HELLP variant: 1. Hemolysis (H) 2. Elevated liver enzymes (EL) 3. Low platelet count (LP) Criteria for severe pre-eclampsia: Blood pressure >160 mmHg systolic or >110 mmHg diastolic Proteinuria >2g in a 24-h urine collection or >3+ in a random specimen Oliguria (<400 mL in 24-h) or increasing serum creatinine Platelet count <100.000/mL Hemolytic anemia, or increase in direct bilirubin levels
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Headache, visual disturbances, or other cerebral signs Epigastric or right upper quadrant pain Cardiac decompensation, pulmonary edema, or cyanosis Fetal growth retardation
Edema: Edema considered pathologic and generalized if it includes hands, face, and legs First aid management when most effective therapy is fetal delivery: Magnesium Sulfate: Administer 4-6 g of magnesium sulfate I.V over 10-15 min to prevent eclamptic convulsion, followed by 1-2g/h as maintenance dose; adjusted dosage based on patellar reflexes, urine output. The maintenance dose is continued during the referral process. Antihypertensive: 1. Indicated when the Diastolic blood pressure 110 mmHg 2. Nifedipine: A calcium-channel blocker can be given orally and should not be used sublingually. One capsule 20-mg is given orally before referral. Continuing antenatal care: Cases with pre-eclampsia and chronic hypertension must be referred to a higher level of health care facility for further management. Referral: When a patient with history and signs of heart disease is in labor she should be referred. Referral to a higher level of health care facility should follow these guidelines: Referral by equipped ambulance provided with a delivery kit. A physician should accompany the patient. The patient should lie in a semi-recumbent position during referral. Administer 100% oxygen via mask continuously. Give ampicillin 2 gm IV (prophylaxis). Restrict IV fluid infusion to <75 ml/hour if the patient is in heart failure.
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2. Eclampsia
Definition: Severe form of pre-eclampsia with convulsions and/or coma Convulsions usually preceded by headache, epigastric pain, visual disturbance, hypereflexia, and hemoconcentration Recurrence of eclamptic fits occurs in 50% before delivery, 25% during labor, and 25% in early postpartum period (most dangerous). Clinical diagnosis: History from the accompanying family about previous fits, severe headache, blurring of vision, or severe epigastric pain. Measure the pulse rate, respiratory rate and blood pressure. Measure proteins in urine by dipsticks. First aid management: The occurrence of convulsions endangers the lives of the woman and fetus, so first aid management is life-saving: Patent Airway: ensure a patent airway by using a mouth gag if necessary, and suctioning. Oxygen: provide 100% oxygen by mask. Insert a Foleys catheter to monitor urine output Then, the following should be done immediately: Magnesium sulfate: Start with a loading dose of 6-gm diluted in 200 cc of Ringers lactate by slow I.V infusion over 15-20 minutes, followed by maintenance dose of 2-gm/hour by slow I.V route. The maintenance dose is continued during the referral process. Antihypertensives: when diastolic BP 110 mmHg Nifedipine: 1 capsule 10-mg orally before referral. Referral: Referral of cases with severe pre-eclampsia to a higher level of health care facility should follow these guidelines: Referral should be by an equipped ambulance. A physician should accompany the patient. Limit IV fluid intake unless there is bleeding
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Avoid giving diuretics. If the patient develops an eclamptic convulsion during referral,
administer magnesium sulfate 2 gm I.V slowly.
3. Chronic hypertension
Definition: Hypertension that proceeds pregnancy and appears before 20 weeks or presents after delivery High risk to develop superimposed pre-eclampsia Clinical Findings Suggestive of Chronic Hypertension: Multiparty with a history of hypertensive pregnancies Retinal hemorrhages or exudates Blood urea >20 mg/dL or serum creatinine >1 mg/dL ECG evidence of cardiac enlargement Presence of diabetes mellitus, renal disease, autoimmune or collagen vascular disease, and any other risk factors of hypertension Management: Follow carefully for increasing blood pressure, and deteriorating renal functions: Limit sodium intake Serial hematocrit, creatinine, uric acid, and 24-hour urine collection for protein Increased uric acid >6 mg/dL early sign of superimposed pre-eclampsia Antihypertensive therapy: Aldomet is the drug of choice Fetal surveillance (fetal movement record and ultrasound) Anti-hypertensive therapy for chronic hypertension: 1. 2-Adrenergic Receptor Agonists a. -Methyldopa (Aldomet): Drug of choice during pregnancy b. Dosage: 250-500 mg every 6 hours according to severity 2. -Adrenergic Receptor Antagonists a. These drugs, especially atenolol and metoprolol, are safe and effective in late pregnancy, but fetal bradycardia can occur.
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b. IUGR when treatment started in early or mid gestation. 3. Peripheral Vasodilators Hydralazine used as adjuvant therapy with methyldopa and -adrenergic receptor antagonists. 4. Calcium-channel blockers Nifedipine: One tablet 20-mg is given orally Figure (6-6): Pregnant woman >20 weeks, Diastolic blood pressure >90 mmHg
Pregnant woman >20 weeks, Diastolic blood pressure >90 mmHg
1. Proteinuria 2. Edema in lower limbs Yes No
Pre-eclampsia
Chronic hypertension
Assessment of severity: 1. Blood prressure >160 mmHg systolic or >110mmHg diastolic 2. Proteinuria >2g in a 24-h urine collection or >3+ in a random sample 3. Generalized edema Yes Severe Preeclampsia -Give magnesium sulfate -Insert Foleys catheter No Mild Preeclampsia
Manage in the outpatient clinic with regular antenatal follow-up
Refer to hospital for admission and management
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Figure (6-7): Eclampsia
Eclampsia
Pregnant patient or just delivered with convulsions
1. Full history taking 2. Measure blood pressure 3. Measure protein in urine
1. Blood pressure 140/90 mmHg 2. Proteinuria +3 in random sample
Yes
No
1. Maintaine a patent air way 2. Give 100% oxygen by mask 3. Insert Foleys catheter 4. Give magnesium sulfate
Refer to hospital for admission and management
Note: In all pregnancy-induced hypertension (severe pre-eclampsia and eclampsia) after giving the first aid management Refer to hospital by an equipped ambulance following the referral guidelines protocol
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Table (6-8): Essential Drugs For Managing Complications In Pregnanacy And Child Birth A-1 ANTIBIOTICS Amoxicillin Ampicillin Benzathine penicillin Benzyl penicillin Cefazolin Ceftriaxone Cloxacillin Erythromycin Gentamicin Kanamycin Metronidazole Nitrofurantoin Penicillin G Procaine penicillin G Trimethoprim/ Sulfamethoxazole STEROIDS Betamethasone Dexamethasone Hydrocortisone DRUGS USED IN EMERGENCIES Adrenaline Aminophylline
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IV FLUIDS Dextrose 10% Glucose (5%, 10%, 50%) Normal saline Ringer>s lactate ANTICONVULSANTS Diazepam Magnesium sulfate Phenytoin ANTIHYPERTENSIVES Hydralazine Labetolol Nifedipine OXYTOCICS 15-methyl prostaglandin F2a Ergometrine Methylergometrine Misoprostol Oxytocin Prostaglandin E2
Atropine sulfate Calcium gluconate Digoxin Diphenhydramine Ephedrine Frusemide Naloxone Nitroglycerine Prednisone Prednisolone Promethazine
ANAESTHETICS Halothane Ketamine Lignocaine 2% or 1% ANALGESICS Indomethacin Morphine Paracetamol Pethidine
A-2 Essential drugs for managing complications in pregnancy and childbirth SEDATIVES Diazepam Phenobarbitone ANTIMALARIAL Artemether Artesunate Chloroquine Clindamycin Mefloquine Quinidine Quinine dihydrochloride Quinine sulfate Sulfadoxine/Pyrimethamine TOCOLYTICS Indomethacin
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Nifedipine Ritodrine Salbutamol Terbutaline OTHER Anti-tetanus serum Ferrous fumerate Ferrous sulfate Folic acid Heparin Magnesium trisilicate Sodium citrate Tetanus antitoxin Tetanus toxoid Vitamin K
Rh isoimmunization
What is Rh? The surface of red blood cells (RBCs) may or may not contain a Rhesus (Rh) antigen. If a person has a Rh antigen, he is Rhesus + (for example, if someone with blood type A has a Rhesus antigen, the blood type is A+. If that person has no Rhesus antigen, he is A). 50% of fetal antigens are from the father and 50% from the mother. The problem with Rh sensitization: The parental combination you must worry about is: Rh mother and Rh+ father. If the pregnant female is Rh, and her fetus is Rh+, then she may become sensitized to the Rh antigen and develop antibodies. These antibodies cross the placenta and attack the fetal RBCs fetal RBCs hemolysis. Sensitization may occur during: Miscarriage or threatened abortion
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Placental abruption or previa Delivery (at time of placental separation) Cesarean section
Fetal danger occurs when: Rh mother becomes sensitized during her first pregnancy in which the child was Rh+. She is exposed to Rh+ blood during that pregnancy and/or during labor So the mother develops antibodies. In her second pregnancy, her immune system, already primed to recognize Rh+ blood, which crosses the placenta and attacks Rh+ fetal blood fetal RBCs hemolysis. Screening: Blood typing (ABO), and Rh factor must be done for all pregnant females during the first antenatal vist In Rh negative woman, an antibody screen performed at the initial visit with an indirect Coombs test (Anti-D titer). Management of first pregnancy when mother is not sensitized: Blood group and Rh factor Antibody screen (Anti-D titer) should be done at 8, 24 to 28 weeks for all Rh negative pregnant women during her first and subsequent pregnancies. Ultrasound screening at 16, 24, 28, and 32 gestational weeks Delivery in hospital with facilities for neonatal intensive care unit. N.B: If Anti-D titer is >1:16 at anytime either in the first or subsequent pregnancies, do ultrasound and refer to higher level of medical care. When to give Rh (D) Immunoglobulin? 1 ampule = 300 g Rh(D) Ig = 1.5 mL 1. First-trimester abortion: Rh-negative patients should receive Rh immune globulin, 150-300g doses according to gestational age 2. Postpartum management: A 300 g Rh-Ig IM within 72 hours of delivery (still indicated if >72 h)
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Teratogenicity and drug effects upon fetus

Can be explained by one of the 3 mechanisms: (I) Hereditary Defects: In each defect the cause is usually an abnormal gene. Example: 1. Blood diseases: hemophilia and hemoglobinopathies. 2. Inborn error of metabolism. (II) Chromosomal Aberrations: These defects arise during cell division. (III) Environmental Factors: These defects arise during the first weeks of pregnancy when fetal cells are differentiating to form various structures. The earlier the effective agent the greater the fetal tissues and organs are affected. Table (6-9): Teratogenicity and drug effects upon fetus Drug Gentamycin, Kanamycin, Neomycin and streptomycin Chloramphenicol Nitrofuradantin Tetracyclines Anti tuberculous drugs SulphaandThiazides Penicillamine Chemotherpeutics (Cytotoxic drugs) Warfarin Corticostroids Deafness Blood dyscrisis Jaundice Yellow teeth and enamel defects Jaundice and kernicterus Neonatal RBCs hemolysis Loose skin 1. Early pregnancy Lethal to fetus 2. Late pregnancy Cleft palate, Hydrocephalus, Neural tube defects Saddlenose, Retarded growth, Limb, Eye, CNS defects Cleft palate,Congenital Cataract.
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Fetal Effect
Androgens Estrogens Stiboesterol Phenytoin Carmazepine Aminoglycosides Lead poison Spironolactone Non-Steroidal antiinflammatory
Masculinization of female fetus Testicular atrophy Vaginal adenosis, vaginal and cervical cancer Cleft palate, Retardation. Microcephaly, Mental
Retardation of fetal head growth. 8th cranial nerve damage Abortions Feminization of male fetus Closure of Ductus Arteriosus and Renal impairment.
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Chapter 7
Labor and related problems
Chapter 7: Labor and related problems
Clinical conduct of normal labor

Patient Instruction: Education is critical regarding specific events: Bleeding Spontaneous Rupture Of Membranes (SROM) Change in normal fetal activity When should pregnant woman call for help? Nullipara patients usually remain home until contractions every 10 minutes for 1 hour Multipara patients are told to call for help as soon as they perceive labor pain. First stage: History taking: Personal history Obstetric history: for previous labors and abortions Last Menstrual Period (LMP) and Expected Date of Delivery (EDD) Past-medical and surgical history Present labor status: Uterine contractions Membrane condition Current pregnancy complications if present Examination Vital signs (Pulse, temperature and blood pressure) every hour Chest and heart examination Fetal lie and presentation Estimated fetal weight by abdominal palpation Auscultation of Fetal Heart Sounds (FHS) every hour Per Vaginal (PV) examination: If term and no bleeding perform examination, defer if ruptured membranes and preterm gestation Dilation, effacement, position (anterior, posterior) and consistency of the cervix are noted and recorded in partogram
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Laboratory Evaluations Blood type, hematocrit, and urine for protein and sugar Referral is considered in the following conditions: High-risk patient Irregular non-reassuring FHS Abnormal labor progress Meconium in cephalic presentation Unexpected vaginal bleeding High blood pressure of the mother Routine Procedures No longer perform extensive vulval shaving Frequent evacuation of urine every 2-4 hours Oral intake is limited (little amount of sugary fluid may be permitted) Ambulation or various positions in chair or bed are encouraged Subsequent Care Temperature every 4 hours Pulse and blood pressure every 1 hour Fetal heart rate: Early in labor every 60 minutes(latent phase) Late in labor every 15 minutes (active phase) In second stage every 5 minutes (fetal delivery) Vaginal examinations Usually every 30-60 minutes in active phase according to labor progress Amniotomy Accelerates latent phase of labor Shortens active labor phase Check for meconium Done during uterine contractions to rupture the bag of fore-water If head not engaged Can lead to cord prolapse in high head stations Second stage of labor: Duration <1 hour in primigravida, and hour in multigaravida
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Critical time for the fetus (maximum Frequent observation of FHR done
in delivery room are important Location and Maternal Position: Usually dorsal lithotomy Delivery of head: Perineum usually washed with antiseptic solution Gentle counter-pressure to keep the head in flexion Episiotomy: Neither routinely required nor routinely avoided May be preferred to control lacerations Mediolateral episiotomy under local infiltration anesthesia using 1/2% concentration (Lignocaine, Zylocaine, Lidocaine) provides efficient local analgesic, duration 45-90 minutes The incision is best made at the height of contraction when the presenting part is distending the perineum. A blunt tip scissor is used, one blade between the presenting part and vagina and the other being outside Suturing in layers is best done after end of the 3rd stage using 2/0 plain catgut on a curved rounded bodied needle from above downwards and from inside out Delivery of the Body After head delivery, suction the nose and mouth with bulb. Manual suction trap used if meconium present Shoulders are delivered after complete external rotation of the head (Occiput towards one thigh and face towards the other sight)
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fetal and maternal distress) every 5 minutes
Sufficient light and access of instruments
Shoulder is delivered with gentle Body of fetus is then delivered in Cord is clamped and cut Start neonatal resuscitation (based
on Apgar scores) Prolonged second stage: If the second stage exceeds 2 hours in ! primipara or 1 hour in multipara, or if there is fetal distress (FHS shows bradycardia <120 bpm, or tachycardia >160 bpm), the woman should be urgently referred to a higher level of health care facility. Third stage of labor: No attempt to deliver the placenta ! until signs of separation appear: Uterus rises in abdomen Uterus become smaller, harder Elongation of the cord Sudden gush of blood from vagina Pressure is applied on uterine fundus with gentle traction of cord; when the placenta distends the vulva, twist to make a rope of the membranes After delivery of placenta inspect for missing pieces of placenta or membranes. Oxytocin (10 IU units I.M) usually given after delivery of placenta Fourth stage of labor: Inspect, the vulva, vagina, and cervix for any lacerations. Cervical laceration: repair if bleeds or extended greater than half way up to vaginal fornix. If unaccessible or excessive bleeding, refer to hospital for higher health care support (repaired under general anesthesia). Vaginal laceration and episiotomy: repaired to provide anatomic reapproximation
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downward traction controlled fashion
Neonatal resuscitation: Scoring system to determine resuscitation required Table (7-1): Initial evaluation of the infant (Apgar Score) Sign 0 1 2 Heart rate None < 100 > 100 R e s p i r a t o r y None Weak cry Strong cry effort Muscle tone Flaccid Some flexion of limbs Active motions Reflexes Non Grimace Cry Skin color Pale Blue Complete pink
7 to 10: No resuscitation needed 4 to 6 : Some resuscitation needed 0 to 3 : Aggressive resuscitation needed Cord Prolapse
Definition: Cord Presentation: Coils of umbilical cord below the presenting part before rupture of membranes. Cord Prolapse: Coils of umbilical cord below the presenting part after rupture of membranes. Predisposing Factors: High/ill fitting presenting part High parity Prematurity Multiple pregnancy Polyhydraminos Malpresentations: e.g. face, breech. Clinical Assessment: Diagnosis is made by palpation or visual inspection of umbilical cord during vaginal examination below or beside the presenting part, before or after rupture of membranes.
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Prevention: Artificial rupture of membranes (ARM)should be done only after engagement of the presenting part Management: Immediate assessment of gestation, presentation, cervical dilatation, and fetal status. Immediate delivery is necessary when the fetus is viable. The presenting part is pushed out of the pelvis upward by fingers in the vagina to relieve pressure on the cord by the presenting part. This is continued until delivery. Woman placed in exaggerated Sims position (left lateral position supported with 2 pillows on her side). If the cord is protruding, replace it back into the vagina. Avoid over handling as it can cause spasm. Administer oxygen via mask, and stop oxytocics Referral should be by equipped ambulance provided with a delivery kit. A physician should accompany the patient Partogram: It is an observational graph recording to assess the condition of the mother and fetus. Warning: For all mal presentations, no attempts for home delivery should be taken and warning should be given to the pregnant mother during the antenatal period. Refer patient to higher level of health care by ambulance early in labor.
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Figure (7-1): Partogarm
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Multiple pregnancies
Antenatal management: Salts are restricted to avoid pre-eclampsia Liberal amounts of proteins, vitamins and minerals Folic acid and iron to guard against anemia Anemia more common; requires 1-mg of folic acid, and 60-mg of elemental iron daily. Rest: both mental and physical Tocholytics: -Sympathomimitics e.g. Isoxsuprine to guard against preterm labor Hospital admission: Patient referred to hospital for admission at 34th week for clinical assessments and more observations
Retained Placenta
Management: If the placenta is not delivered within 30 minutes, and in absence of bleeding, start first aid management by: Continuous uterine massage. Oxytocin 20 lU/L in saline or Ringer solution by IV infusion Emptying bladder by plastic catheter Change of position (encourage semi-sitting position) If the placenta is not delivered or there is bleeding, refer patient to higher level of health care by ambulance
Intrauterine Growth Restriction (IUGR) Fetal weight at or below the 10th percentile for gestational age Diagnosed by ultrasound every 4-6 weeks for interval growth IUGR suspected clinically if the difference between fundal height Prevention of IUGR e.g., smoking cessation, blood pressure
control, and dietary changes (high protein, fat, and sugar).
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and gestational age >4 cm.
Perineal Trauma: Assessment and Repair

Degrees: First degree: The perineal skin + mucosa of the posterior vaginal wall. Second degree: First degree + muscles of the perineal body Third degree: Second degree + external anal sphincter (rectal wall may be torn); it is called a complete perineal tear. Management: The first and second-degree tears repaired under local anesthesia using vicryl or chromic catgut 2/0 as in episiotomy. The vaginal mucosa is sutured from the apex downwards until introits The perineal muscles are then repaired The perineal skin sutured by simple stitches Referral: Refer third degree perineal tears to hospital within the first 24 hours for surgical repair under general anesthesia Post-Surgical care: The woman is advised to wash the perineum daily with warm water and antiseptic solution; then carefully dry the perineum. If infection occurs, some stitches removed to allow drainage. Broad-spectrum antibiotic.
Rupture uterus
It is the most serious obstetric accident Incidence: 95% of cases occur in multigravida due to: Clinical picture: History of trauma to the abdomen or previous operation on the uterus. Sudden onset of severe abdominal pain, collapse with symptoms and signs of internal hemorrhage General examination: Variable degree of shock
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If the fetus has escaped into the peritoneal cavity:
The retracted uterus is felt separated from the fetus Fetal parts are easily felt The presenting part is high with abnormal attitude. Absent FHS or showing marked fetal distress
Vaginal examination: High presenting part Vaginal bleeding Referral: Refer cases with ruptured uterus or even suspected cases to a higher level of health care facility.The following guidelines should be followed: Referral should be in an equipped ambulance. A physician should accompany the patient. IV fluid (using saline or ringer lactate ) irrespective to the amount of vaginal bleeding Patent Airway: ensure a patent airway by using a mouth gag if necessary, and suctioning. Oxygen: Provide 100% oxygen via mask. Insert a Foleys catheter Preparation for Home Birth Checklist: The family is provided with the following checklist to prepare for a clean and safe home delivery (Source BEOC page 301). Some of the items are provided by the health center in a birth package: Family birth plan Clean home Clean surfaces in the room where delivery will take place Enough light Clean gowns for mother Sanitary napkins Bath towels Clean sheets and pillowcases Plastic sheeting to protect mattress Disinfectant soap Cord clamp
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Disposal sterile scalpel Disposable single-use gloves One pair of sterile gloves Trash can lined with a plastic bag Clean cotton blankets to receive the newborn Diapers Clean clothes for the newborn In cold climate, a source of heat
It is very important to keep the newborn warm by wrapping in enough clothes, specially the preterm Women at Risk to Deliver at Home: Home: Infectious disease present (e.g., hepatitis), unsanitary conditions Obstetrical: Pre-eclampsia or eclampsia, multiple gestation, placenta previa, polyhydramnios, Rh isoimmunization, previous cesarean section, previous stillbirth or neonatal death, multipara > 4 Medical: Cardiac disease, tuberculosis, diabetes, venereal disease, essential hypertension, severe anemia history of infertility Fetal: Breech or transverse lie, gestation < 37 weeks, gestation > 42 weeks, intrauterine fetal death, intrauterine growth retardation, previously diagnosed congenital fetal malformation
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Referral Guidelines for the Pregnant Patient First aid management should be taken before referral according to the protocol. Use and properly fill out a standard Referral Form recording the time of referral and signature of referring physician (see Appendices V and C). This form must go with the patient. Referral should be in an ambulance equipped with: o IV stand o Sphygmomanometer o Oxygen delivery system (cylinder, regulator and tubing) o Oxygen masks and nasal catheters o ECG monitor o Suctioning apparatus The patient should be transferred by stretcher. The patient should be accompanied by a physician. A wellqualified nurse is acceptable in the following situations: o Preterm labor o The patient crosses to the right of the Alert Line on the partograph during labor. Maintain a patent airway. Provide 100% oxygen via mask. Warm the patient. Maintain a continuous IV infusion at the suggested rate, according to the protocol. Measure vital signs (blood pressure and pulse) every 5 minutes. Maintain a Foley catheter and monitor urine output every 30 minutes. Administer medications according to the protocol. Preparation of the Ambulance At the beginning of each shift the head nurse on duty in the emergency room is responsible for checking the ambulance for the availability and function of the items and drugs needed. The ambulance should be supplied with the needed items, drugs and
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disposables and any deficiencies or used items should be replaced.
First aid management: Insert two wide bore IV cannulae (size 16 or 18). IV Ringers or saline infusion at a fast drip (1 liter/ hour). Provide 100% oxygen via mask and warm the patient. Obtain a blood sample to type and cross match (ABO, Rh, Hb). Insert a Foleys catheter. Perform uterine massage. Administer oxytocin 20 IU/ liter. Refer according to referral guidelines.
Postpartum Hemorrhage (PPH)
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Figure (7-2): Post-partum hemorrhage
Primary post-partum hemorrhage = within first 24 hours after delivery
Post-partum hemorrhage
Secondary post-partum hemorrhage = after first 24 hours after delivery Refer once ambulance arrives and continue managing inside
A- Medical history B- Physical examination C- Immediate management: 1. IV line (Ringer or saline) 2. Provide O2 by mask 3. Blood sample and cross match (ABO&Rh) 4. Fix Follys catheter Is placenta delivered?
Yes 1. Uterine massage 2. Oxytocin 3. Bimanual compression 4. Repair any perineal tears showing active bleeding
No 1. Uterine massage 2. Oxytocin 3. Controlled cord traction
Yes 1. Monitor for 6 hours 2. Continue massage 3. Continue ecobolic
No
Refer to hospital by equipped ambulance
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Note: During first aid management, prepare equipped ambulance to transfer the patient to hospital accompanied by physician
Preterm labor
Risk Factors: Low socioeconomic status Prior preterm delivery Multiple gestations Uterine malformation Cervical incompetence Special Prenatal Care for High-risk Women: Frequent visits for weeks 22 to 34 weeks of pregnancy Cervical bacterial and urine culture at 24 weeks Vaginal examination for pH and cervical dilatation Uterine tone and activity palpated Education on nutrition and preterm labor Signs and symptoms reinforced at every visit: Increase or change in vaginal discharge Uterine contractions Vaginal bleeding or leaking of fluid Pelvic pressure or backache Management steps: 1. Evaluation of patient with preterm labor: Regular uterine contractions Cervical changes effacement and dilation Gestational age <37 weeks Fetal weight by ultrasound <2500 g 2. Exclusion criteria for Tocolytic Therapy: PROM Maternal or fetal diseases such as: Abruption Chorioamnionitis Pre-eclampsia and HELLP syndrome
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Fetal distress Major fetal anomalies incompatible with life Advanced cervical dilatation (usually >6 cm) 3. Bed Rest and Hydration Increases uterine blood flow 500 to 1000 cc fluid bolus over 30 to 60 minutes Continuous maternal and fetal monitoring Tocolytic therapy 4. Tocolytics The most frequently used agents is -mimetic -Mimetics: Ritodrine Start 100 mg in 500 cc 5% glucose (0.3 mg/ml) I.V. Maternal pulse reflects serum concentration; decrease infusion if maternal pulse >120 beats per minute. When the uterus becomes quiescent, give 10-20 mg every 6 hours orally/day. 5. Fetal Maturation Therapy for Lung maturity (Glucocorticoid therapy): Used for singleton fetus, between 28 to 32 weeks Betamethazone 12 mg IM / 12 hours for two doses or Dexamethazone IM 4 mg / 6 hours for four doses Maximum benefit at 48 hours Repeat weekly until 32 weeks Pre-Mature Rupture of Membranes (PROM) Diagnosis: 90% of patients with history suggestive of PROM confirmed to have PROM on examination Ultrasound is the final confirmatory step in most cases Important information gained from speculum examination: Cervical dilatation Prolapse of fetal part or umbilical cord Collection of AF sample for culture a. Proper Evaluation with Sterile Speculum Visualize pool of fluid in vaginal fornix pooling
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Normal vaginal PH from 4.5 to 6.0 Nitrazine paper turns blue at pH >6.5 b. Establishing Gestational age and Fetal Maturity: Accurate diagnosis of fetal age by history (LMP) and ultrasound c. Establishing the Onset of Labor: Management depends upon the presence or absence of labor pain Do cervical examination in the presence of painful & regular contractions to assess cervical changes d. Ruling out Infection Chorioamnionitis Clinical diagnosis is made by: Maternal fever (>38C) Maternal tachycardia Leukocytosis Fetal tachycardia (FHS >160 b/min) Tender uterus Mal-odorous or purulent vaginal discharge Management: The plane of management is determined according to gestational age. The risk of ascending infection is greatest in the first 48 hours; evaluate against the risk of respiratory distress syndrome (RDS). Before 26 weeks pregnancy: Induction of labor as the danger of intra-uterine infection exceeds the possibility of getting time to deliver a healthy viable fetus. Before 36 weeks pregnancy: Conservative management Refer cases with PROM to a higher level of health care facility After 36 weeks pregnancy:Active management The risk in developing infection is greater than the benefit of further maturity; induction with oxytocin if labor pains do not start spontaneously within 48 hours.
Valsalva sign may reveal leakage of amniotic fluid from cervix PH of amniotic fluid: 7.1 to 7.3
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Figure (7-3): Preterm labor
Preterm labor
1. Medical history 2. Physical examination 3. Investigations: a. Ultrasound b. Vaginal swab for bacteriological study Diagnostic Criteria: 1, Cervical dilatation >4 cm 2. Cervical effacement >50% No Yes
Is there any contra-indications to tocolysis: 1-PROM 2. Serious maternal or fetal disease: a. Abruptio placenta b. Chorio-amnionitis c. Pre-eclampsia d. Fetal distress e. Major Fetal anomalies
No
Gestational age <34 weeks
Refer to hoppital for admission and management
Yes
Gestational age >34 weeks
1. Tocolysis + 2. Steroids
Tocolysis
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Figure (7-4): Premature Rupture of Membranes (PROM)
Premature Rupture of Membranes (PROM)
1. Medical history 2. Physical examination 3. Direct visualization using sterile speculum Does the woman need to deliver immediately = 1. Cervical dilatation > 4cm 2. Cervical effacement > 50% 3. Evidence of Chorioamnionitis
No
Yes
Gestational age
>26 weeks
26-36 weeks
>36 weeks Refer to hospital for admission and management
Delivery
Delivery
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Routine Postpartum Care

Immediately After Labor
Important: Hemorrhage is greatest in the immediate postpartum period. Inadequate postpartum uterine contraction is a major cause of postpartum bleeding. Blood can accumulate within the uterus without visible vaginal bleeding. Watch for palpable uterine enlargement during the initial few hours of postpartum. First hour: Blood pressure and heart rate at least every 20 minutes. Monitor the amount of vaginal bleeding. Palpate the fundus to ensure adequate uterine contraction If the uterus is relaxed, do abdominal massage. If not contracted, give Methergin 0.5 mg I.V or I.M and continue uterine massage. First Several Hours: Early ambulation: Women are out of bed within a few hours after delivery. Advantages include: Decreased bladder complications Less frequent constipation Reduced frequency of puerperal venous thrombosis and pulmonary embolism Care of vulva: The patient taught to clean and wipe vulva from front to back toward anus. If Episiotomy or Lacerations Repair: 1. Apply ice pack for the first several hours to reduce edema and pain. 2. Periodic application of a local anesthetic spray or cream. 3. At 24 hours postpartum, moist heat (e.g., via warm baths) to
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decrease local discomfort. 4. The episiotomy incision is typically well healed and asymptomatic by third week of puerperium. Bladder Function: Ensure that postpartum woman has voided within 4 hours of delivery. If not it indicates voiding trouble: A catheter may be necessary, with a prophylactic antibiotic after catheter removal. Consider genital tract hematoma as a possible cause.
The First Few Days Postpartum

Bowel Function: Lack of a bowel movement may be due to enema administered prior to delivery. Encourage early ambulation and feeding to decrease the probability of constipation. If Fourth-Degree Laceration: Fecal incontinence may result, even with correct surgical repair, due to injury to the innervations of the pelvic floor musculature. Discomfort and pain management: During the first few days of puerperium, pain may result from: Episiotomy or laceration repair Breast engorgement Post-spinal puncture headache Treat with: Aspirin Acetaminophen Abdominal wall relaxation: Initiate abdominal exercise at any time after vaginal delivery. Diet: After vaginal delivery, there are no dietary restrictions or requirements for women. The mother is permitted to eat and drink after 2 hours postpartum. Continue iron and multi-vitamin supplementation for at least 3
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months postpartum. Immunizations: The non-immunized D-negative woman whose baby is D-positive is given 300 g of anti-D immune globulin within 72 hours of delivery. Women not previously immunized against rubella should be vaccinated prior to discharge.
Post-partum patient education

1. Anticipated physiologic changes during the puerperium: Lochia: the bloody discharge that follows delivery Diuresis: the secretion and passage of large amounts of urine Milk secretion: the influx of milk into the mammary ducts 2. She should go to hospital if she develops: Fever Excessive vaginal bleeding Lower extremity pain and / or swelling Shortness of breath Chest pain 3. Family planning and contraception: Do not wait until first cycle to begin contraception; ovulation may come before first bleeding episode. Contraception is essential after the first menstruation. 4. Coitus in Postpartum: Coitus is resumed after 6 weeks, based on patients desire and comfort. A vaginal lubricant prior to coitus may help to increase comfort. Dangers of premature intercourse: Pain due to continued uterine involution and healing of lacerations or episiotomy scars Increased likelihood of hemorrhage and infection 5. Changes in Body Weight: Most women approach their pre-pregnancy weight 6 months after delivery, but retain approximately 1.4 kg of excess weight. 5 to 6 kilograms are lost due to uterine evacuation and normal blood loss. 2 to 3 kilograms are lost due to diuresis.
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Weight gain during pregnancy Primiparity Early return to work outside home 6. Infant Care Prior to discharge: All laboratory results should be normal, including: Coombs test Bilirubin Hemoglobin and Hct Blood glucose Patient education about infant immunizations and baby care
Factors increase puerperal weight loss:
Lactational Mastitis
Introduction: Incidence up to 20% of breast-feeding women Staph aureus is the most common pathogen Women are most vulnerable during first month of breast-feeding [when skin of nipples is most easily cracked]. Mastitis: a soft tissue breast infection, usually associated with cellulitis of the overlying skin Breast abscess: a purulent breast infection that may present with signs and symptoms of mastitis or may only be a focal reaction to the underlying purulent collection Differentiation between mastitis and breast abscess is usually obvious, but may be difficult at early times. Distinction is important because management differs. Signs and Symptoms: Erythema Edema Tenderness Malaise Fever Investigations: Blood cultures if temp >38.5C
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Consider ultrasound if any suspicion of fluid collection.
Management: Mastitis If temp <38.5C and patient is well, staph-sensitive oral antibiotics should be prescribed. Options include: Flucloxacillin 500mg 4 times daily for 10 days Dicloxacillin 250mg 4 times daily for 10 days Cephalexin 500mg 4 times daily for 10 days Erythromycin 400mg twice daily for 10 days. If temp >38.5C and / or patient is unwell, refer to hospital for admission and parental fluids and antibiotic therapy. Breast abscess Refer to hospital for abscess drainage.
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Chapter 8
Gynecology
Chapter 8: Gynecology
Infertility
Definition: Inability to conceive after a reasonable time (usually 1 year) with regular, frequent and unprotected sexual intercourse Primary infertility: Couples who never had any pregnancy before. Secondary infertility: Couples who had previous pregnancy whether ended by abortion or labor. Table (8-1): Etiology of Infertility: Female causes 1. Anovulation 2. Polycystic ovarian disease 3. Adhesions around the tubes or ovaries from PID, STD, previous operation, etc. 4. Endometriosis 5. Endocrine problems 6. Congenital anomalies of uterus or cervix 7. Cervical mucous too thick or too acid (by using litmus paper) 8. Extreme weight loss or gross obesity, excessive exercise, poor nutrition, environmental and industrial toxins, etc. Male Causes A) General causes: 1. Old age and asthenia 2. Obesity from endocrinal disturbance; with proper penetration of penis 3. Narcotics (altered FSH & LH secretion) 4. Endocrine: thyroid or adrenal dysfunction. B) Local factors: 1. Abnormal semen: such as Azo-atheno- and oligospermia 2. Testicular disorders: such as absence of testes or undescended 3. Physical injury: radiation, direct trauma, and surgical removal 4. Vascular occlusion: such as varicocele
Inability to perform proper sexual relations by one or both partners

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Table (8-2): Incidence of Infertility Male factors Female factors Both Unexplained 40% 40% 10% 10%
Investigate and treat couple together Table (8-3): The Role of The Family Physician in Infertility History and clinical examination One year or less and free Reassure and counsel More than 18 months Counsel and refer
Table (8-4): Causes of referral of Infertile Couple Consider Early Referral If: Female 1. Age > 35 years 2. Abnormal menstrual pattern 3. Previous abdominal/pelvic surgery 4. Previous PID/STD 5. Abnormal pelvic examination 1. 2. 3. 4. 5. Male Previous urogenital surgery Previous STD Varicocele Significant systemic illness Abnormal genital examination
The Role of the Family Health Physician before referral: Counseling: Reassure and avoid excitement If there is extreme weight loss, look for the cause and manage Obesity (BMI >30): advice for weight control Treat any genital infections according to protocols Counseling includes: 1. The fertility period: Ovulation timing
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a. History of regular monthly menses is a strong evidence of normal ovulation. b. Calendar calculation: in regular menstrual cycles (28 days), ovulation occurs 14 days + 2 days before next period. c. Vaginal ultrasound: on days 11, 13 and 15 of menstrual cycle, dominant follicle reaches 18-20 mm just prior to ovulation d. Measurement of luteal-phase progesterone level on day 21 of cycle (normal, 4ng/ml) e. Pre-menstrual endometrial biopsy: determines the presence or absence of ovulation f. Cervical secretions: becomes more stretchy and wet at the time of ovulation 2. Sexual Advice: Advise the couple to have regular intercourse 2-3 times per week. The most effective position is the husband facing the wife and a thin pillow under the wife`s hips to raise them. Avoid lubricants such as gel, cream, and even saliva. Dont douche immediately before or after intercourse, unless the cervical mucus is too acidic (as identified by litmus paper). Table (8-5): Semen analysis - WHO Standard Volume > 2 ml. Specific gravity 1030 Reaction > 7.2 Liquefaction time 15-20 minutes Count > 20 million / ml. Motility > 50% active motile with forward progression within 60 min of ejaculation Viability > 75 % are actively motile. Abnormal forms < 70 % White blood cells <1x106 / mL Ova and Nil. parasites Fructose content 300 mg/dl
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Figure (8-1): Infertility Protocol Refer for further investigation and management
Infertile Couple
History and physical examination
Semen Analysis
Abnormal
Normal
Evaluation of male factor
Refer for female evaluation
Referral
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Premenstrual syndrome (PMS)

PMS is a syndrome that appears during the luteal phase of the menstrual cycle. Symptoms are cyclic in nature with resolutions and exacerbations. Symptoms: Somatic complaints: headaches, bloating, breast tenderness Emotional changes: anxiety, depression, and irritability Behavior symptoms: aggressiveness, mode, food and sleep changes Management of PMS: Diet: luteal-phase reductions in caffeine, fats, and tobacco Refined sugars: decreases irritability by decreasing fluctuation in blood sugar levels Sodium restrictiondecreases edema Oral contraceptive pills anovulation Improves symptoms Non-steroidal anti-inflammatory drugs (NSAIDs) decrease inflammation found in PMS
Menstrual abnormalities
Polymenorrhea: Too short menses with regular intervals less than 21 days Menorrhagia: Too long menses (over 7 days) and/or associated with excessive blood loss (>80 mL) occurring at normal intervals Hypermenorrhea: Too long menses in duration (over 7 days) and/or associated with excessive blood loss (>80 mL) occur in regular but not necessarily normal intervals Oligomenorrhea: Menses with intervals that are too long (cycle length more than 35 days) Metrorrhagia: Bleeding occur in irregular intervals; intermenstrual bleeding Menometrorrhagia: Menorrhagia + metrorrhagia; menses long in duration or excessive blood loss + irregular bleeding intervals
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Dysfunctional Uterine Bleeding (DUB) Abnormal uterine bleeding unrelated to anatomic lesions; usually DUB diagnosed by exclusion after workup for other causes of
abnormal uterine bleeding (anatomical lesions) is negative. Evaluation of DUB: History of bleeding Menstrual and obstetric history Signs of systemic disease (thyroid, liver, kidney) Social (extreme exercise, weight changes) Presence or absence of ovulation (regularity, premenstrual body changes) Treatment: Oral contraceptive pills to regulate the cycle Failed treatment or pregnancy is required Refer to higher level of health care caused by hormonal dysfunction.
Postmenopausal bleeding
It is vaginal bleeding after 1 year from menopause. Differential Diagnosis for Postmenopausal Bleeding: Endometrial Hyperplasia or Cancer Cervical cancer Vulval cancer Estrogen-secreting ovarian tumors Vaginal atrophy (most common) General causes: e.g. hypertension Investigations: Endometrial biopsy and endocervical curettage (because of the prevalence and danger of endometrial lesions) Pap smear for cervical dysplasia, and neoplasia Ultrasound Computed tomography (CT)
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Referral: Refer to higher level of health care Remember: Post-coital bleeding in pregnant woman: Consider placenta previa. Post-coital bleeding in non-pregnant woman: Consider cervical cancer. Postmenopausal bleeding: Consider endometrial cancer. Premenopubertal bleeding: Consider PCO.
Acute pelvic pain

Differential of Acute Pelvic Pain: Appendicitis Ruptured ovarian cyst (most common) Ovarian torsion or abscess Pelvic Inflammatory Disease (PID) Ectopic pregnancy Workup: History Physical exam: Signs of PID (cervical motion tenderness, adnexal tenderness, and abdominal tenderness) Labs studies: Pregnancy test (indicate ectopic pregnancy or abortion) CBC (PID or appendicitis might give elevated WBCs) Urine analysis for urinary tract infection (UTI) Pelvic sonogram (ovarian cysts and possibly torsion) Diagnostic laparoscopy
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Chronic Pelvic Pain

Definition and Criteria: 6 months of pain Incomplete relief by medical measures Altered activities due to pain (e.g., missed work, depression, sexual dysfunction) Causes: Leiomyoma (Fibroid) Endometriosis Adhesions, adenomyosis Pelvic Inflammatory Disease (PID) Infections other than PID Neoplasia Workup: 1. Detailed history focusing on the above etiologies: a. Pattern and relation to menstrual cycle b. Radiation c. Associated symptoms 2. Physical exam: a. Masses b. Cervical motion tenderness c. Gastro-intestinal (GI) complaints 3. Lab work: a. Complete blood count (CBC) b. Pregnancy test c. Urinalysis d. Occult blood in urine or stools 4. Radiographic studies: a. Abdominal and vaginal sonogram b. Computed tomography (CT) c. Barium enema d. Renal sonogram / intravenous pyelogram (IVP) 6. Diagnostic laparoscopy 7. Rule out psychosomatic pain.
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Figure (8-2): Pelvic Pain
Pelvic Pain
Fever or purulent vaginal discharge
No Fever or purulent vaginal discharge
1. PID 2. Appendicitis
Positive pregnancy test
Negative pregnancy test
1. Ectopic pregnancy 2. Abortion
1. Uterine fibroids 2. Endometriosis 3. Pelvic congesion 4. Referred pain 5. Ovulatory pain
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Genital tract infection

Diagnosis: Vulval and vaginal pruritus Curd-like vaginal discharge Candida albicans causes > 90% vaginal yeast infection Treatment: Local antifungal: Imidazole cream or pessary for 5 to 7 days Oral antifungal: 150 mg fluconazole single dose Recurrent infection: Prolonged vaginal therapy for 2-3 weeks Treatment of male partner at the same time Check for Diabetes Mellitus Suppressive treatment: 100 mg ketoconazole daily for 1 week Vaginal treatment with imidazole either twice weekly or daily for 5 days
Candidal Vaginitis
Trichomonas Vaginitis
Diagnosis: Profuse, yellow and malodorous vaginal discharge Vulval pruritis however >50% of patients are asymptomatic Male partner is often the carrier Treatment: Metronidazole: 2 g single dose (for both partners), with 95% cure rate Resistance of parasite to metronidazole may occur Avoid this drug during first 20 weeks of pregnancy
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Bacterial Vaginosis Infection with aerobic and anaerobic bacteria (Gardnerelia Vaginal epithelium appears normal Fishy amine odor vaginal discharge Sexual transmission may occurs
Treatment: Cultured vaginal discharge for specific antibiotic. Table (8-6): Differential diagnosis of vaginal discharge: vaginalis)
Candidiasis
Trichomoniasis
Bacterial vaginosis Yellow/Grayish Homogenous Fishy Non
Color Consistency Odor Associated symptoms Vaginal PH Microscopy Saline test Amine test KOH 10%
White Curd-like No Odor Itching Acidic Hyphae Negative
Yellow/Grayish Frothy Mal odor Dysurea Alkaline 5.5) (4.5-
Alkaline 5.5) Clue cells
(4.5-
Flagellated, pear shaped, mobile Positive
May be positive
Pediculosis pubis
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Figure (8-3): Treatment of vaginal infection
Vaginal Infection - Treatment
Candidiasis
Trichomoniasis
Bacterial vaginosis
General measures (Patient counseling)
- Counseling - Personal hygiene - Treat both wife and husband
Antifungal
Local, e.g. Econazol Ketoconazol
Systematic, e.g. Fluconazol (50 mg orally 1 single dose) Itraconazol (100 mg, 2 tablets twice daily for 1 day)
Metronidazol 250 mg tds for 1 week or Tinidazol 2 gm orally once
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Parasitic infestation caused by a louse pthirus pubis Clinical presentation: Intense pruritis with sky-blue spots on the trunk and thighs Treatment: Gamma benzene Hexachloride
Scabies
Parasitic infestation caused by a mite called sacropetis scabii Clinical presentation: 4 types of lesions: 1. Burrows: found on the fingers, genital areas and soles. 2. Papules. 3. Secondary infected lesions. 4. Nodular lesions. Treatment: Gamma benzene Hexachloride
Pelvic Inflammatory Disease (PID)

Definition: Inflammation of the female upper genital tract (uterus, tubes, ovaries, and ligaments) caused by ascending infection from the lower vagina (vagina and cervix) Causative Organisms: Neisseria gonorrhea Chlamydia trachomatis Escherichia coli Bacteroides Mycoplasma Streptococci Other non-specific organisms Risk Factors: Multiple or new sexual partners Unprotected intercourse from diseased partner History of recurrent sexually transmitted disease Diagnosis:
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1. Physical Exam: a. Fever (may or may not be present) b. Abdominal tenderness by palpation c. Adnexal tenderness by pelvic examination d. Tenderness on cervical movement e. Purulent cervical discharge f. Pelvic abscess (tubo-ovarian abscess) 2. Lab examination: a. Gram-positive staining from vaginal discharge b. Increased white blood cell count, and ESR 3. Laparoscopy: It is the gold standard tool for diagnosis, but it is usually done for cases unresponsive to medical therapy. Indications for Hospitalization: Pregnancy Peritonitis Gastrointestinal (GI) symptoms (nausea, and vomiting) Abscess (tubo-ovarian or pelvic) Uncertain diagnosis Treatment: Inpatient: 1. Chlamydia infection Cefotetan + doxycycline 2. Pelvic abscess Clindamycin + gentamicin Outpatient: 1. Ofloxacin + metronidazole 2. Chlamydia infection Ceftriaxone + doxycycline
Sexually Transmitted Diseases (STDs)

Gonorrhea
Infection of the urethra, cervix, pharynx, or anal canal, caused by gramnegative diplococcus (Neisseria gonorrhea) Clinical presentation:
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May be asymptomatic Dysuria (infection of urethra and bladder) Endocervicitis (acute cervicitis) Purulent vaginal discharge Pelvic inflammatory disease (PID) Diagnosis: Culture in ThayerMartin agar (gold standard) Gonazyme (enzyme immunoassay)
Chlamydial infection
Infection of the genitourinary tract, gastro-intestinal tract, conjunctiva, or naso-pharynx caused by obligate intracellular bacteria (Chlamydia trachomatis). Clinical presentation: There are numerous serotypes of chlamydia. Serotypes AK cause more localized genito-urinary manifestations. The L serotypes causes systemic disease (lymphogranuloma venereum). Chlamydia trachomatis can cause the following presentation: Asymptomatic Mucopurulent discharge Cervicitis Urethritis PID Trachoma: conjunctivitis resulting in hypercurvature eyelash and may be blindness from corneal abrasions Lymphogranuloma venereum: Systemic infection can be presented as: Primary lesion Painless papule on genitals Secondary stage Inguinal lymphadenitis Tertiary stage Recto-vaginal fistulas, rectal strictures Lab diagnosis: IgM titers >1:64 are diagnostic. Isolation in tissue culture Enzyme immunoassay
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Genital herpes Infection caused by herpes simplex virus type I (HSV-I) in 85% of 50% of adults have antibodies aganist HSV-II; most cases are
without history of infection. Clinical presentation: Patients with herpes can be asymptomatic, in addition to the following: 1. Primary infection: Multiple very painful vesicles on the vulva and perineum, lymphadenopathy, fever and malaise. Lesion usually appears 1 to 3 weeks after infection, spontaneous regression occurs and the virus become dormant in the sacral nerve ganglion 2. Recurrent infection: Recurrence occurs from viral activation in the sacral ganglia, causing a milder form of infection (vesicles) 3. Initial primary infection: It is infection by HSV-II in the presence of antibodies against HSV-I in the same person. The preexisting antibodies to HSV-II cause mild HSV manifestations. Risks of HSV infection: Cervical cancer Neonatal infection Diagnosis: Examination of vulva for typical lesions Cytological smear multinucleated giant cells (Tzanck test) Treatment: Treatment is palliative and not curative. Primary infection acyclovir Recurrent infection half of original dose of acyclovir Pregnancy acyclovir during third trimester cases, and by HSV-II in 15% of cases
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Treatment Regimens for Sexually Transmitted Diseases

Gonococcal Infections: A single dose of: Ceftdaxone 125 mg IM, or Cefixime 400 mg orally, or Ciprofloxacin 500 mg orally PLUS: A regimen effective against co-infection with C trachomatis, such as doxycycline or azithromycin
Chlamydia: Recommended: Doxycycline 100 mg orally 2 times/day for 7 days, or Azithromycin 1 g orally in a single dose Alternative: Ofloxacin 300 mg orally 2 times/day for 7 days, or Erythromycin base 500 mg orally 4 times/day for 7 days
Genital herpes: First clinical episode: Acyclovir 200 mg orally 5 times/day for 7-10 days Daily suppressive therapy for frequent recurrences (if > 6 per year): Recommended regimen: Acyclovir 400 mg orally 2 times/ day Alternative: Acyclovir 200 mg orally 3-5 times/day
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Figure (8-4): Flow-chart for Scrotal Swelling
Patient complains of scrotal swelling/pain
Take history and examine
Swelling/ pain confirmed? Yes
No
- Reassure patient/educate - Promote/provide condoms
Testis rotated or elevated, or history of trauma Yes Refer immediately
No
- Treat for gonorrhoea and Chlamydia - Educate - Counsel if needed - Promote/provide condoms
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Treatment of Scrotal Swelling

For Gonococcal Infection: - Ciprofloxacin 500 Mgm In A Single Oral Dose Or - Ceftriaxone 250 Mgm I.M., Single Dose Or - Sulfamethoxazole 800 Mgm - Trimethoprim 160 Mgm 5 Tabs Orally Once A Day X 3 Days. PLUS For Chlamydial Infection: - Doxycycline 100 Mgm Orally Bid X 7 Days, Or - Tetracycline 500 Mgm Orally Qid X 7 Days, Or - Erythromycin 500 Mgm Orally Qid X 7 Days.
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Figure (8-5): Flow-chart for Genital Ulcer Syndrome
Patient complains of genital sore or ulcer
Examine
Ulcer present?
No
Urethral or vaginal discharge present? Yes
No
- Educate - Counsel if needed - Promote/provide condoms
Yes Use appropriate flow-chart - Treat for syphilis & chancroid - Educate - Counsel if needed - Promote/provide condoms - Partner management - Advise to return in 7 days
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Treatment of Genital Ulcer

For Syphilis: - BENZATHENE penicillin 2.4 million units, i.m. in a single dose (half dose to each buttock). - For non-pregnant patients who are allergic to penicillin use; DOXYCYCLINE 100 mgm orally BID x 15 days OR TETRACYCLINE 500 mgm orally QID x 15 days - For pregnant patients, who are allergic to penicillin, use ERYTHROMYCIN 500 mgm orally QID x 15 days. PLUS For Chancroid: - CIPROFLOXACIN 500 mgm in a single oral dose OR - CEFTRIAXONE 250 mgm I.m., single dose OR - ERYTHORMYCIN 500 mgm orally QID x 7 days OR - SULFAMETHOXAZOLE 800 mgm - TRIMETHOPRIM 160 mgm one tab.BID x 7 days
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Figure (8-6): Flow-chart for Inguinal Bubo
Enlarged and/or painful Inguinal Bubo
Ulcer(s) present? No
Yes
Use genital ulcers flow-chart
- Treat for lymphogranuloma venereum - Educate - Counsel if needed - Promote/provide condoms - Partner management - Advise to return in 7 days
Treatment Of Inguinal Bubo - Doxycycline 100 Mgm Orally Bid X 7 Days, Or - Tetracycline 500 Mgm Orally Qid X 7 Days, Or - Erythromycin 500 Mgm Orally Qid X 7 Days.
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Human-Immune Deficiency Virus (HIV)

Acquired Immune Deficiency Syndrome (AIDS) HIV is a RNA retrovirus and causes AIDS. The virus infects CD-4 lymphocytes and other cells and causes decreased cellular immunity. Presentation: Initial infection: Mononucleosis-like illness occurring weeks to months after exposure fatigue, weight loss, lymphadenopathy, night sweats. Followed by a long asymptomatic period lasting months to years. AIDS: Multi-system infections, dementia, depression, Kaposis sarcoma, severe weight loss Mods of transmission: 1-Sexual transmission 2- Blood borne 3- Mother to child during pregnancy or labor HIV not transmitted through ordinary practices ( hand washing, hugging, kissing, sharing food or drink, toilets, bathrooms, swimming pools, insects like mosquitos.etc) Diagnosis: Enzyme-linked immunosorbent assay (ELISA) detects antibodies to HIV. It is sensitive but not specific. Western blot done for confirmation if ELISA is positive. It is very specific. Polymerase Chain Reaction (PCR) is an alternative means of testing Treatment: Two antiretroviral agents plus one protease inhibitor has been common treatment.
Pelvic and Pelvi-Abdominal Masses

Differential diagnosis: Pregnancy Ovarian cyst Leiomyoma (Fibroid) Ovarian neoplasm
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Tubo-ovarian abscess(TOA) Endometriosis / adenomyosis Adhesions (touterus) Also, congenital anomalies, other carcinomas / sarcomas
Diagnostic tests of pelvic and pelvi-abdominal masses: Pregnancy: Pregnancy test Ovarian cysts: Physical exam + ultrasound [US] for confirmation Leiomyoma: Physical exam + US if needed for confirmation Ovarian neoplasm: US, computed tomography (CT) scan, CA-125 level Tubo-ovation abscess: history of PID, tender mass and pelvic sonogram Endometriosis / adenomyosis: US + laparoscopy Endometrial neoplasm: D&C Cancer cervix: Pap Smear History suggestive of diagnosis: Table (8-7): Differential diagnosis of pelvic & abdominal masses: Clinical Suspicion Amenorrhea Reproductive age Most Likely Diagnosis Pregnancy, ovarian cysts Pregnancy, Tubo-Ovarian abscess (TOA), ovarian cysts, leiomyoma, ovarian neoplasm Leiomyoma Signs / symptoms of systemic illness TOA, and/or adhesions Endometriosis Adhesions Neoplasm
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Painless abnormal uterine bleeding History of pelvic inflammatory disease (PID) Dysmenorrhea History of surgery / endometriosis Postmenopausal
Menopause Climacteric: A transitory phase between ages of reproductive and Menopause: the permanent cessation of menstruation (>6 months The postmenopausal period is the time after menopause.
Sex-steroid hormonal changes: Levels of androstenedione fall, a hormone that is primarily produced by the follicle. Ovaries increase production of testosterone, which may result in hirsutism. Decrease in estradiol level and decrease in estrone level FSH and LH levels raise due to absence of negative feedback Table (8-8): Sex-steroid hormonal changes Organ/System Effect of Low Estradiol Cardio-vascular High LDL, Low HDL System After 2 decades of menopause, HRT/ ERT results in 50% reduction from cardiac death. Risk of myocardial infarction (MI) and CAD is equal to men. Bone Osteoporosis: Estrogen receptors found on many cells for bone maintenance (i.e., High osteoblast activity, low osteoclast activity) Treatment HRT/ERT results in 50% reduction in cardiac death. of amenorrhea). non-reproductive ability, equivalent to puberty.
HRT/ERT results in 50% reduction in death from hip fracture using: 1. Calcitonin Etidronate (a bisphosphonate = osteoclast inhibitor) 2. Calcium supplement
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Vaginal mucosa
Dryness and atrophy, with atrophic vaginitis and dyspareunia Loss of urethral tone, and dysuria depression Low estrogen levels correlate to Alzheimers disease. Skin: less elastic, more wrinkled Hair: male growth patterns
HRT/ERT pill or cream
Genitourinary Psychiatric Neurologic
HRT/ERT HRT/ERT HRT/ERT
Hair and skin
HRT/ERT pill or cream
LDL = Low-density lipoprotein HDL = High-density lipoprotein Management of menopausal symptoms: Mild: councelling, reassurance, diet , excercise and calcium supliment Severe: Refer
Womens Health
Health maintainance and screening tools: 1. Pap Smear: Early beginning at age 35 or when sexually active 2. Manual Breast Exams: Annual breast exam to all women beginning at age 30. Monthly breast self-exams for all women by the age of 30 years (premenopausal women should examine their breasts one week after their menstrual period). 3. Mammography: Annually from age 35 with positive family history of breast cancer
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Annually from age 40 for all other women
4. Laboratory Testing: Cholesterol: Periodic annual screening if: Familial lipid disorder Family history of premature coronary artery disease (CAD) Elderly patient <55 years History of CAD Lipids: Periodic screening if: Elevated cholesterol History of parent or sibling with blood cholesterol 240-mg/dL Family history of premature CAD Diabetes mellitus (DM) Smoker Obese Preventive health information: Nutrition and Exercise: The value of proper nutrition and ideal body weight should be discussed during the three major transitional periods in a womans life: Puberty Pregnancy Menopause Ones body weight is determined by three major factors: a.Genetics and heredity, which control: o Resting metabolic rate o Appetite o Body fat distribution o Predisposition to physical activity b. Nutrition c. Physical activity and exercise Objectives: 1. Maintain a healthy diet consisting of small frequent meals (i.e., four to six instead of two to three): Utilize the Food Guide Pyramid as a tool in making food choices in daily life.
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Adjust caloric intake for age and physical activity level:
As one ages, there is a decrease in resting metabolic rate and loss of lean tissue. Older women who are physically active are less likely to loose lean tissue and can maintain their weight with higher caloric intake. 2. Physical activity should include exercise at moderate intensity for 30 minutes on most days of the week.
Domestic Violence
It is a relationship in which an individual is victimized (physically, psychologically, or emotionally) by a current or past intimate partner Recognition of the Domestic Violence: Injuries to the head, eyes, neck, breasts, abdomen, and / or genitals Bilateral or multiple injuries A delay between time of injury and the time at which treatment is sought Inconsistencies between the patients explanation of the injuries and the physicians clinical findings A history of repeated trauma The perpetrator may exhibit signs of control over the health care team, refusal to leave the patients side to allow private conversation, and control of victim. The patient calls or visits frequently for somatic complaints. In pregnant women: Late entry into prenatal care, missed appointments and multiple repeated complaints are often seen in abused pregnant women.
Female Genital Mutilation (FGM)

Definition: The World Health Organization (1997) defined Female Genital Mutilation as all procedures involving partial or total removal of the
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female external genitalia or other injury to the female genital organs whether for cultural or other non-therapeutic reasons. Table (8-9): Types of Female Genital Mutilation (FGM) Type I Type II Type III Type IV Excision of the prepuce, with or without part of the clitoris Excision of the clitoris with part or total excision of the labia minora Excision of part or all of the external genitalia or narrowing of the vaginal opening Unclassified, but includes any other procedure which falls under the WHO definition of FGM.
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Chapter 9
Contraception
Chapter 9: Contraception
Methods of Contraception
Natural Barrier Hormonal Intra-uterine device (IUD)
Natural Contraception
These methods are based on the recognition of the naturally occurring symptoms and signs of ovulation and the fertile and infertile phases of the menstrual cycle. The rhythm or calendar method Cervical mucus method Coitus Interruptus Lactational Amenorrhea Method ( LAM ) 1. The Rhythm or Calendar Method: Calculation of the fertile phase is based on the knowledge that: Ovulation occurs fourteen days before menses. Sperm can live up to four days in a womans body. The ovum can be fertilized as late as 24 hours after ovulation. Because the cycle varies from woman to woman and even from cycle to cycle within the same woman, the user must estimate the approximate days of fertility by keeping track of her cycles on a calendar for six months prior to using the method. Maintain a menstrual calendar to record the length of each menstrual cycle for at least six months. (The cycle begins on day one, the first day of menstrual bleeding, and ends the day before the next menstrual bleeding begins). Identify the longest and shortest cycles. The safe (not fertile) and unsafe (fertile) times are calculated as follows: Take the shortest menstrual cycle (over the past number of months) and subtract 18 days.
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The
number you determine is the first unsafe or fertile day of the cycle. Take the longest menstrual cycle and subtract 11 days. The number you obtain is the last unsafe (or fertile) day of the cycle. The days in the cycle from the first unsafe (or fertile) until the last unsafe day are days when the woman could become pregnant. To avoid pregnancy, there are three options during the unsafe or fertile days: Abstain from all sexual activity. Avoid vaginal intercourse and engage in other sexual activity that does not cause semen to be deposited in or near the vagina. Use a temporary method of birth control, such as condoms, spermicides or a diaphragm. Advantages: No medications affecting body systems Does not affect the menstrual pattern Disadvantages: This method is not reliable for women whose cycles are irregular. It needs alert couples . Not suitable for newly married couples. 2. Cervical mucous method: It is also called the Ovulation Method. Based on recognition of cervical mucous changes under the influence of estrogens and progesterone at different times of menstrual cycle (not reliable methods). Four phases are recognized: The dry days following menstruation; thick cervical mucous plug. Early pre-ovulatory phase; the dry sensation disappears. The wet days, prior to ovulation, when mucous becomes more copious and clear. The dry vagina, where mucous becomes sticky, cloudy and scanty. The woman should avoid sexual relation during the wet days.
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Indications: Couples do not wish to use other methods of contraception. Contraindications: Women with irregular cycles. Adolescents and young females. Perimenpausal women who have some difficulty (increased incidence of anovulatory cycles). Advantages: Normal physiology is not affected. No known physical side effects. Inexpensive. Acceptable to many couples. Disadvantages: Sexual behavior is practiced according to certain conditions. High motivation is required to continue these methods. 3. Incomplete Coitus: a. Coitus interruptus: o It is the withdrawal of erect penis from the vagina before ejaculation. It limits the enjoyment of the sexual intercourse. o The failure rate varies with age and experience (4-27 /H.W.Y). b. Coitus interfemorus: o The stimulation of the erected penis and ejaculation between the thighs of the woman instead of in the vagina. Advantages: No medical side effects. Inexpensive. Disadvantages: Sexual intercourse without satisfaction. Chronic pelvic congestion. Unacceptable to many couples. High failure rate (18/HWY), because pre-ejaculatory mucous contains the most active and motile sperms.
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Figure (9-1): Lactational Amenorrhea Method ( LAM ) Mechanism

Nerve impulses to the hypothalamus Release of prolactin and disruption in the release of gona dotropins releasing hormones (GnRH) Suppresses Ovulation Suppression of FSH and LH
Nipple stimulation by infant suckling
Effectiveness: More than 60% of nursing females pass to lactational amenorrhea in the postpartum period. During this period the woman is immune to pregnancy to some extent while nursing 8 - 10 times daily for 10 minutes each time. The average time between nursing should not exeed 4 hours during day time or 6 hours during night . The effectiveness of breast feeding depends upon: There are three important requirements for the LAM to be effective: Exclusive breastfeeding should be practiced day and night, from both breasts, with no supplementation. Menstruation should not occur (no blood at all, not even drops). The client must be within the six months following childbirth. Breast feeding and contraception: Most contraceptive methods, other than COCs, can be used safely with breast feeding as they have no adverse effect on lactation such as IUDs. Progesterone only pills: Broad medical opinion favors progesterone only pills.
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When to begin contraception: It is not safe to wait for the first menses If barrier method is used, it can be started immediately When hormonal contraception is chosen, it is better to wait 6 weeks postpartum until lactation is established IUD could be inserted either: Immediate post partum. Interval IUD insertion i.e after 6 weeks, after involution of the uterus.
Male Condom: Condoms prevent spermatozoa from reaching the upper female genital tract. Most condoms are made of fine, latex rubber and consist of a circular cylinder (3.5 cm in diameter, 15-20 cm long) with closed teat-shaped end. Efficacy: 85 to 98%, depending on if used properly The only contraception effective in protecting against STDs Indications: Following delivery before another method is used. Where another method is unacceptable. When the couples wish to make the man responsible for contraception. Advantages: Protection against venereal diseases.. Easily obtained and cheap. No medical complications. Simple technique. Disadvantages: Interfere with the act. some may loose erection during application.
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Barrier Contraception
Spermicidal: These are chemicals capable of inactivating sperms in the vagina before they ascend in the upper genital tract. Placed in vagina 30 minutes before intercourse Effective for about 1 hour Efficacy: 80 to 97% Types: Nonoxynol-9 and octoxynol-3, in the form of foams, gels, creams Instructions: Placed high up in the vagina. Latent period before sexual intercourse (Ranging from 5-30 minutes according to manufacture instructions). Douching is not allowed for at least 6 hours. Disadvantages: High failure rate (10-30 / HWY). Inserted shortly before intercourse. Irritation up to allergic reaction to some ladies. Irritation of the male phallus. Efficacy 97 to 99.9%
Oral Contraceptive pills
The following are the various types of oral contraceptives: Combined Pills 1. Low dose pills containing 30 mg Estrogen e.g. a. Yasmin (30 mg etninyl estradiol + 3 mg Drospirnone) b. Microcept (30 mg etninyl estradiol + 0.15 mg Levonorgestrel) 2. Biphasic Pills a. 7 pills Etninyl estradiol 0.05 mg + Norethisterone 35 mg b. 14 pills Etninyl estradiol 1 mg + Norethisterone 35 mg 3. Triphasic pills: a. Cycle days = 7 + 7 + 7 days b. Estrogen: Ethinyl estradiol = 35+35+35 mg c. Progesterone: Northisterone = 50+75+100 mg
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Mechanism: Estrogen suppresses follicle-stimulating hormone (FSH) and therefore prevents follicular emergence. Progesterone suppresses the midcycle gonadotropin-releasing hormone (GnRH) surge, which suppresses luteinizing hormone (LH) and therefore prevents ovulation. Causes thicker cervical mucus Causes decreased motility of fallopian tube Causes endometrial atrophy Progestin-Only Pills: Progestin induce LH suppression and therefore no ovulation. The main differences from combined pills are: A mature follicle is formed (but not released). No sugar-pills - empty pills are used. Progestin-only pills are used in the following circumstances: Lactating women (progestin, unlike estrogen, does not suppress breast milk if taken in early lactation) Women >40 years old Women who cannot take estrogens for other medical reasons (e.g., estrogen-sensitive tumors, breast cancer) Benefits of Oral Contraceptives: Decreases risk of ovarian cancer by 75% Decreases risk of endometrial cancer by 50% Decreases bleeding and dysmenorrhea Regulates menses Protects against fibrocystic change, ovarian cysts, ectopic pregnancy, osteoporosis, acne, and hirsutism Risks of Oral Contraceptives: Increases risk of venous thromboembolism /stroke Increases risk of myocardial infarction (smokers >35 years) Depression Contraindications of Oral Contraceptives: Thromboembolism Cerebro-vascular accident (CVA) or coronary artery disease (CAD) Breast cancer
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Cholestatic jaundice Undiagnosed vaginal bleeding Hepatic disease Known or suspected pregnancy Concomitant anticonvulsant therapy Some antibiotics Relative contraindications: Migraines Hypertension (HTN) Lactation Side Effects of Oral Contraceptives: Break-through bleeding Breast tenderness Nausea (10 to 30% of women) How oral contraceptive pills are used? This varies according to the type of pill prescribed, so follow the instructions of the pill manufacturer. Each pill contains a combination of Etninyl estradiol and progestin. Pills are administrated daily starting from the day 1 of the cycle (Counting the first day of mens as day 1) for 21 days, in the first package, then in the 7th day in subsequent packages. Withdrawal bleeding usually occurs 2-3 days after the last pill. Sometimes 7 placebo or iron containing pills are included after hormone containing pills, so pills are taken continuously. When and how pills are taken? The whole tablet swallowed with a small amount of water. It does not matter what time of the day to take it, but once a time has been chosen it is important to get into the habit of taking the pill at the same time (e.g. after breakfast or at bedtime) to be effective as contraception. What if a pill is missed or taken late? The forgotten pill is taken as soon as possible, even if it means taking 2 pills in one day. The next pill is taken at the usual time until end of package without increased risk of getting pregnant. If 3 pills are missed : During 1st or 2nd week of the package:
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Take a pill once you remember. Another method of contraception (as condoms, or spermicidal) is advised for 7 days. Continue the package and wait for the menses. During 3rd week of the package: Take a pill once you remember. Another method of contraception (such as condoms, or spermicidal) is advised. Continue the package and start an other one without pill free days. Table (9-1): Management of common side - effects of oral contraceptive pills
Problem: Nausea Advice: Inform client that nausea usually disappears after first few cycles. Advise her to take the pill at bedtime. If she vomits within one hour of taking the pill, instruct her to take another pill Action: If nausea develops after the client has been on COCs for some time, exclude pregnancy. If cleint prefers to use another method, provide counseling on other appropriate methods.
Problem: Irregular bleeding (bleeding at unexpected times that bothers the client). Advice: Reassure the client that many women experience this side effect and it is not harmful. Question the client to make sure that she is taking her pills regularly. Question the client to make sure that she is not taking other medicine like Rifampin or phenytoin. Inform her about Al-Azhar fatwa that estehada or spotting that occurs apart from menstuation should not prevent her from performing her religious duties, e.g.praying or fasting. Action: When indicated, examine the cervix by speculum to exclude a local cause for spotting (e.g., infection, polyp or cancer) Encourage client to continue using the pill if spotting occurs in the first months (bleeding tends to decrease after that period). If client is bleeding significantly, advise her to stop taking the pill and to restart after five to seven days. (She should use condoms and spermicides, abstinence, or coitus interruptus during these seven days if sexual intercourse takes place. If this is recurrent, consider using another method).
Problem: No withdrawal bleeding after the end of a pill cycle 239
Review pill-taking history. If pregnancy is excluded, advise client to start the pill cycle on time (seven days after the last pill was taken). If withdrawal bleeding does not occur again in the next cycle (amenorrhea continues), again exclude pregnancy. If not pregnant, advise client to start the pill on time.
Action: Exclude pregnancy. (Take history of sexual exposure, consistent use of pill, pregnancy symptoms, do examination and do pregnancy test if indicated). If amenorrhea (no withdrawal bleeding) persists for more than three months, refer client to a specialist for further evaluation
Problem: Menstruation becomes scanty and color becomes darker after using the pills Advice: Inform the client that this sometime happens and that it does not affect the clients general health and that the dark color is related to scanty blood flow through acidic vaginal secretions. Advice: If headaches are mild suggest aspirin or paracetamol Action:
Problem: COC client complains of persistent headaches Action: Ascertain that the clients headache occurred after pill use initiation and was not felt before starting the pills. If headache is increasingly severe or with neurological symptoms, stop pill use and consider referral for evaluation. Help her choose a different method. If headache persists after stopping pill, refer client for appropriate medical evaluation Action: After counseling, look for other causes of depression. Give Pyridoxine (Pyramine) tablets. If depression does not improve, and client desires, to stop the pills, help her choose another method.
Problem: Depression Advice: If depression was not present before initiating COCs, counsel client that it may be caused by the hormones in the pills
Problem: Weight gain 240
Advice: Explain that this may be a side effect of the COCs, Counsel on reducing caloric intake. If the weight gain is of great concern to the client, counsel on use of another method. Advice: If the diastolic blood pressure is below 90 mmHg, advise client to: 1. Lose weight if she is overweight. 2. Reduce salt intake, smoking and caffeine. 3. Closely follow up measuring blood pressure (BP), particularly during any future pregnancies. If the blood pressure is 140-159/90-99 (WHO Category 3) on one occasion without evidence of previous high BP, repeat BP on next visit. If still high, then advise the client to discontinue oral contraceptive pills and to use a non-hormonal contraceptive. If BP > 160/100 stop COC and help her choose another method. Advice: The forgotten pill is taken as soon as possible, even if it means taking 2 pills in one day. The next pill is taken at the usual time until end of package. If the missed pill is forgotten for more than 12 hours after the usual time, or 2 pills are missed, there is an increased risk of pregnancy and so another backup method of contraception (as condoms, or spermicidal) is advised for 7 days.
Action: See advice
Problem: Client develops hypertension Action: Client should have BP measured after discontinuing pills and if BP continues to be elevated, the client should be referred for treatment.
Problem: What if a pill is missed or taken late? Action: If client habitually forgets to take her COC, despite counseling, advise her to change to another method.
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Types: 1. Progestin only Injectables: Medroxyprogesterone acetate (DepoProvera) by I.M injection every 3 months 2. Combined Injectables: Mesygyna: 50 mg Norethisterone enanthate + 5 mg estradiol valerate, by I.M injection monthly. Efficacy: 99.7% Mechanism of Action: High progesterone level to block LH surge anovulation. Thicker mucus and endometrial atrophy. No FSH suppression. Side Effects of Injectable Hormonal Agents: Bleeding irregularity and spotting Weight gain Alopecia Mood changes Decreased high-density lipoprotein (HDL) Decreased libido Contraindications Known or suspected pregnancy Undiagnosed genital bleeding Breast cancer Liver disease
Injectable Hormonal Contraception
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Hormonal Implants
Subcutaneous implantation containing progestin only Implanon 1 capsule (Etonogestrel ), Norplant 6 capsules ( Levonorgestrel ) Efficacy: 99.8% Mechanism of Action: LH surge suppression Thick cervical mucus Endometrial atrophy Side Effects: Irregular uterine bleeding Acne Decrease libido Ovarian enlargement Difficult removal of implants Indications: When contraceptives pills are contraindicated or intolerated Smokers over 35 years Women with diabetes mellitus, HTN, CAD Contraindications: Thrombophlebitis or embolism Known or suspected pregnancy Liver disease or cancer Breast cancer Patient is under anticonvulsant therapy lasts for 3 years lasts for 5 years.
Intrauterine Device (IUD)

Insertion of a T-shaped device (Copper T IUD) into the endometrial cavity with a nylon filament extending through the cervix to facilitate removal
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Efficacy: 97% Copper T 380A: Size: one size only. Threads: 2 white. Length: 36 mm. Composition: Polyethylene carrier with copper wire, surface area of copper is 380mm (sleeves on the horizontal arm and wire on the stem). Duration for use: Up to 12 years Mechanism of Action: Hostile environment (sterile inflammatory reaction) for sperm and fertilized ova prevents fertilization. Progestin containing IUD prevents ovulation and induces endometrial atrophy. Indications: Contraindicated or intolerated oral contraceptive pills Smokers over 35 years Contraindications: History of pelvic inflamatory diseases (PID) Immuno-compromised patient (e.g., HIV, sickle cell disease) Known or suspected pregnancy Complications: PID Uterine perforation Menorrhagia and metrorrhagia Bleeding from IUD IUD expulsion Missed thread, or IUD
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Figure (9-2): Management of Lost threads of IUD
Lost threads and lost device
Uterine sounding or gentle uterine suction or probing
No threads seen or felt
Threads seen and/or IUDs felt No further action
Ultrasound scanning
Not available, or no IUDs seen in the cavity
Confirms IUDs in uterine cavity
X-ray to locate IUDs in pelvis or abdominal cavity
No further action needed
Refer to hospital
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Emergency Contraception For all women at risk of pregnancy after unprotected intercourse No absolute contraindications to emergency hormonal
contraception. Hormonal Methods: Levonorgestrel method: (Postinor 2) 0.75 mg levonorgestrel and repeat 12 hours later Effective within 72 hours of unprotected intercourse 88% reduction in pregnancy risk Yuzpe method: (combined estrogen and progestagen) 100 mg ethinyl oestradiol and 500 mg levonorgestrel (2 tablets Nordiol) and repeat 12 hours later Prescribed with antiemetic. Begun within 72 hours of intercourse Both methods: Patient may or may not bleed after treatment Menstruation may be delayed up to 2 weeks (in 10% women) No evidence of teratogenic effects in failed usage Follow up is advised after the next period A pregnancy test is done if the subsequent period is late or light IUDs (Cu containing IUDs) insertion: Will protect against pregnancy after multiple exposures provided insertion within 5 days of most probable calculated ovulation date (i.e. up to day 19 of 28 day cycle) >90% estimated reduction in expected pregnancy rate Provides ongoing contraception N.B: For more information refer to the text Contraceptive Technology which is avalailable in all FP units.
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Contraception for special groups

Diabetic women: Diabetic women should have only the pregnancies they want or that are medically safe for them. Inform the client of the increased risk to herself and her fetus / infant during pregnancies with Diabetes Mellitus. When Diabetic women decide to become pregnant they should be in optimal medical condition and have controlled blood sugar. Hormonal Contraception may alter glucose tolerance thus requiring adjustment of insulin dosage for the client. This is usually very minor, but the physician providing the diabetic care should be informed of the use of this method if it is chosen by the client. Intra-uterine devices can be used. Condoms and/or spermicidal can be used Because the obstetric complications of diabetes increase with advanced age, and because limitations for the use of hormonal methods may occur with long duration of diabetes. It is advisable to minimize birth spacing intervals and perform surgical sterilization after the client has her desired number of children. Women with Rheumatic and other valvular heart disease: Long term, effective Contraception is extremely important for these women. The risk/benefit of the disease with a pregnancy and the contraceptive must be considered. Optimum birth spacing is three to five years. Injectable contraceptive and subdermal implants (Implanon or Norplant) may be used with these clients. Low-dose of combined oral contraceptive may be provided by a specialist provided that it is documented in the clients record and a strict follow-up is discussed with the client. IUDs may be used, but clients and providers should be aware of the rare possibility of developing bacterial endocarditis if a pelvic infection occurs. Condoms and/or spermicides can be used. It is advisable that these women should only have one or two children,
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if their health status and cardiac condition allows it. Hypertensive women: COCs should never be used, if systolic B.P. is more than 80/110 mm mercury (see WHO Category 4) Depoprovera should be used with caution (see WHO Category 3) if systolic B.P. is more than 180/110 mm mercury. Explain that optimum birth spacing is three to five years. Recently married couples wishing to postpone their first pregnancy: After contraceptive counseling and discussion of the methods with the client, all of the reversible current methods can be considered except IUDs and Depoprovera. Explain that optimum birth spacing is three to five years. Women approaching the age of the menopause (40 + years): (Note that a highly effective contraceptive is needed by this category as they usually have their desired number of children). All current methods of birth control are acceptable. Highly effective longterm methods such as IUDs, Progestogen-only methods (injectables, Implanan and Norplant) and surgical contracetpive methods are also options worth considering. Combined oral contraceptive should be used with caution if the woman is a light smoker (less than 20 ciagarettes a day). As always, condoms should be emphasized to men and women at high risk of STD and HIV. Anemic women: Intra-uterine contraceptive devices may be temporarily unsuitable until correction of anemia because they may cause excessive blood loss. Hormonal contraceptives (oral pills, injectables, Norplant) help to improve the hematological parameters. Optimum birth spacing is three to five years. Liver cirrhosis, Jaundice: All contraceptive choices should be discussed with the client. The risk of pregnancy with such a serious medical problem should be taken into consideration when making a contraceptive decision.
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Progesterone-only contraceptives may be used after discussing with client and documenting in record. Combined oral contraceptives should never be used in severe decompensated cases (WHO Category 4) Other contraceptives may be used. If the problem is chronic, consider medical indicators for sterilization. Once infective hepatitis is resolved, client may be provided by contraceptive. Epilepsy and Tuberculosis: Note that drugs used to treat these conditions (Eqanutin and Rifampicin) reduce effectiveness of oral hormal contraceptives. A back-up method might be used by these women, particularly by those who have breakthrough bleeding. Injectable contraceptives, IUDs, condoms and spermicides can be used. Surgical contraception can be considered if medically indicated. History of deep venous thrombosis: Contraindicates the use of combined hormonal contraceptives (WHO Category 4) History of cerebo-vascular accidents: Contraindicates the use of combined hormonal contraceptives (WHO Category 4) Breast cancer: Contraindicates the use of all hormonal contraceptives (WHO Category 4) Migraine/severe headaches: Contraindicates the use of combined hormonal contraceptives specially when associated with focal neurological symptoms (WHO Category 4) Fibroid uterus: Distortion and/or enlargement of the uterine cavity can contraindicate the use of intra-uterine contraceptive devices because of a high failure rate, and possible difficulty with insertion.
249
Hormonal contraceptive can be used. Watch for increased size or tenderness on the tumor and watch for fever. When indicated, refer to specialist for careful evaluation. Pelvic inflammatory disease: Do not use IUDs in women having or with a recent history of pelvic examination disease, increase risk of STLs, or with a hydro or a pyosalpinx for fear of infection flaring up. Refer for careful evaluation and/or treatment. Hormonal contraceptive, condoms, & spermicides can be used. Dysfunctional uterine bleeding (menorrhagia or metrorrhagia): If organic pathology is excluded, oral contraceptive pills, if not otherwise contraindicated, can serve the purpose of contraception as well as regulation of menstruation. Other conditions which would threaten the womens life, if she becomes pregnant, including grand multiparty or repeated Cesarean section deliveries. Special consultation and consideration must be given to the client or potential client who is put at risk of dying because of severe medical problems if she should become pregnant again. A permanent method of birth control might be made available to the women (surgical contraception, i.e. tubal ligation).
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!
Chapter 10
Pediatrics
Chapter 10: Pediatrics
Figure (10-1): Infant care in delivery room
Approximate time
Birth Clear of meconium? Breathing or crying? Good muscle tone? Color pink? Term gestation?
Yes
Routine care Provide warmth Clear airway Dry
30 sec
No Provide warmth Position, clear airway* (as necessary) Dry, stimulate, reposition Give O2 (as necessary)
Evaluate respirations, heart rate, and color
Breathing HR >100 and pink
Supportive care
Apnea 30 sec
or HR <100 Ventilating HR >100 and pink Ongoing care
Provide positivepressure ventilation*
HR <60
HR >60
30 sec
Provide positive-pressure ventilation* Administer chest compressions
HR <60 Administer epinephrine* Endotracheal intubation may be considered at several steps
253
Referral Guidelines for the Neonate Transport Personnel Transport personnel should be fully skilled in the care of the high-risk neonate and trained in neonatal resuscitation. The personnel may include a physician, neonatal nurse and specially trained transport technician. Transport Vehicle and Equipment An ambulance should be prepared with the following:
Transport incubator Monitors
o Heart rate o Respiratory rate o Temperature o Blood pressure o Inspired oxygen concentration o Oxygen saturation Oxygen delivery system (cylinder, regulator and tubing) Intravascular infusion equipment o Cannulae (sizes 22, 24) o Syringes (sizes 2.5, 3, 5, 10, 20 and 50 cc) o IV infusion sets o Adhesive tape o Alcohol swabs o Gauze Suction equipment o Bulb syringe o Mechanical suction o Suction catheters (size 6, 8 and 10) Medications for resuscitation o Epinephrine o Sodium bicarbonate 8.4% ampules o Volume expanders (Ringers or saline) o Sterile water
254
Equipment for intubation

o Laryngoscope (straight blades size 0 and 1) o Extra bulbs and batteries for laryngoscope o Endotracheal tubes (size 2.5, 3 and 3.5 mm internal diameter) o Ambu bag with cushioned rim mask Other equipment o Stethoscope o Oral airways (size 0 and 00) Monitors Records of each transport should include the complete prenatal history, delivery record and Apgar scores from the hospital of origin and the transport form.
Achieving Successful Resuscitation and Transport All personnel in the transport team should be trained in neonatal resuscitation. All necessary equipment should be available and working. Do not wait for the one (1) minute Apgar score to start resuscitation; the later you begin, the more difficult resuscitation will be. The neonate should be dried to prevent heat loss and properly positioned to maintain an open airway. The upper airway should be cleared by using a bulb syringe; suctioning the mouth first and then the nose. Place the neonate in the incubator to minimize heat loss. Communication with the referral hospital should be done prior transport to ensure a place for the mother and neonate
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Assess, Classify And Treat The Sick Young Infant Age Up To 2 Months
1- Check for possible bacterial infection
Table (10-1): Classification & treatment the Sick Young Infant Age Up To 2 Months ASK:
Is the young infant not able to feed ?
LOOK, LISTEN, FEEL:

See if the infant is convulsing now. Count the breaths in one minute. YOUNG Repeat the count if elevated. INFANT Look for severe chest indrawing. MUST BE CALM Look for nasal flaring. Look and listen for grunting. Look and listen for wheeze. Look and feel for bulging fontanelle. Look for pus draining from the ear. Look at the eyes. Is it draining pus? Is draining pus associated with redness and swelling? Look at the umbilicus. Is it red or draining pus? Does the redness extend to the skin? Measure temperature (or feel for fever or low body temperature). Look for skin pustules. Are there many or severe pustules? See if the young infant is lethargic or unconscious. Look at the young infants movements. Are they less than normal ?
Has the infant had convulsions ?
If the child is: Less than 2 months
Fast breathing is: 60 breaths per minute or more
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Signs
Classify As
(Urgent pre-referral treatments are in bold print)
Treatment
Not able to feed OR Convulsions OR Fast breathing (60 breaths Severe chest indrawing OR Nasal flaring OR Grunting OR Wheeze OR Bulging fontanelle OR Pus draining from ear OR Pus draining from the eyes Umbilical redness
with redness and swelling OR extending to skin OR per minute or more) OR
Treat current
convulsion with rectal sodium valproate.
Give first dose

POSSIBLE SERIOUS BACTERIAL INFECTION
of intramuscular antibiotics. to prevent low blood sugar.
Treat
Advise mother how to

keep the infant warm on the way to the hospital.
Fever (37.5C* or above Many or severe skin

pustules OR OR
or feels hot) or low body temperature (less than 35.5C* or feels cold) OR
Refer URGENTLY to
hospital.
Lethargic or unconscious Less than normal

movements
Red umbilicus or draining
pus OR Skin pustules OR Pus draining from the eyes.
Give an appropriate oral

LOCAL BACTERIAL INFECTION
Teach mother to treat
antibiotic .
local infections at home. Advise mother to give home care for the young infant. Follow - UP in2 days
257
THEN ASK: Does the young infant have diarrhea?

IF YES, ASK: LOOK AND FEEL:
For how long? Look at the young infants general condition. Is the infant: Lethargic or unconscious? Restless and irritable? Classify DIARRHEA
Is there blood in the stool?
Look for sunken eyes. Pinch the skin of the abdomen. Does it go back: Very slowly (longer than 2 seconds)? Slowly?
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Two of the following signs:

for DEHYDRATION
POSSIBLE SERIOUS BACTERIAL INFECTION : Lethargic or - Give fluid for severe unconscious dehydration (PlanC). Sunken eyes OR SEVERE Skin pinch goes back If infant also has DEHYDRATION very slowly. POSSIBLE SERIOUS BACTERIAL INFECTION: - Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way. Advise mother to continue breastfeeding.
If infant does not have
Classify DIARRHEA
Two of the following signs:
SOME Restless, irritable POSSIBLE SERIOUS DEHYDRATION Sunken eyes BACTERIAL INFECTION: Skin pinch goes back - Refer URGENTLY to slowly. hospital with mother giving frequent sips of ORS on the way. Advise mother to continue breastfeeding. Follow up in 2 days
Give fluid and food for some dehydration (Plan B). If infant also has
Not enough signs to classify as some or severe dehydration. Diarrhea lasting 14 days or more.
and if diarrhea 14 days or more
NO DEHYDRATION
Give fluids to treat diarrhea

at home (Plan A). - Follow up in 2 days
SEVERE PERSISTENT DIARRHEA
If the young infant
Blood in the stool.

and if blood in stool
BLOOD IN STOOL
Treat to prevent low blood sugar. Advise mother how to

keep the infant warm on the way to the hospital. Refer URGENTLY to hospital.
is dehydrated, treat dehydration before referral unless the infant has also POSSIBLE SERIOUS BACTERIAL INFECTION. Refer to hospital.
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Check For Significant Jaundice :

ASK
Has Jaundice started in the first 24hours of life? Is the infants age 2 weeks or more?
LOOK
Look for Jaundice : Is it deep jaundice seen in the sclera? Is it extending to palms and/or soles?
Then Check For Feeding Problem Or Low Weight :

Has any difficulty feeding, or Is breastfeeding less than 8 times in 24 hours, or Is taking any other foods or drinks, or Is low weight for age, or low birth weight (less than 2500 grams) or Is in the first week of life AND Has no indications to refer urgently to hospital: ASSESS BREASTFEEDING: Has the infant If the infant has not fed in the previous hour, ask the mother to put her breastfeed in the infant to the breast. Observe the breastfeed for 4minutes. previous hour? (If the infant was fed during the last hour, ask the mother if she can wait and tell you when the infant is willing to feed again.) IF AN INFANT : Is the infant position correct? TO CHECK POSITIONING , LOOK FOR: - Infants neck is straight or bent slightly back, - Infants body is turned towards the mother, - Infantss body is close to mothers body, and - Infantss whole body supported. (If all of these signs are present, the infants positioning is good) poor positioning Is the infant able to attach? good positioning
TO CHECK ATTACHMENT, LOOK FOR: - Chin touching breast - Mouth wide open - Lower lip turned outward and, - More areola visible above than below the mouth (If all of these signs are present, the attachment is good.) no attachment at all not well attached good attachment
Is the infant suckling effectively (that is, slow deep sucks, sometimes pausing)? not suckling at all not suckling effectively suckling effectively Clear a blocked nose if it interferes with breastfeeding.
260
Signs
Classify as
SIGNIFICANT JAUNDICE
Treatment
Jaundice started in
Classify JAUNDICE
the first 24 hours of life and still present OR Deep Jaundice seen in the sclera OR Jaundice extending to palms and/or soles OR Jaundice in an Infant aged 2 weeks or more
Encourage breastfeeding to prevent low blood sugar Advise mother how to keep the
infant warm on the way to the hospital Refer URGENTLY to hospital
Poor positioning or Not well attached to breast or Not suckling effectively or Less than 8 breastfeeds in 24hours or Receives other foods or drinks or Low weight for age or low birth weight or Thrush (ulcers or white patches in mouth) FEEDING PROBLEM OR LOW WEIGHT
Advise the mother to breastfeed
Classify FEEDING

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as often and for as long as the infant wants, day and night. If not well attached or not suckling effectively, teach correct positioning and attachment. - If low birth weight and problems with attachment and suckling persists after counselling: refer to hospital. If breastfeeding less than 8 times in 24 hours, advise to increase frequency of feeding. If receiving other foods or drinks, counsel mother about breastfeeding more, reducing other foods or drinks, and using a cup. If not breastfeeding at all: - Refer for breastfeeding counselling and possible relactation. - Advise about correctly preparing breastmilk substitutes and using a cup. If thrush, teach the mother to treat thrush at home. Advise mother to give home care for the young infant. Follow-up any feeding problem or thrush in 2days. Follow-up low weight for age in 14 days.
Treat The Young Infant
Give an Appropriate Oral Antibiotic

For local bacterial infection: First-line antibiotic : Second-line antibiotic:
AMOXYCILLIN
AMOXYCILLIN COTRIMOXAZOLE
COTRIMOXAZOLE (trimethoprim + sulphamethoxazole) Give two times daily for 5 days Syrup (40 mg trimethoprim +200 mg sulphamethoxazole) in 5ml
Give three times daily for 5 days

AGE or WEIGHT Syrup 125 mg in 5 ml Birth up to 1 month (< 3 kg) 1 month up to 2 months (3-4 kg) 1.25 ml 2.5 ml 1.25 ml Syrup 250 mg in 5 ml
1.25 ml* 2.5 ml
* Avoid cotrimoxazole in infants less than 1 month of age who are premature or jaundiced.
Give First Dose of Intramuscular Antibiotics Give first dose of both ampicillin and gentamicin intramuscular.
GENTAMICIN Dose: 2.5 mg per kg WEIGHT Undiluted 2 ml vial containing 20 mg = 2 ml at 10 mg/ml 1 kg 2 kg 3 kg 4 kg 5 kg OR 0.25 ml 0.50 ml 0.75 ml 1.00 ml 1.25 ml Add 6 ml sterile water to 2 ml vial containing 80 mg = 8 ml at 10 mg/ml Ampicillin Dose: 50 mg per kg To a vial of 500 mg : Add 4.5 ml sterile water = 5.0 ml at 100 mg/ml 0.5 ml 1.0 ml 1.5 ml 2.0 ml 2.5 ml
Referral is the best option for a young infant classified with POSSIBLE SERIOUS BACTERIAL INFECTION. If referral is not possible, give Ampicillin and gentamicin for at least 5 days. Give Ampicillin every 6 hours plus gentamicin every 8 hours. For infants in the first week of life, give gentamicin every 12 hours.
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Early Detection of Congenital Hypothyroidism (CH) Early detection of Congenital hypothyroidism is very important to avoid mental and physical retardation resulted from the untreated CH . Routine neonatal screening is done between the 3rd and 7th day of birth The nurse is responsible to take a blood sample from the newborn on a filter paper by a heel prick. Samples are collected on Saturday and Tuesday of each week They are sent to the Health Directorate on the same day of collection Samples are sent to the Central Lab next day Positive cases are referred to Health insurance to confirm diagnosis and provide treatment and follow up .
The FHU will ensure continuity of treatment through counseling and regular checking during child health care
263
Figure (10-2): Neonatal Conjunctivitis
Neonate with eye discharge
Family physician
Bilateral or unilateral (reddish), swollen eyelids with purulent discharge?
No
Reassure mother Advise to return if not better
Yes
Treat for gonorrhoea Treat mother and partner(s) for gonorrhoea and Chlamydia Educate mother Counsel mother if needed Advise to return in 3 days
Pediatrician/ Neonatologist
Improved? Yes
No
Treat for chlamydia Advise to return in 7 days
Reassure mother
Improved? Yes
No
Refer
Continue Treatment
264
Treatment of Neonatal Conjunctivitis 1. Crystalline penicillin 50.000 units/Kg/day I.V. in 3 divided doses X 7 days. 2. Saline irrigations 4-5 times a day followed by Tetracycline 1% OR Erthromycin 0.5% eye drops 4-5 times a day X 2 weeks. If not improved treat for Chlamydia 1. Erythromycin 10 mgm/kg orally Q.I.D X 14 days 2. Saline irrigation 4-5 times a day followed by Tetracycline 1% OR Erythromycin 0.5% eye drops 4-5 times a day X 2 weeks.
Congenital Infections (TORCH)

Many congenital infections present with jaundice, hepatosplenomegaly, and thrombocytopenia in addition to the descriptions listed in the following table.
265
Table (10-3): TORCH Infection

Infection Toxoplasmosis
Deseription Hydrocephalus, seizures, intracranial calcifications, and ring enhancing lesions on head CT. Disease specific For HIV mothers, treatment of mother pre- and peri-natally as well as prophylaxis of infant for 6 weeks after birth will transmission. Immunize pregnancy mothers prior to
Treatment - Pyrimethamine - Sulfadiazine - Spiramycin.
Prevention Avoid exposure to cats and cat feces during pregnancy; avoid raw/undercooked meal; treat women with infection.
Other
Includes HIV, parvovirus, varicella, Listeria, TB, malaria, and fungi, None.
266
Rubella
Blueberry muffin rash, cataracts, hearing loss, PDA and other cardiac defects, encephalitis Ganciclovir
Cytomegalovirus (CMV) Acyclovir
Petechiat rash, periventricular calcifications, microcephaly, chorioretinitis.
Avoid exposure
Herpes
Skin, eye, and mouth vesicles; can progress to severe CNS / systemic infection.
- Perform a C-section if mother has active lesions at time of delivery. - Highest risk is from mother with infection
Table (10-4): Child development

Fine motor
Tracks past midline. Grasps rattle. Orients to voice, ahgoo, razzes. Babbles. Says mama / dada (nonspecific). Says mama/dada (specific). Uses 4-6 words. Names common objects. Uses 8-10 words. Uses 2 word phrases. Uses 3 word sentences. Counts to 10. Copies a cross. Cooperative play. Stranger anxiety. Waves bye-bye, plays Imitates actions. Temper tantrums. Copies parent in tasks (e.g., sweeping). Follows 2 step commands, removes clothes. Brushes teeth with help, washes / dries hands. Enjoys looking around, laughs. Alerts to sound, coos. Recognizes parent, social smile.
Age
Gross motor
Language
Social / Cognitive
2 months
Lifts head/chest when prone.
4-5 months
Rolls front to back, back to front (5 months). Transfers objects, raking, grasp. Uses 3 finger pincer grasp. Uses 2 finger pincer grasp. Uses cup. Builds tower of 24 cubes. Builds tower of six cubes. Copies a circle, uses utensils.
6 months
Sits unassisted.
9- 10 months
Crawls, pulls to stand.
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12 months
Cruises (11 months), walks alone.
15 months
Walks backward.
18 months
Runs, kicks a ball.
2 years
Walks up / down steps
3 years
Rides tricycle, climbs stairs with alternating feet (3-4 years).
4 years
Hops.
Table (10-5): The compulsory childhood immunizations schedule in Egypt

Administration Oral Intrader-mal Oral IM IM Oral IM IM Oral IM IM Oral Oral Oral Subcutaneous Oral Oral IM Subcutaneous Oral IM IM IM IM IM IM
Age At birth
Dose no. Zero dose
Vaccine Sabin BCG Sabin DTP Hep B Sabin DTP Hep B Sabin DTP Hep B Sabin Polio TB
Disease
Dose size 2 drops 0.05 mm3 2 drops 0.5 mm3 0.5 mm3 2 drops 0.5 mm3 0.5 mm3 2 drops 0.5 mm3 0.5 mm3 2 drops 100,000 IU 2 drops 0.5 mm3 100,000 IU
2 months
First dose
Polio Diphteria, Tetanus, Pertusis Hepatitis B Polio Diphteria, Tetanus, Pertusis Hepatitis B Polio Diphteria, Tetanus, Pertusis Hepatitis B Polio Vit A Polio Measles, mumps and rubella Vit A Polio Diphteria, Tetanus, Pertusis Measles, mumps and rubella Vit A Meningococcal meningitis Meningococcal meningitis Diphtheria ant tetanus Diphtheria ant tetanus Meningococcal meningitis Meningococcal meningitis
4 months
Second dose
6 months
Third dose
9 months
Fourth dose Fifth dose First dose First dose
12 months
Sabin MMR
18 months
Booster dose
Sabin DTP MMR
2 drops 0.5 mm3 0.5 mm3 200,000 IU 0.5 mm3 0.5 mm3 0.5 mm3 0.5 mm3 0.5 mm3 0.5 mm3
4 years 6 years 10 years 12 years 15 years
First dose Second dose Booster dose Booster dose Third dose Fourth dose
AC AC DT DT AC AC
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Assess And Classify The Sick Child Age 2 Months Up To 5 Years

Check For General Danger Signs
Table (10-6): Classification & Treatment The Sick Child Age 2 Months Up To 5 Years ASK: LOOK:
Is the child able to drink or breastfeed? See if the child is lethargic or unconscious. Does the child vomit everything? See if the child is convulsing now. Has the child had convulsions?
Signs
Any general danger sign.
Classify As
VERY SEVERE DISEASE
(Urgent pre-referral treatments are in bold print.)
Treatment
Treat convulsions if present now. Complete assessment immediately. Give first dose of an appropriate antibiotic. Treat the child to prevent low blood sugar. Refer URGENTLY to hospital*.
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Assess cough or difficult breathing:

ASK:
For how long?
LOOK AND LISTEN:

Count the breaths in one Look for chest indrawing.
minute.
Look and listen for stridor.
CHILD MUST BE CALM
Classify COUGH or DIFFICULT BREATHING
Look and listen for wheeze
If the child is: 2 months up to 12 months 12 months up to 5 years
Fast breathing is: 50 breaths per minute or more 40 breaths per minute or more
270
Signs
Any general danger sign OR Stridor in calm child OR Chest indrawing (If chest indrawing and wheeze go directly to Treat Wheezing then reassess after treatment). Fast breathing (If wheeze, go directly to Treat Wheezing then reassess after treatment).
Classify As
SEVERE PNEUMONIA OR VERY SEVERE DISEASE
Treatment
Give first dose of an appropriate antibiotic. Treat wheezing if present. Treat the child to prevent low blood sugar. Refer URGENTLY to hospital.*
PNEUMONIA
Give an appropriate antibiotic for 5 days. Treat wheezing if present. If coughing more than 30 days, refer for assessment. Soothe the throat and relieve the cough with a safe remedy. Advise mother when to return immediately. Follow up in 2 days. Treat wheezing if present. If coughing more than 30 days, refer for assessment. Soothe the throat and relieve the cough with a safe remedy. Advise mother when to return immediately. Follow up in 2 days if wheezing. Follow-up in 5 days if not improving
No signs of pneumonia or very severe disease. (If wheeze, go directly to Treat Wheezing).
NO PNEUMONIA: COUGH OR COLD
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Assess diarrhea:
IF YES, ASK:

For how long? Is there blood in the stool?
LOOK AND FEEL:

Look at the childs general condition. Is the child: Lethargic or unconscious? Restless and/or irritable?
for DEHYDRATION
Look for sunken eyes. Offer the child fluid. Is the child: Not able to drink or drinking poorly? Drinking eagerly, thirsty? Pinch the skin of the abdomen. Does it go back: Very slowly (longer than 2 seconds)? Slowly?
Classify DIARRHEA
and if diarrhea 14 days or more
and if blood in stool
272
Signs
Two of the following signs: Lethargic or unconscious. Sunken eyes. Not able to drink or drinking poorly. Skin pinch goes back very slowly. Two of the following signs: Restless, irritable. Sunken eyes. Drinks eagerly, thirsty. Skin pinch goes back slowly.
Classify As
Treatment
If child has no other severe classification: - Give fluid for severe dehydration (Plan C). OR If child also has another severe classification:** - Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way. Advise the mother to continue breastfeeding. If child is 2 years or older and there is cholera in your area, give antibiotic for cholera. Give fluid and food for some dehydration (Plan B). If child also has a severe classification: - Refer URGENTLY to hospital with mother giving frequent sips of ORS on the way. Advise the mother to continue breastfeeding. If child is 2 years or older and there is cholera in your area, give antibiotic for cholera. Give Zinc Syrup for 14 days. Advise mother when to return immediately. Follow-up in 5 days if not improving. Give fluid and food to treat diarrhea at home (Plan A). If child is 2 years or older and there is cholera in your area, give antibiotic for cholera. Give Zinc Syrup for 14 days. Advise mother when to return immediately. Follow-up in 5 days if not improving. Treat dehydration before referral unless the child has another severe classification. Refer to hospital. Advise the mother on feeding a child who has PERSISTENT DIARRHEA. Give multivitamin, mineral supplement including zinc for 14 days Advise mother when to return immediately. Follow-up in 5 days. Treat for 5 days with an oral antibiotic recommended for Shigella. Advise mother when to return immediately. Follow-up in 2 days.
SEVERE DEHYDRATION
SOME DEHYDRATION
Not enough signs to classify as some or severe dehydration.
NO DEHYDRATION
Dehydration present.
SEVERE PERSISTENT DIARRHEA
No dehydration. PERSISTENT DIARRHEA
Blood in the stool. DYSENTERY
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4- Check for throat problem:
ASK:
Does the child have fever? (by history or feels hot or temperature 37.5 C or more) Does the child have sore throat?
LOOK AND FEEL:

Feel for enlarged tender lymph node(s) on the front of the neck. Look for red (congested) throat Look for white or yellow exudate on the throat and tonsils
Classify THROAT PROBLEM
5- Assess an ear problem:
IF YES, ASK:
Is there agonizing ear pain? Is there ear discharge? If yes, for how long?
LOOK AND FEEL:

Look for pus draining from the ear. Feel for tender swelling behind the ear.
Classify EAR PROBLEM
274
Classify and treat throat problem

Signs
fever OR Sore throat AND Two of the following : Red (congested) throat White or yellow exudate on the throat or tonsils. Enlarged tender lymph node(s) on the front of the neck. Sore throat OR Not enough signs to calssify as streptococcal sore throat No throat signs or symptoms ( with or without fever) STREPTOCOCCAL SORE THROAT
Classify As
Treatment
Give benzathine penicillin. Soothe the throat with a safe remedy. Give paracetamol for pain. Advise mother when to return immediately. Follow up in 5 days if not improving.
NON STREPTOCOCCAL SORE THROAT NO THROAT PROBLEM
Soothe the throat with a safe remedy. Give paracetamol for pain. Advise mother when to return immediately. Follow up in 5 days if not improving. Continue assessment of the child.
Classify and treat ear problem

Signs
Tender swelling behind the ear.
Classify As
MASTOIDITIS
Treatment
Give first dose of an appropriate antibiotic. Give first dose of paracetamol for pain. Treat the child to prevent low blood sugar. Refer URGENTLY to hospital. Give an antibiotic for 10 days. Give paracetamol for pain. Dry the ear by wicking. Advise mother when to return immediately. Follow-up in 5 days. Dry the ear by wicking. Refer to ENT specialist. Advise mother to go to ENT specialist for assessment.
Agonizing ear pain OR Pus is seen draining from the ear and discharge is reported for less than 14 days. Pus is seen draining from the ear and discharge is reported for 14 days or more. No ear pain AND No pus seen draining from the ear.
ACUTE EAR INFECTION
CHRONIC EAR INFECTION NO EAR INFECTION
275
Check For Malnutrition And Anaemia:
LOOK AND FEEL:

Look for visible severe wasting. Look for oedema of both feet. Determine weight for age. Classify NUTRITIONAL STATUS
LOOK:
Look for palmar pallor and mucous membrane pallor Is it: Severe palmar pallor and / or mucous membrane pallor? Some palmar pallor and / or mucous membrane pallor?
Classify ANAEMIA
276
Signs
Visible severe wasting or Oedema of both feet.
Classify as
SEVERE MALNUTRITION
Treatment
Give Vitamin A. (if was not given in the last 4 months) Treat the child to prevent low blood sugar.. Refer URGENTLY to hospital. Assess the child`s feeding and counsel the mother on feeding according to the FOOD box on the COUNSEL THE MOTHER chart. - If feeding problem, follow-up in 5 days. Advise mother when to return immediately. Follow-up in 30 days If child is less than 2 years old, assess the childs feeding and counsel the mother on feeding according to the FOOD box on the COUNSEL THE MOTHER chart. - If feeding problem, follow-up in 5 days. Treat the child to prevent low blood sugar Refer URGENTLY to hospital Assess the child`s feeding and counsel the mother on feeding according to the FOOD box on the COUNSEL THE MOTHER chart. - If feeding problem, follow-up in 5 days. Give Iron. Advise mother when to return immediately. Follow-up in 14 days if child is aged 6 - 30 months, give one dose of Iron weekly.
Low weight for age.
LOW WEIGHT
Not low weight for age and no other signs of malnutrition.
NOT LOW WEIGHT
Severe palmar and / or mucous membrane pallor Some palmar and / or mucous membrane pallor
SEVERE ANAEMIA
ANAEMIA
No palmar or mucous membrane pallor
NO ANAEMIA
277
Give an Appropriate Oral Drugs : For Pneumonia (Give For 5 Days), Or Acute Ear Infection (Give For 10 Days): First-Line Antibiotic: Amoxycillin Second-Line Antibiotic: Cotrimoxazole
AMOXYCILLIN Give three times daily for 5 or 10 days AGE or WEIGHT SYRUP 250 mg per 5 ml 2 months up to 4 months (4 - <6 kg) 4 months up to 12 months (6 - <10 kg) 12 months up to 5 years (10 - 19 kg) 2.5 ml SYRUP 125 mg per 5 ml 5 ml COTRIMOXAZOLE (trimethoprim + sulphamethoxazole) Give two times daily for 5 or 10 days SYRUP 40 mg trimethoprim +200 mg sulphamethoxazole per 5 ml 2.5 ml
2.5 ml
5 ml
5 ml
5 ml
10 ml
7.5 ml
For Dysentery: Give Antibiotic Recommended For Shigella For 5 Days. First-Line Antibiotic For Shigella: Cotrimoxazole Second-Line Antibiotic For Shigella: Ampicillin
COTRIMOXAZOLE SYRUP Ampicillin (trimethoprim + sulphamethoxazole) Give four times daily for Give two times daily for 5 days 5 days SYRUP: SYRUP 40 mg trimethoprim + 200 mg 250 mg/5 ml sulphamethoxazole per 5 ml 2.5 ml 5.0 ml 7.5 ml 2.5 ml 3.5 ml 7.5 ml
AGE or WEIGHT 2 months up to 4 months (4 - <6 kg) 4 months up to 12 months (6 - <10 kg) 12 months up to 5 years (10 - 19 kg)
278
Give Paracetamol for Fever (> 38C) or sore throat or Ear Pain Give paracetamol every 6 hours until fever or pain is gone.
AGE or WEIGHT 2 months up to 4 months (4 - <6 kg) 4 months up to 12 months (6 - <10 kg) 12 months up to 3 years (10 - <14 kg) 3 years up to 5 years (14 - 19 kg) PARACETAMOL SYRUP (120 mg / 5 ml) 2.5 ml 5 ml 7.5 ml 10 ml
Give Iron For treatment of anaemia: give one dose daily for 14 days, then reassess. For Iron supplementation: give one dose per week.
AGE or WEIGHT 2 months up to 4 months (4 - <6 kg) 4 months up to 12 months (6 - <10 kg) 12 months up to 3 years (10 - <14 kg) 3 years up to 5 years (14 - 19 kg) IRON SYRUP Iron syrup 30 mg/ 5 ml (6 mg elemental iron per ml) 2.5 ml 5 ml 7.5 ml 10 ml
Give Oral Salbutamol Give Salbutamol syrup three times daily for 5 days.
AGE or WEIGHT 2 months up to 4 months (4 - <6 kg) 4 months up to 12 months (6 - <10 kg) 12 months up to 3 years (10 - <14 kg) 3 years up to 5 years (14 - 19 kg) SALBUTAMOL SYRUP (Salbutamol syrup = 2 mg / 5 ml ) 1.0 ml 2.0 ml 2.5 ml 5.0 ml
Give Zinc Syrup For some or no dehydration give one dose daily for 2 weeks.
AGE 2 months up to 6 months 6 months up to 5 years ZINC SYRUP 10 mg 20 mg
279
Give An Intramuscular Antibiotic For Children Being Referred Urgently: Give first dose of intramuscular Cefotaxime and refer child urgently to hospital. If Referral Is Not Possible: Repeat Cefotaxime injection every 12 hours for 5 days. Then change to an appropriate oral antibiotic to complete 10 days of treatment.
AGE or WEIGHT Cefotaxime Dose: 50 mg per kg Add 5.0 ml sterile water to vial containing 1000 mg = 5.6 ml at 180 mg/ml 1.5 ml = 270 mg 2.0 ml = 360 mg 3.0 ml = 540 mg 4.0 ml = 720 mg 5.0 ml = 900 mg
2 months up to 4 months (4 - < 6 kg) 4 months up to 9 months (6 - < 8 kg) 9 months up to 12 months (8 - < 10 kg) 12 months up to 3 years (10 - < 14 kg) 3 years up to 5 years (14 - 19 kg)
Give An Antibiotic For Streptococcal Sore Throat Give a single dose of intramuscular benzathine penicillin .
BENZATHINE PENICILLIN Age Add 5 ml sterile water to vial containing 1.200.000 unit = 6 ml at 200.000 unit / ml 3.0 ml = 600.000 unit
< 5 years
280
Treat a Convulsing Child With Sodium Valproate Manage the Airway Turn the child on his or her side to avoid aspiration Do not insert anything in the mouth. If the lips and tongue are blue, open the mouth and make sure the airway is clear. If necessary, remove secretions from the throat through a catheter inserted through the nose. Give Sodium Valproate Rectally Dilute sodium valproate solution (200 mg/ml) 1:7 with tap water. Draw up the dose of sodium valproate into a small syringe. Then remove the needle. Attach a piece of nasogastric tubing to the syringe if possible. Insert 4 to 5 cm of the tube or the tip of the syringe into the rectum and inject the sodium valproate solution. Hold buttocks together for a few minutes.
SODIUM VALPROATE GIVEN RECTALLY 25 mg/ml Solution DoAse 20 mg/kg 4 ml 6 ml 10 ml 13 ml
AGE or WEIGHT
Birth up to 4 months (3-<6 kg) 4 months up to 12 months (6 - <10 kg) 12 months up to 3 years (10-<14 kg) 3 years up to 5 years
If High Fever, Lower The Fever Sponge the child with room temperature water Treat the child to prevent low blood sugar
281
Give Extra Fluid For Diarrhea And Continue Feeding:

Plan A: Treat Diarrhea at Home Counsel the mother on the 3 Rules of Home Treatment: Give Extra Fluid, Continue Feeding, When to Return 1. GIVE EXTRA FLUID (as much as the child will take) Tell The Mother: - Breastfeed frequently and for longer at each feed. - If the child is exclusively breastfed, give ORS in addition to breastmilk. - If the child is not exclusively breastfed, give one or more of the following: ORS solution, food-based fluids (such as soup, rice water, yoghurt drink and belila water), or clean water. It is especially important to give ORS at home when: - the child has been treated with Plan B or Plan C during this visit. - the child cannot return to a clinic if the diarrhea gets worse. Teach The Mother How To Mix And Give Ors. Give The Mother A Box Of 10 Packets Of Ors To Use At Home And 200 Ml Cup. Show The Mother How Much Fluid To Give In Addition To The Usual Fluid Intake: Up to 2 years 50 to 100 ml after each loose stool 2 years or more 100 to 200 ml after each loose stool Tell the mother to: - Give frequent small sips from a cup. - If the child vomits, wait 10 minutes. Then continue, but more slowly. - Continue giving extra fluid until the diarrhea stops. 2. CONTINUE FEEDING 3. WHEN TO RETURN
282
Plan B: Treat Some Dehydration with ORS Give in clinic recommended amount of ORS over 4-hour period Determine Amount Of Ors To Give During First 4 Hours.
AGE* WEIGHT ORS In ml Up to 4 months < 6 kg 200 - 400 4 months up to 12 months up to 12 months 2 years 6 - < 10 kg 400 - 700 10 - < 12 kg 700 - 900 2 years up to 5 years 12 - 19 kg 900 - 1400
Use the childs age only when you do not know the weight. The approximate amount of ORS required (in ml) can also be calculated by multiplying the childs weight (in kg) by 75. If the child wants more ORS than shown, give more. For infants under 6 months who are not breastfed, also give 100200 ml clean water during this period. Show The Mother How To Give Ors Solution. Give frequent small sips from a cup or cup and spoon (one spoon every 1-2 minutes). If the child vomits, wait 10 minutes. Then continue, but more slowly. Continue breastfeeding whenever the child wants. After 4 Hours: Reassess the child and classify the child for dehydration. Select the appropriate plan to continue treatment. Begin feeding the child in clinic. If The Mother Must Leave Before Completing Treatment: Show her how to prepare ORS solution at home. Show her how much ORS to give to finish 4-hour treatment at home. Give her enough ORS packets to complete rehydration. Also give her a box of 10 packets of ORS as recommended in Plan A. Explain the 3 Rules of Home Treatment: 1. GIVE EXTRA FLUID 2. CONTINUE FEEDING 3. WHEN TO RETURN
See Plan A for recommended fluids and See COUNSEL THE MOTHER chart 283
Diagnosis: Neonate/Infant Fever or hypothermia Lethargy or irritability Vomiting Bulging fontanelle, stiff neck, positive Kernig sign Older Child/Adolescent Fever Headache, photophobia Stiff neck (positive Kernig sign, positive Brudzinski sign) Mental status changes Vomiting Cerebrospinal Fluid Findings: Polymorphonuclear leukocytes (>10) Elevated protein Lowered glucose (less than half the blood glucose because of loss of bloodbrain barrier function) Bacteria on Gram stain Vaccines for Meningitis: There are 2 vaccines not used in routine MOH schedule and can be taken out. Preventive measures: 1- Listing of contacts 2- Give chemoprophylaxis for direct contacts: a. Rifampicin capsules for adults 2 capsules twice daily for 2 days b. Children < 1 month give 5 mg/kg twice daily for 2 days c. Children > 1 month give 10 mg/kg twice daily for 2 days Antibiotics: In neonates, ampicillin + cefotaxime or ceftriaxone (non-premature infant, no indwelling catheters). In infants, older children, and adolescents, cefotaxime or ceftriaxone and vancomycin (60 mg/kg in 4 divided doses) and or rifampin (20 mg/kg daily) is necessary because of penicillin-resistant S. pneumoniae.
284
Bacterial Meningitis
Chapter 11
Laboratory Standards
Chapter 11: Laboratory Standards
Plasma levels of sex steroids:

Table (11-1): Plasma levels of sex steroids Follicle-stimulating hormone Follicle-stimulating hormone, ovulatory peak Follicle-stimulating hormone, Prepubertal boys and girls Luteinizing hormone Luteinizing hormone, ovulatory peak Luteinizing hormone, Prepubertal boys and girls Human chorionic gonadotropin in non-pregnant woman Oxytocin, plasma Prolactin, serum Estradiol - Basal Estradiol -Ovulatory surge Progesterone - Follicular phase Progesterone - Luteal phase
287
520 lU/l 520 mlU/ml 1230 lU/l 1230 mlU/ml <5 lU/l <5 mlU/ml 525 lU/l 525 mlU/ml 25100 lU/l 25100 mlU/ml <5 lU/l <5 mlU/ml <3 lU/l <3 mlU/ml 14 pmol/l 1.255 ng/l 215 g/l 215 ng/ml 70220 pmol/l 2060 pg/ml >740 pmol/l >200 pg/ml <6 nmol/l <2 ng/ml 664 nmol/l 220 ng/ml
17a Hydroxyprogesterone Testosterone - Prepubertal boys and girls Testosterone Dihydrotestosterone Dehydroepiandrosterone (DHEA) Dehydroepiandrosterone-sulfate (DHEAS) Androstenedione Table (11-2): Thyroid function tests Radioactive iodine uptake, 24 hours Reverse triiodothyronine (rT3), serum
113 nmol/l 0.34.2 g/l 0.20.7 nmol/l 0.050.2 ng/ml

<3.5 nmol/l <1 ng/ml 0.171.0 nmol/l 0.053 ng/ml 0.670 nmol/l 0.220 g/l 5.49.2 mol/l 8203380 ng/ml 3.57.0 nmol/l 12 ng/ml
0.050.30 530% 0.150.61 nmol/l 104 ng/dl
Thyrotropin (TSH), highly sensitive assay, 0.64.6 mU/l serum 0.64.6 U/ml Thyroxine (T4), serum Thyroxine-binding thyroxine) globulin, serum 5142 nmol/l 411 g/dl (as 150360 nmol/l 1228 g/ml 1.23.4 nmol/l 75220 ng/dl 0.250.35 2535%
Triiodothyronine (T3), serum Triiodothyronine resin uptake, serum

288
Table (11-3): Glucose, plasma - Fasting level Overnight fast, normal Overnight fast, diabetes mellitus 72-hour fast, normal women 75115 mg/dl 4.26.4 mmol/l 7.8 mmol/l >140 mg/dl >2.2 mmol/l >40 mg/dl
Table (11-4): Glucose tolerance test 2hour postprandial plasma glucose Normal Impaired glucose tolerance Diabetes mellitus Table (11-5): Insulin, plasma Insulin, Fasting 35145 pmol/l 520 U/ml <7.8 mmol/l <140 mg/dl 7.811.1 mmol/l 140200 mg/dl >11.1 mmol/l >200 mg/dl
Insulin, during hypoglycemia (plasma glucose <35 pmol/l <2.8 nmol/l, <50 mg/dl) <5 U/ml Table (11-6):Total cholesterol Desirable Borderline High
289
<5.20 mmol/l <200 mg/dl 5.26.18 mmol/l 200239 mg/dl 6.21 mmol/l 240 mg/dl
Table (11-7): Highdensity lipoprotein (HDL) cholesterol Desirable Borderline High 1.29 mmol/l 50 mg/dl 0.91.27 mmol/l 3649 mg/dl 0.91 mmol/l 35 mg/dl
Table (11-8): Low-density lipoprotein (LDL) cholesterol Desirable Borderline High Table (11-9): Triglycerides levels in plasma Triglycerides, plasma Table (11-10): Serum Electrolytes Sodium Potassium Total Calcium Ionized Calcium 136145 mmol/l 136145 meq/l 3.55.0 mmol/l 3.55.0 meq/l 2.22.6 mmol/l 910.5 mg/dl 44.6 mg/dl <1.80 mmol/l <3.36 mmol/l <130 mg/dl 3.394.11 mmol/l 131159 mg/dl 4.14 mmol/l 160 mg/dl
290
Magnesium Phosphorus, inorganic Bicarbonate Chloride Table (11-11): Other lab tests Angiotensin II, plasma, 8 AM Creatinine, serum Uric acid, serum 17-Ketosteroids
0.81.20 mmol/l 1.83.0 mg/dl 11.5 mmol/l 3.04.5 mg/dl 1823 mmol/l 1823 meq/l 98106 mmol/l 98106 meq/l
1030 ng/l 1030 pg/ml <133 mol/l <1.5 mg/dl 120420 mol/l 27 mg/dl 1452 mol/d 415 mg/d
291
Annexes
Annexes
Hepatotoxic Drugs
Drug Monitoring Recommendations
LFTs prior to initiation and at regular intervals (every 6 months), especially for patients receiving high maintenance doses.
Comments
If LFTs are >3 times the ULN, or doubles in a patient with an elevated baseline, decrease the dose or stop the drug
Amiodarone (Cordarone)
Azathioprine (Imuran)
ALT, AST, alkaline phosphate, Discontinue therapy if and bilirubin every 2 weeks for hepatic veno-occlusive the first 4 weeks and monthly disease is suspected. thereafter.
Carbamazepine LFTs at baseline and (Tegretol) periodically. Felbamate (Felbatol) AST, ALT, and bilirubin at baseline and every 1 to 2 weeks while treatment continues. If a patient develops abnormal LFTs, discontinue treatment immediately. Discontinue therapy if LFTs > 3 times ULN persist.
Fenofibrate and LFTs periodically. Gemfibrozil
Imatinib (Gleevec)
If elevations in bilirubin >3 times ULN or transaminases >5 times LFTs (transaminases, bilirubin, ULN, withhold until and Alk.Phos) at baseline, bilirubin <1.5 times ULN monthly and as clinically and transaminase <2.5 indicated. times ULN. Treatment may then be continued at a reduced dosage. 295
Annexes
Drug
Monitoring Recommendations
LFTs and bilirubin at baseline. Repeat LFTs periodically (monthly or more, as needed) especially in high-risk patients (e.g. 35yrs, daily alcohol use, chronic liver disease, etc.) LFTs at baseline and at weekly or biweekly intervals until response to treatment is established. LFTs in patients with preexisting hepatic function abnormalities or patients who have had prior drug-induced liver toxicity. LFTs should be considered in all patients, especially with therapy lasting 1 month or longer. LFTs (GGT, Alk.Phos., ALT, AST and bilirubin) at baseline and at frequent intervals during therapy. Canadian labeling suggests LFTs after 2 weeks and monthly or more frequently during treatment.
Comments
Discontinue use if LFTs are >3 to 5 times the ULN or if patients develop symptoms of hepatitis.
Isoniazid
Isotretinion (Accutane)
Itraconazole (Sporanox)
If LFTs are >3 times the ULN, or doubles in a patient with an elevated baseline, decrease the dose or stop the drug.
Ketoconazole (Nizoral)
Discontinue treatment if transient minor elevations of liver enzymes persist, worsen or symptoms develop.
Leflunomide (Arava)
ALT at baseline and at monthly intervals during the first six months then, if stable, every 6 to 8 weeks thereafter.
Reduce dose if ALT elevation is >2 to 3 times ULN. Discontinue if ALT >3 times ULN and start treatment with cholestyramine.
296
Annexes
Drug
Comments
Further evaluation is needed for persistent LFT abnormalities and/or decreased serum albumin. More frequent monitoring may be needed during antineoplastic therapy, during initial or changing doses, or during periods of increased methotrexate levels.
Methotrexate (Rheumatrex)
AST, ALT, Alk.Phos. and albumin at baseline and every 1 to 2 months during therapy. Liver biopsy recommended in appropriate patients.
Nefazodone (Serzone)
LFTs at baseline and Discontinue therapy periodically thereafter (e.g. at 3 if AST or ALT>3 times to 6 month intervals) ULN. LFTs at baseline. Intensive monitoring during the first 18 weeks of treatment. Continue frequent monitoring during therapy. Check immediately at any sign or symptom of hepatitis and for all patients who develop a rash in the first 18 weeks. AST and ALT at baseline, followed by every 6 to 12 weeks for the first year, then periodically thereafter (e.g. at 6-month intervals) If AST or ALT >2 times ULN, then liver tests should be monitored more frequently during regular clinic visits. If AST or ALT increase to >5 times ULN, stop therapy immediately. Discontinue therapy if LFTs increase to 3 times ULN, or if elevated LFTs are associated with symptoms. Discontinue treatment if abnormal LFTs persist or worsen. ALT may be the most sensitive indicator of NSAID-induced liver dysfunction.
Nevirapine (Viramune)
Niacin (SR) (Niaspan)
NSAIDs
LFTs at baseline and periodically.
297
Annexes
Drug
ALT at baseline and periodically thereafter. Some experts are monitoring at 3 to 6 month intervals. Canadian labeling advises that liver enzymes be monitored every two months for the first twelve months, and periodically thereafter. LFTs and bilirubin at baseline. Repeat LFTs periodically. LFTs including bilirubin at baseline. LFTs every 2 to 4 weeks especially if drug is used in patients with impaired hepatic function. LFTs at baseline. Also, at 12 weeks following both the initiation of therapy and dose elevation. Check every 6 months thereafter. Canadian labeling recommends ALT or AST levels be repeated promptly and more frequently if found elevated. ALT every other week from at least week 4 to week 16 following initiation of treatment, then every 3 months thereafter. If therapy is interrupted for >4 weeks, resume initial LFT monitoring schedule when therapy restarted. 298
Comments
Discontinue therapy if ALT levels >3 times ULN persist or if the patient is jaundiced. Both rosiglitazone & pioglitazone-associated fatal liver failure have been reported. Discontinue therapy if signs of hepatotoxicity occur. Discontinue therapy if signs of hepatotoxicity occur.
Pioglitazone & Rosiglitazone (Actose & Avandia)
Pyrazinamide
Rifampin (Rifadin)
Statins
Reduce the dose or stop the drug if an increase in ALT or AST of >3 times ULN occurs.
Tacrine (Cognex)
Modify the dose and monitoring regimen for ALT elevations >2 times ULN (refer to product information).
Annexes
Drug
Valproic acid (Depakote)
LFTs at baseline and at frequent intervals thereafter, especially during the first 6 months. LFTs (including bilirubin) at baseline and periodically.
Comments
Voriconazole (Vfend)
Discontinue if clinical signs and symptoms consistent with liver disease develop.
Abbreviations: Alk.Phos.= Alkaline Phosphatase, GGT= Gammaglutamyltransferase, LFT= Liver Function Test, ULN= Upper Limits of Normal, ALT= Alanine Aminotransferase (formerly serum glutamatepyruvate transaminase of SGPT), and AST= Aspartate Aminotransferase (formerly serum glutamic-oxalacetic transaminase of SGOT)
299
Drug-induced toxic renal syndromes

ACUTE RENAL FAILURE INTRINSIC ACUTE INTERSTITIAL NEPHRITIS TTPHUS* NEPHROTIC SYNDROME RENAL TUBULAR DYSFUNCTION CHRONIC RENAL FAILURE OBSTRUCTIVE
Annexes
PRERENAL
DRUGS
ACUTE TUBULAR NERCOSIS
ACE inhibitors*
Acyclovir
Aminoglycosides
Amphotericin B
Analgesic abuse
Cephalosporins
300

Chinese herbs
Cisplatin
Ciprofloxacin
Clopidogrel
Cocaine
COX-S inhibitors
Cyclosporine
Diuretics
Fiscarbet
Gold
Ifosfamide
Immunoglobulin
Indinavir
Interferon
Interleukin-2
Lithium
Mannitol
Mesalamine
Mitomycin
Nitrosureas
NSAIDs*
Penicillamine
Penicillins
Pentamidine
301
Quinine
Rifampin
Sucrose
Streptozocin
Sulfonamides
Tacrolimus
Ticlopidine
Triamterene
Valproic acid
*ACE----angiotensin-converting enzyme
COX---cyclo-oxygenase
NSAID---nonsteroidal anti-inflammatory drug
Annexes
TTP-HUSthrombotic thrombocytopenic purpura-hemolytic uremic syndrome
Annexes
National Disease Surveillance

Recommended Frequency of Reporting Notifiable Diseases The following table shows the communicable diseases under surveillance with the recommended frequency of reporting. Diseases are grouped according to the timing of reporting and the need for public health action. Group A diseases are conditions which require prompt public health action and should be immediately reported by phone or fax to the District Surveillance Unit (DSU). Most of the conditions in Group B are diseases with epidemic potential that require more indepth investigation and monitoring by the DSU. Group C diseases are reported on a monthly basis.
Group A: Immediate Reporting Required 1 2 3 4 5 6 7 8 9 10 Meningitis Encephalitis Acute Flaccid Paralysis/Poliomyelitis HIV/AIDS Rabies Diphtheria Malaria Plague Tetanus (Neonatal) Acute Food Poisoning Unusually Severe Health Events: Botulism Viral Hemorrhagic Fever Rift Valley Fever Cholera Avian Influenza / Swine Influenza Other (SARS Anthrax .) 302
11
Annexes
Group B: Weekly Reporting Required 1 2 3 4 5 6 7 Typhoid Brucellosis Tuberculosis Measles Rubella Pertussis Bloody diarrhea (dysentery) Group C: Monthly Reporting Required 1 2 3 4 5 6 7 Acute Hepatitis Mumps Leprosy Schistosomiasis Faschioliasis Filariasis Animal bite
303

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Diagnosis & Management

Handbook for Family Physicians

Ministry Of Health November 2010

Diagnosis & Management

Ministry of Health November 2010

61 61 61 62 62 63 64 61 72 73 73 74 77 78 79 80 81 90 91 92 95 95 96 97 98 98 98 99 100 101 102 102 107

Chapter 1: Emergency Medicine

Chapter 1: Emergency Medicine

Table (1-1): Drug toxicity Test

Hypokalemia Hypoglycemia Wide QRS complex

Prolongation of the QT interval Atrioventricular block

Plain abdominal x-ray

Radiopaque pills or objects

Chapter 1: Emergency Medicine

Chapter 1: Emergency Medicine

Chapter 1: Emergency Medicine

Figure (1-1): Toxin Exposure

Yes 1.Continue first aid management 2. Toxin Antidote if available

Follow the referral guidelines No

Yes Continue management and

Chapter 1: Emergency Medicine

Chapter 1: Emergency Medicine

Figure (1-2): Patient with trauma

ABCS and Survey

Continue first aid management and

Chapter 1: Emergency Medicine

Chapter 1: Emergency Medicine

Foreign body aspiration

Chapter 1: Emergency Medicine

Chapter 1: Emergency Medicine

Figure (1-3): Burn

Determine the depth of burn

1. First degree 2. Second degree (superficial)

1. Second degree (deep) 2. Third degree 3. Fourth degree

Chapter 1: Emergency Medicine

The current pathway determines which organs are affected.

with nausea or vomiting and dull headache.

Chapter 1: Emergency Medicine

Chapter 1: Emergency Medicine

Meningococcal Yellow Fever

Chapter 1: Emergency Medicine

Figure (1-4): Anaphylaxis

Refer to hospital by equipped ambulance with life support

Chapter 1: Emergency Medicine

Figure (1-5): Hypotension, shock and acute pulmonary edema

Administer fluids/blood Consider vasopressors Apply hemostatis Treat underlying problem

Determine blood pressure

Be ready for CPR

Refer to hospital by equipped ambulance with life support accompanied by physician

Chapter 1: Emergency Medicine

Chapter 1: Emergency Medicine

Chapter 1: Emergency Medicine

Chapter 1: Emergency Medicine

Figure (1-6): Basic Life Support

Basic Life Support

Head tilt / chin lift

Look, Listen and Feel

Assess 10 sec only

Circulation present Continue rescue breathing

No circulation Compress chest

100 per min Check circulation every min

Call for help as soon as possible according to guidelines

Basic Surgical Skills

Chapter 2: Basic Surgical Skills