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Participant Manual Acute Care

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Participant Manual Acute Care Powered By Docstoc
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publication is complete and correct and shall not be liable for any damages incurred as a
result of its use.




                              WHO IMAI Project
          Department of HIV/AIDS, Treatment and Prevention Scale-up
                  Please send comments to imaimail@who.int.




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The IMAI Acute Care guidelines are designed to be applicable for adolescent and
adult patients with and without HIV infection. They are important in caring for HIV
patients because they provide guidance for the management of the common
bacterial infections which occur more frequently in HIV-infected patients,
opportunistic infections, and neurological complications (such as peripheral neuritis).
These guidelines can also be used for HIV negative patients or patients whose HIV
status is not yet known.

This manual explains what is in the IMAI Acute Care guideline module, revision 2.
Please refer to it as you read through the manual and do the exercises. After the
course, you will use the IMAI Acute Care guidelines as a job aid.

See glossary at end of this manual and the acronym list at the end of the Acute Care
guideline module for abbreviations or words that may not be familiar.

This training manual is for health workers learning to use the IMAI Acute Care
guideline module. Several short courses use this same training manual.

(1) Using the IMAI Acute Care guideline module to learn to manage
opportunistic infections (OIs) in the context of scaling up access to HIV
prevention, care, and ARV therapy.

The urgent need to increase access to ART and the need to treat or at least stabilize
opportunistic infections prior to ART has led to requests for very short OI training.
For nurses and other multipurpose health workers who have not had training in the
case management of adults, we have developed a staged introduction to the
management of acute illness in adults which emphasizes OI management (and other
HIV-related complications) in a very short course (2 days), based on presenting the
approach to case management, how to use the Acute Care module as a job aid, and
management of key OIs.

The Acute Care/Opportunistic Infection training course covers:
    How to do a ―Quick check‖ for medical emergencies
    How to assess, classify, and identify treatments for adolescents or adults
     presenting with an acute illness (or an acute exacerbation or new problem in
     someone with a chronic disease). The following conditions are covered:
         o Cough: pneumonia and TB; when to refer during follow-up
         o Skin problems: limiting consideration to classification of lumps,
           infections, and the common HIV-related skin problems
         o Headache/when to suspect meningitis
         o Peripheral neuropathy
         o Mouth problems: limited to consideration of thrush and ulcers
    When to suspect HIV infection and how to encourage HIV testing and
     counseling and link to chronic HIV care
    When to suspect TB

This participant manual is to be read and used both during the Acute Care/OI short
course and in preparation for further short courses on STI management and the
management of mental health and neurological disorders. It is possible to read the
participant training manual and do exercises on your own when you return home,


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then discuss them with a clinical mentor or when you attend subsequent short
courses.


(2) Using the IMAI Acute Care guideline module to learn to manage mental
health and neurological problems in the context of scaling up access to HIV
prevention, care, and ARV therapy.

The Acute Care/Mental Health training course covers both the mental health and
neurological pages in the Acute Care guideline modules. The management of mental
problems, hazardous and harmful alcohol use, and other drug use is very important
in the management of HIV-infected patients.

The mental health section was developed by Dr Rita Thom (University of the
Witwatersrand, South Africa) with technical assistance provided by:
      Dr Atalay ALEM (Addis Ababa University, Ethiopia)
      Dr Jose BERTOLOTE (WHO, Switzerland)
      Dr Jose CATALAN (Chelsea & Westminster Hospital United Kingdom)
      Dr Pamela COLLINS (Columbia University, USA)
      Dr Francine COURNOS (New York Psychiatric Institute, USA)
      Dr Sandra GOVE, (WHO, Switzerland)
      Dr Joseph MBATIA (Ministry of Health, Tanzania)
      Professor D. MKIZE (N Mandela Medical School, South Africa)
      Dr Vikram PATEL (Sangath Centre, India)




(3) Using the IMAI Acute Care guideline module to learn to manage STIs and
other genitourinary problems in the context of scaling up access to HIV
prevention, care, and ARV therapy.

The Acute Care/STI and other GU problems training course covers genitourinary
problems including:
    STIs—screening in all adults on every visit and management
    urinary tract infections
    menstrual problems.

Some text in the GU sections is adapted from Training modules for the syndromic
management of sexually transmitted infections 2nd edition, WHO 2004.


(4) Using the IMAI Acute Care guideline module to manage fever, including
malaria, in adolescents and adults.

This short course is in development. It will complement the use of IMCI in its support
for case management of malaria in children.




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(5) Provider-initiated testing and counselling
This is a 1-day training in provider-initiated testing and counseling.

By the completion of this training, participants will be able to:

   1. Discuss benefits of HIV testing with patients who are offered HIV tests;
   2. Provide brief, targeted health education on HIV, transmission and prevention,
      and access to treatment and care;
   3. List procedures associated with performing HIV rapid testing;
   4. Identify need for confidentiality and informed consent, and understand how to
      employ these in their practice settings;
   5. Administer HIV rapid tests in medical settings; and
   6. Deliver HIV test results, including referral to treatment and care, prevention
      support, as well as potential need to notify partners.

This short course is designed for physicians, nurses and midwives in primary health
care level settings who wish to increase their comfort in offering provider-initiated
HIV testing and counseling. This 1 day course will be offered to health care workers
as part of the IMAI (Integrated Management of Adolescent and Adult Illness) Acute
Care course, but is also designed for providers in STI settings, women‘s health
settings, and clinics with high HIV seroprevalence rates.

It is also important to note that this 1-day PITC course is meant to follow closely the
IMAI Basic ART Clinical Course and the Acute Care Course. Because of the
integration of this course with those two, this course does not include important
clinical information that would need to be part of a stand-alone course on diagnostic
testing for suspicion of HIV infection.

It must be noted that the goal of this course is primarily to increase the provider‘s
comfort and understanding of HIV rapid testing. Because this course cannot deal
with in-depth issues (e.g., quality assurance, procurement and storage) related
to rapid testing, participation in more intensive rapid testing courses is
strongly suggested for someone on the clinical or laboratory team. WHO and
the U.S. CDC have jointly produced a more intensive course on HIV rapid testing
which would be suggested for all health facilities offering rapid testing without
existing experience and/or training.




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                               Table of contents

(in the order the symptoms appear in IMAI Acute Care Revision 2)


Chapter                                                             Page

   1      Introduction to IMAI Acute Care guideline module           7

   2      Quick check for emergency signs                            8

   3      Introduction to the IMAI acute care algorithm              13

   4      Cough or difficult breathing                               18

   5      Undernutrition and anemia                                  27

   6      Mouth or throat problems                                   31

   7      Genital or anal sores, ulcers and warts                    37

   8      Genito-urinary symptoms and lower abdominal pain in men    51

   9      Fever                                                      58

  10      Diarrhoea                                                  65

  11      Genito-urinary symptoms and lower abdominal pain in        67
          women

  12      Skin problems and lumps                                    86

  13      Headache and neurological problems                         93

  14      Mental health problems                                    109

  15      How to use diazepam, haloperidol and amitryptiline        120

  16      Provider-initiated testing and counselling                128

          Glossary                                                  136

          Answers to self-study questions                           144




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Chapter 1: Introduction to IMAI Acute Care guideline module

The Acute Care guideline module first starts with a quick check for emergency signs.

If no emergency signs are present, the patient is assessed for acute problems,
based on common symptoms. The section on Assess and Classify guides the
assessment for the common main symptoms in adolescents and adults. For each
important main symptom, classification tables guide decisions on whether to refer
the patient, provide specific treatment as an outpatient, or recommend home care
with symptomatic management. The treatments and advice or counselling are
specified for each classification.

Follow-up care for acute illness are provided in summary boxes on pages 61 to 66.
Long term chronic care guidelines are in separate guideline modules such as
Chronic HIV Care with ART and Prevention.

Detailed instructions for each treatment are found on pages 67 to 93 of Acute Care
Revision 1. Detailed instructions for advice and counselling are found on page 95 to
110.

For each main symptom, a chapter in this participant training manual describes the
assessment, how to make the classification, and how to provide the key treatments
or how to advise and counsel.




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Chapter 2: Quick Check for EMERGENCY SIGNS

First do the Quick Check for emergency signs. This takes less than a minute if all
signs are negative.

Many deaths in hospital or health center occur within 24 hours of arrival or the
patient dies at home of a severe illness within days of becoming ill.

Some of these deaths can be prevented if very sick patients can be promptly
identified on arrival and treatment started without delay. The Quick Check helps you
to very rapidly (in seconds) identify patients with emergency signs who need
immediate treatment. The most experienced doctor or other health worker should
direct this treatment. If this is not possible, the emergency treatment should be given
by a trained member of staff without delay while a call is put out for help, including if
possible the most senior health worker and doctor when available, and
arrangements made for referral. These emergency treatments are based on the use
of a limited number of drugs and procedures that can be administered safely by
nurses and medical assistants after a short training. It is very important to provide
certain treatments before referral.

After emergency treatment is given, the patient should be assessed with the acute
care algorithm to establish the disease classifications or, if a doctor or clinical officer
has arrived, by them to determine the diagnosis. Then further appropriate treatment
should be given.


Summary of steps in the Quick Check for Emergency Signs

The emergency triage assessment and treatment process can summarized as
follows:

Step 1. First, the health worker should check for an airway or breathing problem.
Since an airway or breathing problem is life-threatening, a patient with a breathing
problem needs immediate treatment to restore breathing. Before managing the
airway and positioning the patient or moving the head/neck ask about and look for
head/neck trauma.

Step 2. The assessment should then continue to quickly determine if the patient has
shock; is unconscious or is convulsing (now or recently); has chest, severe
abdominal, or neck pain or severe headache; or has a fever from a life-threatening
cause. The assessment of these signs can be done very quickly, almost
simultaneously. Emergency treatments should be immediately implemented if signs
are positive.




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If you find any emergency signs (in Step 1 or 2), immediately:

    Give appropriate emergency treatments.
    Call a senior clinician and other health workers to help but do not delay
     starting the treatment. The clinician should direct the treatment and
     immediately continue with core and directed assessment.
    Do emergency investigations (blood glucose, malaria smear, haemoglobin).
     Also send blood for type and cross-match if the patient is in shock, appears
     severely anaemic, or is bleeding significantly.

If a patient has trauma or other surgical problems, get surgical help or follow surgical
guidelines. Simplified guidelines for managing trauma can be found in the IMAI
Quick Check and Emergency Treatments guideline module. Only the medical section
of these guidelines are included in Acute Care.

Step 3. Proceed to use the acute care algorithm, to identify other specific
treatment the patient may need acutely.

Most patients will not require emergency treatment. However, when a patient is
identified who needs emergency treatment (such as treatment for shock), it is
essential to react as quickly as possible. The health worker should begin giving the
emergency treatments, call for help from other health workers and call for a senior
clinician. The team needs to stay calm and work together efficiently. The person in
charge of the emergency management of the patient should assign tasks so that the
assessment can continue and treatments can be initiated quickly. Other health
workers need to help to give the treatments needed, especially since a very sick
patient may need several treatments at once. The senior clinician should direct
treatment and then immediately continue with a core and directed assessment of the
patient, to identify all problems and develop a treatment plan.

Quick check for emergency signs

The triage assessment identifies any emergency signs that require immediate
treatment.

ASSESS AIRWAY AND BREATHING (page 4)

    Is the patient breathing? A patient who is alert, talking or crying is obviously
     breathing. If not, look for chest movement, listen for breath sounds, feel for
     breath.

    Does breathing appear (or sound) obstructed? Look and listen to
     determine if the breathing problem appears to involve poor air movement.
     You may see the patient trying to breathe in without success, then air goes in
     noisily. Obstructed breathing can be due to blockage of the airway by the
     tongue, a foreign body, or laryngospasm. Upper airway obstruction causes
     very noisy breathing.

    Is there central cyanosis (blue mucosa)? Indicated by a bluish or purplish
     discoloration of the tongue and the inside of the mouth.


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   Is there severe respiratory distress?
        o The patient is in severe respiratory distress if he or she is clearly
           distressed by severe problems breathing or catching their breath. The
           breathing is very laboured and the patient may appear tired. The
           patient‘s distress is visibly apparent and not something that the patient
           just reports. Patients with severe respiratory distress may be confused
           or agitated due to the lack of air. If the patient is talking, looks
           comfortable, or appears happy, or if this condition has been present for
           some time, the patient does not have severe respiratory distress.

            If any of these signs are present, check for obstruction, wheezing and
            pulmonary edema. Immediately follow the emergency treatment
            instructions.

            If the breathing sounds wet and the patient has a history or heart
            disease, consider giving furosemide before referring.


ASSESS CIRCULATION (FOR SHOCK) (page 4)

   Is the patient‟s hand cold?

     Check the pulse. Is the pulse weak and fast? If the radial pulse is strong
      and not obviously fast, the patient is not in shock. If you cannot feel a radial
      pulse, feel for the femoral or carotid pulse. If the pulse is weak and fast, the
      patient may be in shock

   Check the capillary refill. Is it longer than 2 seconds? Apply the pressure
    necessary to whiten the nail of the thumb for 3 seconds. Time the capillary
    refill time from the moment of release until total recovery of the pink colour.
    Usually the pink colour comes back immediately. This test is abnormal if it
    takes more than 2 seconds for the colour to come back.* (This test can be
    falsely positive if the room is very cold).

      If the room is very cold, rely on the pulse rather than the capillary refill to
      determine whether the patient may be in shock.

      If any of these signs are present, immediately measure the BP and count the
      pulse. Look for bleeding and any signs (or history) of trauma. Ask about
      diarrhoea.

            Look at photo booklet Group 1
            A. Central cyanosis
            B. Severe respiratory distress
            C. Capillary refill




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CHECK: CONVULSING OR UNCONSCIOUS? (page 5)

   Is the patient convulsing (now or recently)? Are there spasmodic repeated
    movements in an unresponsive patient? Or has a convulsion happened very
    recently?

   Is the patient unconscious? Is the patient awake and alert? If not, try to
    rouse him/her by talking. Then shake the arm to try to wake him/her, or
    squeeze the fingernail to cause mild pain. If the patient does not respond to a
    voice or shaking of the arm, s/he is unconscious and needs emergency
    treatment.

     CONSCIOUSNESS:
     A conscious patient maintains an alert state. Consciousness depends on the
     proper functioning of the alerting system of the brain which maintains the alert
     state. Inactivation of this system by an infection or a problem of metabolism
     can lead to impairment of consciousness.

     UNCONSCIOUSNESS:
     This is a reduction in the level of awareness of self and the environment to the
     extent that the patient does not respond to external stimuli.

     In the unconscious state there is a danger of airway obstruction and
     aspiration. Furthermore, the cause of the unconscious state may also lead to
     respiratory depression or circulatory failure. Assess for the possibility of
     poisoning, alcohol or substance abuse. Examine and ask questions of the
     family or friends who brought the patient into clinic.

     If either the patient is either unconscious or has had a convulsion,
     immediately measure the BP and temperature while protecting the patient
     from a fall or injury.
         clear all sharp or hard objects near the patient to avoid injury.
         do not restrain the patient as this might result in injury

     Assist the patient into the recovery position (wait until the convulsion ends).

            Look at photo booklet Group 2
            Recovery position and how to move patient into it.

     Then start an IV, give appropriate IV/IM antibiotics, quinine or artemether IM,
     and slow fluids.

     If the patient is convulsing, give rectal or IV diazepam (the instructions for this
     are on page 71. This treatment may need to be repeated en route to the
     hospital. The health worker should accompany if possible and the patient
     should never be left alone.




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CHECK FOR SERIOUS PAIN (page 6):

Chest pain? If chest pain, what type of pain?
      Determine whether this could be trauma or ischemic chest pain. Immediately
      check the BP, pulse and temperature. Give emergency treatment.

         o Severe abdominal pain?
           Immediately check BP, pulse and temperature. Insert an IV and refer
           urgently to hospital.

    Neck pain or severe headache?
     Has there been any trauma? Check BP. Consider meningitis and other
     causes of acute headache—see page 46 of the acute care algorithm.

CHECK FOR FEVER FROM LIFE-THREATENING CAUSE (page 14):

    Any fever with:
       o Stiff neck
       o Very weak/not able to stand
       o Lethargy
       o Unconscious
       o Convulsions
       o Severe abdominal pain
       o Respiratory distress

      If any of these signs are present, measure the temperature and BP, do a
      malaria smear if possible. Provide emergency treatments—Insert an IV and
      immediately give appropriate IV/IM antibiotics and quinine. Give glucose.

      If all the clinical signs in this triage assessment are negative, the
      screening can be done very quickly. Now turn to page 6 to 7 of the
      module which explains the case management sequence your should
      follow in providing acute care to any adolescent or adult patient.




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Chapter 3: Introduction to the IMAI Acute Care algorithm

An algorithm is a structured approach for solving a problem. The algorithms in IMCI
(for children) and IMAI (for adolescents and adults) have been simplified for use
where there are limited resources, at health centre or district outpatient level. They
represent a syndromic approach which means that signs and symptoms are used to
classify the problem, with only limited laboratory. They graphically show which
patients need to be referred (pink row), which patients can be managed as an
outpatient using specific treatment such as antibiotics or antifungals (yellow row) and
which patient require only home care (green row).

The main clinical syndromes in adolescents and adults are:

      Cough or difficult breathing
      Undernutrition and anaemia
      Genitourinary symptoms including genital and anal ulcers and other STIs
      Mouth, throat or dental problems
      Fever
      Diarrhoea
      Skin problems or lumps
      Headache or other neurological problems
      Mental health problems

Each of these has a section in the Acute Care guideline module which explains how
to assess the patient (ask then look and feel) and how to classify the problem then
treat or provide advice or counselling.

Pain can occur with many conditions and deserves separate consideration.

In Acute Care, we present a systematic approach to an adult or adolescent who
presents with an acute problem. Follow this step by step as follows:

Page 6:

ASK: What is your problem?

Then listen.

This is the first question and is very important. It is important to listen carefully and
ask questions as needed to clarify why the patient came.

Listen and do not interrupt right away. The most important problem may not be
presented first. The problems that the patient volunteers (without direct questions
from the health worker) are often the most important. For example, it is more
significant if the patient complains of cough or difficult breathing on his own than if he
answers ―yes‖ to the question, ―Do you have cough or difficult breathing?‖ We often
have a slight cough, and might answer yes to try to be truthful when asked if we
have cough or difficult breathing, but that is not why we sought care.



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Using good communication skills during the assessment

 Listen carefully to what the patient says. This will show the patient that you
  are taking his or her concerns seriously.
 Use words that the patient understands. If the patient does not understand the
  questions, the patient cannot give the information needed to assess and classify
  correctly.
 Give the patient time to answer questions. The patient may need to decide if
  the sign asked about is present. The patient may have an additional symptom but
  will not mention it if you seem in a hurry.
 Ask additional questions when you are not sure about the answer. More
  questions may be required to determine whether a certain symptom is present. It
  may be necessary to probe and ask clarifying questions. Adults often have long
  histories for their illness. You need to sort through what the patient says and stay
  on track to get the essential information. Listen carefully to convey respect and
  concern for the patient‘s story. Ask additional questions to help obtain clear
  answers. Ask ―Is there more?‖ to be sure you have gotten a complete answer.

A patient may say that he has fever, or the clinic may have measured his
temperature at registration and recorded this on his form.

Based on what the patient says or what you observe, decide whether the patient has
come to the facility for:

    an acute illness,
    follow up care for an acute illness, or
    follow-up of a chronic illness.

Determine if your patient has acute illness, follow-up care for an acute illness, or
follow-up of a chronic illness. Circle this on the recording form.

Based on the reason for the visit, select the section of this module to use to care for
the patient. There are separate sections for acute care of a sick patient and follow-up
care for acute illness. There are also separate modules on the chronic care of
specific illnesses such as HIV/AIDS and diabetes. illnesses.

Acute Illness

We use ―acute‖ to mean any new or worse illness or problem, even if the patient has
suffered from it for some time before coming to clinic. A patient who came for care
because he has had cough and fever for several days has an acute illness. Acute
care is also needed when chronic patients suddenly get worse with a problem that is
their usual chronic illness, or with something different. For example, an asthma
patient who comes in with an acute attack should be considered to have come for an
acute illness. Use the guidelines in the IMAI Acute Care module, even though he
may also be known to have a chronic illness such as asthma.

Follow-up Care for an Acute Illness




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If the patient was seen a few days ago for the same illness, this is a follow-up visit
for that acute illness. A follow-up visit has a different purpose than an initial visit.
During a follow-up visit, the health worker finds out if the treatment he gave during
the initial visit has helped the patient. If the patient is not improving or is getting
worse after a few days, the health worker may refer to hospital or change the
treatment.

When a patient has pneumonia, the health worker asks the patient to come back in
2 days. This return visit is follow-up care for an acute illness. If a patient has
cough for more than 3 weeks, the health worker collects sputum and asks him to
return later to the facility for the results. When the patient returns, the health worker
will check the sputum results and determine whether he needs to go to the TB clinic.
This patient is not yet a chronic patient because we do not know if he has TB. The
patient might just have a cough or cold. Therefore this visit is also considered
follow-up care for an acute illness. Use the guidelines for Follow-up Care.

Follow-up of a Chronic Illness (chronic care)

We know that a patient has chronic obstructive pulmonary disease (COPD) or
asthma if a diagnosis has been made at the district hospital level 1 by an experienced
clinician. TB can be diagnosed either at the district hospital level or, in a new patient
with positive sputums, at your clinic. These patients have a chronic illness and
need chronic care. If a patient comes to clinic for a routine follow-up of asthma and
says he has no special problem today with cough or difficult breathing, he has come
for follow-up of a chronic illness. Still he may need acute care if his condition
suddenly worsens. Use the guidelines in the appropriate Chronic Care module. You
will learn about this later.

How to find out if a patient has come for an initial or follow-up visit depends on how a
clinic registers patients and identifies the reason for their visits. Some clinics give
patients follow-up slips that they show when they return. In other clinics the health
worker consults the multi-visit card or chart to check if there are notes from a
previous visit. In many clinics, when a patient registers, the health worker asks
questions to find out why the patient has come.

ASK: How old are you?

Age is used in determining what breathing rate is considered fast and for drug
dosages.

If woman of childbearing age, ASK: are you possibly pregnant?

Childbearing age is from as young as 12 years up to 50 years. If a girl or woman is
within this age range, ask her if she is or could be pregnant.

If a patient is pregnant, ask her how long she has been pregnant or when her baby is
due, to estimate which trimester she is in. Knowing the patient is pregnant is very

1
 Some patients will have been diagnosed as COPD or emphysema or asthma by a private
doctor.


                                                                                      15
important. She needs antenatal care, in addition to your management of the problem
which brought her to the clinic. Her pregnancy may change what drugs you use to
treat a problem or to manage a problem differently. If she is second or third trimester
and has signs of pneumonia, she will need to be hospitalized since her pregnancy
puts her at higher risk of complications. If she is bleeding this is dangerous—use
antenatal guidelines.

In all patients, there are now seven things to check. We will explain how to do this
assessment in the sections which follow. For these symptoms, we do not rely on the
patient to volunteer them. We check for these in all patients to not miss TB
(presenting with cough), to not miss HIV presenting with mouth signs, and to not
miss STIs. Often patients may not volunteer these symptoms and important
conditions will be missed.

They may not recognize that these are a problem (for example, anaemia or
undernutrition) or are embarrassed to report a problem (STI).

    Ask: Do you have cough or difficult breathing?
    Check for undernutrition and anaemia.
    Look in the mouth (and respond to volunteered mouth/throat problems)
    Ask: genital or anal ulcer, sore or warts? (This should be phrased in a
     culturally appropriate manner)
    Ask men: do you have a discharge from your penis?
    Ask about pain
    Ask: Are you taking any medications?

It is very important for prevention of HIV transmission to screen all patients for STIs.
We do this by asking both men and women about genital or anal ulcers or sore
(using an appropriately phrased question) and by asking men about a discharge
from the penis.

It is important to ask about pain in all patients to make sure that it is in good control.
Sometimes patients do not complain of pain. It is important and possible to control
pain in both patients with acute and chronic problems. If pain is present, grade the
pain and manage it, following the Palliative Care guidelines.

We ask about medications in all patients because many problems are related to the
medications themselves. Knowing about medications also gives us clues as to what
problems the patient has and what care he or she has been provided before.

Respond to volunteered problems or observed signs using the appropriate section of
Acute Care.

Mark with an X on the recording form all the main symptoms the patient has. Then
use this form to record all the positive signs that you find, by circling these.




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SELF STUDY EXERCISE #1 (Answers in Annex)

Purpose: to practice determining the reason a patient has come and selecting the
appropriate guidelines to use.

Instructions: Decide if the following patients need acute care or follow-up care for
an acute or chronic problem. Identify where to go in the Acute Care guideline module
to CLASSIFY the patient.

1. A 20 year old woman in 7th month of pregnancy has been coughing for 3 weeks.
2. A young man who started ART 2 months ago comes in with a new rash.
3. A 35 year old woman with much heavier menses than usual and a delay of
   menses by one month.
4. A 40 year old man was treated for pneumonia 2 days ago. He still has fever and
   cough.
5. A 25 year old man complains of diarrhoea for 3 weeks. This is his first visit to the
   clinic..
6. An 18 year old woman has low abdominal pain for 2 days. She was followed for
   her first pregnancy at the clinic one year ago.
7. A 22 year old man with TB comes in for a drug refill.
8. A 60 year old woman was treated for bladder infection 3 days ago and now has
   fever.




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Chapter 4: Cough or difficult breathing

Page 16: In all patients, ask: Do you have cough or difficult
breathing?

ASK
Ask all patients if they have cough or difficult breathing or if you observe this, and it
is an acute illness, assess the patient as described in the assessment of ―Cough and
Difficult Breathing‖ on page 16 of the Acute Care module.

Note: If the patient does not have cough or difficult breathing, skip that section and
move to page 18, where you will assess for undernutrition and anaemia.

A person who has a cough or difficult breathing may have an acute or chronic
respiratory illness depending on his or her signs and symptoms and the length of
time they have been present. Health workers need to be able to identify severe
illness in order to provide emergency treatment and refer the patient to hospital as
soon as possible. Health workers should also be able to assess and classify non-
severe cases that need referral for diagnosis and to distinguish these from diseases
that can be treated at home.

Note: You will not know whether the patient has a mild or severe illness until you
have completed the assessment and classification steps in the guidelines.

The text below describes how to assess each sign or symptom listed in the box. To
assess the patient with cough or difficulty breathing, first ASK questions and then
LOOK and LISTEN for certain signs.

An important exception to this order is a patient who has severe difficulty breathing
or other signs of severe illness. In these cases rapidly do the Look and Listen part of
the assessment and begin providing treatment as soon as possible. You may be
able to find out some of the history information from family or friends who brought the
patient to the clinic.

As you ASK, LOOK and LISTEN for certain signs; you may record your findings on a
special recording form, similar to the Assess boxes of the chart. It lists the questions
to ask and the signs to look and listen for. Circle signs that are present. Refer to the
recording form later when classifying the patient‘s illness and identifying treatments
needed.

―Difficult breathing‖ is any problem with breathing. Patients may complain that they
cannot catch their breath or that it takes effort to breathe or that they feel out of
breath all the time. They are more aware of their breathing than usual.




                                                                                      18
   For how long? (have you been coughing? Have you had difficult
    breathing?)

    Listen carefully to the answer. Determine whether the patient has had the
    cough for more than three weeks.

    If the patient complained of difficult breathing, determine if the patient has had
    difficulty breathing for more than three weeks.

   Are you having chest pain?

    People have different kinds of chest pain, which may indicate different
    illnesses. This is why the next questions are:

   If yes, is it new? Is it severe? Describe it.

    Pleuritic chest pain may be described as a pain that occurs when the patient
    breathes in and out and is not present between breaths. The pain increases
    when the chest muscles are used. Pleuritic chest pain occurs when
    inflammation from a lung infection involves the lining of the lung (the pleura).
    Normally the pleura moves smoothly and without any feeling along the inner
    chest wall when breathing. When the pleura is inflamed, the movement during
    breathing causes pain.

    A person with severe pleuritic chest pain has great difficulty taking a deep
    breath because of the pain. When he breathes, his chest wall may move less
    on the side where he has pleuritic chest pain.

    Do not confuse pleuritic chest pain with chest pain that feels like:
        a great weight crushing the chest that does not go away with rest or
        a pain which is constant or
        a pain that goes from the chest to the jaw, neck, or arms, or
        a pain that occurs with exercise.

    Pain described like any of the above may be angina or a heart attack
    (myocardial infarction), not pleuritic chest pain. This patient should be seen
    by a doctor and referred to hospital. Use other guidelines to diagnose and
    manage those conditions.

   Do you have night sweats?

    This is soaking the bedding during the night and can be due to recurrent
    fever from a variety of causes (see fever) including TB or HIV. Ask for how
    long night sweats have been occurring.

   Do you smoke?

    Determine whether the patient is smoking now or recently. It is important to
    determine this because all patients who smoke should be counseled to stop



                                                                                   19
    smoking. However, do not take the time to assess smoking in a severely ill
    patient who should be urgently referred to hospital.

   Do you have asthma, COPD, heart failure, or TB?

    Some patients come back repeatedly and you will recognize them as having a
    chronic diagnosis. If you do not recognize the patient, ask if he has asthma,
    COPD, heart failure, or TB, or check the patient‘s treatment card (if he has
    one). If the patient does not know whether he has any of these diseases or is
    unable to respond and does not have a treatment card, look in the facility‘s
    Chronic Disease Registry.

    COPD means Chronic Obstructive Pulmonary Disease. It is a name that
    covers two medical conditions, emphysema and chronic bronchitis. These are
    both chronic lung diseases which damage the air passages, interfering with
    (obstructing) the ability to breathe in and out. These two diseases usually
    occur together although one or the other can predominate in an individual
    patient. Consider that the patient has COPD only if the patient has had this
    diagnosis, or the diagnosis of emphysema or chronic bronchitis, from a doctor.

    If no known asthma, COPD, heart failure, or TB:

    Ask these questions to find out whether the patient might have a chronic lung
    disease, indicated by recurrent episodes of cough and difficult breathing, that
    has not yet been diagnosed at the district hospital level:

    Have you had previous episodes of cough or difficult breathing?

    If the patient says he had previous episodes, ask the patient to describe the
    previous episodes during the past year. Determine whether the episodes are
    recurrent, that is, occurring several times a year. Recurrent episodes may
    indicate a chronic lung problem.

    Everyone has had several episodes of a common cold with a cough, and
    these are not considered recurrent episodes. Patients with recurrent (chronic)
    lung problems have them every week or every few weeks; the episodes get
    better but come back several times over a year. Patients may or may not have
    sought medical care for them, or may have treated them with remedies at
    home.

    If the patient had recurrent episodes, circle ―recurrent episodes‖ on the
    recording form and ask more questions to further describe the problem. (If not,
    skip these next two questions.)

     If yes, do these episodes of cough or difficult breathing wake you up
    at night or in the early morning?

    Waking up at night, or increased problems with breathing in the early morning,
    can be a sign of asthma. Patients with chronic lung problems may also have



                                                                                20
      some heart failure that makes it difficult for them to breathe when they lie flat.
      This may cause them to wake up at night.

       If yes, do these episodes occur with exercise?

      Cough or difficult breathing episodes that occur with exercise can be an
      indication of asthma or another chronic lung problem. This is different from
      getting out of breath during extreme exercise or with moderate exercise in a
      person in poor physical condition (these are normal).

LOOK, LISTEN

     Is the patient lethargic?

      A lethargic person appears sleepy, is not alert when he should be, and shows
      no interest in what is going on. It is difficult to arouse a lethargic person.


     Count the breaths in one minute.

      To count breathing, watch a part of the chest move. Use a watch with a
      second hand or a digital watch. Wait until the patient is calm. Do not tell the
      patient you are counting or watching his breathing because this may cause his
      breathing to change. Count while holding the wrist as if you are counting the
      heart rate. Do not count breathing using a stethoscope.

      Then determine whether the patient has fast breathing or very fast breathing.

      Use the chart from page 16 of the guidelines to determine whether the patient
      has fast or very fast breathing. If count is elevated, repeat.


       AGE              FAST BREATHING IS:  VERY FAST BREATHING
                                            IS:
       5-12 years  30 breaths per minute or 40 breaths per minute or
                   more                     more
       13 years or 20 breaths per minute or 30 breaths per minute or
       more        more                     more



     Look and listen for wheezing.

      Look to see when a patient is breathing OUT (expiration). A patient with
      wheezing makes a soft musical or whistling noise when breathing OUT or
      shows signs that breathing OUT is difficult. Listen for the wheeze noise by
      holding your ear near the patient‘s mouth (at a distance of 30 centimeters or
      two spread hands), since the noise may be difficult to hear.




                                                                                     21
       Wheezing is caused by a narrowing of the air passages in the lungs.
       Breathing out takes longer than normal and requires effort. Sometimes so little
       air moves that there is no noise. Look to see if the breathing out phase
       requires great effort, and is longer than normal. If so, the patient has
       wheezing.

       If you hear wheezing by listening near the mouth, it is audible wheezing (that
       is, it can be heard without a stethoscope). Some patients have wheezing
       which can only be heard with a stethoscope. If there is no audible wheezing,
       listen for wheezing with a stethoscope or put your ear to the patients chest in
       the back.

       To auscultate by stethoscope, place the patient in the sitting position and ask
       him to breathe with normal size breaths. Sometimes people take very small
       breaths when someone is trying to listen. If this happens, ask the patient to
       take a larger breath.

       Abnormal sounds that may be present include wheezing, crepitations, or
       rhonchi. Wheezing as heard by stethoscope is high-pitched hissing or
       whistling sounds that usually occur when breathing OUT but may occur also
       during breathing IN (inspiration). Wheezing is different from crepitations (also
       called crackles or rales) which are high-pitched crackling sounds when
       breathing IN. These sounds resemble the sound that is created when a piece
       of hair is held close to the ear and rubbed between fingers or the sound of
       velcro. Wheezing is also different from rhonchi which are wet and coarse
       sounds. They are low-pitched sounds early in breathing IN that clear or
       decrease following cough.

      Determine if the patient uncomfortable lying down?

If the patient says he is not uncomfortable lying down and does not appear
breathless, conclude that this sign is not present. If the patient says that he is
uncomfortable lying down, but does not look breathless, confirm this sign by
observation. Ask the patient to lie down for several minutes and observe whether he
is uncomfortable. Do this while asking the history questions or counting the
breathing. If the patient is uncomfortable lying down, help the patient sit up again.

    Measure temperature (or, if already measured, use this measurement).
     Determine if the axillary temperature is abnormal—is it < 35C (abnormally
     low body temperature or hypothermia), 37.5C or higher (fever), or 40C or
     higher (very high fever). Circle the appropriate one on the recording form if the
     temperature is not normal. If the temperature is normal, you do not circle
     anything.

      If not able to walk unaided or appears ill, also:

       Not able to walk unaided means the patient needs to be carried or supported
       by another person. Appears ill means at a glance the patient does not look
       well. Usually the patient would not be laughing or happy.



                                                                                    22
       Next determine whether to spend the time to count the heart beats in one
       minute and measure the blood pressure (BP). In your clinic, the blood
       pressure and temperature may already have been measured before you see
       the patient. If so, use that measurement. In some clinics, there is not enough
       time to do this in all the patients who present with cough and are not very sick.
       However, if the patient cannot walk, has any of the neurological signs
       assessed earlier (lethargic, confused or agitated), or if the patient appears ill,
       it is important to also count heart beats and measure blood pressure.

      Count the pulse (the heart beats in one minute.

       Place your fingers on the patient‘s wrist and feel the pulse. Do not use your
       thumb. You can count for only a half minute (that is, 30 seconds) then
       multiply by 2.

      Measure blood pressure

       NORMAL AND ABNORMAL. Tell the facilitator if you do not know how to
       measure systolic and diastolic blood pressure, or want to review the
       technique.

The following explanation summarizes how to use this assessment to classify
the patient with cough or difficult breathing.

How the acute care algorithm works

See "Steps to Use the IMAI Acute Care Module" on page 6 and 7
The IMCI chart booklet and the algorithm in the IMAI Acute Care guideline module
both use severity classification tables. Each classification table lists clinical signs of
illness and their classifications. The tables are divided into three columns titled
'SIGNS,' 'CLASSIFY AS' and 'TREATMENT.'

To use a classification table, start at the top of the SIGNS column on the left side of
the table. Read down the column and decide if the patient has the signs in this row
or not. When you reach the sign or combination of signs that the patient has, stop.
The patient should be classified in that row and the treatment provided which are
listed in the right column. Do not proceed to lower rows. In this way, you will always
assign the patient to the more serious classification.

In any classification table, the patient fits into only one row or classification.

If the patient has a symptom or sign that fits with additional arrows, also enter these
classification tables and choose a single classification from each table. This can
result in several classifications in an ill patient. For example, on page 10, a patient
may have both white patches and a mouth ulcer. Two classification tables would be
used on this page.




                                                                                       23
Only a limited number of clinical signs are used. A single sign or combination leads
to a classification, rather than an exact diagnosis, based on the severity of the
condition and indicating the action required. These classifications are colour-coded:
pink suggests hospital referral or admission; yellow for specific treatment that can be
given as an outpatient; and green for home treatment only.

Detailed treatment instructions are provided in boxes in the treatment section. The
page numbers are usually indicated. Tabs in the final version will make rapid use
easier.

There are three basic rules to use the IMAI acute care algorithm:
   1. Use all severity classification tables where the patient fits the description in
      the arrow (after your assessment). This means that many patients will have
      more than one classification (and more than one treatment)—or counseling.
   2. Start at the top of the classification table. Decide if the patient‘s signs fit the
      signs in the first column. If not, go down to the next row.
   3. Once you find a row/classification—STOP!

Use only one row in each classification table (once you find the row where the signs
match, do not go down any further, even if the patient has signs that also fit into
other, lower rows or classifications.

Use these rules to classify the patient with cough or difficult breathing.

CLASSIFY
How to use the table to classify the patient for cough or difficult breathing

There are four possible classifications for an adult with cough or difficult breathing.
They are:

SEVERE PNEUMONIA OR VERY SEVERE DISEASE (pink row) or
PNEUMONIA (yellow row) or
POSSIBLE CHRONIC LUNG PROBLEM (yellow row) or
NO PNEUMONIA: COUGH, COLD or BRONCHITIS (green row)

Look at the classification table on page 17 while reading the explanation below. Use
the findings of the assessment of symptoms and signs to classify the patient‘s
illness.




                                                                                      24
SIGNS:                          CLASSIFY AS:            TREATMENTS:
One or more of the following
signs:                               SEVERE
 Very fast breathing or         PNEUMONIA OR
 High fever (39 C or above) or   VERY SEVERE
 Pulse 120 or more or               DISEASE
 Lethargy
 Not able to walk unaided or
 Uncomfortable lying down or
 Severe chest pain
Two of the following signs:
 Fast breathing                   PNEUMONIA
 Night sweats
 Chest pain
 Cough or difficult breathing
   for more than 2 weeks, or        POSSIBLE
 Recurrent episodes which:      CHRONIC LUNG
   - Wake patient at night or       OR HEART
       in the early morning or       DISEASE
   - Occur with exercise

 Insufficient signs for the            NO
  above classifications             PNEUMONIA:
                                    COUGH/COLD
                                   OR BRONCHITIS

    Look at the top (pink) row. Does the patient have one or more of the signs
     listed in the left column?

      If yes, select the classification SEVERE PNUEMONIA OR VERY SEVERE
      DISEASE. These are all severe signs. Only one of these signs is required to
      select the severe classification (pink row).

    If the patient does not have a sign for the severe classification, consider the
     classification in the next (yellow) row, PNEUMONIA.

      Does this patient have two of the following signs?

              Fast breathing?
              Night sweats?
              Chest pain?

       If the patient has any two of these signs, select the classification
       PNEUMONIA. If the patient has only one of the above signs, for example, has
       fast breathing, but does not have fever or chest pain, this is not sufficient to
       select the classification PNEUMONIA.




                                                                                    25
      All patients with PNEUMONIA should have sputums sent for TB. It is often
      easiest to collect one now, then the other two when the patient returns for
      follow-up.

     If the patient does not have sufficient signs to select either the top (pink) row
      or the next (yellow) row, move down to the next row and consider whether the
      patient has POSSIBLE CHRONIC LUNG DISEASE. Does the patient have
      any of the signs in this row?

      Cough or difficult breathing for more than 2 weeks, or

      Recurrent episodes which:
         Wake patient at night or in the early morning or
         Occur with exercise

      If yes, select the classification POSSIBLE CHRONIC LUNG DISEASE.

   If the patient does not have sufficient signs to select one of the first three
    rows, select the classification in the bottom row, NO PNEUMONIA—COUGH,
    COLD, or BRONCHITIS.

      Whenever using a classification table, start with the top row and work your
      way down until you select a classification. In each classification table, a
      patient receives only one classification. The appropriate treatments are listed
      to the right of the classification in the ―Treatment‖ column.

SELF STUDY EXERCISE #2 (Answers in Annex)

Use the table on p. 17 to CLASSIFY the following patients. Assume all signs
not mentioned are negative.

  1. A 50 year old man is helped by his wife into the clinic. He complains of cough
     for 1 week. He has been seen here in the past for cough (4 times in the past
     year) and is known to be a heavy smoker. He has fever of 37 C, has 22
     breaths per minute, a pulse of 90 and appears ill.

  2. A 25 year old woman complains of night sweats and has fast breathing and
     fever for 5 days. She appears ill and uncomfortable. although she has come
     to the clinic alone. Her pulse is 120, her breathing rate is 34 per minute and
     her temperature is 39C.

  3. A 30 year old man complains of difficulty breathing and runny nose for 5 days.
     He has no fever, is not breathing fast and appears healthy.


Page 18: After classifying the illness if there is cough or difficult
breathing, go on to the next page for all patients.




                                                                                    26
Chapter 5: Undernutrition and anaemia

Check all patients for undernutrition and anemia.

ASK
      Have you lost weight?
       Reported weight loss or measurable weight loss >5% is significant and may
       be caused by any infection, particularly one which causes decreased food
       intake (nausea, vomiting, diarrhea).

      Ask about diet

      Ask about alcohol use

      What medications are you taking?

LOOK AND FEEL

    Visible severe wasting—very thin, has no fat, and looks like skin and bones.
     Some adults are thin but do not have visible severe wasting. Look rapidly at
     the arms and legs and pull up the shirt to look at the chest. See if the adult
     appears very thin and has no fat. Look for severe wasting of the muscles of
     the shoulder, arms, and thighs, and visible outlines of the ribs.

          o MUAC: this is the mid-upper arm circumference. Measure this at the
            midway point between the tip of the shoulder and the tip of the elbow
            (the colcannon and the chromium). The tape should fit but not be tight
            or loose. Measure in mm (millimeters).

          o Weight loss: if the former weight is available on clinic record and the
            new weight today is less, subtract the old weight from the new weight
            then divide this by the old weight. Express this as the percentage
            weight loss.

Example of how to calculate weight loss:

Maria‘s weight was last recorded as 50 kg. six months ago. Today her weight is 40
kg. What is her percent weight loss?

Old—new weight divided by old weight.
50 kg—40 kg = 10 kg
10/50 = 0.20

Multiply by 100 to obtain percentage
0.20 x 100 = 20%

Maria has lost 20% of her weight in the last 6 months


                                                                                 27
      Look for edema of the legs.
       If present, does the edema go up to the knees? Check for pitting.

       Oedema is caused when a large amount of fluid collects in the tissues. To
       check for pitting- press gently with you thumb for a few second on the top side
       of each foot or ankle. The patient has pitting edema if an impression remains
       in the patient‘s foot when you lift your thumb.


CLASSIFY UNDER-NUTRITION
If there is visible wasting or weight loss classify using the table at the top of p.
19.

CLASSIFY as severe under-nutrition
If the MUAC is <160 mm or more, OR between 160-185 plus one of the following
signs,

    Pitting edema to the knees on both sides
    Cannot stand
    Sunken eyes

This patient needs referral for therapeutic feeding if nearby, or community-based
feeding. Consider sending TB sputums (send first one now if possible) and consider
HIV-related illness (p. 54). Counsel on HIV testing.

LOOK FOR ANEMIA
Look for signs of anemia which are pallor and breathlessness. Anemia is a lack of
the red blood cells which carry oxygen to all parts of the body. Pallor is visible when
a person is anaemic because fewer red blood cells make the blood pale.
Breathlessness is present because of the lack of oxygen which causes a person to
breathe more in an attempt to increase oxygen intake.

    Palmar pallor: Compare the colour of the woman or man‘s palm with your
     own palm. If the skin is pale, this shows some palmer pallor. If the skin is very
     pale or so pale that it looks white, this is severe palmar pallor.

    Conjunctival pallor: This is unusual paleness of the inner eyelids and the
     exposed surface of the white of the eyeball

      Breathlessness: Since red blood cells are the oxygen-carrying cells of the
       body, if there are not enough of them the person is breathless. Look for
       breathlessness as the patient walks in and sits talking with you.

       A patient who is breathless appears out of breath. He may appear anxious
       about his breathing. The breathing may be fast or slow. You may or may not
       hear abnormal noises—these do not necessarily mean the patient is



                                                                                    28
       breathless. A breathless patient may be restless. Another medical term for
       breathlessness is dyspnoea.

       If the patient shows any of the above signs of breathlessness:

       Ask: When do you experience breathlessness?

             At rest?
             Talking?
             Walking?

       Then also observe when the patient is breathless. For the assessment of the
       severity of anaemia, we are only interested in the patient who is breathless at
       rest. That means they will be breathless while sitting during the examination.
       Count the number of breaths in one minute.

CLASSIFY
If there is pallor, classify using the table at the bottom of p. 19:

CLASSIFY as Severe anaemia or other severe problem if there is:

      Severe palmer and conjunctival pallor or,
      Any pallor with 30 or more breaths per minute, or
      Bleeding gums or patchier, or
      Black stools, or blood in stools

Severe anemia can be life-threatening because the body is not obtaining sufficient
oxygen or nutrients; the patient can eventually go into shock. Anemia can be caused
by:

    ARV drugs, particularly ZDV, and by co-trimoxazole prophylaxis.

    Malaria if the patient has low immunity or increased exposure to malaria.
     Malaria causes anaemia because the parasites attack and destroy red blood
     cells.

    Intestinal bleeding causing black stools, which requires urgent transport in
     case surgery is needed;

    Heavy or chronic parasitic infection of the intestines (amoebas, hookworm and
     whipworm) if left untreated.

    Heavy bleeding of any kind from injury, tumor, ectopic pregnancy, or
     chronically heavy menstruation.

CLASSIFY as some anemia if there is only palmer or conjunctival pallor.




                                                                                     29
Consider HIV-related illness (p. 54), ARV drugs (zidovudine and cotrimoxazole) and
malaria depending on risk. Treat anemia with iron/folate and counselling on diet.
Albendazole should be given for hookworm and whipworm if none has been given in
the last 6 months, and metronidazole for amoebas. Heavy menstruation should be
treated with iron/folate and the cause identified.

Follow-up after one month.



      Look at photo booklet Group 3
      A. Where to measure MUAC
      B. Pitting oedema
      C. Sunken eyes
      D. Palmar pallor—some
      E. Palmar pallor—severe
      F. Conjunctival pallor—some
      G. Conjunctival pallor—severe
      H. Bleeding gums
      I. Petechiae




                                                                                30
Chapter 6: Mouth and throat problems

Page 24: Look in the mouth of all patients and respond to any
complaint of mouth or throat problem.

It is important to look in the mouth of all patients since this can show signs of HIV
infection which may not be reported. Mouth or throat problem includes a sore throat,
sores on the lips or tongue or cheeks, pain when swallowing or difficulty swallowing,
tooth pain—anything in the mouth or throat. In this course, we include the lips as part
of the mouth.

If the patient has a mouth or throat problem
To help with learning the assessment of a mouth or throat problem, look at the
demonstration photos as you go through the assessment. Look for these problems
routinely whenever you examine the mouth in patients both during outpatient and
inpatient clinical practice.

ASK

      Do you have pain?
       If yes, when does it occur? (When swallowing? When eating hot or cold
       food? All the time?)

       Ask about pain. To try to locate the pain, ask when it occurs. A sore throat or
       esophageal infection with candida commonly cause pain with swallowing.
       Pain from tooth decay is common when a hot or cold food touches the tooth.
       Constant pain may result from an abscessed tooth.

       Remember to only ask "when does it occur?" if the patient says there is pain.
       When we use a "-" dash and underline If yes, this tells us we can skip this if
       the patient did not complain about the symptom just above it.

      Do you have problems swallowing?

       Throat infection (tonsillitis) or candidal infection of the esophagus can cause
       difficulty swallowing.

      Do you have problems chewing?

       Tooth pain from decay or an abscess or from painful mouth or gum ulcers can
       make it difficult to chew.

      Are you able to eat?

       It is important to know whether the patient is able to eat at all. Most patients
       with mouth or throat problems have pain when eating but they are still able to



                                                                                    31
       eat something. If they cannot eat anything, this is a serious problem since
       they will lose weight and soon become much sicker from undernutrition.


LOOK
Look in the mouth for:

    White patches or red patches anywhere in the mouth .
     If yes, can they be removed?

       White patches from candida can be removed by gentle scraping with a swab.
       Or they sometimes appear mostly as red patches. They are painful.

       Finer white patches on the side of the tongue which cannot be removed are
       called Oral Hairy Leukoplakia. This is different from candida and it is painless.

      Ulcers
       If yes, are they deep or extensive? These can be found on all surfaces in the
       mouth. If there are many ulcers or they are deep they can be extremely
       painful and the patient cannot eat.

      Tooth cavities
       If patient complaining of tooth pain, does tapping or moving the tooth cause
       pain? Are parts of the tooth missing or discolored or softened?

      Bleeding from gums
       Bleeding may already be there, or may occur when you touch the gum.

      Swelling of gums
       Gums may be puffy and red and painful. Gums may have receded below the
       tooth in places.

      Gum bubble
       This occurs when the pus from a dental abscess collects at the base of the
       tooth. It is small and round and painful.

      Pus
       Pus may leak from an abcess at the base of a tooth and may be present in
       infected ulcers or on the tonsils.

      Dark lumps
       These are abnormal purple growths called Kaposi sarcoma. In whites, they
       appear purple. They can occur on the palate or anywhere in the mouth.




                                                                                     32
Look at throat (pharynx) for:

      White exudate
       White patches on the back of the throat or on the tonsils may occur with fever,
       pain and difficulty swallowing.

      Abscess
       An abscess in the throat is a serious bacterial infection which may occur with
       or after tonsilitis; it is red and bulges out. If it is large, it may push the uvula to
       one side and can interfere with swallowing and breathing. This requires
       URGENT referral to hospital.


Jaw and neck:

      Look for swelling over jaw
       This can be due to a tooth abscess—Is the face swollen on one side? Look at
       the teeth and gum on that side for decay, swelling of the gum, a gum bubble,
       or pus.

      Feel for enlarged lymph nodes in the neck
       Almost everyone has small nodes in the neck—feel you own neck. What is
       abnormal is a large node, or nodes the patient says are tender.


       Look at photo booklet Group 4
       A. White patches—these are oral thrush (candida)
       B. Red patches—another appearance of oral thrush
       C. Oral hairy leukoplakia—cannot be scraped off
       D. White exudates on throat
       E. Abscess in tonsil
       F. Enlarged lymph node in neck
       G. Swelling over jaw
       H. Ulcer which is not deep
       I. Ulcer—this would be called deep
       J. Swollen face from dental abscess
       K. Gum bubble
       L. Dark lump on palate—this is Kaposi sarcoma
       M. Loss of tooth substance
       N. Visible tooth cavities


CLASSIFY the patient with a mouth or throat problem:
On this page, there are four classification tables. Use every classification table where
your patient fits the description in the arrow. In some patients, you may even need to
use 3 tables!




                                                                                           33
Look at what is written in the arrows:

    If patient has white or red patches

    If sore throat without mouth problem (in some countries, this table will only be
     used in patients under 15 years of age)

    If ulcers

    If tooth or jaw pain or swelling

Use every classification table that applies.

If your patient has a painful mouth when eating especially with hot food and you find
white patches on the palate and tone, a small ulcer under the tongue, and visible
cavities, you would use the first, third and fourth classification tables.

If patient has white or red patches

In this patient we are trying to distinguish between patients with ESOPHAGEAL
THRUSH, ORAL THRUSH, and ORAL HAIRY LEUKOPLAKIA.

Esophageal thrush is a serious infection since it can prevent the patient from eating.
If the patient has HIV infection, esophageal thrush indicates his or her infection has
caused major immune suppression. If the patient has so much pain that he or she
cannot swallow, this is SEVERE ESOPHAGEAL THRUSH, a pink, severe
classification. This patient needs to be referred to hospital if you cannot get the
patient to swallow the fluconazole tablet. If it is not possible to refer and you have
fluconazole, try to help the patient to swallow the fluconazole and follow them
closely. Also tell them to come back immediately if their problem gets worse instead
of better. Not all pain on swallowing is due to candida. If it is, it usually responds
quickly to fluconazole. Herpes simplex virus can also infect the esophagus in patient
with HIV/AIDS.

If the patient has pain or difficulty swallowing but is able to swallow fluid and take the
tablets, classify the patient as ESOPHAGEAL THRUSH is in the yellow row.

ORAL THRUSH or candida occurs in adults with HIV, other immune suppressing
diseases, and sometimes in diabetes mellitus. The white patches can be anywhere
in the mouth, tongue or on the throat. The white patches can be scraped off, showing
a red base. Sometimes the patches are only red when you see them. ORAL
THRUSH makes the patient‘s mouth very sore. Treatment should be with whatever
is on your national formulary for thrush in the mouth in adults- nystatin pessaries or
suspension or fluconazole. You also need to advise your patient how to give good
oral care, to wash out the mouth. Because HIV infection is now the most common
cause of ORAL THRUSH, consider HIV-related illness (see page 54).

ORAL HAIRY LEUKOPLAKIA only occurs on the side of the tongue. These are
white, heaped up lesions that are oriented vertically. They cannot be scraped off.
They are also associated with HIV infection (see page 29). However, they are not


                                                                                       34
painful and do not require treatment. This is why it is important to distinguish them
from ORAL THRUSH.

Dark lumps, a Kaposi's lesion: If you see a Kaposi lesion, suspect HIV-related
illness—see page 29.

If patient has sore throat without mouth problem

If the patient is not able to swallow or has an abscess in the throat or on the tonsil,
classify as TONSILLITIS, a pink, severe classification. This requires immediate
treatment with benzathine penicillin and URGENT referral to hospital.

If patient has white exudates on the throat with swollen lymph node on the neck,
classify as STREPTOCOCCAL SORE THROAT. Treat with benzathine penicillin,
paracetamol and safe remedy to soothe throat such as warm water with honey and
lemon.

A patient with only one or no signs in the above row is classified as NON-STREP
SORE THROAT and does not need antibiotics. Give them paracetamol and a safe
remedy to soothe the throat.

If patient has mouth ulcer or gum problem

If deep or extensive mouth or gum ulcers are present or the patient is unable to eat,
classify as SEVERE GUM/MOUTH INFECTION, a pink classification. This can be
caused by Herpes Simplex Virus or other viruses. Herpes usually presents as small
groups of shallow blisters or ulcers which are very painful. There can also be co-
infection with bacteria and pus might be present. One or more enlarged and tender
nodes may be present in the neck. The patient should be referred urgently to the
hospital (unless palliative care is planned) because severe malnutrition and
dehydration may result. A trial of acyclovir can be given for suspected Herpes.
Metronidazole could be started to treat other causes of gum infection. HIV-related
illness should be considered (See p. 54). A patient started on co-trimoxazole or INH
prophylaxis or ARV therapy might be having a drug reaction.

Less extensive swollen or puffy gums are a sign of gum disease and can be
classified as GUM/MOUTH ULCERS, a yellow classification. This can occur because
of poor dental hygiene, malnutrition, and anemia. The patient or family needs
instructions on good oral hygiene for treatment and prevention and should be
followed up in 7 days.

In both cases, pain relief may be needed. See Palliative Care.

If the patient has bleeding gums or swollen gums with no other symptoms, classify
as GUM DISEASE, green. This can be caused by poor oral hygiene, malnutrition or
anemia, which should be treated. Instruct them carefully in oral care.




                                                                                    35
If patient has tooth problem or jaw pain or swelling

If there is constant pain with swollen face, or gum bubble near the tooth and possibly
fever, classify as DENTAL ABSCESS. This should be treated with antibiotics and
urgent referral made to a dental assistant. The abscess should be lanced or the
tooth pulled as soon as possible. Be sure the pain is not due to sinusitis, as in that
case no tooth should be pulled. In sinusitis there is usually facial pain directly over or
under one eyebrow or over the mouth; pain can not be localized on a tooth and
there are no signs in the mouth.

Classify as TOOTH DECAY if there is pain with hot or cold, visible decay or loss of
part of a tooth. Simple tooth decay is treated with application of oil of clove to the
tooth directly or on gauze or cotton packing and referral for dental care.



SELF STUDY EXERCISE #3
[Use the Acute Care Recording Form]

Instructions: Fill in the Recording Form for this patient and including
CLASSIFY and TREATMENT (use the tables on p. 19 and 21). See answers in
Annex.

Case study: Asha is a 33 year old woman has come in complaining of a sore mouth
for 5 days. Her temperature is normal, her weight is 45 kg and she is breathing 30
times per minute. You notice when she walked in she seemed breathless. When she
sat down she took several deep slow breaths but still seemed uncomfortable. She is
slow responding to your questions and although her answers are reasonable you
think she might be a bit confused. This is her first clinic visit and you have no prior
weight. She takes no medicines. She says she has had malaria twice this season.
She denies black stools or heavy menses, night sweats, cough or other problems.
When asked, she thinks she has lost weight. Her clothes fit loosely and she is thin
but has no signs of wasting. She is able to eat some foods but has little appetite and
offers that she also has little food at home.

You measure her MUAC which is 190 mm. Her palms and upper eyelids have some
pallor. She has white patches on all surfaces of her mouth which can be scraped off
easily. Her gums bleed easily when touched. She is able to drink water. The rest of
your examination is normal.

      How will you CLASSIFY Asha?

      What treatment does she need?




                                                                                       36
Chapter 7: Genital or anal sores, ulcers and warts

Introduction to the IMAI approach to STI

IMAI integrates STI prevention and care within its overall approach to the acute care
of adolescent and adult illness. Screening for STIs is included in all patients‘ visits
and a simplified approach to STI management is included.

Implementing these IMAI guidelines will contribute to successful STI control.
STI control has important aims:

   1. Interrupt the transmission of sexually transmitted infections.
   2. Prevent development of diseases, complications and sequelae.
   3. Reduce the risk of HIV infection.

STIs are very common. The most widely known are gonorrhoea, syphilis and HIV but
there are more than 20 others. STIs can cause serious and permanent complications
in infected people who are not treated in a timely and effective way. In people with
untreated STIs, the complications and sequelae can be devastating. The social and
economic burden of STIs can be enormous. Untreated STIs can lead to loss of
employment and broken marriage. STIs can place a heavy financial burden on
families, communities, and health services. If an epidemic of STI is uncontrolled, the
loss to the national income can be significant. For example, in one African country,
more than 70% of the budget for antibiotic drugs was used for STI treatment.

The outcome—fewer STIs—means fewer complications (PID, infertility, ectopic
pregnancy, etc.) as well as less efficient HIV transmission during unprotected sexual
contacts. It is the less efficient HIV transmission that will save the most lives.

For patients who are HIV negative or who have not been tested, the presence of an
STI is an important indication to trigger testing (or repeat testing).

Because STIs and HIV infection frequently travel together, anyone seen for an STI is
offered HIV testing and counselling.

How to implement STI control within IMAI
In addition to improved diagnostic and treatment skills, this course strengthens STI
control. Improved STI control means more than just improved diagnosis and
treatment at health care facilities. Achieving control means actually reducing the
burden (prevalence) of STIs in the community. This requires coordinated
implementation to:

   1. Improve STI services—at a district level. This can mean both specialized STI
      clinics and STI management integrated within acute care (IMAI), for both
      patients attending with an acute problem and during routine clinical reviews
      for those in chronic HIV care. Raise awareness and encourage people to use
      those services.

   2. Target interventions where STIs are spreading most rapidly. This includes
      peer outreach to high-risk groups such as sex workers and interventions to


                                                                                    37
       prevent transmission to girls through intergenerational sex. Special care for
       sex workers in clinic is covered in the Sex Worker Job Aid.

Your district health team will be working with you and your clinical team to implement
STI control by preparing you to provide good STI case management during case
reviews and during clinical mentoring visits.

Integration of STI services within primary care
In order to improve access, people with STIs should not need to attend a centre
devoted to STI treatment. STI treatment should be available at all health facilities
throughout the country including health centres and outpatient clinics. IMAI
integrates STI management into both the acute care of all priority adolescent and
adult problems within several sections in the IMAI guideline module: within the
sections on genitourinary problems (GU) in men and in women and in a separate
section on anogenital ulcers (for use for both men and women). IMAI can be used to
integrate STI treatment into primary care in medical outpatient clinics, in health
centres, and in family planning clinics. This means that service providers are trained
to recognize STIs (and other problems) syndromically and then to offer their patients
comprehensive care. Prevention and prophylaxis are offered during all IMAI primary
care visit. For STI and HIV prevention this mean that all patients are routinely offered
HIV counselling and testing, are counseled on safer sex, and offered family planning.
Managing STIs within antenatal clinics is presented in the IMPAC materials.

In most countries, STIs are under-reported for a number of reasons. There may be
many more actual than recorded cases among people who have unprotected sexual
intercourse with many partners.

STIs spread quickly. Where selling sex is one of the few economic activities open to
women, more women are put at risk. STIs affect the outcomes of pregnancy and
childbirth and can lead to infant morbidity and mortality.

Integration of STI services does not mean dispensing with specialized STI clinics.
Specialized STI clinics (or genitourinary centres, GUC) should be reserved as
reference centres for difficult cases where specially trained health workers can give
more time to those referred.

As you will learn, the relationship between HIV and other STIs makes it even more
urgent to prevent and control curable STIs. It is important to remember that HIV is
transmitted in the same ways as any other STI. There are strong links between
having an STI and becoming HIV-positive. HIV-infection may make people more
susceptible to other STIs—and may make other STIs more resistant to treatment.

      WHO estimated that in 1999 there were 340 million new cases of curable
       STIs. In other words, almost one million new infections occur every day.

      According to the 2002 Joint United Nations Programme on HIV/AIDS
       (UNAIDS), five million people were newly infected with HIV. Another 42 million
       people were already living with HIV/AIDS.




                                                                                     38
Both symptomatic and asymptomatic infections can lead to the development of
serious complications.

The most serious complications and sequelae (long-term consequences) of
untreated STI tend to be in women and newborn babies. These can include cervical
cancer, pelvic inflammatory disease (salpingitis), chronic pelvic pain, fetal wastage,
ectopic pregnancy and related maternal mortality.

Chlamydial infections and gonorrhoea are important causes of infertility, particularly
in women, with far-reaching social consequences. Chlamydial infection is an
important cause of pneumonia in infants. Neonatal gonococcal infections of the eyes
can lead to blindness.

Congenital syphilis is an important and significant cause of infantmorbidity and
mortality. In adults, syphilis can cause serious cardiac, neurological and other
consequences, which can ultimately be fatal.

                                            The Public Health Approach to STD Control,
                                             UNAIDS/WHO Technical Update, May 1998.




          STI organism                                  Complication
Gonococcal and chlamydia infection       Infertility in men and women
                                         Epididymitis in men
                                         Ectopic pregnancy due to tubal
                                         damage in women
Gonorrhocal infecton (gonorrhoea)        Conjunctivitis and blindness in infants
Gonococcal, chlamydial and               Pelvic and generalized peritonitis
anaerobic bacterial infections
Acquired syphilis                        Permanent brain and heart disease
Congenital syphilis                      Extensive organ and tissue
                                         destruction in children
Human papilloma virus                    Genital/cervical cancer
Chlamydia, gonorrhoea and                Increased transmission of HIV from
trichomoniasis bacteria                  genital inflammations (cuts, tears,
                                         abrasions, etc.)


The link between STI and HIV/AIDS
Certain STIs facilitate the spread of HIV. In fact, the interrelationship between STI
and HIV is more complex, in that:

      certain STIs facilitate the transmission of HIV
      the presence of HIV can make people more susceptible to the acquisition of
       STIs
      the presence of HIV increases the severity of some STIs and
      their resistance to treatment.



                                                                                     39
Which STIs facilitate the transmission of HIV?
A person with open sores in the genital area is much more likely both to contract and
to transmit HIV. Chancroid and syphilis are the main bacterial causes of sores: if
promptly diagnosed and treated, these links can be reduced.

Genital herpes (a virus) also facilitates HIV transmission:

“There is evidence that genital herpes, an incurable viral infection in which patients
have recurrent genital ulcers, may play a more important part than previously
thought...In high-income countries, genital herpes—infection with the herpes simplex
virus-2 (HSV-2)—is the leading cause of genital ulcers, though rates are low. HSV-2
is now assuming that position in sub-Saharan Africa too...An ulcer in the genital area
provides an „open door‟ through which HIV can easily pass. Unfortunately, HSV-2 is
lifelong and incurable...The best way to deal with the exponentially rising risks of HIV
and HSV-2 infection is to increase efforts to prevent them both, particularly by
increasing condom use.”
Report on the Global HIV/AIDS Epidemic, UNAIDS, Geneva,
                            June 2000, p. 71-2.

Chlamydia, gonorrhoea and trichomoniasis can also facilitate the transmission of
HIV. This may be for one or both of two reasons:

      these non-ulcerative diseases stimulate the body‘s immune system to
       increase the number of white blood cells, which are both targets and sources
       of HIV.
      genital inflammation associated with these STIs can cause microscopic cuts in
       genital tissues, creating potential sites where HIV can enter the body.

HIV makes infection with other STIs more likely
It is also true that people infected with HIV are more vulnerable to getting
multiple infections. This is because changes in their bodies make them
more vulnerable to infection in general.

The interrelationship of STI and HIV infection
The obvious link between STI and HIV is behavioural: unprotected sexual behaviour
exposes people to both HIV and other STIs.

Equally, the consistent use of condoms can PREVENT both kinds of infection.

STI control is also important for positive prevention (prevention for patients positive
for HIV infection). People living with HIV are more likely to transmit HIV to others if
they also have another STI. PLHA should thus be taught how to recognize STI
symptoms and encouraged to seek care promptly if they think they may have an
infection. In the IMAI Chronic HIV Care clinical review, PLHA are asked about
symptoms and examined and treated if STI is suspected.




                                                                                     40
The IMAI Acute Care/STI Short Course is based on the STI syndromic
approach.

A syndrome is simply a group of the symptoms a patient complains about and the
clinical signs you observe during the exam.

The syndromic approach as used in the IMAI course offers many benefits in this
struggle:

It enables all trained first-line service providers to
     screen for STI during all contacts with adolescents and adults--both when they
       come for any acute problem and during the periodic clinical review for those in
       chronic HIV care.
     to assess and classify for STI
     to treat patients ‗on the spot‘, without waiting for the results of time-consuming
       and costly laboratory tests.
     by offering complete STI treatment on the patient‘s first visit, it helps to
       prevent the further spread of STI.
     IMAI also includes patient education (about the infection, how STIs are
       transmitted, risky sexual behaviour and how to reduce risk), partner
       management and the provision of condoms.

STI treatment (antimicrobial regimens) are chosen to cover the major pathogens
responsible for the syndromes in the specific geographic area. In order to make this
determination, a laboratory analysis of the syndromes is made and the pathogens for
each syndrome are identified. This means that, afterwards, the management of
individual patients will not depend on laboratory investigation.

Periodically, the syndromes are reviewed. This is for two reasons: to ensure that the
antimicrobial choices are still valid and to monitor any antimicrobial resistance, which
may necessitate a change of therapeutic choices. Because of this, the syndromic
approach has a scientific foundation and should not be considered second-rate
medicine.

The syndromic approach is based on a wide range of epidemiological studies in both
the industrialized and developing world. This approach has been used and adapted
in more than 20 countries throughout the world. Validation studies have compared
syndromic and laboratory diagnosis to assess the accuracy of syndromic diagnosis
and found their results to be similar, so syndromic diagnosis is accurate. Other
studies have thrown light on the possible impact of syndromic case management on
the incidence of STI and HIV in a given population. In 1995 in the Mwanza region of
Tanzania there was a trial to learn what impact STI case management and
treatment-seeking behaviour would have on HIV transmission and STI in a
population. After two years, findings in the trial areas compared with control areas
included the following:

      50% reduction in the prevalence of symptomatic urethritis in men
      significant reduction in the prevalence of serological syphilis
      38% reduction in HIV incidence



                                                                                     41
While a clinical or laboratory diagnosis tries to identify just one causative agent,
syndromic diagnosis leads to immediate treatment for all the most important
causative agents. This is important because mixed infections
occur frequently.

This means that, if the necessary drugs are available and affordable, syndromic
treatment can quickly render the patient non-infectious.

Here is an example of syndromic diagnosis and treatment in practice.

       A patient complains of a discharge from the penis. Upon examination, you
       notice a discharge from the urethra. The sign and symptom together suggest
       urethral discharge syndrome.

Urethral discharge syndrome is commonly caused by gonorrhoea and/or chlamydial
infection. Not only can these cause serious complications, but also they can facilitate
the transmission and acquisition of HIV. It is therefore essential that we treat the
patient for both.

Here is another example that you might like to work on.

       A young woman complains of a sore. Upon examination you notice an ulcer
       on the outer labia. This indicates the syndrome of genital ulcer. There are two
       main bacterial causes of genital ulcer: chancroid and syphilis.

Clinically, it is not possible to distinguish the cause of a genital ulcer with any
accuracy, so the safest option is prompt treatment for both causative agents, leaving
the patient no longer infectious.


ASK

Page 20-21: In all patients (male or female), ask: Do you have a genital or anal
sore, ulcer or wart?

This is part of screening all patients for an STI.

This basic question should have been rephrased during the national adaptation to
make it understandable and acceptable. For example, in some cultures, it might be
phrased as "Do you have a sore or ulcer down there, in your private parts?"

For all questions like this or any examination for an STI or other genitourinary
symptom, be sure that you have a private place to assess, examine, counsel and
treat the patient. Talking about problems with the genitals is highly sensitive for
people of both sexes in almost all cultures, particularly with a provider of the opposite
sex. Do everything possible to establish a trusting relationship with the patient even
in a short visit, by treating them respectfully and explaining why you need to ask
certain questions or do certain exams. Make it clear that everything you discuss is



                                                                                      42
confidential and will not be shared without permission from her or him, and only then
if it is necessary to refer or discuss medical aspects of the problem.

If the patient says yes to your question on genital or anal sore, ulcer or wart,
then ask:

      Are these new? If not, how often have you had them?


LOOK and FEEL
Improving your ability to gather information during a genitourinary (GU) assessment
is the key to making an accurate diagnosis of STI in the time available. The
information collected will be the starting point for understanding the patient‘s
behavioral risks of transmitting or contracting STI in the future, as well as for partner
management and treatment.

    Remember: behave professionally with the patient before and during the
     exam
    Reassure the patient who is reluctant to be examined and gain his/her
     confidence and co-operation—most patients feel shy about showing their
     genitals to another person
    Ensure privacy and adequate light
    Explain what you are going to do and why an exam is important
    Ask the patient for his or her permission to make an exam
    Even though you may have little time to examine the patient, never suggest
     impatience with him or her
    Even though syndromic management does not require an internal exam,
     WHO recommends the use of gloves when examining patients
    Approach the exam in a confident way yet sensitive to the patient‘s needs
    Ask only one question at a time
    Reassure patients about privacy and confidentiality
    Explain that the exam will be brief and painless as possible

Preparation for the examination for the anogenital area.
It is best if a woman can be on an exam table or a couch, and covered with a sheet
or her clothing to maintain dignity and respect. A man can be examined standing up
if there is no exam table or couch or other appropriate alternative. Ask patients to
expose the area from the chest to knees for the exam.

      Look for anogenital sores or ulcers
       Ulcers may be large and wet, or single rather than grouped, and painful
       (chancroid, herpes) or painless (syphilis). The cause of genital ulcers cannot
       be distinguished except by laboratory testing.

      Look for vesicles
       Vesicles are small blisters, which eventually break open to form small painful
       ulcers. Grouped vesicles or small ulcers are usually caused by Herpes
       Simplex Virus type 2 (HSV2), the etiological cause of herpes.


                                                                                      43
   Look for warts
    Warts are rough, light-colored raised bumps that are often found in groups
    anywhere in the ano-genital area. They are usually grouped together and can
    be quite small or large, up to several centimeters in diameter.

   Look/feel for enlarged lymph nodes in inguinal area.
    If present, is it painful?
    Inguinal nodes: a single enlarged and painful inguinal lymph node is a bubo.
    Multiple smaller non-tender nodes are normal, but if tender may be due to
    genital ulcers.




                                                                              44
CLASSIFY GENITAL SORES, ULCERS OR WARTS
SIGNS:            CLASSIFY:           TREATMENTS:
 Only                            Keep clean and dry
   vesicles   GENITAL HERPES      Give acyclovir, if available
   present                        Promote/provide condoms
                                  Educate on STI, HIV and risk
                                   reduction. Offer HIV testing,
                                   counselling and syphilis testing
   Sore or                       Give benzathine penicillin for syphilis
    ulcer     GENITAL ULCER       Give ciprofloxacin for chancroid
                                  If vesicles also give acyclovir if
                                   available
                                  Promote/provide condoms
                                  Consider HIV infection. Offer HIV
                                   testing and counselling
                                  Consider HIV-related illness if
                                   ulcerations present > one month
                                  Educate on STIs, HIV and risk
                                   reduction
                                  Treat all partners within last 3 months
                                  Follow up in 7 days if sores not fully
                                   healed, and earlier if worse
   Enlarged                      If ulcer also present give cipofloaxin for
    and      INGUINAL BUBO         3 days
    painful                       If no ulcer give doxycycline for 21 days
    inguinal                       also treat partner
    node                          If fluctuant, aspirate through healthy
                                   skin; do not incise.
                                  Promote/provide condoms
                                  Partner management
                                  Consider HIV infection. Offer HIV
                                   testing and counselling and syphilis
                                   testing
                                  Educate on STIs, HIV and risk
                                   reduction
                                  Follow up in 7 days
   Warts                         Apply podophyllin
              GENITAL WARTS       Consider HIV-related illness
                                  Offer HIV testing and counselling
                                  Educate on STIs, HIV and risk
                                   reduction.




                                                                                45
Note that for any classification for STI, treatment should be provided along with

      education on STI/HIV
      risk reduction counseling
      condom promotion and provision
      consideration of HIV-related illness.
      RPR testing for syphilis, and encouragement for HIV testing

Genital ulcers offer easy access to HIV through the open sore during sexual contact
with infected partners. Early treatment and prevention of further spread of STI to
partners is an essential component of HIV prevention—patients who come for
treatment present an important opportunity to impact the HIV epidemic.

In HIV infected persons, the natural history of genital ulcers and their signs may
differ:

    Chancroid—ulcers may be larger, more painful, multiple and may be
     accompanied by fever and chills.

    Genital Herpes (HSV2) is more common where HIV prevalence is high and it
     may infect other ulcers as well. In HIV infected persons it can be more
     extensive, painful, last longer and recur more frequently.

Antiviral treatment becomes important for the patient‘s comfort; this treatment
protocol in patients with HIV may require adapting, which you must refer to in your
local setting. HSV-2 and HIV operate in a vicious circle, each increasing the risk of
contracting and passing on the other. Unfortunately, HSV-2 infection is lifelong and
incurable. Drugs that suppress the genital ulcers and viral shedding associated with
HSV-2 do exist, but they are very expensive, and their widespread use in poor
countries is problematic. Thus, the only practicable option for HSV-2 is prevention.

CLASSIFY as GENITAL HERPES if only vesicles are present. Aciclovir can be
given if available, with follow-up in 7 days if no better, and sooner if worse. Pain
control may be necessary with analgesics or frequent soaks with plain water.
Keeping lesions dry and exposed to air promotes healing.

On the management of herpes, reassure the patient that, although the herpes virus
infection cannot be cured, the lesions will go away of their own. They may recur.
Explain the importance of keeping the area clean and dry, and advise the patient not
to have sexual contact until the area has healed and to use condoms. Herpes can be
spread to sexual partners both when the lesions are present and at other times.

Specific treatment for herpes, acyclovir, can be used to both clear the lesions faster
and to prevent their recurrence if taken on a regular basis—however, this is
expensive. Explain to patients that this treatment only controls the vesicles and
ulcers, but does not cure herpes.

CLASSIFY as GENITAL ULCER if one or more sores are present depending on
local epidemiology. It is key that health workers have access to the most current STI


                                                                                    46
prevalence and treatment protocols. Genital herpes is the most frequent cause of
genital ulcer in many parts of the world. But in some areas syphilis or chancroid have
a higher prevalence. Treat for both syphilis and chancroid since they are difficult to
tell apart, and results of RPR test for syphilis may not be immediately available or
syphilis may be misdiagnosed. Note that patients identified through screening will
have an unknown duration of infection and should be treated for late syphilis.

If ulcers have been present for more than one month, consider HIV-related illness (p.
54).

CLASSIFY as INGUINAL BUBO if there is an enlarged and painful node.

When examining the patient, try and determine whether the swelling is really a bubo
or simply enlarged lymph nodes or any other pathology that has enlarged nodes in
other sites. A bubo is usually painful, warm, tender when palpated and fluctuant.
There may be one large mass or a collection of smaller painful swellings.
Occasionally the bubo might have ruptured and a sinus, discharging pus, will be
present.

LOOK for an ulcer: If a bubo is present, make sure to look for genital ulcers.
Whether an ulcer is present or not determines the treatment.

In men, remember to examine the underside of the foreskin and the parts normally
covered by the foreskin. If the patient cannot retract the foreskin because of swelling,
assume there is a genital ulcer and classify accordingly.

Buboes are usually caused by either chancroid or lymphogranuloma venereum
(LGV). If an ulcer is present, treat for chancroid and syphilis; if not ulcer, treat for
LGV.

If an ulcer is also present, treat with ciprofloxacin, as you would for chancroid.
In many, but not all, cases of chancroid, a genital ulcer may be visible. Also give
benzathine penicillin for possible syphilis.

If there is NO ulcer, then treat with doxycycline for lymphogranuloma
venereum.

Infections of the lower limb and other non-STIs can also cause swelling of the
inguinal lymph nodes.

Drain a fluctuant bubo through normal skin: A bubo can be drained if fluctuant,
through normal (not affected) skin. It should not be incised, drained or excised
through the nodes because they may delay healing. If the bubo is fluctuant, aspirate
it through healthy skin.

CLASSIFY as GENITAL WARTS if warts are present. Podophyllin can be applied to
warts by the health worker, or by the patient if the right compound (Podofilox or
Imiquimod) is available. Patients should not apply podophyllin on their own.
Podophyllin should not be used in pregnant women or children.



                                                                                     47
Small warts, which do not bother the patient, do not require treatment as they
eventually go away on their own (unless the immune system is very weak).

Patients with anogenital warts should be made aware that they are contagious to
sexual partners. The use of condoms is recommended to help reduce transmission.
Sexual partner(s) should be examined for evidence of warts.

     Look at photo booklet Group 8
     A. Genital herpes
     B. Genital ulcer—male
     C. Genital ulcer—female
     D. Inguinal bubo
     E. Genital warts—male
     F. Genital warts—female


CASE STUDIES:

1. Mrs. Bogatsu complains of a painful vulva for 2 days. This is the first episode and
   she never had vesicles or ulcers before. She also complains of fever. On exam,
   she has many small sores filled with a clear liquid on both labia majora and
   minora, and no visible ulcer.

2. Mr. Thomas complains of a painful sore on his penis for the past week. This is
   the first time he has ever had such a sore and never had vesicles before. On
   exam, you find three shallow ulcers on the penile shaft.

3. Mr. Ahmed complains of a painful sore on his penis for the past week. There is
   no past history of ulcers or vesicles. He also has pain in the groin. On exam, one
   ulcer is found on the penile shaft and there is an enlarged painful inguinal lymph
   node on the right side.

4. Mrs. Singh complains of lumps ―down there‖ for the past 2 weeks. She never had
   this before and does not have a history of ulcers or vesicles. On exam, you find 3
   vulvar warts the size of a pea.




                                                                                   48
SELF-STUDY EXERCISE #4

CLASSIFY the following patients. Assume all signs not mentioned are
negative. First do the exercises then check that your answers are correct—see
Annex.

ASK, LOOK and FEEL results                         What                What
                                                   classification(s)   treatment(s)
                                                   does the patient    should you
                                                   have?               give?
20 year old man with enlarged and painful
inguinal node on right, with fluctuance. No
ulcer.

32 year old woman with enlarged and
painful left inguinal node; not fluctuant; ulcer
an 1 cm ulcer on her left labia.

23 year old woman with many painful
vesicles with a red base on both labia and
her perineum; no ulcers. These are new in
the last few days. Several small, non-tender
lymph nodes in both inguinal areas.
50 year old man with painful sore on penis
for the past week. He has never had this
before. He has no discharge or other
symptoms.




                                                                                      49
LABORATORY TESTS for SYPHILIS

The Acute Care guideline module includes instructions for RPR testing for
syphilis. This is only one of several available screening tools for syphilis which
include:

    Non-treponemal tests, such as rapid plasma reagin (RPR) and venereal
     disease research laboratory (VDRL) tests are the preferred tests for syphilis
     screening. RPR can be performed in clinic without a microscope (see
     instruction on page 118) while the VDRL requires microscopic examination.
     These tests detect almost all cases of early syphilis but false positives are
     possible.

    Treponemal tests (e.g. Treponema pallidum haemagglutination assay (TPHA),
     if available, can be used to confirm non-treponemal test results and rule out
     false positives. However, they are not useful as a screening test since they
     stay positive for life, even after a case of syphilis is adequately treated.

    Quantitative (RPR or VDRL) titres can help evaluate the response to
     treatment.

Note: where additional confirmatory tests are not available, all patients with reactive
RPR or VDRL should be treated.

Syphilis testing should be done on site wherever possible to maximize the number of
patients who receive their results and are treated. Ideally:

    Patients should receive their test results before leaving the clinic.

    Patients with reactive (positive) results should be treated immediately
     according to the stage of syphilis (see section 5.6). Note: many patients
     identified through screening will have an unknown duration of infection and
     should be treated for late syphilis.

    Sex partners should also be treated.




                                                                                    50
Chapter 8: Genito-urinary symptoms and lower abdominal pain in
men

Page 22-23: Ask men: Do you have a discharge from your penis? If
male patient has genito-urinary symptoms or lower abdominal
pain…

In your initial assessment, you asked each man whether he has a discharge from
their penis. If he said "yes" or "maybe" or if he complains of other genito-urinary
symptoms or lower abdominal pain, you should do the full assessment that appears
on page 22 as follows:


ASK
      What is your problem?
      Do you have discharge from your penis?
          o If yes, for how long?
          o If this is a persistent or recurrent problem, see follow-up box
      Do you have burning or pain on urination?
      Do you have pain in your scrotum? If yes, have you had any injury
       there?
      Do you have sore(s) on your genitals or anus?


LOOK and FEEL

Perform genital exam:

Review the considerations about being privacy and respect in examining the genital
region in the genital ulcer section at the beginning of Chapter 7.

Put on gloves and feel for inguinal lymph nodes to see if they are enlarged, tender,
inflamed.

      Look for scrotal swelling

      Feel for tenderness

          o Palpate the scrotal sac gently, comparing the two sides. Is there
            swelling of the testis (inside the scrotal sac)?
          o Feel for tenderness of the scrotum. Determine if palpation of the scrotal
            sac causes pain.
          o Feel for tenderness or swelling of the epididymis—this is a coiled tube
            lying on top and in back of each testis. It can also be infected with
            GC/CT.




                                                                                  51
       Infection can cause swelling, tenderness or both, even in the absence of a
       urethral discharge.

      Look for ulcer. If present, also use the sore/ulcer/wart page (see
       previous chapter).
       Examine all surfaces of the external genitals for ulcers—the scrotum, around
       the anus and penis for ulcers (also note any warts or vesicles). Pull back the
       foreskin and examine the underside—this is a common place for the sores of
       chancroid and other ulcers. Look at the opening of the urethra as warts and
       ulcers can be found just inside.

      Look for urethral discharge
       Look. If the patient reports a discharge but you do not see it, ask him to milk
       the urethra. Ask him to squeeze the shaft of the penis gently from the base to
       the tip where the urethral opening is. Have him do this several times to milk
       out any discharge, which may be present.

      Look and feel for rotated or elevated testis
       Look for bruising or evidence of trauma to the scrotal sac.

       Determine the position of the testis in the scrotal sac—determine if it is
       elevated or rotated. Sudden onset of pain and/or swelling of the scrotum may
       be due to acute epididymo-orchitis, torsion of the testis, injury to the testis, or
       a strangulated inguinal hernia. Torsion of the testis is very painful. Several of
       these conditions may require surgical interventions.

       Scrotal or inguinal swelling which increases when the patient bears down (as
       if having a bowel movement) may be due to a hernia. This requires non-
       urgent referral if it is painless.

If abdominal pain (if patient complained of pain), feel for tenderness.

    Feel for abdominal tenderness. Tenderness means the patient experiences
     pain when you touch or press in. Abdominal palpation should first be
     superficial to detect tenderness (pain) on light palpation.   Then make a
     careful and deep palpation to identify any masses, enlarged organs, and the
     location of pain.

       Lower abdominal tenderness is in the lower half of the abdomen on both sides
       below the umbilicus.

       If tenderness:

          o Is there rebound? Check for rebound in the area where you found
            pain on light palpation. Press down slowly and very gently then release
            the pressure suddenly. Any severe pain that results is known as
            rebound tenderness.




                                                                                       52
         o Is there guarding? On palpating the abdomen, the abdominal muscles
           become stiff and board-like when even slight pressure is applied. They
           resist your pressing in.

             Guarding and rebound occur when the lining of the abdominal cavity is
             irritated (peritonitis) by severe infection.

         o Can you feel a mass? Swelling or lump in the patient‘s abdomen on
           light abdominal palpation. (This could be an abscess, cancer, hard
           stool or enlarged liver or spleen.

         o Are bowel sounds present? Use a stethoscope or put your head on
           the stomach, after asking him permission. If you hear no bowel sounds
           at all, listen again for two minutes or more at a spot just under and to
           the right of her umbilicus. Absent bowel sounds is a serious sign that
           the bowels have stopped moving.

         o Measure temperature if it has not already been done.

         o Measure pulse if it has not already been done.


CLASSIFY

If lower abdominal pain, use the top classification table on page 23.

Use this table in men with lower abdominal pain

SIGNS:                 CLASSIFY AS:                  TREATMENTS:
Abdominal tenderness                             Give patient nothing by
with:                   SEVERE OR                 mouth (NPO).
 Fever > 38ºC or       SURGICAL                 Insert IV.
 Rebound or            ABDOMINAL                Give appropriate IV/IM
 Guarding or           PROBLEM                   antibodies
 Mass or                                        Refer URGENTLY to
 Absent bowel sounds                             hospital*
    or
 Not able to drink or
 Pulse > 110
 Abdomen soft and                               If diarrhoea see p. 32
                        GASTROENTERITIS
    none of the above
                        OR OTHER GI
                                                 If constipation, advise
    signs               PROBLEM                   remedies
                                                 Return if not improved.


It is important to urgently refer patients with a severe or surgical abdominal
problems. If a man has both abdominal pain and any one of these signs—fever or
rebound or guarding or mass or absent bowel sounds or not able to drink or a pulse
more than 110, this may be a SEVERE OR SURGICAL ABDOMINAL PROBLEM.


                                                                                53
This could be appendicitis, a bowel obstruction, internal bleeding, peritonitis, or other
serious problems—the possibilities in an adult are many.

    Rebound tenderness or guarding may be present because of an inflamed
     appendix, other abscess, or inflammation of the lining of the abdominal cavity
     (peritonitis).
    Bowel sounds may be absent because severe infection in the intestinal tract
     causes intestinal movement to stop, an ominous sign—this may also cause
     vomiting of fluids.
    High pulse rate >110 results from fever and infection and may indicate sepsis.

Patients classified as SEVERE OR SURGICAL ABDOMINAL PROBLEM require
URGENT referral to hospital for possible surgical intervention. IV or IM antibiotics
and IV fluids should be started before transfer.

If urethral discharge or urination problems:

Table page 23

Use this table in men with urethral discharge or urination problem:
 Not able to urinate                              Pass urinary catheter if
   and                       PROSTATIC               trained
 Bladder distended          OBSTRUCTION           Refer to hospital
                                                   Treat patient and partner
 Urethral discharge or      POSSIBLE                with antibiotics for
 Burning on urination       GONORRHOEA/             possible GC/chlamydia
                             CHLAMYDIA               infection
                             INFECTION             Promote/provide
                                                     condoms
                                                   Return if worse or not
                                                     improved within 1 week
                                                     (p. 65).
                                                   Offer HIV/STI counselling
                                                     and HIV and syphilis
                                                     testing.
                                                   Consider HIV infection
                                                     (p. 54).
                                                   Partner management

Prostatic obstruction can cause a very painful distended bladder. It is important to
relieve this by passing a urinary catheter if you have been trained. Refer this patient
to hospital.

If the man has either a visible urethral discharge or just complains of burning on
urination, treat for possible GC/chlamydia infection.




                                                                                      54
If scrotal swelling or tenderness:
Table page 23
Use this table in all men with scrotal swelling or tenderness

   Testes rotated or                                Refer URGENTLY to
    elevated or              POSSIBLE                 hospital for surgical
   History of trauma        TORSION                  evaluation
                                                     Treat patient and partner
   Swelling or              POSSIBLE                 with antibiotics for
    tenderness (without      GONORRHOEA/              possible GC/chlamydia
    the above signs)         CHLAMYDIA                infection
                             INFECTION               Promote/provide
                                                      condoms
                                                     Follow up in 7 days:
                                                      return earlier if worse (p.
                                                      65).
                                                     Offer HIV/STI counselling
                                                      and HIV and syphilis
                                                      testing.
                                                     Consider HIV infection


Infection of the testis or epididymis is a serious complication of gonococcal urethritis
and chlamydial urethritis. When infected, the testis becomes swollen, hot and very
painful. If early and effective therapy is not given, the inflammation will heal with
fibrous scarring and destruction of testicular tissue. This may lead to infertility.

It is important to consider possible non-infectious causes of scrotal swelling and
pain, as well as non-sexually transmitted infections. Non-infectious causes include
trauma, tumour and testicular torsion and all require referral.

In men over 35 years with no risk of STI, and among pre-pubertal boys, other
general infections may be responsible.

       Look at photo booklet Group 7
       A. Urethral discharge
       B. Scrotal swelling
       C. Elevated testis




                                                                                     55
CASE STUDIES:
     1. Jon, a young businessman, complains of pain when he passes urine for
        the past 4 days. He denies urethral discharge, pain in the scrotum or
        sores. Jon‘s wife is in their village 150 kilometres away: he has not seen
        her for three months. On examination, you note a slight watery discharge
        from the tip of his penis.

       2. Mas is an adolescent boy of 15 years who lives in the slum area of a large
          town. He has been brought to the district hospital because his scrotum is
          swollen and he is vomiting. On examination, the scrotum is swollen and
          painful; the testes elevated and rotated. How do you manage this patient?

       3. A young man called Tram comes into the health centre complaining of a
          painful groin. The testes are swollen and painful, with no history or
          evidence of trauma or torsion.

SELF STUDY EXERCISE #5

CLASSIFY the following patients. Assume all signs not mentioned are
negative. First do the exercises then check that your answers are correct—see
Annex.

ASK, LOOK and FEEL results                       What                What
                                                 classification(s)   treatment(s)
                                                 does the patient    should you
                                                 have?               give?
8 year old boy with pain in swollen testis. He
was playing football yesterday and got
knocked down and kicked in the groin.

66 year old man who has not been able to
urinate for several days.

50 year old man with an acute pain in his
right side and high fever for two days.


42 year old man with painless scrotal
swelling when he pushes down.

31 year old man who came to the health
centre to pick up some drugs for his sister.
When he sees you, he mentions that he has
had a burning sensation when urinating for
the past 10 days that is very uncomfortable.
He has no discharge.
12 year old adolescent moaning with pain in
the right lower abdomen. He is guarding. He
has a temperature of 39.5C.



                                                                                    56
In all patients, ASK: Are you in pain?
If the patient is in pain, grade the pain, determine location and consider cause.
Manage pain using Palliative Care guideline module.

In all patients, ASK: Are you taking any medication?
Fever can be caused by toxicity from ARV drugs and immune reconstitution
syndrome in the first 2-3 months of ART. This should be considered when
evaluating new signs and symptoms in patients on ART.

For all acute (and chronic) patients, check status of routine screening,
prophylaxis, and treatment—use page 58.

If there are no volunteered problems or observed signs, use the section "Prevention"
(page 57) to choose what preventive interventions are needed for your patient.
Record them on the recording form.

You can delay using this page until the end of your assessment and classification, if
there are other volunteered problems or observed signs. However, do not forget, it is
very important to do so.




Page 23: Respond to volunteered problems or observed signs.
From this page onward, you will use each page only if the patient complained of the
problem or if you observe the patient to have the main symptom.




                                                                                  57
Chapter 9: Fever

Page 24: if the patient has fever

Fever is an elevation of body temperature above normal which results from a
number of possible causes. Numerous infections (bacterial, viral, parasitic) cause
inflammatory and immune responses which affect body temperature. Allergic
responses to medicines and foods can also cause fever. Fever is an important sign
of illness but determining its cause can be difficult. If fever is classified according to
the tables on p. 25 and 26 as SEVERE FEBRILE ILLNESS but the cause is not
obvious, it is necessary to start treatment for all possible serious causes.

A patient has the symptom of fever if he:
    has a history of fever (within the last 48 hours) or
    feels hot or
    has an axillary temperature of 37.5C or above

The patient‘s temperature should be already measured and recorded.

To assess the patient with fever, first ASK questions and then LOOK and LISTEN.

ASK

      How long have you had a fever?

       The patient should tell the number of days that he has had fever.

      What medications have you taken?

       If the patient has taken medications to reduce fever (paracetamol, aspirin,
       ibuprofen) in the last few hours, the fever may be normal now.

      Determine if patient has taken an antimalarial in the previous week. If
       yes, what and for how long?

       This information is useful to determine whether a drug appropriate for treating
       malaria was taken and whether it was taken long enough to constitute
       adequate treatment.

       It is also important to determine whether the patient is taking ARV therapy.
       Fever may be a side effect of the ARV treatment or immune reconstitution.

      Decide malaria risk

       Malaria risk for an individual adolescent or adult can be High or Low or No
       malaria risk. The risk is determined for each individual. In some countries,
       because there is malaria transmission throughout the county, everyone is at
       High or Low risk (no patients are considered to have "no malaria risk").



                                                                                       58
 This is different from IMCI where all children under 5 in a certain area are
 considered to have high, low or no malaria risk—in these guidelines, you can
 determine the malaria risk for the clinic setting and do not need to do it for
 each individual child.

 Ask the following questions and use the answers to determine the individual
 patient's malaria risk:

    o   Where do you usually live?
    o   Have you recently traveled to a malaria area?
    o   If woman of childbearing age: Are you pregnant?
    o   Is an epidemic of malaria occurring?
    o   Is the patient HIV clinical stage 3 or 4?

 You must have knowledge of whether there is intense, moderate, low or no
 malaria transmission, both in the areas where your patients live and in the
 areas that they visit.

    o Intense transmission area: The majority of malaria cases occur in
      the below five years age group.
    o Moderate transmission area: The majority of malaria cases occur in
      the 5-14 year age group.
    o Low transmission area: Malaria cases occur equally in all age
      groups.

 Once you have this information, and have done the look and listen part of the
 assessment, use the choices in the arrows to decide whether the individual
 patient (not the setting) has high or low or no malaria risk.

 Table page 28

        If low immunity (with malaria transmission):
         Pregnant
         Child < 10 years, if there is intense or moderate malaria
   HIGH  Stage 3 or 4 HIV infection (See Chronic HIV Care
MALARIA      module)
   RISK Or increased exposure:
         Epidemic of malaria is occurring
         Moved or visited area with intense or moderate malaria

        If high immunity:
   LOW  Adolescent or adult who has lived since childhood in
MALARIA     area with intense or moderate malaria
   RISK Or low exposure:
         Low malaria transmission and no travel to higher
            transmission area.

    NO        If no malaria transmission and
MALARIA       No travel to area with malaria transmission
   RISK


                                                                            59
LOOK AND LISTEN

     Look at the patient‟s neurological condition. Is the patient:

         o Lethargic?
         o Confused?
         o Agitated?

These three signs are used to assess the neurological condition.           How to
assess each of them is described below.

     Is the patient lethargic?

      A lethargic person appears sleepy, is not alert when he should be, and shows
      no interest in what is going on. It is difficult to arouse a lethargic person.

     Is the patient confused?

      A confused person seems disoriented and may not understand what he is told
      or may not be aware of his surroundings. The person may not act
      appropriately. It is helpful to ask other family members whether the patient‘s
      behavior is unusual for the patient. Or you can ask the patient, ‗Can you tell
      me where you are now?‘ ‗Do you know why you are here?‘ If not confused,
      they should provide reasonable answers.

     Is the patient agitated?

      An agitated person moves irregularly, rapidly, or violently. He may speak in a
      garbled manner.

      Later, we refer to these 3 signs again—lethargic, confused and agitated—as
      neurological signs.

     Count the breaths in one minute. If breathing is fast, is breathing deep?

      Count the breaths in one minute by watching a place on the patient‘s chest as
      it moves up and down. Decide of the patient has fast breathing, using the
      table on page 7. (If you did this before to assess the patient with cough or
      difficult breathing, just use that breathing rate.) If fast breathing, assess
      whether the breathing is also deep.

      Deep breathing takes longer for each breath and the chest expands more
      than usual. The patient is breathing in and out more air than normal with each
      breath.

     Check if able to drink

      The patient is not able to drink if he is too weak to drink and is not able to
      swallow when offered a drink.


                                                                                  60
      Feel for stiff neck

       A patient with fever and stiff neck may have meningitis and need urgent
       referral to hospital. While talking to the patient during the assessment, look to
       see if the patient moves and bends his neck easily, particularly as he looks
       down. If the patient is moving and bending his neck, he does not have stiff
       neck.

       If you did not see any movement, or if you are not sure, ask the patient to look
       down at his toes or stomach. ask patient to bend head to touch chin to chest.

       If the patient cannot cooperate (and if you are sure there has been no trauma
       to the head or neck), lie the patient on his back. Lean over the patient, gently
       pick up his head. Then carefully bend the head forward toward the chest. If
       the neck bends easily, the patient does not have stiff neck. If the neck feels
       stiff and there is resistance to bending, the patient has stiff neck. Often a
       patient with stiff neck will feel pain when someone else tries to bend his neck.

      Check if able to walk unaided

       If the patient walked into or across the room, then you know that the patient
       can walk unaided. If you have not observed the patient walking, ask him to
       walk a short distance for you.

      Look for apparent cause of fever—assess all symptoms in this acute
       care algorithm.

       Look for signs of a problem that may be causing the fever. Whether a patient
       has an apparent cause of fever will be important when determining if he may
       have malaria.       Classifications such as PNEUMONIA or SEVERE
       PNEUMONIA or DYSENTERY may be a likely cause of fever. Also, look for
       another apparent cause of fever, for example, a runny nose, a skin infection,
       an infected wound, or symptoms of influenza.

CLASSIFY THE PATIENT WITH FEVER
There are three different classification tables for patients with fever.    Select the
appropriate table based on the patient‟s malaria risk:

High malaria risk or Low malaria risk (in most African countries no one is at no
malaria risk). These two classification tables appear on page 29 of the chart booklet
(right side). Use only one of these severity classification tables to classify a patient
who has fever.




                                                                                     61
If patient has high malaria risk

There are two possible classifications for a patient with fever and high malaria risk:

       VERY SEVERE FEBRILE DISEASE (pink row)
       MALARIA (yellow row)

    First look at the top (pink) row. Does the patient have one or more of the
     signs in this row? If yes, select the classification VERY SEVERE FEBRILE
     DISEASE.

       Patients with high malaria risk who have confusion, agitation, lethargy; fast
       and deep breathing; not able to walk unaided; not able to drink; or who have a
       stiff neck have a very severe febrile disease. These patients require urgent
       referral to hospital after treatment with an IM antimalarial and antibiotic. They
       may have severe malaria, meningitis, sepsis or another life-threatening
       condition.

    If the patient has none of the signs in the top row, but has fever or history of
     fever, select the classification MALARIA.

       If patient has low malaria risk

       There are three possible classifications for a patient with fever and low
       malaria risk:

              VERY SEVERE FEBRILE DISEASE (pink row)
              MALARIA (yellow row)
              FEVER—MALARIA UNLIKELY (green row)

    Look first at the top row. If the patient has one or more signs in the top row,
     select the classification VERY SEVERE FEBRILE DISEASE.

       As it is difficult to quickly identify the cause of fever in a patient classified with
       VERY SEVERE FEBRILE DISEASE, urgent support and treatment for the
       possible causes, and referral to hospital are needed. Give IM quinine or
       artemether, a first dose of IM antibiotics and glucose and transfer the patient.
       Causes of fever other than malaria may be meningitis in a patient with fever
       and stiff neck, pneumonia, septicemia, HIV related disease and others.


    If the patient has none of the signs in the top row, does the patient have all of
     the signs in the next (yellow row)?
             Fever or history of fever and
             No new rash and
             No other apparent cause of fever




                                                                                          62
      If the patient has all of these signs, select the classification MALARIA. Patient
      should follow up in 3 days if still febrile.

      If you are able to do a malaria dipstick or smear, choose this classification if
      the malaria dipstick or smear is positive.

    If the patient does not have all of these signs, move down to the bottom
     (green) row. Does the patient have

             PNEUMONIA, SEVERE PNEUMONIA, or
             Another apparent cause of fever?

      If yes, select the classification FEVER—MALARIA UNLIKELY.


Treatment should be given according to the apparent cause of fever, and if the
patient is classified as SEVERE PNEUMONIA, IM malaria treatment should also be
given. This is because symptoms of malaria can overlap with those of severe
pneumonia and to miss malaria in someone this ill might have fatal consequences.

If there is no other apparent cause of fever of more than 7 days, send sputums for
TB and refer to hospital.

Consider HIV related illness if unexplained fever >30 days (p. 54). Fever can be in
reaction to an ARV drug, or can be related to immune reconstitution syndrome in
someone recently started on ARVs (see the Chronic HIV Care module, page H41).

Use the table on page 30 if there is no malaria risk

If signs on the far left are present, classify as VERY SEVERE FEBRILE DISEASE,
and treat as in the first two tables but without giving antimalarials.

If there is fever for >7 days, classify as PERSISTENT FEVER and treat according to
apparent cause. TB, HIV, or ARV related fever should all be considered and patient
referred to hospital for further evaluation.

None of the signs above is classified as SIMPLE FEVER and treated according to
apparent cause, and followed up in 2-3 days if still present.

SELF STUDY EXERCISE #6
Using the classification charts on page 29, classify the following cases. (See
answers in Annex).

Case A: Joanna complains of a high fever and headache for 3 days. She returned
home one week ago from visiting her family at the coast. She is 19 years old and 6
months pregnant with her first child. She weighs 52 kg. and her temperature is 38°C.
She had an antenatal visit one month ago at this clinic, but this is the first time she
has been seen for this illness. She has no cough or difficulty breathing but you notice
her breathing is just over 30 breaths per minute and she appears somewhat lethargic



                                                                                    63
though she walked her by herself. She took paracetamol yesterday but has taken no
other medicines. She denies having any other health problems.

Although malaria risk is low where the clinic is, it is high along the coast where
Joanna has been recently.

    Is Joanna at high or low risk of malaria?
    CLASSIFY this illness.


Case B: Robert is a 34 year old man who complains of fever and cough for 3
weeks. Two months ago he was seen for cough and fever and treated with
antibiotics and his TB sputums were negative. He declined HIV testing at that time.
This is the dry season and malaria risk is low. Robert has not traveled to any areas
with malaria in the last 3 months. He does not smoke. His temperature today is 37.5
C, he weighs 55 kg. and his Quick Check was negative. He is not confused or
lethargic and his breathing rate is normal. He is thin and his clothes fit him loosely.

    Is Robert at high risk of malaria?
    CLASSIFY this illness.


Treatment

[In development]

This needs local adaptation.




                                                                                    64
Chapter 10: Diarrhoea

Page 32: If the patient has diarrhoea

Diarrhoea is the passing of 3 or more loose or watery stools in a day (not passing
normal stools multiple times a day). Because of the loss of fluids, diarrhoea is often
accompanied by dehydration which can be life-threatening.

First, assess and classify the level of dehydration so that treatment can be
provided urgently if needed, then classify the diarrhea.

LOOK
Is the patient lethargic? (already examined)

Does the patient have sunken eyes? Do the eyes appear unusually sunken in their
sockets? Ask the family if the patient‘s eyes are more sunken than usual.

Does a skin pinch go back very slowly (longer than 2 seconds)? Pinch the inner
skin of the forearm. Pinch for 1 second, then release and observe. The inside of the
forearm is suggested because it is still feasible in a pregnant woman and because it
does not require underdressing the adult patient.


       Look at photo booklet Group 5
       A. Very slow skin pinch—inside forearm


CLASSIFY
If two of the signs in the pink box of the table on page 33 are positive, the patient has
SEVERE DEHYDRATION (this should be picked up already with the Quick Check).
Severe dehydration requires immediate administration of fluids (Plan C, p. 90—Note
that Plans A, B and C for IMAI differ from IMCI Plans with the same letters)—if the
patient is unable to drink, this should be intravenous (IV), or possibly with a naso-
gastric (NG) tube. If an IV or NG tube cannot be inserted or the patient has another
severe classification, transport immediately to a hospital where this can be done.
During transfer encourage small frequent sips of Oral Rehydration Solution (ORS)
along the way. If the patient has no other severe classifications and you are able to
do so, administer fluids without transfer by IV or NG tube.

If two of the signs in the yellow box of the table are positive, classify as SOME
DEHYDRATION. Treat with Plan B (p. 89) in the clinic for 4 hours and then classify
dehydration again. The patient can return home if taking fluids well and able to eat.

If there is NO DEHYDRATION, follow Plan A.




                                                                                      65
In all cases of diarrhea, patients should be instructed to follow the 3 rules for home
treatment

       1. Drink extra fluid
       2. Continue eating
       3. Know when to           return    (if   problem    persists   or   worsens).

Second, assess and classify the diarrhoea.

Diarrhoea can be caused by bacterial infection (such as Shigella, cholera), parastic
infection (such amoebas, giardia), viruses, medications (ARV drugs, antibiotics) and
other non-infectious problems of the GI tract. It can be acute and self-limited with a
recent onset of only a few days, persistent, lasting longer than 14 days, severe and
persistent, or dysentary (bloody diarrhoea).

ASK

      How long have you had diarrhoea?
       A duration more than 14 days with severe dehydration requires urgent
       treatment and possibly transfer to hospital.

      Is there blood in the stool?

CLASSIFY as:
SEVERE PERSISTENT DIARRHOEA if it has lasted more than 14 days with some,
or severe dehydration present. This requires URGENT treatment of dehydration as
above. Transfer to hospital may be required especially if another severe
classification is present (fever). Treatment involves continued IV and oral rehydration
when possible, and treatment of the cause of the diarrhoea.

PERSISTENT DIARRHOEA if it has lasted more than 14 days, with some
dehydration. This requires ORS and empirical treatment of the diarrhoea.
Management of persistent diarrhoea for HIV infected persons is different from those
who are HIV uninfected. For HIV negative patients, metronidazole should be given
for 7 days.

For known HIV infected patients, add cotrimoxazole to metronidazole and follow up
in 7 days. See Chronic HIV Care module, p. 42.

DYSENTERY if patient says there is blood in the stool. This requires treatment for
Shigella with an antibiotic appropriate to your area for 5 days and follow-up. More
than half of all cases of bloody diarrhea are caused by Shigella.




                                                                                    66
Chapter 11: Genito-urinary symptoms and lower abdominal pain in
women

Pages 36-39: If female patient complains of genito-urinary
symptoms or lower abdominal pain.

Use this section if she has any symptoms related to her vagina or uterus, has lower
abdominal pain, menstrual problems, abnormal vaginal bleeding or any condition
―down there.‖

Genitourinary symptoms in women have more possible causes in women than in
men. This section presents the current WHO STI guidelines plus the management of
urinary tract infection (UTI) and menstrual problems. It also helps you to recognize
which women may be pregnant, are definitely pregnant and need antenatal care, or
might have been pregnant and had an incomplete abortion. Getting women into
antenatal care early is important. It will also help you remember to ask about
contraception use and to refer (or provide) family planning advice.

ASK

      What is the problem?

      What medications are you taking?
       Some reproductive health problems may be related to medicines that affect
       hormonal contraception. Antibiotics can cause overgrowth of yeast and result
       in vaginal candidiasis. Continue probing by asking ―anything else‖ until you
       are sure she has mentioned all drugs she is taking or has taken recently.


Ask if she has:

      Burning or pain on urination?
       This can mean there is an infection of the urine or STIs. Make sure this is a
       new complaint. Urine infections are often accompanied by more frequent
       urination so you now ask about that:

      Increased frequency of urination?
       There may be the urge to urinate very often, but very little urine is produced.
       Again reassure her that it is very important that she answer these personal
       questions to help you know what the problem is and how to treat her.

      Ulcers or sore in your genital area?
       Ask if any sores or genital ulcers are present, and whether the sore is painful
       or not and when she first noticed it. Passing urine over the sore might be the
       cause of pain on urination. Has she had similar sores in the same place
       before?




                                                                                   67
   An abnormal vaginal discharge? If yes, does it itch?
    A small amount of vaginal discharge is normal and healthy. Discharge is
    increased during the fertile period (mid-cycle), during and after sexual activity,
    and during pregnancy and lactation. Women complain of vaginal discharge
    when they think it is unusual for them or if it causes itching or discomfort. In
    general, they will not seek medication for a discharge they consider normal.
    An adolescent may not understand her normal body functions and needs to
    have more discussion about this to determine whether discharge is new but
    normal, or new and abnormal.

    A change in vaginal discharge such as a large increase in amount of
    discharge with a new bad smell or itching is abnormal. Most vaginal
    discharge is due to non-sexually transmitted infections. Women develop the
    symptom of vaginal discharge if they have either vaginitis (infection of the
    vagina) or cervicitis (infection of the cervis) or both.

       o If yes, does it itch?
         Vulval itching can be a sign of vaginal infection that is not sexually
         transmitted. It can also be a sign of irritation from using products to
         clean or dry the vagina, or from douching, or using certain harsh soaps.
         If she says she has itching, ask if she uses any of these products or
         practices.

   Any bleeding on sexual contact?
    This could result from irritation of the vagina or lesions on the vagina or cervix
    such as warts, cancer or precancerous lesions, ulcers or sores. Be sure she
    understands the question before going on to the next question, that is, that the
    blood is not related to her menstruation.

   A partner who has had a problem with his genitals?
    Determine whether he has a urethral discharge or any sores, or has recently
    been diagnosed or treated for a sexually transmitted infection. This can be a
    sensitive question. Explain that this information will help determine the cause
    of her problem and the treatment needed.

       o If partner is present, ask him about urethral discharge or sore.
         If it is acceptable, ask him directly in confidence. Explain that it is
         important for his wife or partner and any future children to treat any
         existing problems of the genitals.

           Arrange for partner assessment, treatment and education that day
           before couple leaves the clinic.

   When was your last menstrual period?

       o If missed period: Do you think you might be pregnant?
         Determine the number of weeks since last menstrual period. Determine
         if a period has been missed. This would mean possible pregnancy, if
         she has been sexually active, especially without adequate protection.
         Women usually know whether they are or could be pregnant. An


                                                                                   68
           adolescent girl will need more help if she doesn‘t know the signs or
           understand how she could become pregnant.

           If pregnancy is unplanned or unwanted she may need counselling and
           accurate information on legal abortion and the danger of unsafe
           abortion. If a woman has had an illegal abortion or tried to terminate a
           pregnancy herself, she may be reluctant to share this information. Be
           sensitive to this possibility if she has abnormal vaginal bleeding with
           missed period and abdominal pain.


   Do you have very painful menstrual cramps?
    This can be a problem that causes many days of disability and pain for
    women. Most women have some menstrual cramps. Determine if they are so
    painful that she cannot work or enjoy time with her family.

 Have you had very heavy or irregular periods? Determine if her bleeding is
  irregular, frequent, prolonged or altogether absent (amenorrhoea).
      o If yes, is the problem new?
          How many days does your bleeding last?
          How often do you change pads or tampons?
          [You need to modify these questions to fit the local practices for
          menstruation.]

   Are you using contraception? If yes, which one?
    Hormonal contraceptive methods may cause some changes in menstrual
    bleeding patterns; intrauterine devices may cause heavy bleeding or pain with
    menses. Be sure to use words that ensure she understands what you are
    asking, that is, pills, ―something the nurse or doctor inserted in your vagina or
    arm to prevent pregnancy, etc., condoms.

   Are you interested in contraception?
    If yes, use the Family Planning guidelines.

    It is important not to miss opportunities to offer family planning. Family
    planning services and information is recognized not only as a key intervention
    for improving the health of women and families, but also a human right.
    Ensure that all patients have access, choice, and the benefits of family
    planning. Medical, social, behavioural, and other non-medical criteria,
    particularly client preference, must be considered when contraceptive use is
    recommended. Follow the guidelines carefully.

    It is important not to miss opportunities to offer condoms to all sexually active
    women for prevention of STI including HIV as well as pregnancy (this is dual
    method). Adolescents (girls particularly) need access to condoms, accurate
    information on their use and how to negotiate their use.

    As you know, condoms help people to have safer sex by preventing direct
    contact of the genitals with either vaginal or seminal fluids. Using condoms is
    especially important if your patient has sex with more than one partner or with


                                                                                  69
      one partner who has other sexual partners or with a new partner. However it
      is not enough to know that condoms are important. Patients must also know
      how to use them properly. Many people resist the idea of using condoms, not
      because of the embarrassment or cost of buying them, but due to
      misconceptions and myths about them. For instance, they think that condoms
      spoil sex or that they are too big or too small. There are often myths about
      them—such as the condom itself is infected with STI. People may also
      associate them with illicit sex—rather than for use with a regular partner. It is
      important to be aware of negative ideas about condoms because, clearly, they
      would form a barrier to the patient‘s willingness to comply with condom use as
      a safer sexual behaviour. You also need to explain that condoms work well if
      used properly and consistently. Describe the benefits of using condoms most
      relevant to the individual patient. Additional safer sex training and counseling
      skills will be discussed in the Patient Education Module.


LOOK AND FEEL
Review the considerations about being privacy and respect in examining the genital
region in the genital ulcer section.

In women, ask the patient to bend her knees and separate her legs, then examine
the vulva, anus and perineum. It is best if you have clean gloves so you can
separate the labia to look for ulcers yourself. If you do not have clean gloves, ask the
patient to separate the labia so that you can examine the mucous surfaces for
ulcers. Be sure to examine the skin of the external genitalia and to look between the
inner and outer labia, the skin covering the clitoris and the urethra. Note vaginal
discharge (type, color and amount) at the same time, and whether generalized
inflammation or excoriation is present on the vulva or inner thighs.

We recommend that you ask the female patients to lie down comfortably on a couch
for genital exam. Ask female patients to expose the area from the chest to knees for
the exam. The patient should be covered with a sheet to maintain dignity and
respect.

A woman with severe abdominal pain will often walk slowly and bent forward, and
look ill or pained when you ask her to move or lie down for an exam. Tell her what
you are going to do before you do it.


    First, check for bowel sounds. Use a stethoscope or put your head on the
     stomach, after asking her permission. If you hear no bowel sounds at all,
     listen again for two minutes or more at a spot just under and to the right of her
     umbilicus. Absent bowel sounds is a serious sign that the bowels have
     stopped moving.

    Feel for abdominal tenderness. Tenderness means the patient experiences
     pain when you touch or press in. Abdominal palpation should first be
     superficial to detect tenderness (pain) on light palpation. Then make a



                                                                                     70
   careful and deep palpation to identify any masses, enlarged organs, and the
   location of pain.

   Lower abdominal tenderness is in the lower half of the abdomen on both sides
   below the umbilicus.

   If tenderness:

      o Is there rebound? Check for rebound in the area where you found
        pain on light palpation. Press down slowly and very gently then release
        the pressure suddenly. Any severe pain that results is known as
        rebound tenderness.

      o Is there guarding? On palpating the abdomen, the abdominal muscles
        become stiff and board-like when even slight pressure is applied. They
        resist your pressing in.

   Guarding and rebound occur when the lining of the abdominal cavity is
   irritated (peritonitis) by severe infection.

 Can you feel a mass? Swelling or lump in the patient‘s abdomen on light
  abdominal palpation. (This could be an abscess, ovarian cyst, fibroid, cancer,
  hard stool or enlarged liver or spleen.)

 Measure temperature if it has not already been done.

 Measure pulse if it has not already been done.

 Perform external genital exam following the steps outlined at the
  beginning of this module. Be sure to have the door closed or curtain drawn
  and that no one will enter during the exam. Explain to the patient what you will
  do before and as you are doing it.

 Look for ano-genital ulcer or sores. If present, use page 20. There can be a
  single ulcer or sore, or groups of sores.

 Feel for enlarged inguinal lymph node or nodes. If it is present, use page
  20.

 Look at the vulva to see if there is redness, sores, ulcers, blisters, swelling,
  signs of scratching.

 Look any vaginal discharge coming from the vagina.
  A small amount of whitish discharge is usually normal. Yellow or green or foul
  or fishy smelling discharge may be a sign of infection.

 If you are able to do bimanual exam, feel for cervical motion tenderness.
  This is the best test for PID (pelvic inflammatory disease) and involves moving
  the cervix left and right using the index finger of the gloved hand within the



                                                                               71
      vagina. If the woman says cervical motion is painful, or winces when you
      move the cervix, the test is positive.

    If you are able to do a speculum exam, look for discharge, inflammation,
     ulcers, warts and abnormal lesions on the vaginal walls, and the cervix.

    If she said she had bleeding with intercourse, look for inflammation of the
     cervix that bleeds easily on contact.

    If she said she had burning or pain on urination especially with fever

          o Percuss flank for tenderness: gently first tap, then lightly pound with
            your fist on flanks for tenderness where the ribs touch the vertebral
            column (costovertebral angle) while she is sitting. The kidney lies
            beneath this spot and jarring it when infected will elicit tenderness
            (pain) if there is infection. See photo illustrating percussing the
            flank for kidney tenderness (6B).

Now use the signs and symptoms you have found on the assessment to classify the
woman‘s problems (pages 37-39). Go down all the arrows that she fits into. You may
need to use several classification tables.

CLASSIFY
Use the top classification table on page 37 in all women with lower abdominal pain,
other than menstrual cramps.

In addition to menstrual cramps, there are several possible classifications for a
woman with lower abdominal pain:

CLASSIFY as SEVERE SURGICAL OR ABDOMINAL PROBLEM if patient has
abdominal tenderness plus if any one of the following signs in the pink row is
present:
    Fever >38C in a patient with abdominal tenderness indicates possible serious
      abdominal infection that could be due to pelvic inflammatory disease (PID),
      appendicitis or septic abortion. PID is usually caused by Gonorrhoea or
      Chlamydia which travels up from the cervix into the uterus and sometimes
      fallopian tube and ovary—infection can be extensive and life-threatening
      causing an abscess in the tube, ovary or both (tubo-ovarian abscess)
      requiring surgery and/or antibiotic therapy in hospital. Septic abortion with
      products of conception still in the uterus is also life threatening and requires
      manual vacuum aspiration of the uterus (MVA) and IV antibiotics.
    Rebound tenderness or guarding may be present because of pain and
      pressure of an abscess of the tube, ovary, or appendix or inflammation of the
      lining of the abdominal cavity (peritonitis).
    Bowel sounds may be absent because severe infection in the abdomen
      causes intestinal movement to stop, an ominous sign—this may also cause
      vomiting of fluids.
    High pulse rate >110 results from fever, infection and possible sepsis (which
      can cause shock).


                                                                                   72
    Recent missed period and abnormal bleeding could signal ruptured ectopic
     (tubal) pregnancy, especially with severe pain, history of fainting and high
     pulse rate due to internal blood loss. These signs with fever can also be due
     to septic abortion.

Patients classified as severe or surgical abdominal problem require URGENT
referral to hospital for possible surgical intervention. IV or IM antibiotics and IV fluids
should be started before transfer.


CLASSIFY as PID (pelvic inflammatory disease) if there is either lower abdominal
tenderness or cervical motion tenderness.

The term pelvic inflammatory disease (PID) refers to infections of the female upper
genital tract: the uterus, fallopian tubes, ovaries or pelvic cavity. It occurs as a result
of infection going through the cervix. It can be caused by gonorrhoea, chlamydia and
some anaerobic bacteria. PID includes endometritis, salpingitis, tubo-ovarian
abscess and pelvic peritonitis. It can also lead to generalized peritonitis, a potentially
fatal condition. Salpingitis may lead to a blocked fallopian tube, resulting in
decreased fertility or total infertility, if both tubes become infected. It may also lead to
partial tubal obstruction, allowing spermatozoa to pass through, but not the relatively
larger fertilized ovum. The result can be a tubal or ectopic pregnancy, which will
eventually rupture, causing massive intra-abdominal haemorrhage and, possibly,
death.

Women with PID usually have a history of lower abdominal pain and vaginal
discharge. However, in addition, some women with PID or endometritis will not
complain of lower abdominal pain. Other suggestive symptoms include pain during
intercourse, vaginal discharge, abnormal bleeding from the womb at any time
including during a period, painful urination, pain during menstruation, fever and
sometimes nausea and vomiting. Although difficult to diagnose, PID becomes more
probable when one or more of the symptoms above combine with lower abdominal
tenderness, vaginal discharge and cervical motion tenderness.

PID can usually be treated with appropriate antibiotics by mouth, but follow-up within
two days is necessary if there is no improvement to avoid missing a more serious
diagnosis above. PID is usually a complication of GC/chlamydia infection so
counseling on HIV/STI, partner treatment and condoms are needed. PID can also
be the result of medical procedures (such as IUD insertion or termination of
pregnancy).

CLASSIFY as POSSIBLE GONORRHOEA/CHLAMYDIA (GC/CT) INFECTION if:
    she is a sex worker, because she is at very high risk of infection from multiple
     partners who do not use condoms. Offer HIV/STI counselling and encourage
     condom use.
    there is bleeding with or after sexual intercourse—this can be a sign of
     cervical infection but also of pre-cancerous or cancerous lesion of the cervix.
     Therefore if bleeding does not resolve after STI treatment, follow-up and
     referral for cervical cancer screening is needed.



                                                                                         73
    she knows her partner has a urethral discharge or burning on urination
     because this is evidence of male infection with GC/CT
    she thinks she has an STI for any reason as she may have risks she prefers
     not to discuss.

Vaginal discharge that is due to cervical infection (cervicitis) with Gonorrhea (GC) or
Chlamydia Trachomatis (CT), are sexually transmitted. In this module if the woman
has a discharge and you suspect GC or CT, go to the table POSSIBLE
GONORRHOEA/CHLAMYDIA INFECTION. In areas of higher prevalence of
gonorrhoea and chlamydia, more specific questions have been developed to
evaluate the risk of GC/CT. If this is true in your area, ask those questions here.

We can summarize the differences between vaginitis and cervicitis with this table.

Vaginitis                                  Cervicitis
Caused by trichomoniasis, candidiasis      Caused by gonorrhoea and
and bacterial vaginosis                    chlamydia
Most common cause of vaginal               Less common cause of vaginal
discharge                                  discharge
Easy to diagnose                           Difficult to diagnose
No complications                           Major complications
Treatment of partner unnecessary           Need to treat partner
except for TV

It is important to distinguish between these conditions because one of them,
cervicitis, leads to serious complications, so the patient‘s sexual partner(s) must also
be treated to avoid reinfection. Without a speculum exam, we decide which patients
to treat for possible GC/chlamydia infection based on factors that make cervicitis
more likely—sex worker, bleeding on sexual contact, partner with urethral discharge
or burning on urination, and any woman who thinks she may have an STI.


For women with abnormal vaginal discharge, use the classification table at the
top of page 38.

Use this table in all women with abnormal vaginal discharge:

SIGNS:               CLASSIFY AS:                 TREATMENTS:
 Itching            CANDIDA                    Treat with nystatin
 Curd-like          VAGINITIS                  Return if not resolved
   vaginal                                      Consider HIV related illness if
   discharge                                     recurrent (p. 54)
 None of the        BACTERIAL                  Give METRONIDAZOLE 2gm
   above             VAGINOSIS (BV)              at once
                     OR TRICHOMIASIS            Follow up in 7 days if nor
                                                 resolved (p. 66).




                                                                                     74
For women with abnormal discharge and no other signs (fever, abdominal pain or
bleeding, partner with symptoms) classify as vaginitis

    If itching or curd-like white discharge, classify as Candida vaginitis. Candida
     vaginitis is not sexually transmitted. Often there is also erythema, which are
     red areas of skin on the vulva (vulvo-vaginal redness), or excoriations, which
     are abraded parts of the skin. If candida vaginitis is recurrent (occurs
     frequently) or is very resistant to treatment, consider HIV related illness (p.
     54).

    If none of the above, consider Bacterial Vaginosis (BV) or Trichomoniasis. BV
     may have a characteristic ‗fishy‘ odour. She should return for follow up after
     treatment if the discharge persists since other more serious problems could be
     the cause of discharge. Treat her partner if possible since Trichomonas is
     sexually transmitted(such as Candida or Bacterial Vaginosis (BV).

      Vaginal problems such as discharge, itching or dryness can also be due to
      douching or the use of other local products to clean or dry the vagina—these
      practices are harmful and should be discouraged. Ask if patient uses such
      products.

If she complains of burning or pain on urination (dysuria) or flank pain, use the
lower classification table on page 38.

Use this table in all women with burning or pain on urination or flank pain:
 Flank pain or                              If systematically ill:
 Fever                    KIDNEY             Give appropriate IM antibiotics
                           INFECTION          Refer URGENTLY to hospital.
                                                 Also refer if on indinavir (an
                                                 ARV drug)
                                             If not:
                                              Give appropriate oral
                                                 antibiotics.
                                              Follow up next day. (p. 66).
 Burning or pain on                          Give appropriate oral
   urination and           BLADDER               antibiotics
 Frequency and            INFECTION          Increase fluids
 No abnormal vaginal                         Follow up in 2 days if not
   discharge                                     improved
 None of the above        BLADDER            Treat for vaginitis if abnormal
                           INFECTION             discharge
                           UNLIKELY           Dipstick urine if possible




                                                                                  75
CLASSIFY as KIDNEY INFECTION if she has either flank pain or fever. Kidney
infection is the result of bacteria within the bladder ascending up the tubes (the
ureters) that lead to the kidney.

    Flank pain on percussion indicates infection in the underlying kidney when
     percussion causes it to move).
    Fever with burning on urination, even without flank pain, indicates kidney
     infection.

Treatment for KIDNEY INFECTION
Patients need URGENT referral to hospital if systemically ill with lethargy,
dehydration, high fever, or shaking chills. This could indicate she has sepsis and
needs parenteral antibiotics. Otherwise treat as on p. 73 and have her return the
following day. She may require a change of antibiotics or referral to hospital if there
is no improvement.

Also refer if she has these signs and is taking indinavir (an ARV drug). Indinavir can
cause kidney stones.

CLASSIFY as BLADDER INFECTION if there is burning, pain on urination or
frequency without fever, and without abnormal vaginal discharge or vulvo-vaginal
sores.

Treatment for BLADDER INFECTION
Treat with appropriate oral antibiotics (see page and encourage increased fluid
intake that helps to flush bacteria from the bladder. If no improvement in 2 days,
have patient return for follow-up as the infection may be resistant to the antibiotic
used.

CLASSIFY as BLADDER INFECTION UNLIKELY if none of the above symptoms
are present. Treat abnormal discharge if present, and perform dipstick test on the
urine if possible to see if there is evidence of infection. If she complains of menstrual
pain or missed period or irregular bleeding or very heavy period, use the
classification table on page 39.

Use this table in all women with menstrual pain or missed period:




                                                                                      76
SIGNS:                CLASSIFY AS:         TREATMENTS:
 If irregular        PREGNANCY-          Follow guidelines for vaginal
   bleeding and       RELATED              bleeding in pregnancy (e.g.
 Sexually active     BLEEDING OR          IMPAC) or
   or                 ABORTION            Refer
 Any bleeding
   in known
   pregnancy
 Missed period       POSSIBLE            Confirm pregnancy
   and                PREGNANCY           Discuss plans for pregnancy
 Sexually active                         If she wishes to continue
   and                                     pregnancy, use guidelines for
 Not using a                              antenatal care (e.g. IMPAC**)
   very reliable                          Refer or provide PMTCT
   method of                               Interventions if pregnant
   contraception*
Not pregnant with:    IRREGULAR           Consider contraception use
 New, irregular      MENSES OR VERY       and need (see Family
   menstrual          HEAVY PERIODS        Planning guidelines):
   bleeding or        (MENORRHAGIA)        - If contraception desired
 Soaks more                                   suggest oral contraceptive
   than 6 pads                                 pill.
   each of 3 days                          - IUD in the first six months
   (with or without                            and long-acting injectable
   pain)                                       contraceptive can cause
                                               heavy bleeding: combined
                                               contraceptive pills or the
                                               mini-pill can cause spotting
                                               or bleeding between
                                               periods.
                                          If on ART, consider withdrawal
                                           bleeding from drug injection.
                                           (See Chronic HIV Care
                                           module)
                                          Refer for gynaecological
                                           assessment if unusual or
                                           suspicious bleeding in women
                                           > 35 years
                                          If painful menstrual cramps or
                                           to reduce bleeding, give
                                           ibuprofen (not aspirin)
                                          Follow up in 2 weeks
   Only painful      DYSMENORRHOEA       If she also wants
    menstrual                              contraception, suggest oral
    cramps                                 contraceptive pill
                                          Give ibuprofen (Aspirin or
                                           paracetamol may be
                                           substituted but are less
                                           effective)


                                                                              77
CLASSIFY as PREGNANCY-RELATED BLEEDING OR ABORTION if she has
irregular bleeding and is sexually active, or has any bleeding and knows she is
pregnant.

CLASSIFY as IRREGULAR MENSES OR                        VERY     HEAVY      PERIODS
(MENORRHAGIA) if she is not pregnant and has:

    new irregular menstrual bleeding, or
    soaks more than 6 pads each of 3 days with or without pain.

Irregular and heavy bleeding can be due to:

    Use of some IUDs; combined oral contraceptive pills or the progestin-only pill
     can cause spotting between periods.
    Changes in female hormone levels, especially in the years leading up to
     menopause.
    Cervical cancer
    Uterine fibroma (benign tumors of the uterus) cause heavy bleeding and can
     be removed surgically if necessary.
    Cancer of the endometrium (uterine lining) is also a cause of heavy, irregular
     bleeding in women 35 and older; women should be referred for gynecological
     evaluation if bleeding has no other obvious cause.

Refer any vaginal bleeding after menopause for evaluation for endometrial cancer.
Refer any persistent vaginal bleeding, which does not respond to treatment before or
after menopause, for cervical cancer screening.

Hormonal contraceptive pills, injections or implants can be given to decrease
bleeding if contraception is acceptable, provided a serious cause of bleeding has
been ruled out. Refer to someone trained in family planning.

CLASSIFY as DYSMENORRHOEA (painful menstruation) if the only symptom is
painful menstrual cramps. Oral contraceptives can decrease cramping, and
ibuprofen or other non-steroidal anti-inflammatory (NSAID) given just before the start
of menses is effective.

      Look at photo booklet Group 6
      A. How to test for rebound
      B. How to percuss for flank tenderness
      C. Curd-like vaginal discharge




                                                                                   78
CASE STUDIES
1. Asha is a 30 year-old woman complaining of abdominal pain for 3 days and chills
   and fever last night. Her last menstruation was 3 weeks ago and she uses oral
   contraceptive pills to prevent pregnancy. She has no burning on urination or
   genital sores or discharge. Her husband came back from the city two weeks ago
   and she has had sexual intercourse with him every night since then. You find that
   she has fever of 38oC and general tenderness over the lower abdomen.

2. Doris, aged 22, attended the family planning clinic for her usual check-up while
   on the contraceptive pill. She tells the nurse about a yellow, itchy vaginal
   discharge that she has had for the past four days. She has no abdominal pain or
   urination pain. She had her period two weeks ago and it was normal. Shyly, she
   discloses that she sometimes does free-lance sex work. She last had sex with
   her regular boyfriend a month ago, as he is out of town.

3. Ami is 17 years old, living in an urban area. She reports a slight yellow discharge
   but no other symptoms. She has lived with her current boyfriend for nine months
   and has had no other partners. Her boyfriend has no symptoms.

4. Sara moved in with her present partner four months ago. She is 22 years old. In
   addition to reporting a non-itchy discharge, she says has pain in her lower
   abdomen. Her partner has no symptoms. On examination, she has no fever and
   general lower abdominal tenderness.

5. Jasmin complains of a slight vaginal discharge. She is 25 years old and has been
   married for eight years. Her third child was born four months ago, so she‘s been
   busy caring for him at home. Apart from this discharge, she feels well and has no
   other symptoms. Her husband has GU symptoms that she knows of. They do not
   use condoms.

SELF-STUDY EXERCISE #7

CLASSIFY the following patients. Assume all signs not mentioned are
negative. First do the exercises then check that your answers are correct—see
Annex.

ASK, LOOK and FEEL results                      What                What
                                                classification(s)   treatment(s)
                                                does the patient    should you
                                                have?               give?
45 year old woman with burning on
urination, chills and right-sided flank pain.

32 year old woman in the 3rd month of
pregnancy, who comes to the health centre
with vaginal bleeding.
25 year old woman with painless bleeding
after sexual intercourse with her boyfriend.
External exam is normal.



                                                                                   79
Educate and Counsel on STIs
Speak in private, with enough time, and assure confidentiality.

The best time to do this is while you are still in the exam room with the patient. If this
is not possible, work with your supervisor to ensure that you always have a private,
confidential space to provide counselling.

Education is important because patients are more likely to comply with treatment if
they understand why it is important to do so. The patient‘s initial visit is a unique
opportunity for patient education. Often the only time that patients are interested to
learn about a disease or its prevention is when they are faced with that disease.

Explain

      The disease
       The first issue is to explain what a sexually transmitted infection is. Explain
       that sexually transmitted organisms can be bacterial (e.g. the gonococcus),
       parasitic (e.g. Trichomonas vaginalis or pubic lice), or viral (e.g. herpes
       simplex virus or HIV). Explain which STI the patient has.

   ASK
          o Ask the patient if s/he understands about the STI they have.
          o Ask if they have any questions or concerns
          o Assess patient‘s local beliefs about STIs.

   These are some of the more frequently found beliefs about STIs that are
   important to understand and address:

    one STI can turn into another one
    you can only get one STI at a time
    all STIs, including HIV, are detected using one diagnostic test
    health care personnel can tell if a patient has STI without examination
    people with STIs always have symptoms
    you can‘t have STI and HIV at the same time
    you can tell who has an STI by how he or she looks or feels
    you can tell who has an STI by his/her actions, occupation, social class or
     number of sex partners
    one can get STIs through witchcraft.


      How it is acquired.

       It is important that the patient understands that the infection is transmitted
       mainly through sexual intercourse with an infected person. The sex act may
       be penile-vaginal, oral or anal.




                                                                                       80
   How it can be prevented.

    Once you are sure that the patient understands what infection they have, ask
    if they understand the risk of infecting others or becoming reinfected. This
    means that you assist the patient to assess his/her own risk level.

    Changing sexual behaviour
    Remember: high-risk behaviour is behaviour that exposes the patient to sex
    fluids and blood. Therefore, changing from high risk to low risk sexual
    behaviour is one way to prevent future infection. Reducing the number of sex
    partners or the rate of change of sex partners is important. Sexual abstinence
    virtually guarantees against contracting or transmitting an STI. This is
    particularly important during treatment for STIs.

    Condoms
    Another practice for preventing the spread of STIs is the use of condoms.
    Male latex condoms can reduce the risk of contracting or transmitted STIs if
    consistently and correctly used. The health care provider must demonstrate
    the correct use of condoms, using a penile model, where available.

    ASK the client to practise on the model so that they understand how to put
    the condom on, can demonstrate this skill and feel confident about handling a
    condom.

    Sexual practice
    It is also important to inform patients that some sexual practices have a
    higher risk of infection. For example, anal sex, whether it is male to female or
    male to male, carries a higher risk than penile-vaginal sex.

    Other barrier methods
    Inform your patients of any other existing prevention methods such as the use
    of spermicides that may also be bactericidal; microbicides or vaccines (e.g. for
    hepatitis B).

    Personal hygiene and cultural practices
    Vaginal douching, for example, may remove protective bacteria in the vagina
    increasing the risk of getting some STIs, e.g. HIV. Washing with soap and
    water may help prevent colonization with parasites, such as pubic lice or
    scabies.

   The treatment.

    Explain the treatment including the name of the medication and how much to
    take, how often and for how long. Write down these details for the patient—or
    use recognizable symbols if the patient cannot read.

       o Advise about any common side-
       o Encourage the patient to comply with treatment.
       o As with all treatments, it is essential that patients complete the
         recommended treatment, even if the symptoms disappear or improve.


                                                                                 81
          o Remind them that if they do not take all the medication, the symptoms
            may recur and that they will not be completely cured.

      Remind them that most STIs can be cured, except HIV, herpes and
       genital warts.

      Remind them of the need to also treat the partners (except for vaginitis):

       Remember; always inform patients how important it is to have all their known
       sex partners treated. Reassure the patient that you will maintain confidentiality
       and discuss how they can persuade the partner(s) to attend for treatment.
       Stress that treatment will benefit both partners because there will be no risk of
       reinfection and the partner, who may not be aware of the infection, will have
       the STI treated and avoid future serious complications.

       This is all factual information, and you could supplement it with a brochure
       that a patient can take home to read at leisure. Once the patient has
       assimilated the information, they will know about STIs and how to prevent
       them.

      Recent sex partner(s) are likely to be infected but may be unaware.

       Because this is syndromic management, treatment must be given
       presumptively and the partner treated even if there are no symptoms or signs
       of STI. We assume the period of infectiousness to be two months. So all
       partners within the last two months must be treated. Identifying the ―source‖
       patient has no particular value because the aim is to treat all partners or all
       those partners that can be reached and their partners in turn.

          o If partners are untreated, they may develop complications.
          o Sex with untreated partners can lead to re-infection.
          o Treatment of the partner, even if no symptoms, is important to the
            health of the partner and to you.
          o It is also an opportunity for the partner to be examined for other STIs.

Listen to the patient: is there stress or anxiety related to STIs?

After hearing that his or her partners also need to be treated, many patients might be
very uncomfortable with this news. It might cause far-reaching damage to the
individuals concerned. Partner management must take account the possible impact
on the lives of each individual. News of STI can be especially damaging when a
patient or partner hears of their partner‘s infidelity for the first time. Equally someone
with mistaken ideas about the cause of STI may respond in ways that are
inappropriate or extreme. Patients are sometimes blamed for being the source of
infection when it is rarely possible to identify the source of infection.

Such events might lead to marital breakdown, divorce, loss of home or livelihood, or
even ostracism from the social group. Please discuss this in more detail with your
colleagues and supervisor.



                                                                                       82
Take the time to assess the patient‘s stress or anxiety level about their STI. Use the
counseling skills on pages 107 and 108 to help you do this. Assist the patient to
identify and resolve their real concerns and the obstacle of embarrassment by
educating them about their STI and supporting them properly so that treatment and
partner referral will be effective. Suggest various options to the patients and respect
the choices that they ultimately make. Verify that the patient has understood what
has been discussed by having her repeat the most important information because it
might be a misunderstanding about the STI or treatment that is causing the anxiety
and stress.

Promote safer sexual behaviour to prevent HIV and STIs
    Counsel on limiting partners (or abstinence) and careful selection of partners.
        o Instruct in condom use (p. 102).

Educate on HIV (p. 97)

Advise HIV testing and counselling (p. 98)
An adult or adolescent with an STI should be offered HIV counselling and testing.
People who are HIV negative and continue to engage in high-risk behavior and
contract STIs should be referred for additional counselling.


Inform the partner(s) or spouse

      Ask the patient, can you do this? Ask, is it possible for you to:
         o Talk with your partner about the infection?
         o Partner management must be confidential and voluntary.
         o Convince your partner to get treatment?
         o Bring/send your partner to the health centre?

       Patients might approach partners in several ways:
          1. By directly explaining about the STI and the need for treatment.
          2. By accompanying a partner to the health centre or asking the partner to
              attend without specifying why.
          3. By giving each partner a card asking him or her to attend the centre.


      Determine your role as the health worker.

       Depending on your clinic‘s guidelines, you may or may not be involved in
       partner referral and contact. Your facilitator will provide you with the activities
       and exercises that fit your partner referral guidelines.

      Strategies to discuss and introduce condom use.

       Condoms are an important option for any sexually active person for both
       pregnancy prevention and disease prevention. In addition, they have other
       benefits. These are factors that can be cited in condom promotion. Ask the
       patient what they think of condoms, discuss their response and any barriers
       towards using them and suggest appropriate benefits.


                                                                                       83
       It is important to be aware of negative ideas about condoms because,
       clearly, they would form a barrier to the patient‘s willingness to comply with
       condom use as a safer sexual behaviour. You also need to explain that
       condoms work well if used properly and consistently. Describe the benefits of
       using condoms most relevant to the individual patient. Here are some
       examples:

       Benefits of Condoms
       1. Condoms prevent transmission of STI, including HIV.
       2. They help women to avoid pregnancy.
       3. Condoms reduce the risk of transmission of an STI if a patient does not
          wait for the STI to be cured before having sex—but the health care
          provider should encourage the patient to wait!
       4. Women feel dryer inside.
       5. The patient will feel safer, with fewer worries.
       6. Many men can prolong intercourse if they wear a condom.
       7. Bed linen needs washing less often!

      Risk of violence or stigmatizing reactions from partners and family.

       Remember that, for the patient, anticipating the need to talk to partners about
       STI may provoke feelings as uncomfortable as those the patient first felt when
       told that he or she had a disease that was sexually transmitted.

Special counselling for adolescents:
See Adolescent Job Aid.

Refer for counselling on:
    Concerns about herpes infection (no cure).
    Possible infertility related to PID.
    Behavioural-risk assessment.
    Patient with multiple partners.
    Difficult circumstances or risk.

Three things to remember:

   1. It is important to keep in mind some issues that may come up when screening
      or presumptively treating for STI. Women who have come to the clinic for
      other reasons may not be prepared to hear that they may have an infection,
      especially one that is sexually transmitted. They may be even more upset if
      they are told that they have to inform their sexual partner. Such situations
      must be handled carefully to avoid losing the patient‘s trust and damaging the
      reputation of the clinic in the community.

   2. It is also important to remember that no screening test is 100% accurate, and
      many are much less so. This should be carefully explained to patients and the
      possibility of error should be acknowledged. Most importantly, health care
      providers should avoid labelling problems as sexually transmitted when this is
      uncertain. A more cautious approach—and one often more acceptable to


                                                                                   84
   patients and their partners—is to explain that many symptoms are non-
   specific; treatment can then be offered as a precaution to prevent
   complications, preserve fertility and protect pregnancy.

3. If there is no evidence of a sore, ulcer or vesicles or other STI, the fact that
   the patient feels concern about STI makes this an excellent opportunity for
   education. Educate the patient, counsel him or her if necessary, offer HIV
   counselling and testing if available, and promote the use of condoms,
   supplying them if possible. In fact, this is an excellent opportunity for
   education because the patient has come to you with concerns about STI.




                                                                                85
Chapter 12: Skin problems and lumps

Pages 40-44: If patient has a skin problem or lump
Skin problems have many different and sometimes overlapping causes. Any skin
problem can develop secondary bacterial co-infection. It is crucial to determine if co-
infection exists because even a simple skin problem can be serious if the infection is
not treated appropriately. For every skin problem encountered, ask yourself the
question ‗Is it infected?’ and determine the answer.

Some skin problems or lumps are sexually transmitted (these all can also have non-
sexual transmission, especially in children )
    scabies
    molluscum contagiosum
    syphilis lymphadenopathy

Other skin problems occur more commonly in patients with HIV infection.
Seborrhoea, prurigo and herpes zoster can be the first symptom of HIV infection
since they occur early, in WHO clinical stage 2 (see Chronic HIV Care with ART,
section 3). HIV immunosuppression can also cause severe forms of some skin
conditions that can cause significant problems, such as severe and prolonged
herpes simplex infection, extensive or severe skin infection, extensive or giant
molluscum contagiosum, or extensive warts. This is why it is important to know how
to classify and manage skin problems in caring for HIV patients.

Almost all of the skin conditions also appear in children. Where the management is
different in children, it is indicated in this chapter.

ASK
Where is the sore or skin problem or lump? Many skin problems have a specific
distribution on the body. A generalized rash on the trunk and extremities is more
likely to be a drug reaction or systemic illness; psoriasis occurs on the knees,
elbows, scalp and lower back; eczema occurs on the face and flexures (inner arms,
legs); Herpes Zoster follows a skin dermatome; the rash of secondary syphilis occurs
on the palms; acne occurs on the face and upper back.

Does it itch? A very itchy rash may cause the patient to scratch uncontrollably and
you may also see nail marks or excoriations and secondary bacterial infection on
top of the original lesions.

Does it hurt? If yes, for how long has it been painful, does it hurt all the time or only
some of the time? Herpes simplex and zoster infections can be very painful even
before lesions appear and after they disappear. Pain is often a sign of infection if
other signs (redness, swelling, fever) are present.

Duration? How long have you had the problem? Ask if it comes and goes (gets
better and worse) and what relieves the problem. For example cool water or hot
water might make it better, or lotion might soothe it.


                                                                                      86
Do any others in the family have the same problem? Who does, and for how long
have they had the problem? Scabies is highly infectious; impetigo is infectious.

Are you are taking any medications? If they are on ART or co-trimoxazole
prophylaxis, skin rash could be a serious side effect. See Chronic HIV Care with
ART.

LOOK AND FEEL
Are there lesions?

    Look where the patient says the problem is, but also look at the rest of the
     body.
    If there are lesions, how many are there?

Are they infected? Signs of infection are:
    Redness
    Warmth to the touch
    Hard or tense
    Fluctuant—this is softer, such as when a boil or abcess comes to a head and
      the upper part is soft and moveable
    Tender to the touch

Look and feel for lumps elsewhere. Look at and feel the lymph nodes closest to the
lesion/s. Are they tender and enlarged?

If there are painful inguinal nodes or genital sores or lumps, refer to p. 39.

If there are dark lumps, consider HIV-related illness, (p. 54). These could be Kaposi
lesions.


CLASSIFY using the chart p. 41
Enlarged lymph nodes or a mass present?

If yes,

         Is the size >4 cm. or
         Is it fluctuant, or
         hard, or
         Is there fever?

If any of these signs is present, CLASSIFY the lump as a suspicious lymph node
or mass. This might be caused by lymphoma or other cancer or by tuberculosis.
Refer to district hospital for further diagnosis.




                                                                                  87
    Is there nearby infection?
    Are there red streaks?

If yes, CLASSIFY this as reactive lymphadenopathy. Give an oral antibiotic (p. 76)
and follow-up in one week.

Are >3 lymph node groups affected with:
    >one node
    1 cm
    >1 month duration
    no local infection to explain

If yes, CLASSIFY as persistent generalized lymphadenopathy (PGL). Consider
HIV-related illness or syphilis. It is important to offer HIV and syphilis testing.

Is the lesion infected?

Use the table at the bottom of page 41 if you think any lesion in this section is
infected.

Signs of severe soft tissue or muscle infection include:

    Fever, often greater than 38C
    Person appears unwell, weak, without appetite (sytemically ill)
    Infection extends to muscle—moving the body part is painful? Other?

If any of these signs are present, CLASSIFY as severe soft tissue or muscle
infection. Refer patient to hospital and start IV/IM antibiotics immediately. If not
available give oral cloxacillin. Consider HIV-related illness (p. 54)

Signs of a soft tissue infection or folliculitis are:

      Size of lesion >4 cm: this is probably an abcess. It may be red, warm and
       hard, or soft and fluctuant if it is ‗ripe‘ and pus has collected in the center.

    Red streaks: faint red or warm lines may lead away from the lesion or infected
     area. Cellulitis is a soft tissue infection which may have no sore, simply a
     hard, red, tender area which may be accompanied by red streaks and tender
     regional lymph nodes.

    tender nodes: these become tender in the region of the infection

    multiple abcesses: Folliculitis is one or more boils, larger than pustules; they
     are raised red lesions with white tops (pus).

CLASSIFY as soft tissue infection if any of these signs are present. Start
cloxacillin. If an abcess is fluctuant it should be incised and drained. Counsel and
advise the patient on care at home and follow-up the next day.



                                                                                    88
Impetigo has none of the above signs (fever, streaking, tender nodes). There may be
multiple small sores or bullous, blister-like lesions with water in them (bullous
impetigo). Sores may be wet with draining yellow fluid or dry with honey-coloured
crusts or scabs.

CLASSIFY lesions with these signs as impetigo or minor abscess. Sores should
be cleaned carefully with antiseptic or soap and water and left uncovered. A fluctuant
abscess should be drained. Follow-up in 2 days.

HIV infected children may get severe and/or recurrent impetigo. Treat the child with:
    Erythromycin 10mg/kg/dose 6 hourly OR
    Cloxacillin 12-25mg/dose 6-hourly OR
    Terramycin OR
    bactroban ointment

CLASSIFY lesions which are itching. Itching can be caused by any of the
following in Table p. 42:

    Scabies: the mite burrows and leaves tracks in the webs and sides of fingers,
     toes, male genitals. An allergic papular rash on armpits, thighs and umbilicus
     may be present.

       If you have assessed the patient and classified the itchy skin condition as
       ―scabies‖, treat the itching and manage with anti-scabies medication as
       directed on page 86.

    Papular itching rash (purigo). This is a maculopapular skin condition which
     is associated with HIV/AIDS.

    Eczema (also called atopic dermatitis): usually appears in childhood as itchy
     scaly patches of skin on face, flexures, hands.

    Tinea (ringworm and others): a group of fungi; tinea capitus has round scaly
     patches on the scalp with raised borders and central clearing and with hair
     broken off just above the scalp surface. Tinea pedis causes athlete‘s foot—
     redness, itch and scaling between the toes.

    Dry itchy skin (xerosis)


CLASSIFY if blisters, sore or pustules. Some of these lesions may also itch.

    Contact dermatitis a hypersensitivity reaction to a plant or other substance
     (nickel, soaps).

    Herpes simplex (HSV): affects mucus membranes and causes fever blisters
     on the mouth (HSV1), and genital herpes (HSV2).



                                                                                    89
       Herpes simplex in children: Herpes will appear as very painful ulcers in the
       mouth and on the lips. In HIV infected children, and this in some children with
       POSSIBLE HIV INFECTION, repeated infections occur and around the mouth.
       You must give regular pain relief—Paracetamol every 4 hours—and treat
       feeding problems according to IMCI. Also give oral acyclovir:
          o <2 years 200mg every 8 hours for 5 days;
          o >2 years 400mg every 8 hours for 5 days

       In addition to this, also give flucloxacillin (12-25mg every 6 hours; max.
       500mg/dose). Follow up in 5 days. Advise the mother to return immediately if
       the child is vomiting everything or becomes sicker or is unable to drink or
       breastfeed. If, on follow-up, the child has not responded to treatment, refer.

    Herpes zoster: shingles, caused by the varicella (chicken pox) virus is more
     common in elderly or immune deficient persons. Starts out as painful small
     blisters which become small sores that follow skin dermatomes (a part of the
     skin served by a specific spinal nerve).

    Drug reaction. This can present as urticaria (hives)—raised white or red welts
     which come and go quickly anywhere on the body and are usually an allergic
     reaction to a medicine or food, or to stress.

    Impetigo or folliculitis: Impetigo is a superficial bacterial infection caused by
     staph and/or strep with crusting and oozing which can be itchy. Folliculitis has
     small tender bumps.

CLASSIFY if skin rash with no or few symptoms. Some of these lesions may also
itch in some patients, such as seborrhoea.

      Leprosy

      Seborrhoea

       Seborrhoea in children: there may be eczematous, diffuse scaling of scalp,
       skin folds, napkin area. Seborrheic dermatitis may be severe in HIV infected
       children. Secondary bacterial infection may be common.

       Treat the child with seborrheic dermatitis with 1% hydrocortisone cream twice
       daily, aqueous cream. If the dermatitis is severe, treat with betamethasone
       valerate 1:10 or 1:4 in aqueous cream or with nystatin cream and terramycin
       ointment. Advise the mother to return immediately if the child get sicker or if
       he develops a fever. If on follow-up the child has not responded to treatment,
       refer.

      Psoriasis

    Molluscum contagiosum: a pox virus frequently, but not exclusively,
     transmitted by sexual contact. It manifests as dome-shaped papules, 2-8 mm
     diameter, with an umbilicated center. There may be a few lesions or large crop


                                                                                   90
         of lesions in the genital area. The most commonly affected sites are the
         genital areas and inner aspect of the thighs.

         If you have assessed the patient and classified the condition as molluscum
         contagiosum, each lesion must be treated separately. Apply phenol or tincture
         of iodine to the central core of each lesion with the sharp end of an orange
         stick or swab stick. If available, cryotheraphy or electrocuatery may also be
         used for refractory lesions.

        Warts
         HIV infected adults and children (and thus children with POSSIBLE HIV
         INFECTION) may present with flat warts which may be localised or
         generalised, or with large genital warts.

         In adults, warts can be sexually transmitted. They can be treated with
         podophyllin (page 85). Do not use this in young children. Refer if the warts are
         very severe or of they cannot be managed at the first level facility.


SELF STUDY EXERCICE
The answers are in Annex 1

The answers to the following questions are at the end of this section.

You will notice in the tables that some of these skin problems may indicate HIV
infection. List the skin problems for which HIV should be considered:

1.

2.

3.

4.




List the skin problems that can be sexually transmitted:

1.

2.

3.

4.




                                                                                      91
Look at photo booklet Group 9
A. TB adenopathy
B. Red streaks
C. PGL
D. Pyomyositis
E. Severe soft tissue infection
F. Cellulitis with size >4 cm
G. Folliculitis with multiple small abscesses
H. Impetigo
I. Scabies
J. Papular itching rash
K. Eczema
L. Ringworm
M. Contact dermatitis
N. Herpes zoster
O. Herpes simplex—non severe
P. Herpes simplex—severe
Q. Drug reaction—Stevens Johnson
R. Fixed drug reaction
S. Leprosy
T. Seborrhoea
U. Psoriasis




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Chapter 13: Headache and neurological problem

Page 46-48: If patient has a headache or neurological problem:

Assess for NEUROLOGICAL PROBLEMS

ASK
     Do you have weakness in any part of your body?
      Weakness or loss of function of a part of the body and/or headache can be
      caused by a lesion in a particular part of the brain. The lesion can be caused
      by trauma, infection (for example, abscess), a stroke, or other medical
      condition (for example, a tumour).

     Have you had an accident or injury involving your head recently?
      Any loss of body function or persistent acute headache in a patient with recent
      head trauma or recent convulsion can be serious and will probably need
      referral to hospital. This is why it is important to ask about an accident or
      injury involving the head, including any falls in which the patient hit his or her
      head.

     Have you had a convulsion?
      Remember that other terms such as seizure or fit can be used when reporting
      this.

      Convulsions result from excessive and abnormal discharge of brain neurons.
      There are different types of convulsions.

      A generalized convulsion involves the whole brain resulting in loss of
      consciousness, leading to a fall. All limbs extend and stiffen, the back arches
      (tonic phase) and the eyes roll up. Then there are repetitive jerking
      movements. This stops after a few seconds to minutes. The patient is
      exhausted and falls asleep. Patients are often incontinent of urine and bite the
      tongue. The patient wakes up later, disoriented and unable to remember what
      happened. Sometimes, however, the convulsion is subtle and just manifests
      as blank staring for a few seconds.

      Focal convulsions involve just one part of the brain and can result in only a
      focal dysfunction such as jerking movements of a single limb while the patient
      remains conscious.

      Convulsions may be caused by an underlying medical condition, such as
      tuberculosis, HIV infection, tumours or a head injury, However, often no cause
      can be found.

      There has been a lot of superstition about convulsions. There is still some
      confusion in some parts of the world regarding the cause of seizures. Some
      people still feel that they are a sign of possession by evil spirits.




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    If the patient is having a convulsion just now, go the Quick Check on pages
    12- 13 for emergency treatment instructions.

   Assess alcohol and drug use
    Long-term excessive alcohol can be lead to neurological problems (or alcohol
    dependence). These include severe memory impairment, acute confusional
    states, cognitive deficits, gait disturbance and falls. (The assessment of
    alcohol use is included in the mental health section of the Acute Care
    guideline module, page 50.)

    Acute alcohol withdrawal, particularly in persons with a history of long term
    excessive alcohol use may also lead to convulsions, typically occurring
    between 12—60 hours after cessation of drinking

   Are you taking any medications?
    Side-effects of medication can cause impaired cognitive ability or even
    confusion. Medications such as benzodiazepines, narcotics and hypnotics,
    excessive alcohol or recreational drugs can decrease people‘s cognitive
    capacity. In some people ART can contribute to confusion either alone or as a
    result of a drug interaction

   Do you feel your brain/mind is working more slowly?
    Some patients with dementia experience memory difficulties as the first sign
    of a problem. This is the typical complaint in Alzheimer‘s dementia. Others
    find that their main problem is that they feel like their brain is working more
    slowly and less efficiently. This is a common complaint in people with
    HIV/AIDS.

   Do you have trouble keeping your attention on any activity for long?
    It is common for patients with serious neurological problems to be easily
    distracted and have difficulty concentrating on any activity for long. This will
    usually be reported as a change from previous function. Patients with
    dementia may also show this pattern.

   Do you forget things that happened recently?
    Memory problems are commonly seen with various neurological problems and
    are reported as a change from previous function. There may be short-term
    memory loss (e.g. forgetting where things were put, or events that recently
    occurred, or appointments made), or there may be more serious problems
    affecting long-term memory (e.g. recognition of close relatives). Typically,
    short-term memory problems occur before long-term memory problems

   Ask the family:
      o Has the patient‘s behaviour changed? in what way?
      o Is there a memory problem?
      o Is patient confused?

    The patient‘s mental state may impair or prevent accurate or coherent
    answers to questions. The report of family members (or other close
    associates) is therefore very important. It is important to probe in order to


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       obtain as full a picture as possible about the nature and severity of any
       problem, its onset and duration.

      If patient or family report memory problem, tell the patient you want to
       check his/her memory.
       This is a memory screening test only and should be modified according to the
       literacy level of the patient. (An adapted local instrument is preferable if
       available.) The patient must be able to understand and follow instructions for
       the test to be done.

       Name three unrelated objects (e.g. ball, house, train), clearly and slowly.
       Ask the patient to repeat them:

          o Can s/he repeat them?
            If not able to repeat, the patient has a registration problem
          o If able to repeat, wait 5 minutes (proceed with other questions
            meanwhile) and ask again: “Can you recall the 3 objects I named
            just now?”

       If not able to repeat, the patient has a recall problem

       Patients who have major difficulties with these tests should be referred for
       further evaluation to determine the nature and the extent of their cognitive
       problems and the likely cause. Other screening tests can assess the patient‘s
       attentiveness:
           o Ask the patient to count from 20 backwards to 1 or
           o Ask the patient to recite the days of the week backwards
           o Ask the patient to count backwards from 20 by 3‘s (20,17,14,11,8,5,2)

If confused (either patient appears confused or family reports confusion):

      When did it start?

       It is important to know when the confusion started—is it a new problem or has
       it been present for a long time? It is also useful to know how sudden was the
       onset?

       The onset of a confusional state is very important as it is often a distinguishing
       feature between delirium and dementia. The onset of delirium is often acute
       (i.e. hours to weeks) while that of dementia is gradual. Psychosis also usually
       presents acutely.

      Determine if the patient is oriented to place and time.

          o Place: ask country, town/district, village, place/institution
          o Time: ask time, date, day, month, season, year

      Does the patient complain of painful burning or numb or cold feeling in
       feet or lower legs (or hands)?



                                                                                      95
If patient has a headache:

Headaches are commonly occurring symptoms, but may indicate serious
neurological problems and should therefore be carefully assessed to develop a
detailed picture of how the headache manifests in a particular patient.

Ask:
      For how long?
       For how long have you had this headache?

       If the patient has a headache for more than 2 weeks, this is considered to be
       prolonged headache.

      Visual defects?
       Ask about visual disturbances accompanying the headache. Visual
       disturbances e.g. zig-zag lights, dots and spots or other defects in the visual
       field.

      Vomiting?
       Nausea and vomiting is a common feature of a migraine during the episode of
       headache and goes away when the headache resolves. Nausea and
       vomiting that occurs in the context of a worsening daily headache, particularly
       in a patient that looks sick even when the headache is not present may
       indicate a space occupying lesion, e.g brain tumour, meningitis or some other
       major neurological problem.

      Prior diagnosis of migraine?
       Because migraine signs are shared with other more serious causes of
       headache, it is useful to know whether the patient has been diagnosed before
       to have migraine. It is also common for patients with migraine to have a family
       history of migraine headaches.

      On one side?

      In HIV patient, new or unusual headache?
       Patients with HIV/AIDS commonly develop headaches for reasons similar to
       anyone else. The evaluation of the headache is the same. Sometimes a
       cause cannot be found and the headache is attributed to inflammation due to
       HIV brain infection. Some antiretroviral medications may cause headache as
       a side effect. In those with a low CD4 count, a new or unusual headache may
       be an early sign of cryptococcal meningitis. It is important to diagnose and
       treat this early which is why even an unusual headache that has not lasted 2
       weeks< 200 may develop cryptococcal headache as a symptom of a central
       nervous system opportunistic condition and require assessment




                                                                                   96
LOOK AND FEEL
Check for focal neurological signs

Focal neurological problems refer to specific areas of dysfunction, for example,
weakness in the left leg, or loss of sensation in the right side of the face. These
deficits suggest that there is a specific lesion (damage) in the part of the brain that is
responsible for controlling that body part and that this single lesion can explain the
deficit. In general the person with a focal neurological deficit remains conscious. For
example, a person with a tumour in the left side of the brain may present with signs
on the right side of the body but maintains a full level of consciousness. Patients with
late stage HIV/AIDS (CD4 < 200) can develop secondary central nervous system
opportunistic conditions including toxoplasmosis, tubercular abscess, lymphoma,
and progressive multifocal leukoencephalopathy (PML). These can present with
focal neurological deficits.

Focal neurological deficits are distinguished from neurological conditions that are
associated with diffuse processes, such as acute confusional state due to delirium or
generalized decrease in level of consciousness or generalized weakness affecting
multiple body areas.

      Is the patient‟s face flaccid on one side?
       Look for drooping face on one side. This can be due to a lesion affecting the
       facial nerve.

      Does the patient have a problem walking?
       May be due to weakness of one or both legs or a problem with balance
       (cerebellum and its connections)

      Does the patient have a problem talking?
       Abnormalities of speech may reflect problems in understanding language
       and/or thought and word finding and generation. Some patients may talk
       fluently, without making sense, while others may have non-fluent or halting
       speech and struggle to express themselves, but still be able to understand
       what others say. These abnormalities may be due to a problem affecting the
       speech centre (usually on the left side in right handed people).

       Problems with articulation (speech content is normal) may be due to muscle
       weakness, or a problem with the brain area or cranial nerves that control
       speech production and coordination.
      Does the patient have a problem moving his/her eyes?
       Look to see if the patient‘s eyes both move together and smoothly through a
       full range of movement. Problems with eye movement may indicate a
       problem with the brain or the cranial nerves that connect the brain to the
       muscles that control eye movement.

      Flaccid arms or legs? If yes, test for loss of strength?
       Flaccid means loss of tone—the limb feels floppy. If flaccid, test for strength.




                                                                                          97
    Reduced strength and/or tone of the limbs may indicate problems in the brain,
    spinal cord, peripheral nerves or muscles. Reduced strength in a single limb
    may indicate a focal brain lesion in the area of the brain controlling that limb.
    Weakness in both legs may suggest a lesion of the spinal cord.

    Generalized weakness may indicate a diffuse process in the brain, nerves or
    muscles.

   Feel for stiff neck
    This should not be done in a patient with a recent head, neck or back trauma
    or neck instability as you do not want to damage the spinal cord. You must
    first ensure that the neck and vertebral column has been adequately
    stabilized.

    Gently rotate and lift the head. The neck should move easily in all planes.

    If the neck is rigid and stiff this indicates irritation of the meninges (brain
    covering). Common causes of meningeal irritation are infectious meningitis
    (viral, bacterial, fungal) or a subarachnoid bleed that is irritating the meninges.

    Patients with HIV/AIDS, particularly if CD4 < 200, are at risk for developing
    tubercular meningitis, syphilitic meningitis and cryptococcal meningitis.

   Measure BP
    Patients with vascular disease and hypertension (high blood pressure) are at
    risk of developing focal neurological deficits due to strokes.

   If headache, feel for sinus tenderness

   Is the patient confused?
    (based on patient or family report and your observation)

    Confusion refers to a condition where a person is unable to think with their
    usual state of clarity, judgment and intelligence. It may be due to a delirium
    where the ability to think clearly is due to an acute impairment in level of
    consciousness or it may be due to a dementia process where the chronic
    decline in cognitive abilities interferes with the person‘s ability to remember
    and process information with clarity and coherence. Confusion in dementia is
    typically a later stage complication.

   Look for physical cause, alcohol and drug intoxication or withdrawal or
    medication toxicity.




                                                                                    98
CLASSIFY if headache or neurological problem (loss of body function or
convulsion or any

SIGNS:                             CLASSIFY AS:                   TREATMENTS:
 Loss of body functions or                            Refer urgently to
 Focal neurological signs or       SERIOUS             hospital.
 Stiff neck or                      NEURO-            If stiff neck or fever, give
 Acute confusion or                LOGICAL             IM antibiotics and IM
 Recent head trauma or             PROBLEM             antimalarial.
 Recent convulsion or                                 If flaccid paralysis in
 Behavioural changes or                                adolescent < 15 years,
 Diastolic BP > 120 or                                 report urgently to EPI
 Prolonged headache                                    programme.
   (> 2 weeks) or                                      If recent convulsion,
 In known HIV patient:                                 have diazepam
   o Any new unusual                                    available during referral.
       headache or                                     Consider HIV-related
   o Persistent headache                                illness (p. 54).
       more than 1 week
 Tenderness over sinuses                              Give appropriate oral
                                    SINUSITIS           antibiotics.
                                                       Give ibuprofen.
                                                       If recurrent, consider
                                                        HIV-related illness (p.
                                                        54).
   Repeated headaches with                            Give ibuprofen and
    o Visual defects or             MIGRAINE            observe response.
    o Vomiting or                                      If more pain control is
    o One-sided or                                      needed, see Palliative
    o Migraine diagnosis                                Care guidelines on
                                                        acute pain.
   None of the above                                  Give paracetamol.
                                    TENSION            Check vision–consider
                                   HEADACHE             trial of glasses.
                                                       Suggest neck massage.
                                                       Reduce: stress, alcohol
                                                        and drug use.
                                                       Refer if headache more
                                                        than 2 weeks.
                                                       If on ARV drugs, this
                                                        may be a side effect.
                                                        (See Chronic HIV Care.)

If any of listed signs, classify as possible serious neurological problem:
     recent head trauma or
     recent convulsion or
     loss of body functions or
     focal neurological signs or


                                                                                       99
      acute confusion or
      behavioural changes or
      stiff neck or
      diastolic BP>120

New onset of any of these signs requires referral for further assessment to determine
the underlying cause and treatment

A headache or neurological problem can be serious is there is loss of body function
or recent head trauma, acute confusion, or recent convulsion—these patients need
to be referred to hospital. (An exception is a patient with known recurrent
convulsions (epilepsy) who has no change in function or frequency of the
convulsions. These patients do not require urgent referral.)

Patients with elevated blood pressure should be investigated and treated for
hypertension to decrease their risk of future strokes

If headache does not fit the criteria for a serious neurological problem, consider an
alternative less serious classification (see further below)

Differentiating between headaches
Any headaches with one (or more) of the signs in the pink row may be serious and
requires urgent referral. Serious headaches can occur from increased intracranial
pressure due to a brain tumour, brain abscess, hydrocephalus, etc. These serious
headaches from space occupying lesions often get worse over time; are often worse
in the morning with some improvement as the day progresses; may be associated
with vomiting; and may be worse when patient coughs, bends down & on lying
down. The headache may persist through the night, but show some improvement as
the day progresses. This type of headache is also made worse by bending down and
coughing.

A prolonged headaches (more than 2 weeks) can be a sign of a serious neurological
problem such as cryptococcal meningitis, with or without fever, or a space occupying
lesion such as tumour or abscess.

Headache associated with sinusitis should be suspected when there is tenderness
over the sinuses. Other common signs and symptoms include:
    recent onset headache
    associated sinus trouble
    post-nasal drip
    symptoms worse when patient bends down

Migraine headaches are usually recurrent headache with headache-free intervals.
They are throbbing in nature, and usually on one side of the head but may be on
both sides. They may or may not be associated with a visual defect. Often there is
nausea and vomiting if not treated promptly. Although the first attack is usually
during teenage years, they can start later.




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Visual disturbances are common features of migraine headaches. Other types of
headache may also, however, produce visual field loss. These include temporal
arteritis (patients are usually >50 years), and headaches associated with glaucoma
and benign intracranial hypertension. In some of these headaches, the visual loss
may be permanent if not treated quickly.

Unless the patient has a definite diagnosis of migraine and has had similar visual
disturbances before which have passed, it is best to refer all headaches with new
onset visual disturbances.

Migraine is probably the commonest cause of episodic headache with no symptoms
in between attacks. Trigeminal neuralgia, where there is facial pain in the distribution
of the fifth cranial nerve (trigeminal), can also produce episodic headache with facial
pain. Actions like combing hair or brushing teeth act as triggers for the pain. There
are other rare causes of episodic headache.

Tension headache
    family history of migraine
    chronic daily headache
    like a ―pressure‖ or ―band around the head‖
    stable over many months/years
    analgesic overuse
    related to stress/depression
    nuisance for patient, but not a dangerous headache

A tension or simple headache can be a side effect of ART.


       Look at photo booklet Group 10
       A. Bell‘s palsy (face flaccid on one side)
       B. Test for sinus tenderness


CLASSIFY if painful foot or leg (or hand) neuropathy

Peripheral neuropathy is a common neurological complaint. It presents as a painful
burning or numb or cold feeling in the feet or lower legs (less commonly in the
hands). This is described as a glove or stocking (sock) distribution. On examination
there may be reduced or altered sensation. Common causes of peripheral
neuropathy include diabetes, vitamin deficiency (often seen in patients with chronic
excessive alcohol use), HIV/AIDS, and as a side effect of some medications
including antiretroviral medications.

If painful, feet or hands, without focal signs, classify as painful peripheral neuropathy.
The patient should be assessed at least once for an underlying cause. Patients with
HIV/AIDS on ART who develop painful peripheral neuropathy may need a
substitution of the d4T drug in their ARV regimen (see Chronic HIV Care with ART
and Prevention guideline module).




                                                                                      101
Consider diabetes—check the urine for glucose or measure the blood glucose.

Low dose amitriptyline can be an effective treatment.

CLASSIFY if cognitive problems—problems thinking or remembering or
disorientation

Cognitive problems include decreased memory, diminished attention, or decreased
intellectual abilities Cognitive problems refer to difficulties in specific thinking tasks.
These include memory, attention, speech and language skills, visual-spatial skills,
abstract thinking and speed of information processing

In case of confusion or cognitive problems (decreased memory, diminished attention,
or decreased intellectual abilities), use the classification table on page 48 to consider
the following possibilities:

Delirium

Delirium is a condition characterized by an abrupt change in the patient‘s mental
status. The change is usually acute in onset (hours to weeks) and the level of
symptoms may fluctuate over the course of the day. Core symptoms are clouded
level of consciousness and confusion. Patients have a reduced level of clarity of
awareness about their surroundings and are often disoriented. They have difficulty
sustaining attention, may have a decreased or fluctuating level of arousal and are
often distractible. Confusion when seen in delirium results from the patient‘s acute
change in mental state associated with a fluctuating level of arousal and awareness.

In addition to the confusion, patients with delirium may have:
     memory impairment and attentional problems,
     perceptual abnormalities such as hallucinations
     restlessness, irritability and agitation
     paranoia and develop delusions
     rapidly shifting emotional state (fluctuating between tearful, scared, angry,
       irritable)
     poor judgement and impulsive behaviour
     disturbed sleep-wake cycle with symptoms of agitation, often worsening at
       night

The mental state change is usually very obvious in a confused and agitated patient
with delirium. In some patients the mental state change is an abrupt reduced level of
arousal and is harder to notice as they are ‗quietly confused‘. In either case it is
important to ask caregivers about the onset and course of the mental state changes
and be aware that the symptoms can fluctuate over the course of the day.

Delirium is most common in elderly patients and in people with major medical
illnesses. Diagnosis is made by clinical evaluation with a complete history, including
details on any recent changes in medical status, medications or drug and alcohol
usage and physical examination. The goal of treatment is to identify and correct the
underlying medical problems.



                                                                                       102
Causes of delirium

Delirium is due to either a single or multiple underlying medical conditions. Most of
the causes of delirium are amenable to treatment. Every effort must therefore be
made to find the cause and treat. If the cause is not obvious, it is always best to refer
a patient with delirium as the cause may be life threatening if not treated quickly

Common causes of delirium include:
   Infection: both systemic infections such as pneumonia, malaria and sepsis
    and central nervous system infections such as meningitis or encephalitis can
    cause an acute confusional state or delirium
   Drug intoxication or withdrawal (including alcohol)
   Medication related (either treatment emergent side effect or intoxication due to
    excess ingestion/overdose)
   Acute metabolic abnormalities including hypoglycemia, electrolyte
    abnormalities, kidney failure, liver failure, acid—base derangements and
    severe dehydration
   Hypoxia (insufficient oxygen to the brain) including anemia, heart failure,
    pulmonary failure
   Central nervous system pathology including stroke, tumour, infection,
    subdural hematoma or vasculitis
   Head trauma
   Exposure to toxins including heavy metals such as lead or pesticides
   Vitamin deficiencies and endocrine disorders

Patients in advanced stages of HIV/AIDS are at high risk for developing delirium and
the evaluation must consider all possible usual causes of delirium as well as the
secondary opportunistic conditions that people with advanced immune suppression
(CD4 count < 200) are at risk for developing.

Patients with HIV disease are also often on multiple medications which may
potentially interact or result in additive layering of side effects which lead to an acute
confusional state. Medications that may be associated with delirium include sedative-
hypnotics, antidepressants, anticonvulsants, antihistamines, steroids, antibiotics, and
narcotics. Many of these interact with ART and drug interactions should be
considered in a patient with delirium.

What to do if the patient has DELIRIUM:

Most causes of delirium are amenable to treatment. Every effort must therefore be
made to find the cause and treat. If the cause is not obvious, it is always best to refer
a patient with delirium as the cause may be life threatening if not treated quickly.

Patients with delirium should be referred to hospital, in order to determine the cause
and provide urgent treatments. Ensuring a safe environment for the patient
meanwhile is important so that the patient does not accidentally harm themselves or
interfere with medical treatments in their confused state. If not able to refer




                                                                                      103
immediately, it is important to prevent dehydration by giving fluids. Check blood
glucose and give glucose and thiamine.
Treatment includes correcting the underlying medical disorder (e.g. systemic illness,
suspected malaria) and providing supportive care and management of the symptoms
of delirium until such time as the underlying disorder is resolved, or referral can be
arranged. If the delirium is due to alcohol withdrawal, then benzodiazepines such as
diazepam should be used (see p.86). For causes of delirium other than alcohol
withdrawal, symptoms of confusion and agitation should be managed using low
doses of haloperidol (see section on using haloperidol, p.86). It is important to
remember that patients with HIV/AIDS and in particular in advanced stages of illness
are extraordinarily sensitive to haloperidol and low doses (i.e. 0.5 mg as starting
dose) must be used.


Dementia

Dementia is an acquired impairment of several intellectual/cognitive abilities.
Memory is prominently affected, as are other intellectual functions such as attention,
learning, information processing, language, reasoning, and judgment. Personality
and behaviour are often affected.

There is no altered or fluctuating level of consciousness. Confusion, when seen in
dementia, results from the cognitive impairment that the person experiences:
    The person is confused because they cannot remember who others are or
    They get lost and confused because they can‘t remember where they are and
      are disoriented or
    They seem confused because they have lost the ability to process information
      correctly.

Dementia results in failure to cope with activities of daily living and loss of
independence.

Typically the onset of dementia is insidious. It often starts with gradual development
of forgetfulness. This progresses to more severe memory problems and difficulty
with attention and concentration. These changes result in decreased efficiency at
work and then with everyday tasks and finally with personal care. At later stages
patients are at risk of getting lost, even in familiar surroundings.

Patients may develop personality changes, apathy, and behavioural problems such
as wandering, becoming obstinate, or even psychotic symptoms such as delusions
and hallucinations. Dementia in relatively young people (< 60 years) has more
serious implications.

Many patients are not aware of the problems or deny that the cognitive changes are
a problem. It is the relatives who often notice the changes so it is important to get a
history from them as well.

Causes of dementia
There are many different causes of dementia. Each cause has somewhat different
manifestations and progression but all are insidious in onset and development and


                                                                                   104
result in chronic impairment in several cognitive and intellectual functions. Some
common causes of dementia are Alzheimer‘s disease, vascular problems, HIV/AIDS,
neurosyphilis, thiamine deficiency (often seen in persons with chronic excessive
alcohol consumption), Vitamin B12 deficiency, or head injury/subdural haematoma.
Patients with severe depression can often have significant impairment of memory
and concentration that can look like a dementia.

Every patient with dementia should be assessed well once to make sure that there
are no reversible causes to account for the cognitive changes. Reversible or
treatable causes include hypothyroid disease, neurosyphilis, Vitamin B12 deficiency,
thiamine deficiency, depression, a subdural haematoma, or even alcohol excess.
HIV/AIDS can cause dementia and, if treated before significant cognitive decline
occurs, may improve with ART.

HIV-related Dementia

Cognitive complaints are common in HIV disease. With progression of HIV/AIDS and
declining immune function there is an increased prevalence of HIV associated brain
disease. In its most severe form, it limits the patient‘s capacity to work and attend to
activities of daily living and is referred to as HIV-associated dementia complex
(HADC). A more minor form is referred to as HIV-associated minor cognitive motor
disorder (MCMD), where there are some cognitive complaints and functioning is not
optimal, but the symptoms are usually not progressive and are not severe enough to
diagnose dementia.. (See Appendix A for more detail on HADC and MCMD).

It is important to realize that not all people develop HIV related cognitive syndromes
as a component of their HIV disease, even at very late stages of their illness.

Some patients with HIV associated dementia complex will develop behavioural
complications. Most commonly this is characterized by fatigue, depression and loss
of energy and motivation. Some patients will develop agitation, irritability, aggressive
behaviour and even psychotic symptoms as a component of HIV associated
dementia complex.

Diagnosis is made clinically through history, mental status and neurological
examination, and where available, neuro-psychological assessment. HIV disease
staging and laboratory markers of immune dysfunction and viral load are also
important in the assessment. If suspected, referral is therefore necessary. Patients
may be inaccurate in their subjective assessment of their cognitive symptoms so it is
often useful to get the input of supportive caregivers.

Cognitive complaints may also be due to major depression, medication side effects,
substance related disorders, or other cognitive disorders or a secondary central
nervous system opportunistic condition. These need to be excluded (see further
below).

It is important to interpret cognitive symptoms (confusion, disorientation, diminished
attention, memory problem, difficulty thinking clearly) in the context of the patients
overall health status:



                                                                                    105
What is the patients CD4+ count?
   If the CD4+ count is less than 200, the patient is at risk of secondary central
      opportunistic conditions associated with HIV/AIDS and is also at risk of HIV
      associated dementia complex. Often these conditions can both exist and be
      contributing to the symptoms
   If the CD4+ count is between 200 and 500, the patient is at risk of MCMD but
      less likely to have HIV associated dementia and unlikely to have a secondary
      CNS opportunistic condition
   If the CD4+ count is greater than 500, the cognitive symptoms are unlikely to
      be due to HIV disease (ie unlikely to be MCMD, HIV associated dementia or
      secondary opportunistic conditions) and other causes should be considered
      such as substance related disorders, medication side effects, other
      neurological disorders, longstanding neurodevelopmental delay

Is the patient medically unwell?
If the patient is medically unwell, the cognitive symptoms may be due to a secondary
central nervous system opportunistic condition, especially if the patient has a CD4
count below 200. These conditions can coexist with HIV associated dementia
complex. It is important that they be identified and treated. Symptoms that
accompany cognitive decline that may suggest a secondary condition include fever,
headache, focal neurological deficit, meningeal signs (neck stiffness, photophobia)
and constitutional symptoms of systemic illness.

See question:
 Do you feel your brain/mind is working more slowly?

Additional questions to clarify possible HIV-related dementia

   Cognitive symptoms
          o Do you feel as if your brain is working more slowly and less efficiently
             than it has in the past?

   Mood/behavioural symptoms
         o Do you feel apathetic, unmotivated and flat?
         o Do you feel irritable and agitated?

   Motor symptoms
         o Do you feel clumsy and uncoordinated?

   Level of severity and function
          o How do these symptoms affect you?
          o Do they make it hard for you to remember to take your medications
             everyday?

   Also ask the patient if you can check on their level of function with a supportive
   caregiver. If they give permission, ASK THE CAREGIVER:
          o Do you think the patient‘s memory and concentration problems pose
             any danger to their living independently or reliably taking their
             medications everyday?



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          o What supports exist at home to help the patient compensate for their
            thinking problems?

Normal ageing

Cognitive problems may be due to normal ageing processes. Usually the problems
are less severe: occasional decreased concentration or minor short-term memory
loss. The problems may nevertheless be distressing for the patient and relatives,
who should be reassured as to their normality.

What to do if the patient is classificed as DEMENTIA:

If not previously done, refer for full assessment to exclude a reversible cause. Also
consult or refer for treatment if the cause of dementia is uncertain.

Counsel family or friends on how to manage the patient. It is important to provide a
safe, protective environment for the patient. Attention should be given to regular
intake of fluids to prevent dehydration. Supportive contact with familiar people can
reduce confusion. Rehabilitation strategies that can help patients adjust to their
cognitive losses may help them to continue to function somewhat normally
particularly in the early stages of forgetfulness and impaired efficiency of cognition.
Such strategies can include keeping a written record to keep track of appointments,
undertaking one action at a time rather than multitasking and using to do lists.

Caring for family members and friends with dementia is extremely stressful. Make
sure to ask the caregivers how they are coping and help them access emotional and
practical supports to ensure that they are able to successfully take care of
themselves as well as the patient.

HIV-related dementia
Antiretroviral therapy is the main treatment for HIV associated dementia complex. It
is important that patients with HIV associated dementia complex be identified and
offered ART. ART that fully suppresses viral replication will be helpful in preventing
further progression of cognitive deficits and may help reverse deficits in some, but
not all patients. If there is no improvement, or there is further deterioration after 4-8
weeks, the patient should be referred for further investigation. It is important that
delirium and secondary CNS opportunistic conditions be identified and treated as
well, as they can coexist with HIV associated dementia.

It is essential that patients have excellent adherence to ART and because patients
with HIV associated dementia complex have memory problems they may need extra
support and reminders to help them achieve excellent adherence. In patients who
develop behavioural complications, depression or psychotic symptoms, it is
important to stabilize and treat these (see mental health section for
depression/psychosis treatments) and then initiate ART for the treatment of the
underlying HIV associated dementia complex.




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For self study materials on neurological and mental disorders, see Annex.

For all acute (and chronic) patients, check status of routine screening,
prophylaxis, and treatment—use page 21.

If your classifications lead you to consider HIV infection, use page 54




                                                                            108
Chapter 14: Mental health problems

Page 50-52: If patient has a mental problem, looks depressed or
anxious, sad, fatigued (tired), has an alcohol problem or recurrent
multiple problems:

If sad or loss of interest or decreased energy…

Assess for DEPRESSION
ASK: It is important to listen without interrupting to the responses:

      Do you feel sad or depressed?
      Have you lost interest/pleasure in things you usually enjoy?
      Do you have less energy than usual?

       If the patient complains of fatigue or feeling more tired orhaving less energy
       than usual, also consider medical causes of fatigue such as anaemia (use
       page 18), infection, other medications, HIV disease progression, lack of
       exercises, sleep problems, fear of illness, hypothyroidism, etc.

       Ask about medications: Certain medications can also cause depression. In
       particular, in an HIV infected patient, who has recently started taking the
       antiretroviral drug efavirenz, depression may occur quite suddenly, and can
       be severe enough to cause suicidal thoughts. See Chronic HIV Care with
       ART, H41

       Most of us have depressed feelings at some stage in our lives. This is usually
       in reaction to things that happen that are upsetting or difficult. These feelings
       usually pass quickly and we recover our usual positive state of mind.

       However, in some people, depression is an illness that can persist for lengthy
       periods of time and can cause functional impairment (i.e. the person is not
       able to function normally in terms of social, work and leisure activities). The
       severity of a depressive illness also varies from only mild functional
       impairment (inability to concentrate at work or to make decisions) to very
       severe impairment (with suicidal ideas or behaviour, inability to move or eat or
       drink or maintain personal hygiene). In less severe cases, it is sometimes
       difficult to decide whether the person needs medical treatment. If there is any
       doubt, you should refer the patient to a mental health practitioner for an
       opinion.

       To decide if someone has Major Depression, or only a Minor Depression or
       Complicated Bereavement, or is just suffering from Difficult Live Events or
       Loss, it is necessary to ask more questions, as outlined under ASK. You will
       then use these responses to classify the patient:

          o disturbed sleep—usually insomnia (inability to sleep). This may be
            initial (inability to fall asleep on going to bed), middle (waking during the


                                                                                     109
             night and unable to go back to sleep for more than an hour) or terminal
             (waking in the early hours of the morning and unable to go back to
             sleep before the usual waking time). Sometimes the person may sleep
             more than usual.
         o   appetite loss or increase—usually loss of appetite (and significant
             loss of weight). Sometimes there can be increased appetite and weight
             gain.
         o   poor concentration—Poor concentration and/or inability to make
             decisions—the person is unable to concentrate on conversations,
             reading, listening to the radio or watching a TV programme. There is
             also often difficulty in making decisions. This can range from major
             decisions to minor everyday decisions such as what clothes to wear or
             what to eat.
         o   moves slowly—observable slowing of movements (i.e. not based
             solely on patient‘s report)
         o   decreased sex drive—markedly decreased interest/engagement in
             sexual activity
         o   loss of self-confidence or esteem—The person may lack confidence
             to do their normal activities, may feel bad about themselves (think they
             are not a good person, that they are useless etc) and this may become
             extreme to the extent that they develop:
         o   thoughts of suicide or death—This is very common in major
             depression and suicide is a very real risk in this illness. Sometimes
             health workers are reluctant to ask a depressed patient about suicidal
             thoughts, fearing that this may ―give the depressed person ideas‖. This
             is not likely, as the person has very often already thought about it, and
             very often is very relieved to be able to express their thoughts.
         o   guilty feelings—The person may feel that s/he is responsible for bad
             things that happen to him/herself, to loved ones, acquaintances or
             other less distantly related people. This may be of such severity that
             the person loses touch with reality and believes that they have
             committed a terrible sin, done something dreadful and caused mayhem
             and destruction. In this case we would say that the person has a
             delusion and has a psychotic depression (see section on psychosis for
             definition of a delusion).

ASK
     Have you had bad news for yourself or your family?

      If a patient has had bad news, this may explain why s/he is depressed. If they
      are helped to deal with the bad news, they may recover and may not need
      further treatment. However, it is always important to consider the severity of
      the depression, the duration of the depression and the presence or absence
      of suicidal thoughts in making a decision about whether the person suffers
      from a Major Depression or from a Minor Depression or Complicated
      Bereavement or Difficult Life Events or Loss. Sometimes Major Depression
      occurs without any reason, but it may also occur as a result of a specific
      stress in the patient's life.




                                                                                  110
   Assess the risk of suicide

    It is important to assess the level of risk of suicide in someone who expresses
    thoughts of suicide or a wish to die.

    Risk assessment: factors to consider include the following:
       o Does the person have a well-thought out plan which has a high chance
           of succeeding?
       o Is the method the person is planning (or has attempted) to use a lethal
           one? (e.g. taking poison, using a firearm, jumping from a high building)
       o Is there a history of previous suicide attempts, and how serious were
           these?
       o Has the person told anyone else? Is anyone in their family aware of
           how they are feeling?
       o Does the person have a serious medical illness, severe alcohol
           problem or a serious mental illness such as major depression or
           psychosis?

For all patients, ASK
 Do you drink alcohol?
   It is important that this be asked in all patients. Harzardous and harmful
   alcohol use are very common and cannot excluded by just looking at the
   patient. If the patient drinks any alcohol, you need to ask about the number of
   drinks to determine if they exceed the number of drinks per week that are
   considered hazardous.

If yes:
 Calculate drinks per week over the last 3 months.
    Help them to calculate:
        o How many drinks do you have per day (you need to know what the
           local equivalent is of one drink.
        o How many days in the week do you drink.
        o Calculate usual drinks per week.
 Have you been drunk more than two times in the past year?
    This is a screening question for possible harmful alcohol use. Getting drunk
    carries risks such as accidents and risky sex.
   Are you taking any medications?
    If not previously asked (see page 23 of Acute Care guideline module), ask (or
    repeat question if unsure).

    Certain medications can also cause depression. In particular, in an HIV
    infected patient, who has recently started taking anti-retroviral treatment
    (especially efavirenz), depression may occur quite suddenly, and can be
    severe enough to cause suicidal thoughts. (See also Chronic HIV Care,
    p.H41)




                                                                               111
LOOK AND FEEL

     Does the patient appear:
        o agitated?
        o depressed?

      Does patient appear agitated? Is the patient verbally or physically aggressive?

   Is the patient disoriented to time and place? (see previous chapter for this
    assessment)

     Is the patient confused?

      It is important to assess patients who are confused or have a cognitive
      problem using the neurological assessment—this may not be a mental health
      problem.

     Does the person express bizarre thoughts? If yes:
        o Does the patient express incredible beliefs (delusions) or see or
            hear things others cannot (hallucinations)?
        o Is the patient intoxicated with alcohol or on drugs which might
            cause these problems?

      It is important to distinguish between signs which may indicate psychosis and
      those that are due to alcohol or other drugs (which may disappear when the
      drug wears off).

     Does patient have a tremor?

      Many of the signs and symptoms characteristic of psychosis are common to
      severe alcohol intoxication or severe withdrawal, which should always be
      assessed and excluded or, if present, appropriately treated. This includes
      assessing whether the patient is intoxicated with alcohol or has severe tremor.




                                                                                 112
CLASSIFY

Classify if sad or loss of energy or decreased energy:
 Suicidal                               If high risk, refer for
   thoughts            SUICIDE RISK       hospitalization (if available) or
 If patient also                         arrange to stay with family or
   has a plan and                         friends (do not leave alone).
   the means, or                         Manage the suicidal person.
   attempts it with                      Remove any harmful objects.
   lethal means,                         Mobilize family support.
   consider high                         Follow up.
   risk

   Five or more                           If suspect bipolar disorder (manic
    depression           MAJOR              at other times), refer for lithium.
    symptoms and       DEPRESSION          If patient is taking efavirenz
   Duration more                           (EFV), see Chronic HIV Care.
    than 2 weeks                           Otherwise, start amitryptiline (p.
                                            82).
                                           Educate patient and family about
                                            medication.
                                           Refer for counselling if available
                                            or provide basic counselling to
                                            counter depression (see p. 107-
                                            108).
                                           Follow up.
   Less than 5                            Counsel to counter depression.
    depression            MINOR            Give amitryptyline if serious
    symptoms or        DEPRESSION/          problem with functioning.
   More than 2       COMPLICATED          If problems with sleep, suggest
    months of         BEREAVEMENT           solutions.
    bereavement                            Follow up in 1 week.
    with functional
    impairment
   Bereaved,                              Counsel, assure psychosocial
    but functioning   DIFFICULT LIFE        support.
                      EVENTS/LOSS          If acute, uncomplicated
                                            bereavement with high distress
                                            and not able to sleep, give
                                            diazepam 5 mg or amitryptiline 25
                                            mg at night for one week only.




                                                                                  113
SUICIDE RISK
If patient has a plan and the means, or has attempted suicide, consider the suicide
risk to be high. It is important to intervene (see page 51 of Acute Care guideline
module—suicide risk)

The immediate treatment should be to manage suicide risk if present. If high risk, refer
for hospitalization or make arrangements with family or friends to supervise the
patient. Do not leave the high risk suicide patient alone.

Explain the condition (depression) to the patient, the need for treatment, the likely
response to treatment and the fact that suicidal thoughts and feelings are likely to
disappear with treatment. Ensure the safety of the patient (and others if necessary),
mobilize family support and arrange follow-up.


MAJOR DEPRESSION
If the person has five or more of the depression symptoms (one of the 5 symptoms
MUST be depressed mood or loss of interest/pleasure) for more than two weeks,
then s/he is suffering from Major Depression.

Major depression is an illness that requires medication or specific kinds of
psychological counselling. The core features are persistent depressed mood for
most of the day, every day, for at least two weeks, or loss of pleasure or interest in
normal activities for most of the day, every day, for at least two weeks. These
symptoms may be expressed in culturally specific ways (e.g. ―have a sore heart‖).
The person may also present with persistent physical complaints for which no
underlying cause can be found. There may also be other signs and symptoms (see
below).

Treat MAJOR DEPRESSION
If you are going to start treatment for major depression, refer to page 82 in the Acute
Care guideline module on how to use amitryptiline. If you are unsure of the
diagnosis, the patient is or becomes a suicide risk, or there is no response to
treatment after one month, then refer the patient.

It is also important to provide counselling and support to a patient with Major
Depression. Use the instructions on pages 98-99 of Acute Care guideline module).

MINOR DEPRESSION OR COMPLICATED BEREAVEMENT
If the patient has less than 5 signs or has been in bereabement for more than 2
months with significant functional impairment, provide both counselling and consider
low dose amitryptiline if the functional impairment is serious. If inability to sleep is a
problem, discuss and suggest solutions (see Palliative Care guideline module).
Follow-up in 1 week- it is important not to lose these patients because they may
develop a major depression or suicide risk.

DIFFICULT LIFE EVENTS/LOSS
It is normal to grieve. If the patient is able to function but there is very high distress
and the patient is not able to sleep, consider offering diazepam 5 mg or amitryptiline



                                                                                      114
30 mg at night for one week only. Counselling and support for the patient from family
and peers. are more important.


CLASSIFY if bizarre thoughts

PSYCHOSIS
Psychosis is a severe mental illness where there is loss of contact with reality and
lack of insight (the person does not appreciate that his/her behaviour is bizarre),
together with either delusions or hallucinations. People with psychosis may speak
incoherently because of their confused thinking. This confusion in thinking and
speaking is part of the illness and is called ―thought disorder‖. There is also usually
severe functional impairment (lack of ability to work, take care of self, interact
normally with other people) and abnormal behaviour (often as a result of the
delusions or hallucinations).

Delusions are fixed false beliefs that are not culturally acceptable and which are not
open to rational discussion (the deluded person holds the beliefs despite evidence to
the contrary and cannot be swayed or persuaded that these beliefs are not true).
Delusions may be paranoid (the person believes that someone or something is trying
to harm them, that there is a conspiracy against them, that they are in severe
danger, etc.), grandiose (the person believes that they are someone very important,
has special powers that others do not have, etc.), have a religious content (usually
also grandiose), or somatic (for example, believing that one is rotting inside, or that
something is eating one‘s intestines up). There are also delusions of reference,
where a person believes that others are talking about him, or that there are special
references to him on the radio or on TV. Delusions are a disorder of thinking.

Hallucinations are perceptual disturbances, where the person perceives a stimulus
that others do not. For example, a person may hear voices that other people do not
hear. A true (clinically significant) auditory hallucination has the following
characteristics: the voice (usually) is heard in clear consciousness (while awake);
often it is experienced as talking into the person‘s ears, or maybe heard inside the
person‘s head. The voices are persistent and present for considerable periods of
time; they may comment on what the person is doing, or tell the person to do certain
things (called ―command hallucinations‖).

In addition to the core features of delusions and hallucinations, people with a
psychotic illness may also exhibit disorganized and incoherent speech, disorganized
behaviour (agitated, aggressive or bizarre behaviour, which may be based on
delusions or hallucinations), poor self care, and abnormal motor activity
(restlessness, catatonia—lack of movements, and bizarre posturing). However,
some people with psychosis may appear to be quite normal and their illness only
becomes obvious during conversation, or even when reported by family members.

Causes of psychotic symptoms:
   Some general medical conditions (including HIV) can present with psychotic
     symptoms.
   Drug effect—It is important to exclude alcohol or other drug intoxication.
     Psychosis can be a side effect of efavirenz, an antiretroviral drug.


                                                                                   115
    Schizophrenia and other related psychotic disorders


TREAT
If due to general medical condition or alcohol/drug effects, treat underlying condition
before referral
Refer for psychiatric care
If acutely agitated or dangerous to self or others, give haloperidol, (pg 83)


If the person is tense, anxious or worrying excessively, consider an
Anxiety Disorder
Assess for ANXIETY DISORDER
If the patient expresses the above feelings or appears agitated, explore further, using
additional questions—ASK:
      Do you sometimes suddenly begin to feel extremely anxious?
      Is there anxiety in specific situations?
      Do you worry a lot generally, feel very tense, or unable to relax?

CLASSIFY if tense, anxious or excess worrying

ANXIETY DISORDER
Anxiety disorders are common, and are often undetected and untreated. People with
anxiety disorders often feel ashamed of their symptoms and the way they feel and
may not talk about their difficulties. There are a number of specific types of anxiety
disorder that are important to identify as there are effective treatments available.

Panic Disorder: This is a condition where the person experiences sudden episodes
of extreme anxiety (panic attacks). The onset is very sudden and there are many
physical symptoms: difficulty breathing; heart beating very hard and fast; feeling of
choking, sweating, shaking; and/or feeling of impending doom. The episode usually
lasts ten to thirty minutes and may occur without any warning. Sometimes the person
associates a certain situation with their panic attacks (e.g. being in a crowd of
people, or being in a taxi or an elevator), and then they may avoid these situations.
Sometimes things get so bad that the person is not able to leave their house
because they are afraid of having a panic attack. This condition can be treated with
antidepressant medication.

Stress disorders: These disorders may develop after exposure to a life-threatening
stressor, for example, being raped or assaulted, witnessing someone else being
violently killed, or being in a natural disaster. Not everyone who experiences such a
stress develops acute stress disorder or post-traumatic stress disorder.

The symptoms include:
    Persistent re-experiencing of the traumatic event (e.g. images, thoughts,
      dreams)
    Hyperarousal (excessive awareness or and responsiveness to stimuli)
    Avoidance (of anxiety-provoking situations)


                                                                                   116
    Numbing of feelings

These symptoms interfere with the person‘s ability to function normally.

Stress disorders may develop within a short while or only some time after exposure
to the stressor. In less severe cases, the disorder usually settles within a month. If
symptoms persist for more than a month, this indicates a more severe form of stress
disorder (post-traumatic stress disorder).

People who suffer from these disorders need counselling (psychotherapy if
available) and may also need medication.

Generalised Anxiety Disorder
In this condition there is a constant feeling of anxiety and tension, with an inability to
relax. The anxiety may interfere with sleep and appetite and also interferes with the
person‘s ability to function. This condition often responds to counseling and stress-
relief methods. In some cases, medication may also be useful, such as short term
use of anti-anxiety medications.


TREAT
   Refer possible panic disorder or post-traumatic stress disorder
   Counsel on managing anxiety in specific situation
   Teach slow breathing and deep relaxation
   If severe anxiety, consider short-term use of an anti-anxiety medication such
    as diazepam (for two weeks only)
   Follow-up in two weeks
   If no response to counselling, stress-relief interventions and short-term use of
    benzodiazepines, refer for higher level intervention. Do NOT continue giving
    diazepam or other benzodiazepines!



Classify If more than 21 drinks/week in men and more than 14
drinks/week in women or drunk more than twice in last year
In the patient is drinking more than this limit, they have at least hazardous alcohol
use. Further assessment is needed to determine which of these patients have
harmful alcohol use. If possible, assess further using a questionnaire such as the
WHO AUDIT questionnaire which has been locally adapted (a simplified version will
be added to the next version of the Acute Care guideline module).

Low Risk Drinking
This refers to occasional, moderate, controlled drinking, with low risk of harm to self
or other

Hazardous Alcohol Use
This involves a pattern of drinking which carries a risk of harmful consequences to
the drinker or others. Possible consequences include damage to physical or mental



                                                                                      117
health, or injury to self or others. In assessing risk, the pattern of use (e.g. despite
generally moderate drinking, on some occasions drinking to intoxication, resulting in
acute risk of injuries, violence), as well as other factors (e.g. family history), should
be taken into account.

Harmful Alcohol Use
This is alcohol consumption that is already causing damage to health. This may be
physical (e.g. liver damage) or mental (depressive episodes secondary to
drinking).However, despite drinking excessively on a regular basis, there may be
little overt sign of impairment due to the person having developed tolerance. Hence
the pattern of drinking taken as a whole must be considered.

Patients with hazardous alcohol use may progress to HARMFUL ALCOHOL USE—it
is important to assess carefully using the WHO AUDIT or another tool. There are
effective brief interventions that the health worker, can provide that can help a
patient with hazardous or harmful alcohol use, before the problem becomes very
serious or contributes to an injury, or progresses to alcohol dependence.

SEVERE ALCOHOL WITHDRAWAL SIGNS
Severe alcohol withdrawal is a sign of alcohol dependence. The symptoms develop
over a few days. In severe alcohol withdrawal the person will be very anxious and
agitated, tremulous, with tachycardia (racing pulse), high blood pressure and may
have symptoms of delirium (see pg 48) as well as hallucinations (commonly visual or
tactile e.g. seeing things or feeling things crawling on the skin). The blood glucose
may also be low.

Alcohol dependence involves a physical addiction to alcohol and is reflected in a
cluster of symptoms. Dependence can also be determined by using the AUDIT. It
can be suspected if three of more of the following were present at some time in the
previous 12 months:

    a strong desire or feeling compelled to drink
    difficulty controlling drinking in terms of starting, stopping, or levels of use
    physiological withdrawal state when stopping alcohol use, or use of alcohol to
     relieve or avoid withdrawal symptoms
    evidence of tolerance i.e. increases amount of alcohol needed to achieve
     effects originally produced by lower amounts
    progressive neglect of other pleasures or interests because of alcohol use
    continued use despite clear evidence of harmful consequences


TREAT

Severe withdrawal:
Give glucose and thiamine (do NOT give glucose alone!)
Refer to hospital
If sedation is needed, give diazepam

Suspected dependence:
Refer for specialized assessment and treatment


                                                                                     118
Hazardous or harmful alcohol use:
Assess further and use brief intervention (see Appendix B)
Refer for specialized assessment and treatment if no improvement


For self study materials on neurological and mental disorders, see page 90.

For all acute (and chronic) patients, check status of routine screening,
prophylaxis, and treatment—use page 58 (Acute Care guideline module)

If your classifications lead you to consider HIV infection, use page 54 (Acute
Care guideline module)




                                                                              119
Chapter 15: How to use diazepam, haloperidol and amitryptiline

Using diazepam to treat severe alcohol withdrawal

Diazepam is a drug that has a sedative (dampening) effect on the brain. Its effects
include the following:
     calming an agitated person or sedating them (making them drowsy or sleepy)
     stops fits/seizures
     relaxes tense muscles or muscles that are in spasm
     can be used to help a person to sleep (but use with caution, for not more than
       2 weeks)

Diazepam is an addictive drug—the body can become reliant on it if it is used daily
for an extended period of time. It is usually recommended that it should not be given
for more than two weeks at a time. It should preferably not be given every day
(except in the case of treating alcohol dependence) and it should not be used to treat
sleep problems. Diazepam orally should be prescribed and managed at a district
hospital/medical officer/auxiliary level only. However, diazepam may need to be used
in certain emergencies at a primary care level. The two main reasons for giving
diazepam in this situation are:

Emergency treatment of ongoing epileptic fits/seizures (status epilepticus): see page
71 IMAI Acute Care guideline module

Emergency treatment of severe alcohol withdrawal (delirium tremens).
Give 5 to 10mg diazepam rectally or IV, and repeat 2 to 6 hourly if symptoms persist.
If the patient has a fit, treat as for status epilepticus (page 71).
In both cases, the patients should be sent to hospital for further treatment.

The most important side-effect of diazepam is that it can cause the person to stop
breathing. It is very important that the patient‘s pulse, breathing and level of
consciousness is monitored after being given diazepam rectally or IVI. Ensure that
the patient‘s airway is open. S/he should be nursed in a semi-prone position.
Transfer to hospital as soon as possible, accompanied by a health worker during
transfer. If the patient stops breathing, use the Quick Check on pages 10-11 in the
Acute Care guideline module.


Page 83: GIVE HALOPERIDOL.

Haloperidol acts on the brain and affects certain chemicals in the brain. These
chemicals are involved in psychotic disorders. So the main reason for using
haloperidol is to treat psychotic disorders. Haloperidol can also be used to treat
agitated or uncontrolled behaviour in someone with a delirium (due to a general
medical condition, e.g. infection, drug or alcohol withdrawal). Haloperidol will usually
calm the person immediately after the first dose, but psychotic symptoms such as
delusions or hallucinations may take some time (a few weeks) to disappear
completely.




                                                                                    120
If the patient is psychotic and there is no evidence of a medical illness, then the
usual dose is 5 to 10mg orally a day. This can be given in a single dose or twice a
day if necessary.

If there is evidence of a medical illness and/or if the person has a delirium, then a
much lower dose should be used. Usually 0.5mg to 2mg in divided doses is
sufficient. Sometimes a patient in Stage 3 or 4 HIV disease may have severe
psychotic symptoms and be difficult to control. In that case, give 0.5mg and repeat
after one hour. If there is still no response, then one can add diazepam 2mg to 5mg.

Haloperidol can also be used intramuscularly or intravenously in an emergency,
when the psychotic patient needs immediate sedation. The usual dose is 5 to 10mg.
Additional diazepam (5 to 10mg; preferably intravenous or rectal) or lorazepam
(4mg; intramuscular—must be stored in a refrigerator) can be given if necessary. It is
important to monitor pulse, blood pressure and respiration in these situations.

The most important side-effects of haloperidol are on the nervous system: these
include muscle spasms, stiffness, shaking, restlessness and abnormal movements.
People with HIV infection are especially sensitive to these side-effects, which is why
lower doses are used in these patients. Some of these effects occur soon after
starting treatment (muscle spasms, stiffness and shaking), while others occur later,
especially in people who are on haloperidol for a long time (years), e.g. abnormal
writhing movements of the face, jaw and neck (tardive dyskinesia).

The most life-threatening side-effect usually occurs soon after starting treatment.
This is an acute muscle spasm, called acute dystonia. This commonly affects young
men, and those who are medically ill and thus sensitive to the side-effects. The
muscles of the face, jaw, neck, eyes and chest may be involved. In addition, the
muscles in the larynx (airway) may be involved. This can cause difficulty with
breathing and suffocation. The most important things to do in this situation are to:
    Maintain an airway
    Stop the haloperidol
    Give biperiden 5mg IMI or IVI if it is available
    If not available, give diazepam 5mg rectally.
    Refer the patient to hospital


Page 82: GIVE AMITRYPTILINE.

Amitryptiline is a medication that acts on the brain. It is useful to treat serious
depressive illnesses, sleep problems and pain. It is always important to look for and
treat any underlying cause of sleep problems or pain. In these conditions, a low dose
(25mg) of amitryptiline may give some relief. The main reason why amitryptiline is
used is for the treatment of serious depressive illness. Amitryptiline has some
serious side-effects, so it is important to understand how it works and to be able to
explain this to your patient.

Amitryptiline affects certain chemicals in the brain. These chemicals are thought to
be involved in depressive illnesses. It takes some time (usually two to three weeks)
for the symptoms of depression to begin to be relieved by drugs such as


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amitryptiline. However, the side effects of amitryptiline can be felt immediately after
the first dose. So there is usually a period of time (two to three weeks) when the
person is still feeling very depressed and they also have side-effects of the
medication. This must be explained very clearly otherwise the depressed person will
simply stop taking the medication because it is making him/her feel worse than ever.
It is also important to explain that this is a course of treatment and that it is important
that the person takes the medication regularly for it to work.

The common side-effects of amitryptiline are dizziness (especially when standing up
quickly from sitting or lying down), feeling tired (sedated), dry mouth and
constipation. These usually fade in one to two weeks. Amitryptiline only needs to be
given once a day, so it is a good idea for it to be taken at night before going to bed.
This will also help the person to sleep, and s/he will also experience less of the side-
effects during the day.

Another way to reduce the side-effects of the medication is to start with a low dose
and increase the dose slowly. So we usually start with 50mg daily (at night) and
increase the dose by 25mg every week until an effect is seen. The usual effective
dose is between 100mg and 150mg. If the person is in hospital, it is possible to
increase the dose more quickly (usually every three days). If the person has HIV or
another serious medical illness, or is elderly, then it is especially important to start at
a low dose, increase slowly and not exceed 75 to 100mg a day.

A very important and serious side-effect of amitryptiline is its effect on the heart. It
can cause dangerous abnormalities in the rhythm of the heart (arrhythmias) and
should not be given to anyone with heart disease (especially a history of myocardial
infarction—―heart attack‖, or any existing abnormalities in the rhythm of the heart). If
too much amitryptiline is taken (for example, in an overdose), it is poisonous to the
heart and will also cause arrhythmias. Amitryptiline is broken down in the liver in the
body, and should also not be given to anyone with liver disease as this will then
cause very high levels of amitryptiline in the body and again poison the heart.

Because amitryptiline is so dangerous in overdose, it is especially important to be
careful in depressed patients who are suicidal. If possible, admit the person.
Otherwise, try to involve a caregiver who can supervise the person and their
medication. If that is not possible, then only give one week‘s supply of medication at
a time and see the patient every week.

Sometimes a depressive illness is part of a bipolar mood disorder (i.e. the person
has manic (―high‖) episodes as well as depressive (―low‖) episodes. Amitryptiline and
other anti-depressants can cause a person with bipolar mood disorder to ―switch‖
from depression to mania. This is a very serious side-effect and makes the course of
this illness much worse. If there is any indication that the person has had previous
―high‖ episodes, then s/he should not be treated with an antidepressant, but should
be referred to a higher level for assessment and treatment. Also, if the patient
―switches‖ while on the medication, s/he should be referred immediately.

Two other side-effects are important to be aware of: amitryptiline may cause urinary
retention in older men with enlarged prostate glands. Also, amitryptiline can
aggravate glaucoma (increased intra-ocular pressure).


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Once the medication is working, the patient will start to feel better, and will often be
tempted to stop the tablets. It is important to emphasize that the medication must be
taken for at least six months, and sometimes for up to a year, otherwise the
depressive illness may come back.



SELF STUDY EXERCISE #9 (NEUROLOGICAL AND MENTAL DISORDERS)

In each of the following scenarios consider what may be happening to the person
and what plan of action you would follow. Model answers are in the Annex.

1.   A 45 year old woman presents at your clinic. She is HIV-positive and was
     coming to the clinic for treatment of TB last year. Her TB treatment was
     completed 6 months ago. She is accompanied by her sister who says that the
     patient is not able to look after herself or her children anymore. She just sits at
     home and doesn‘t eat or look after herself or the children. This has been going
     on for the past four months. She cries a lot of the time. Twice she has used a
     blade to cut at her wrists, but without doing herself major harm. Recently she
     disappeared from her home, and they could not find her for a few days.
     Eventually she was found in another village. She looks dishevelled and
     confused. She stares vacantly; she moves slowly and she is unable to answer
     any questions you ask her.

2.   A 28-year old woman has just been diagnosed HIV-positive during her first
     pregnancy. She is very shocked and upset—she is happily married and was
     looking forward to the birth of her baby. She says she now has nothing left to live
     for and wants to kill herself.

3.   A 25-year old man has been attending your clinic for follow-up of his chronic HIV
     infection. He is now in stage 3 and his CD4 count has dropped to 150. He is due
     to start ART. You have suspected for a while now, that he abuses alcohol,
     although he has denied this in the past. He now comes to the clinic and appears
     to be intoxicated and smells of alcohol. He is unsteady on his feet and has a
     slight tremor. At first he denies that he has been drinking, but then confesses
     that he has ―one or two drinks every now and then‖ and that he is drinking more
     than he used to do. On further questioning, he admits to 2 or 3 drinks a day
     during the week and more at weekends and to being drunk at least twice in the
     last year. The drinking leaves him ―hung over‖ the next day and, recently, he has
     started to take a drink in the morning to get him going for the day. He says he
     really intends to stop, because he knows it‘s bad for him.

4. A 54-year-old woman is brought into the clinic by relatives. She is HIV positive
   and has been on the ART programme run from the clinic for a number of years.
   Her response to ART has been good. Her relatives state that, over the past three
   days, she has become confused and ‗difficult‘, resisting their efforts to get her to
   eat or take her medication. She has been restless and agitated and seems to
   sleep poorly. She talks to herself and sometimes seems to be seeing things that



                                                                                    123
    are not there. Today she seems confused, not fully alert and does not make eye
    contact. She does not respond to questions.


5. A 29-year old man is brought to your clinic for a check-up. He is well-known to
   you as he has a serious mental illness, probably schizophrenia, and he has been
   getting antipsychotic medication from the clinic for the past 10 years. You notice
   that he has lost a lot of weight since you last saw him three months before and
   he has swollen neck glands. You suspect that he may either have TB and/or be
   HIV-positive.

6. A 43-year old mother of 5 who is HIV-positive and who has been attending your
   clinic for follow-up is now in Stage 3. Her CD4 count is 300. She complains that
   she has not been sleeping well for the past month. She looks unhappy and says
   that she has been having a lot of trouble with her teenage son, who is
   argumentative and disrespectful. She is a single parent and works as a cleaner
   and assistant at a local supermarket. She has difficulty falling asleep and
   sometimes wakes during the night and can‘t get back to sleep. She is finding it
   difficult to get up to go to work in the morning. At work, sometimes she loses
   track of what she is doing and it seems to take longer to finish things. Her
   appetite is poor and she has to force herself to eat properly. She acknowledges
   feeling depressed, especially because of the battles with her son, which make
   her feel that she is no good as a mother. If it was not for the younger children,
   she might have thought of killing herself. For their sake, she feels she has to go
   on.

7. You are asked to see a 33 year old HIV positive man, who is brought to the clinic
   by his wife. She says he has been behaving strangely for the last few weeks. He
   has become very withdrawn, but sometimes gets very angry for no reason. In
   the last few days, he has refused to eat anything, saying that ‗they are trying to
   poison me‘. It is not always easy to understand what he is saying. Sometimes he
   seems to be talking to someone, even though there is nobody there. Sometimes
   he seems to be hearing voices. He has been sleeping poorly and often wakes up
   suddenly during the night, sometimes shouting, as if he has had a bad dream.
   All this started shortly after he was started on ART. The man is agitated and
   restless. He does not respond to his name or answer questions you ask. At
   times, he seems fearful.

8. A woman of 35 years who has been doing well on ART reports for her regular 3-
   monthly check-up. She reports that, since her last visit, she has been having
   attacks where she feels very anxious, her heart beats very fast, she starts to
   sweat and shake and she feels as if she is going to die. These attacks happen
   without warning and usually last about 10 minutes. They have been happening
   more often—she has had two attacks in the last week. She wonders whether
   they are due to the medication, or are a sign that the medication is not working
   properly—perhaps she should stop the medication. Although there are no
   outward signs of anxiety during your consultation, you can see that the patient
   finds these attacks very frightening and that they have made her question being
   on ART.



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9. A 19 year old man is brought to your clinic by his mother. He has been behaving
   strangely for the last few weeks. He talks to himself and seems to hear voices.
   He doesn‘t eat properly and has lost weight. He hasn‘t been washing himself
   and refuses to put on clean clothes. If you try to get him to do something, he
   becomes angry, but if left alone, just sits quietly staring into space. He has
   stopped going to work, but still sometimes goes out with friends. When he
   comes home, his clothes smell of dagga, but when his mother asks him about it,
   he just shouts at her. He is a thin young man, who is difficult to interview. He
   takes time to answer questions and often does not answer or answers
   incompletely. He is able to tell you his name, his home address and where he
   is, but, although he knows the month and year and that it is morning, he cannot
   remember the day or date.

10. You are asked to assess a 72 year old woman who has been brought to the
    clinic by her daughter. She has always been healthy and active until three years
    ago when she started to slow down. About two years ago the daughter noticed
    that her mother seemed more forgetful, often forgetting where she had put things
    and forgetting what things were called. Over the past six months she has been
    even more forgetful, cannot remember the names of her grandchildren and on
    several occasions gone to sleep forgetting to turn off the stove. The patient is
    medically well and has no concerns about her memory. Her mood is good but
    she does admit to feeling her age.

11. It is six months later and the same lady is brought back to clinic by her daughter.
    After her last visit she had a comprehensive workup and it was determined that
    she had Alzheimer dementia. Her HIV and syphilis tests were negative. She was
    started on medication to better control her blood pressure and she was given
    vitamin B12 supplementation. Her daughter was reassured that there was a
    diagnosis but was saddened to hear that things would likely get worse for her
    mother with the passage of time. She tells you that the mother had been doing
    reasonably well until four days ago when she started to have a cough and a
    fever. She has been getting progressively worse and two days ago she was
    acutely confused. She did not know where she was and did not know who her
    daughter was. She even seemed very frightened by her daughter at some times.
    She was sleeping very poorly and resisting any attempts that the daughter made
    to help her eat or bathe. The daughter noticed that her mother seemed most
    confused at night-time and yet at some points during the day she seemed
    reasonably clear-headed.

12. A man aged 27 years, who is a patient at your clinic, reports that, shortly after
    his last visit a month ago, a taxi he was travelling in was involved in an accident.
    Luckily he had only minor abrasions, but some of the other passengers were
    badly injured and two died at the scene of the accident. At the time, all he could
    think was how lucky he had been. But lately he finds he keeps thinking about
    what happened, going over and over in his mind where he was sitting in the taxi,
    how he saw that they were going to hit the other vehicle, the sound of the crash
    and the cries and moans of the other people. He tries hard not to think about
    what happened, but this is very difficult. He even wakes at night sweating and
    crying out, as if it was happening all over again. Now, he gets very anxious if he
    has to use a taxi, so instead tries to get a lift or walk, but this is not always


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    possible. Because of all this, he has not been sleeping properly and feels
    irritable a lot of the time. He seldom goes out any more and, when he is with
    other people, he feels cut off from them. You notice that, although the patient
    looks well, he seems low on energy. It took some time to extract this story from
    him, which he told as if talking about somebody else.

13. You are asked to see a 47 year old man who is brought in to the clinic by his
    wife. She tells you he has been a heavy drinker all his adult life, drinking eight
    standard drinks every day for many years. He recently became concerned about
    his health and decided it was time to stop drinking. He quit completely two days
    ago. Earlier today he became confused and disoriented. He is irritable and
    shaky. He said he was seeing things on the roof even though she could see that
    there was nothing there.

14. A 45-year-old woman on ART at your clinic reports for her regular check-up. Her
    CD4 count and viral load are stable and she appears in good physical health,
    although she has lost weight. She says that her appetite is poor and she has to
    force herself to eat. She has not been sleeping well—she wakes during the night
    and finds herself worrying about all sorts of things. In fact, she feels anxious
    most of the time, so much so that, at times, she can‘t sit still and has difficulty
    concentrating on things that she is supposed to be doing. She can‘t think of
    anything in particular that set this off—it has just gradually got worse, making it
    difficult for her to do things she used to manage quite easily. You can see that
    the patient has lost weight and she is clearly restless and agitated.

15. A 17-year-old boy was held up at gun-point on his way to the clinic a week ago.
    He had to hand over his watch, cell-phone and money. He missed his
    appointment and has come today instead. He tells you what happened and
    reports that he has been very anxious about coming to the clinic since then. He
    keeps thinking it could happen again and goes over and over in his mind what
    happened and wondering what he could have done to avoid it. He has not been
    sleeping well and sometimes wakes up with a start, thinking that he can hear
    someone breaking into the house. You can see that the patient is agitated and
    upset. He seems to blame himself for what happened.

16. A 26-year old woman comes to your clinic. She is HIV positive and her CD4
    count is 15. She is due to start ART. She looks wasted and she complains of
    severe generalized body pain. She moves very slowly and appears to be in a lot
    of pain. She looks very depressed, and on questioning admits to feeling very low
    and lethargic for the past month. There was no identifiable stressor, except that
    she has been getting weaker physically She has been having difficulty sleeping
    (initial and middle insomnia—difficulty falling asleep and wakes during the night,
    then unable to go back to sleep for a few hours). Her appetite is very poor and
    she has very little energy. She thinks all the time about how sick she is and
    worries that she is going to die before she can start ART. She feels that cannot
    relax or enjoy anything about her life at the moment. She blames herself for
    getting sick, and feels that she deserves to die because she is such a bad
    person. She says that people are always talking about her when she walks in the
    streets—she thinks they are saying that she has AIDS and that she deserves it.
    Although she is worried about dying, she also admits to feeling so bad that she


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    feels she may be better off dead. She does not have any active plans to commit
    suicide. On testing, her short term memory is poor and she is unable to perform
    tests for psychomotor function (repetitive sequential hand movements).

17. You are asked to assess a 28 year old woman known to be HIV+. She has not
    been to a clinic appointment for one year but on her last visit her CD4 count was
    220 and her doctor told her she would probably have to start taking antiretroviral
    therapy (ART) soon. She was frightened by that and never returned for further
    visits. She has felt very unwell over most of the last year and in the last six
    months she has felt her mind getting more and more slow. She is often forgetful
    and cannot pay attention when others are speaking with her. She moves slowly
    and feels clumsy. She is sad and flat and does not want to do anything

18. The same woman is brought back to the clinic four weeks later by her sister. She
    is confused and lethargic and narrowing her eyes, saying that the light is
    bothering her. Her sister tells you the patient had her CD4 count measured and
    it was 10 and she is waiting to start on ART. The sister tells you that the patient
    started to feel unwell one week ago. She has had a fever all week and has been
    sweating more than usual at night. She is nauseated and vomiting and not able
    to eat or drink. Over the last two days she has been confused and hard to
    arouse.

19. An 18 year old woman is brought to the clinic by her sister, who says she has
    become very withdrawn and uncommunicative. She talks to herself a lot, usually
    under her breath so it‘s hard to know what she is saying. Sometimes she looks
    anxiously about, almost as if she is hearing or seeing something that no-one
    else can see. She dropped out of her first year of a teacher training course a few
    months ago and stopped seeing her friends. It was difficult to get her to come to
    the clinic today and while waiting to be seen, she kept trying to leave and had to
    be restrained. She appears agitated and keeps trying to leave the room. She
    does not make eye contact. She responds to her name, but does not respond to
    questions. When she does talk, it is difficult to understand what she is saying.




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Chapter 16: Provider-initiated HIV Testing and Counselling


Background and Rationale

Since HIV antibody testing first became available, WHO has advocated for persons
at risk for HIV to voluntarily seek out HIV testing and counseling. The cornerstone of
WHO‘s guidance on HIV testing has remained constant for nearly twenty years:
confidentiality, informed consent, and access to quality counseling. Programs
offering voluntary counseling and testing (VCT) have been successful in many
countries in providing individuals with knowledge about HIV, prevention measures,
and in providing HIV test results to millions of individuals. Still, in many high-
prevalence countries, fewer than one in ten HIV-positive individuals are aware they
are infected with the HIV virus. Reaching individuals living with HIV who do not know
their serostatus must clearly be a global public health priority.

In light of this, and coupled with advances in treatment and care, WHO and UNAIDS
have advocated for an increase in provider-initiated HIV testing and counseling in
addition to voluntary counseling and testing. This is an important step to achieving
the goal of universal access for all persons with HIV/AIDS. Using provider-initiated
HIV testing and counselling—coupled with effective counseling for behavior
change—provides a seminal opportunity for HIV prevention.

The WHO/UNAIDS guidance on provider-initiated HIV testing and counseling in
health facilities recommends HIV testing in the following scenarios:
   1. For all patients, irrespective of epidemic setting, whose clinical presentation
        might result from underlying HIV infection.
       (e.g. TB or medical symptoms e.g. OIs or unexplained significant weight loss.
       See IMAI Acute Care module, p 54)

    2. As a standard part of medical care for all patients attending health facilities in
       generalized HIV epidemics.

    3. Selectively in concentrated and low epidemics.

An important caveat in the shift to provider-initiated HIV testing and counselling is
the importance of having an enabling environment. Provider initiated HIV testing and
counselling should be accompanied by a recommended package of HIV-related
prevention, treatment, care and support services. Mechanisms should be put in
place to assure referral to post-test counseling services to all patients, and referrals
to medical and psychosocial support for those testing positive. In addition, moving to
an „opt-out‟ model of obtaining consent (e.g. "I recommend that you have an HIV
test. If it is OK with you, I will go ahead with the test") raises concerns about whether
testing is truly voluntary. Every effort must be made to ensure voluntary
informed consent to HIV testing. WHO/UNAIDS have consistently refuted any
benefit to mandatory testing, and ensuring consent is a principle that cannot be
overlooked. Finally, health workers should remain aware of the power—and potential
status—of the health care provider in their setting and in their community. The
recommendation for HIV testing will be, for some patients, tantamount to an edict.



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Sensitivity to patient volition and recognition of the right to refuse testing should
guide a provider‘s interactions in obtaining consent.

When moving to recommendation of HIV testing and counselling, the standard pre-
test counseling components used in VCT are adapted to simply ensure informed
consent, without a full education and counseling session. However, it is an
expectation that every effort will be made to identify additional support within the
health care setting for education and emotional support as part of the HIV testing
interaction.

How to recommend HIV testing and counselling
See the procedure in details on page 100-102 in the Acute Care guideline module
and the scripts at the end of this section. It is important to adapt these to country
circumstances so they are well understood.

          1. Provide key information on HIV/AIDS
          2. Explain procedures to safeguards confidentiality
          3. Confirm willingness of patient to proceed with test and seek informed
             consent.
             Additional information should be provided as necessary with referral for
             additional counseling, as needed.


By using provider-initiated testing and counselling, you will be one of an increasing
number of health care workers offering HIV testing and counseling to patients
engaging in high-risk behavior or exposed through partner‘s risk behavior or to all
patients seeking care in regions with high rates of HIV seroprevalence.

This approach has been adapted to address concerns of about time constraints in
busy medical settings and to provide clear and direct suggestions for how to do the
intervention, by providing scripts that you can practice.

In addition to this brief intervention, it is important that staff on the clinical team
provide information and support to individuals in the HIV testing and counseling
setting. While research suggests some prevention benefit solely due to knowledge of
serostatus, there is significant evidence that following testing with personalized HIV
risk reduction counseling is more effective. (This can be seen in terms of drug
dosing: testing is the first dose; additional prevention activities are extra doses to
alter HIV risk behavior.)

The next page provides a flowchart on how recommendation of HIV testing and
counseling might be accomplished. This needs to be tailored to your facility set-up
and local conditions.

The shaded area in the flowchart shows the limited role and time required from
clinicians. The provider recommends HIV testing and counselling using language
that ensures informed right of the patient to decline the intervention. The provider
also assures confidentiality, and obtains informed consent. The pre-test information
giving may be offered by health care workers, but it is anticipated that the bulk of
pre-test counseling and information-giving and post-test support and behaviour


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change counselling will fall to other staff, including lay counselors, before the patient
sees the clinician. Often pre-test information can be given to groups of patients. It is
often helpful to give brief risk reduction counselling while the test is being performed.
Depending on test technology, this is typically a 5-30 minute period of time.

These staff may or may not have formal academic preparation in counselling. At a
minimum, it is anticipated that many of these workers will have had training offered in
the IMAI Basic ART Aid Course: peer counselling, HIV/AIDS, and communication
skills which will allow them to provide support, offer education, and assist in behavior
change counselling. The 3-day PITC course (Behavior Change Counseling and
Support) is meant to be an integrated part of the Basic ART Aid Course.

An important assumption is that the most practical testing mechanism is HIV rapid
testing. In many settings, this testing technology is dependant on a blood sample
obtained by finger stick; increasingly, we anticipate that specimen collection for HIV
testing may shift to oral fluids. For the purpose of this material, however, we have
chosen to exclusively address the process of rapid testing with serum collection
using fingerstick.




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                    PROTOCOL FOR PROVIDER-INITIATED HIV TESTING AND COUNSELLING
     Group Pre-test Education                                                     Provider Initiates Intervention

 Explanation of HIV/AIDS                    For Patients Who Opt Out            Recommend HIV testing
 Review prevention measures              Counsel on testing benefits           Pre-test information
 Test may be offered                     Identify barriers to testing
                                          Provide emotional support             Assure confidentiality
See Acute Care module p 97-101
                                          Re-assess intention to test           Seek informed consent
                                        See Acute Care module p 100-102        See Acute Care module p 97-101
 HIV Risk Reduction Counseling
 Counselor/ART Aid conducts HIV
    risk assessment
 Counselor/ART Aid negotiates
    personalized risk reduction plan       Specimen Collected and
                                               Test Performed
     Counselor/ART Aid Gives             Specimen for HIV test collected          Provider Gives Test Results
           Test Results                   by appropriate person (5-30
                                         minute wait for results). If initial   Provider delivers HIV test results
Counselor/ART Aid delivers HIV test       test is positive, second sample       and interprets meaning
results and interprets meaning                obtained and new test             See Acute Care module p 103
See Acute Care module p 103                         performed.
                                          See Acute Care module p 120

     Post-Test Support/Referral                                                    Post-Test Advice and Referral
Counselor/ART Aid provides                                                      Provider offers information about
emotional support, reinforces risk-                                             referrals, and if positive, refers to
reduction plan, and, if positive,                                               treatment and care and advises on
refers to treatment and care and                                                importance of disclosure.
reinforces importance of disclosure                                             See Acute Care module p 104
See Acute Care module p 104
Provider initiated HIV testing and counselling for diagnostic
purposes irrespective of epidemic setting
     "You have lymphadenopathy; I want to find out why. In order for us to
     diagnose and then treat your illness, you need tests for TB and HIV
     infection. Unless you object, I will conduct these tests."



Provider initiated HIV testing and counselling as a standard
medical care practice in generalized epidemics
     "One of our hospital policies is to provide everyone with the opportunity
     to have an HIV test so that we can provide you with care and treatment
     while you are here and refer you for follow-up after discharge. So, I
     recommend that you have an HIV test. If it is ok with you I will go
     ahead with the test and provide you with counseling and the results."



Pre-test Information
     ―HIV is a virus or a germ that destroys the part of your body needed to
     defend a person from illness. The HIV test will determine whether you
     have been infected with the HIV virus. It is a simple blood test that will
     allow us to make a clearer diagnosis. Following the test, we will be
     providing counseling services to talk more in-depth about HIV and HIV-
     related illness. If your test result is positive, we will provide you with
     information and services to manage your disease. This may include
     antiretroviral drugs and other medicines to manage the disease. In
     addition, we will help you with support for prevention and for disclosure.
     If it is negative, we will focus on ensuring you have access to services
     and commodities to help you remain negative.‖



TB
     "There is a very important issue that we need to discuss today. People
     with TB are also very likely to have HIV infection. In fact, HIV infection
     is the reason many people develop TB in the first place. This is
     because people living with HIV are not able to fight off diseases as well
     as persons who are not infected.

     If you are living with both TB and HIV, it can be serious and sometimes
     life-threatening without proper diagnosis and treatment. Treatment for
     HIV is becoming more available and can help you feel better and live
     longer.

     Also, if we know you have HIV infection, we can treat your TB disease
     better.
      HIV is a virus or a germ that destroys the part of your body needed to
      defend a person from illness. The HIV test will determine whether you
      have been infected with the HIV virus. It is a simple blood test that will
      allow us to make a clearer diagnosis. Following the test, we will be
      providing counselling services to talk more in-depth about HIV and
      HIV-related illness. If your test result is positive, we will provide you
      with information and services to manage your disease. This may
      include antiretroviral drugs and other medicines to manage the
      disease. In addition, we will help you with support for prevention and
      for disclosure. If it is negative, we will focus on ensuring you have
      access to services and commodities to help you remain negative.‖

      For these reasons, we recommend that all our TB patients be tested for
      HIV. So, I recommend that you have an HIV test and counselling. If it
      is ok with you I will go ahead with the test."

STI
      "People with a sexually transmitted infection are also very likely to have
      HIV infection. This is because certain sexually transmitted infections
      make it easier to become infected with HIV.

      If you are living with HIV, it is very important for you to know. Treatment
      for HIV is becoming more available and can help you feel better and
      live longer.

      HIV is a virus or a germ that destroys the part of your body needed to
      defend a person from illness. The HIV test will determine whether you
      have been infected with the HIV virus. It is a simple blood test that will
      allow us to make a clearer diagnosis. Following the test, we will be
      providing counseling services to talk more in-depth about HIV/AIDS. If
      your test result is positive, we will provide you with information and
      services to manage your disease. This may include antiretroviral drugs
      and other medicines to manage the disease. In addition, we will help
      you with support for prevention and for disclosure. If it is negative, we
      will focus on ensuring you have access to services and commodities to
      help you remain negative.‖

      For these reasons, we recommend HIV testing and counselling for you.
      So, I recommend that you have an HIV test. If it is ok with you I will go
      ahead with the test."



Confidentiality
      ―The results of your HIV test will only be known to you and the medical
      team that will be treating you. This means the test results are
      confidential and it is against our facility‘s policy to share the results with
      anyone else, without your permission. It is your decision to tell other
      people the results of this test.



                                                                                133
     Are you ready to be tested? Or would you like to have more time to
     discuss the implications of a positive or negative test for you?‖
Negative Result
     "The test result is negative, which suggests you do not have HIV in
     your blood system.

     However, there is a very small chance that the test may have missed a
     recent infection. So I want you to have another test at (name of
     community VCT center) in 6 weeks. They can also give you more
     information about staying uninfected.

     In the meantime, HIV infection is common in our community. You need
     to take steps to assure that you do not become infected in the future.

     As you probably know, you can get HIV infection from having sex with
     someone who is infected. For this reason, you need to ask your sex
     partner to be tested.

     If your partner does not have HIV, the two of you will need to be faithful
     and not have sex with any other partners. This will protect both of you
     from getting HIV.

     If your partner does have HIV or you do not know his/her status, or if
     you have sex with more than one partner, you can protect yourself from
     HIV by:

        Not having sex until your partner is tested and you find out if he/she
         has HIV.
        Or by using condoms properly every time you have sex.

     We have condoms available in the clinic and you are welcome to take
     some. The (name of community VCT or other source ……) also has
     condoms.

     Here is some information about where your partner can go to be
     tested, and how you can protect yourself from getting HIV.

     I hope you will ask your partner to be tested by the time of our next
     visit. We will discuss this at your next visit."




                                                                           134
Positive Result
     "The test result is positive, which suggests you do have HIV in your
     blood system.

     In addition to getting support from family and friends, you need medical
     care that can help you feel better and live longer even though you have
     HIV infection.

     You need to go to the clinic that provides long-term care and treatment
     for HIV.

     Here is a referral for you to give to the healthcare provider in that clinic
     that will let him/her know that you are receiving treatment in the TB
     clinic, and that you have been tested for HIV.

     Also, if you/your partner are pregnant or planning to get pregnant, you
     should tell your healthcare provider at the HIV clinic so that he/she can
     talk to you about protecting your unborn child from getting HIV.

     If you do not want others to know about your HIV status at this time,
     you should take care to keep your letter in a private place until you give
     it to the healthcare provider in the HIV clinic.

     It is important that you go to this clinic as soon as possible. I hope you
     will be able to go before our next visit. We‘ll talk about this at your next
     visit."




                                                                             135
IMAI Acute Care Glossary—Participant Manual

Acute: as used in this course, a new condition or a problem that has
worsened suddenly. A chronic condition has symptoms that last for more
than three weeks. A patient with a chronic illness can have an acute problem
such as an acute attack of wheezing in a patient with asthma.

Agitation: to move irregularly, rapidly, or violently [need to improve this- not
just movement]

AIDS: Acquired Immune Deficiency Syndrome, caused by infection with the
Human Immunodeficiency Virus (HIV). AIDS is the final and most severe
phase of HIV infection. The immune system works poorly, and the patient
may have various symptoms and diseases (such as diarrhoea, fever, wasting,
pneumonia).

Airways: passages by which air gets to and from the lungs, including nose,
throat, larynx, trachea, bronchi, and lungs.

Ambulatory: ability to walk about and not be bed-ridden.

Anaerobic bacteria: Bacteria that grow without air or need an oxygen-free
environment to live; one of the causes of PID

Angina pectoris: temporary lack of oxygen in the heart causing heavy
squeezing chest pain.

Antenatal: Period between conception and giving birth

Antimalarial drugs: drugs that are claimed to stop or decrease the signs and
symptoms of malaria.

Aspirate: Draw fluid away by suction e.g. draw pus out of an abscess

Assess: to consider the relevant information and make a judgment. As used
in this course, to ask questions then examine a patient for particular signs and
symptoms of illness.

Asthma: a condition marked by repeated attacks of wheezing in which the
airways narrow due to bronchospasm (tight muscles around the airways.)
(Also called wheezy bronchitis, although this term should be avoided.) It is
caused by inflammation of the airways.

Axillary temperature: temperature measured in the armpit.

Blood pressure: the force of blood on the walls of blood vessels.

Breathing rate: number of breaths per minute. Same as respiratory rate.



                                                                               136
Breathless: out of breath. Breathing may be fast or slow; you may or may
not hear abnormal noises. The patient may appear anxious or restless. The
medical term is dyspnoea.

Bronchi: the large air passages of the lungs.

Bronchiectasis: a chronic condition characterized by dilation of the
bronchioles due to inflammatory disease or obstruction.

Bronchitis: an infection of the bronchi.

Bronchodilator: drugs which help to open the air passages when the
wheezing is caused by tight muscles around the airways.

Bronchospasm: a tightening (spasm) of the muscles around the airway,
which narrows the airway and causes wheezing.

Bubo: Swelling in the groin; usually a sign of LGV or chancroid

Bulla: elevated skin lesion containing fluid, large or small. Can be caused by
impetigo, Herpes infections, chicken pox, drug reactions and burns.

Cervix: Lower part of the uterus that protrudes into the vagina, often called
the neck of the uterus/womb

Cervicitis: Infection of the uterine cervix, commonly by the STIs Gonorrhoea
or Chlamydia.

Chronic: symptoms that last for more than three weeks. Acute is a new
condition or problem that has worsened.

Chronic obstructive pulmonary disease (COPD): a term describing several
chronic lung problems that cause permanent damage to the airways, including
chronic bronchitis and emphysema (NOT including asthma since this can
change.)

Classify: as used in this course, to select a category of illness and severity
(called a classification) based on a patient‘s signs and symptoms.

Clinic: as used in this course, any first-level outpatient health facility such as
a dispensary, rural health post, health centre, or the outpatient department of
a hospital.

Clinical diagnosis: Using clinical findings and experience to establish the
cause of a infection or disease.

Closed questions Questions that only encourage one or two word answers,
for example, ―Are you married?‖ (compare with open questions)




                                                                                137
Cold: an acute viral infection of the upper respiratory tract (also called the
common cold).

Communication skills: as used in this course, skills used in teaching and
counseling with patients, including: ASK AND LISTEN, PRAISE, ADVISE,
AND CHECK UNDERSTANDING.

Complication: A secondary disease or condition that can arise if the primary
disease is not treated

Confusion: a condition in which a person seems disoriented.

Congenital syphilis Syphilis passed from the mother to the child during
pregnancy

Conjunctivitis Inflammation of the mucous membrane of the eyes and
eyelids

Contagious: easily spread, infectious.

Convulsions: a sudden loss of consciousness with uncontrollable, jerky
movement. It can be caused by high fever, meningitis, hypoxia, cerebral
malaria, epilepsy, and other conditions. (Also called fits.)

Cough: a noisy burst of air from the lungs that may produce sputum or be dry.

Counsel: as used in this module, to teach or advise a patient as part of a
discussion which includes: asking questions, listening to the patient‘s
answers, praising and/or giving relevant advice, helping to solve problems,
and checking understanding. Counseling is different from simply advising or
teaching or instructing a patient because it is interactive. The counselor listens
to the patient and takes into account their concerns and problems.

Cyanosis: blue, purple, or gray skin due to hypoxia.

Dermatitis: Inflammation of the skin which can be infectious or allergic.

Deteriorate: to become worse.

Diagnostic test: a special test, such as a laboratory test or x-ray, to
determine the type or cause of illness.

Diastolic: the lower of the two readings when blood pressure is measured.
Diastolic is the period when the heart relaxes and refills with blood. Systolic is
the higher of the two readings when the blood pressure is measured. Systolic
is the period when the heart contracts and sends blood to the blood vessels.

Difficult breathing: when a person‘s respiratory rate, chest indrawing, stridor,
or wheezing make it uncomfortable for the patient to breath.



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Dysuria: pain or burning on urination. A common symptom of bladder
infection in women and Gonococcal or Chlamydial urethritis in men.

Ectopic pregnancy A potentially fatal condition caused by a pregnancy that
occurs outside the uterus (usually in the fallopian tubes)

Emphysema: a very serious and incurable condition chronic lung problem
usually caused by smoking or indoor smoke pollution. The patient has a hard
time breathing, especially with exercise. The chest often become big like a
barrel.

Enlargement: increase in size.

Epidemic: an outbreak of disease.

Epididymis: An elongated cord-like duct, along the posterior border of the
testis, which provides for storage, transit and maturation of spermatozoa

Epinephrine: a bronchodilator which is injected subcutaneously to relax
bronchospasm (also called adrenaline).

Episodes: Occurrences of disease.

Etiologies: Causative agents

Falciparum malaria: the most potentially serious of the four kinds of
malaria—it can cause cerebral malaria and death.

Fast breathing: 25 breaths per minute or more. Very fast breathing is
greater than 30 breaths per minute in an adult.

Feedback: information provided by others on the way a person is doing
something. For example, a manager is giving feedback when he informs his
staff of work they are doing well or makes suggestions for improvement.

Febrile: having a fever.

Fever: a low fever is 38-39 degrees Celsius (or 100.4-102.2 degrees
Fahrenheit.) A high fever is over 39 degrees Celsius (or 102.2 degrees
Fahrenheit.)

First level health facility: a place such as health center, clinic, rural health
post, dispensary, or the outpatient department of the hospital, which is
considered the first place within the health system that one seeks care. In this
course, the term clinic is used for any first level facility.

Fistula: Abnormal passage between a hollow organ and the skin surface

Follow-up visit: a return visit requested by the health worker to see if
treatment is working or if further treatment or referral are needed. There are


                                                                             139
two categories of follow-up visits: follow-up for an acute or new problem and
routine follow-up scheduled for chronic problems.

Frank haemoptysis: coughing up a teaspoon or more of red blood, often in
clots. The blood is easy to see, not just small flecks or streaks.

Garbled speech: confused speech; hard to understand.

Glans penis: the head of the penis.

Glucose: a sugar used in intravenous (IV) fluids and in oral rehydration salts
(ORS.)

Heart failure: a condition in which the heart is unable to pump enough blood
to meet the body‘s needs.

Heart rate, pulse: the number of times per minute that the heart beats.

Hypoxia: a condition in which too little oxygen is reaching the organs of the
body.

Illness: sickness. The signs and symptoms need to be assessed and
classified in order to select treatment.

Infectious: easily spread, contagious.

Inhalant: a medication that is taking into the body by breathing in.

Inhale: to breathe in.

Intramuscular (IM) injection: an injection into a muscle.

Low blood sugar: too little sugar in the blood, also called hypoglycemia.

Lethargy: abnormal drowsiness; almost unable to wake up.

Malaria: an infection of the blood that causes chills and high fever.
Mosquitoes spread it.

Metered-dose inhaler: a small hand-held canister of pressurized salbutamol
with a spray valve.

Mucus: a thick, slippery liquid that keeps linings of the nose, throat, stomach,
and other parts of the body moist.

Nebulizer: a device for pressurizing liquid into vapor or spray.

Neurological: relating to the nervous system.




                                                                             140
Oedema: swelling from excess fluid under the skin; usually occurring in the
lower legs, ankles, and feet.

Palpate: to feel or examine with the hands.

Papular rash: made up of multiple small (less than 1 cm.) superficial, solid,
bumps on the skin.

Parenteral: not taken orally but rather by injection such as under the skin
(subcutaneous), into the vein (intravenous), or into the muscle
(intramuscular).

Persistent fever: fever for five days or more.

Persistent diarrhoea: diarrhoea for 14 days or more.

Pleuritic chest pain: pain caused by inflammation of the chest lining.

Pneumonia: an acute infection of the lungs. It is classified according to
severity based on clinical signs.

Precancer: abnormal cells on the uterine cervix with the potential to become
malignant cancer.

Pre-referral: before referral to a hospital.

Psoriasis: chronic skin condition characterised by reddish patches with
silvery scales on extensor surfaces of the body.

Pulse: see heart rate.

Pustule: elevated skin lesion containing pus.

Radial pulse: the pulse felt over the radial artery, which is the main blood
vessel at the wrist on the outside of the thumb.

Reassessment: as used in this course, to examine the adult again for signs
of specific illness to see if the adult is improving.

Full reassessment: to do the entire assessment process on the ASSESS and
CLASSIFY chart again to see if there has been improvement and also to
assess and classify any new problems.

Referral: as used in this course, sending a patient for further assessment
and care at a hospital.

Respiratory distress: discomfort from not getting enough air into the lungs.

Respiratory function: ability to breathe.



                                                                                141
Respiratory tract:
      Upper: nose and throat
      Lower: Lungs and bronchi

Respiratory rate: same as breathing rate- the number of times a person
breathes in one minute

Salbutamol: a bronchodilator. Available as a tablet, syrup, liquid, metered-
dose inhaler or delivered by nebulizer.

Septicaemia: an infection of the blood, also called ―sepsis.‖

Serious: a term describing a patient‘s overall condition. See “Condition”
above.

Severe classification: as used in this course, a very serious illness requiring
urgent attention and usually referral or admission for inpatient care. Severe
classifications are listed in the pink colored rows on the ASSESS and
CLASSIFY chart.

Severe, very severe, moderate, mild—scale used to describe the acuteness
or extensiveness of a patient‘s particular disease or injury. The definition of
each term is based on the particular disease or injury.

Shock: a dangerous condition with severe weakness, lethargy, or
unconsciousness, cold extremities, and fast, weak pulse. It is caused by
diarrhoea with very severe dehydration, hemorrhage, burns, or sepsis.

Sign: physical evidence of a problem that a health worker observes by
examining the patient (looking, listening or feeling).

Sputum: Mucus and pus coughed up from the lungs and bronchi of a sick
person.

Stable: not changing.

Symptom: health problems that the patient reports. Example: cough or
difficult breathing.

Systolic: the higher of the two readings when blood pressure is measured.
Systolic is the period when the heart contracts and sends blood to the blood
vessels. Diastolic is the lower of the two readings when blood pressure is
measured. Diastolic is the period when the heart relaxes ands refills with
blood.

Thrush: ulcers or white patches on the inside of the mouth and tongue,
caused by a yeast infection.




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Tinea: superficial infections of the skin caused by fungi of the Trichophyton
and Microsporum family responsible for ringworm (tinea capitus), athlete‘s
foot (tinea pedis) and numerous others.

Transmission: passing on of a disease from one person to another

Tuberculosis: a chronic infectious disease caused by a mycobacteria that
can cause a chronic cough. It most often harms the lungs but can cause
fever, weight loss, and infection of the lymph nodes. (Also known as TB.)

Unconscious: does not respond to voice, touch, or pain. Cannot be woken
by voice, shaking, or pain.

Ureter: tubes leading from the bladder to each kidney.

Urethra: the tube leading from the tip of the penis to the bladder in a male,
and from just above the vaginal opening to the bladder in a woman.

Urethral meatus: opening of the urethra at the tip of the penis.

Urethritis: infection of the urethra.

Vesicle: a small, superficial blister on the skin.

Vulva: the external female genital area consisting of the prominent fleshy part
over the pubic bone (mons pubis), the labia majora and labia minora (lips), the
clitoris, and opening of the vagina.

Wheezing: a soft musical noise when the patient breathes out. It may be
caused by a swelling and narrowing of the small airways of the lungs. The
contraction of the smooth muscles causes bronchospasm surrounding the
airways in the lung. The condition of restricted airflow caused by the above is
called wheezing. Wheezing can be a symptom or classification.




                                                                                143
ANNEX
To the IMAI Acute Care
Participant Training Manual

Answers to Case Studies and Self-study Exercises
SELF-STUDY EXERCISE #1, Chapter 3

Purpose: to give you practice determining the reason a patient has come
and selecting the appropriate guidelines to use.

Instructions: Decide if the following patients need acute care or follow-
up care for an acute or chronic problem. Identify where to go in the
Acute Care Booklet to CLASSIFY the patient.

1. A 20 year old woman in 7th month of pregnancy has been coughing for 3
   weeks. Acute, go to page 16-17 and the ANC guidelines.
2. A young man who started ART 2 months ago comes in with a new rash.
   Follow-up of chronic problem (drug reaction). See Chronic HIV Care.
3. A 35 year old woman with much heavier menses than usual and a delay of
   menses by one month. Acute, see page 35.
4. A 40 year old man was treated for pneumonia 2 days ago. He still has
   fever and cough. Follow-up of acute problem. Page 62.
5. A 25 year old man complains of diarrhoea for 3 weeks. This is his first visit
   to the clinic. Acute. Page 28-30.
6. An 18 year old woman has low abdominal pain for 2 days. She was
   followed for her first pregnancy at the clinic one year ago. Acute p. 32-35.
7. A 22 year old man with TB comes in for a drug refill. Follow-up of chronic
   problem, see Chronic HIV Care.
8. A 60 year old woman was treated for bladder infection 3 days ago and
   now has fever. Follow-up of acute problem, p. 34.


SELF-STUDY EXERCISE #2, Chapter 4

1. A 50 year old man is helped by his wife into the clinic. He complains of
   cough for 1 week. He has been seen here in the past for cough (4 times in
   the past year) and is known to be a heavy smoker. He has fever of 37 C,
   has 22 breaths per minute, a pulse of 90 and appears ill. CLASSIFY as
   PNEUMONIA and POSSIBLE CHRONIC LUNG OR HEART PROBLEM.

2. A 25 year old woman complains of night sweats and has fast breathing
   and fever for 5 days. She appears ill and uncomfortable. although she has
   come to the clinic alone. Her pulse is 120, her breathing rate is 34 per
   minute and her temperature is 39 C. CLASSIFY as SEVERE
   PNEUMONIA OR VERY SEVERE DISEASE.


                                                                            144
3. A 30 year old man complains of difficulty breathing and runny nose for 5
   days. He has no fever, is not breathing fast and appears healthy.
   CLASSIFY as NO PNEUMONIA; COLD (bottom green row of the
   table).



SELF-STUDY EXERCISE #3, Chapter 6

How will you CLASSIFY Asha?
   SIGNIFICANT WEIGHT LOSS—she appears thin, her clothing is loose,
     and she has oral thrush which might have contributed to weight loss.
   SEVERE ANEMIA OR OTHER SEVERE PROBLEM—She has pallor
     with breathlessness so either her anemia is severe or she has another
     severe problem. Recent bouts of malaria have probably contributed to
     the anemia.
   ORAL THRUSH—this contributues to the two problems above and also
     indicates likely advancing AIDS.

What treatment does she need?
   For her first problem, WEIGHT LOSS, TB and HIV should be
      considered (p. 54), especially since she also has oral thrush which is
      now affecting her ability to eat. Send sputums for TB and counsel her
      on HIV testing and improving her nutrition.

    For her second problem, SEVERE ANEMIA OR OTHER SEVERE
     PROBLEM, she needs referral now to hospital for further diagnosis and
     treatment. As she has no sign of malaria now she doesn‘t need
     treatment.

    For her third problem, ORAL THRUSH, treat her now with an antifungal
     according to your national guidelines.


CASE STUDIES, Chapter 7
1. Mrs. Bogatsu
Classify as GENITAL HERPES. A first episode accompanied by fever
suggests primary infection.

2. Mr. Thomas
Classify as GENITAL ULCER. Doxycycline 100 mg twice daily for 14 days or
tetracycline 500 mg orally 4 times daily for 14 days.

3. Mr. Ahmed
Classify as GENITAL ULCER and INGUINAL BUBO

4. Mrs. Singh
Classify as GENITAL WARTS



                                                                          145
SELF-STUDY EXERCISE #4, Chapter 7
1. INGUINAL BUBO
2. GENITAL ULCER and INGUINAL BUBO
3. GENITAL HERPES. The inguinal nodes are not characteristic of a bubo.
4. GENITAL ULCER.


CASE STUDIES, Chapter 8
1. Jon
Classify as POSSIBLE GC/CHLAMYDIA.

2. Mas
Classify as POSSIBLE TORSION.

3. Tram
Classify as POSSIBLE GC/CHLAMYDIA.


SELF-STUDY EXERCISE #5, Chapter 8

1. Non-infectious trauma caused scrotal swelling and pain. Tumour and
   testicular torsion can also cause scrotal swelling. All require referral.
2. Prostatic obstruction can cause a very painful distended bladder. It is
   important to relieve this by passing a urinary catheter if you have been
   trained. Refer this patient to hospital.
3. This could be appendicitis, a bowel obstruction, internal bleeding,
   peritonitis, or other serious problems—the possibilities in an adult are
   many. Patients classified as SEVERE OR SURGICAL ABDOMINAL
   PROBLEM require URGENT referral to hospital for possible surgical
   intervention. IV or IM antibiotics and IV fluids should be started before
   transfer.
4. Scrotal or inguinal swelling which increases when the patient bears down
   (as if having a bowel movement) may be due to a hernia. This requires
   non-urgent referral if it is painless.
5. If a man has either a visible urethral discharge or just complains of burning
   on urination, treat for possible GC/chlamydia infection.
6. This could be appendicitis or peritonitis or other severe abdominal problem
   and should be referred to a hospital for surgical evaluation as in #3.



SELF-STUDY EXERCISE #6, Chapter 9

      Is Joanna at high or low risk of malaria?
      CLASSIFY this illness.

       She is at high risk of malaria because she has been in a high risk area
       and she is pregnant, which decreases immunity to malaria.



                                                                             146
       According to the upper chart on page 25 she has two signs of VERY
       SEVERE FEBRILE DISEASE, lethargy and fast breathing.

      Is Robert at high risk of malaria?
      CLASSIFY this illness.

       Robert is at low risk of malaria because there is low transmission of
       malaria at this time and he has not traveled to a high transmission
       area.

       CLASSIFY as FEVER, MALARIA UNLIKELY in the lower table. Since
       he has had fever more than 7 days and this is his second episode of
       cough and fever in two months, send sputums for TB and refer him to
       the hospital for assessment. Go to the classification table on p. 17 for
       cough.


CASE STUDIES, Chapter 11

1. Asha
Classify as PID.

2. Doris
Classify as POSSIBLE GONORRHOEA/CHLAMYDIA and CANDIDA
VAGINITIS.

3. Ami
Classify as BACTERIAL VAGINOSIS OR TRICHOMONIASIS.

4. Sara
Classify as PID and BACTERIAL VAGINOSIS.

5. Jasmin
Normal vaginal discharge. Reassure her.


SELF-STUDY EXERCISE #7, Chapter 11

1. KIDNEY INFECTION.
2. PREGNANCY-RELATED BLEEDING OR ABORTION
3. POSSIBLE GC/CHLAMYDIA


SELF-STUDY EXERCISE #8, Chapter 12

Skin problems that may indicate HIV
Long-lasting ulcers from herpes simplex
Herpes zoster
Giant or extensive molluscum contagiosum
Seborrhoea


                                                                               147
List the skin problems that can be sexually transmitted:
Scabies
Molluscum contagiosum
Herpes simplex
Syphilis lymphadenopathy


SELF-STUDY EXERCISE #9, Chapter 15

1.   45 year old woman, HIV-positive, completed TB treatment 6 months ago.
     Assessment: Observe patient, attempt to interview; ask family about
     possible signs of psychosis or other signs of dementia (slowing, memory
     impairment, disorientation, inability to calculate, provide correct answers
     to abstract questions such as proverbs, similarities etc); also consider
     delirium—usually quite sudden onset, but could be superimposed on
     dementia
     Signs: Marked and persisting change of behaviour and inability to function
     as usual, depressed mood (cries a lot), suicidal attempts (but not high
     risk, provided supervised); not eating; confused, unresponsive, slowing of
     movements; no report suggesting hallucinations, delusions or thought
     disorder
     Apparently not on ARVs, despite HIV+ status
     Classification: Consider: psychosis, major depression, HIV-related
     dementia (latter most likely), mood disorder secondary to HIV or other
     general medical condition; delirium due to medical disorder
     Treatment/management: Primary level: Refer for full assessment:
     Secondary level: confirm whether HIV-related/exclude other medical
     causes; if indicated, initiate ART. If HIV-related illness/other medical
     causes excluded, treat as major depression.
     Primary and secondary level: Provide counselling for family

2.   28-year old woman, just diagnosed HIV-positive during her first
     pregnancy.
     Assessment: Use open-ended questions to explore patient‘s feelings,
     suicidal intent, support systems
     Signs: Acute anxiety in reaction to specific life-threatening stressor (HIV+
     diagnosis), suicidal thoughts (unlikely to be high-risk in sense of having
     plan and means, but likely to need support and some supervision)
     Classification: Acute anxiety disorder; psychological reaction to bad news.
     Treatment/management: Explore knowledge of HIV transmission and
     course of illness and correct any misconceptions; normalize anxiety in
     situation; counsel on managing anxiety (including relaxation techniques);
     discuss ways to access support; follow-up at short interval

3.   25-year old man attending for follow-up of chronic HIV infection, due to
     start ART.
     Assessment: Assess for confusion, orientation, hallucinations, anxiety,
     tremor; use AUDIT or CAGE to establish level of risk



                                                                                148
     Signs: Scenario does not indicate evidence of severe tremors, anxiety,
     hallucinations.
     Classification: Excessive alcohol use (possibly dependence)
     Treatment/management: Counsel to accept referral for treatment. Needs
     supervised detoxification (but could be outpatient with proper
     supervision).

4.   54-year-old woman, HIV positive, on the ART programme for a number of
     years.
     Assessment: Exclude drug toxicity or ARV side-effect
     Signs: Restless, agitated, confused, reduced level of consciousness,
     withdrawn, not eating, possibly hallucinations,
     Classification: Most likely is a delirium due to medical illness or
     medication side-effect; possible psychosis, delirium
     Treatment/management: Refer for medical assessment first; if no physical
     cause found, then refer for psychiatric assessment/treatment

5.   29-year old man with a serious mental illness, probably schizophrenia,
     has been on antipsychotic medication past 10 years.
     Assessment: Ask about coughing, night sweats, change in appetite.
     Assess and ask family about any change in mental state since last seen.
     Signs: Loss of weight, swollen neck glands
     Classification: ?TB or HIV-positive
     Treatment/management: Assess for TB. Discuss with patient (if possible)
     and family possibility of HIV infection and need for HIV test. Obtain
     informed/proxy consent. If HIV positive, refer for further assessment for
     staging.

6.   43-year old mother of 5, HIV-positive and attending clinic for follow-up.
     Assessment: Assess for depression, anxiety, suicidal intention
     Signs: Depressed and anxious mood, loss of appetite, disturbed sleep,
     loss of concentration, loss of self-esteem, suicidal thoughts (but ?not high
     risk); significant stressors
     Classification: Major depression (at least 5 symptoms, at least 2 weeks)
     Treatment/management: Counsel to counter depression, assist to identify
     support in dealing with son. Prescribe amitryptiline with 2-week follow-up
     to assess.

7.   33 year old HIV positive man, who has been behaving strangely for the
     last few weeks.
     Assessment: Exclude alcohol intoxication (unlikely because of
     persistence of symptoms), other infection
     Signs: Agitated, restless, sleep disturbance, nightmares, thought disorder,
     hallucinations, delusions; onset shortly after starting ART
     Classification: ART-induced psychosis
     Treatment/management: Refer this case, if possible. Stopping and
     changing ART in the presence of psychosis is a secondary level function.
     Stop ART. If unmanageable at home, refer for psychiatric care; if acutely
     agitated or aggressive (or becomes so), give haloperidol; otherwise
     review after one week and consider alternative ART regimen.


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8.   35 year-old woman, who has been doing well on ART
     Assessment: Exclude drug toxicity or ARV side-effect
     Signs: Episodic attacks of extreme anxiety
     Classification: panic attacks (?medication side-effect)
     Treatment/management: Refer for psychiatric assessment/treatment;
     counsel on use of relaxation techniques to assist meanwhile

9.   19 year old man, who has been behaving strangely for the last few
     weeks.
     Assessment: Exclude current drug intoxication, other infection; assess for
     psychosis
     Signs: Withdrawn, loss of appetite, possible auditory hallucinations,
     disorientation; onset linked to recurrent substance use
     Classification: Substance-induced psychosis
     Treatment/management: Refer for psychiatric care

10. 72 year old woman, who has been healthy and active until three years
    ago when she started to slow down.
    Assessment: Observe patient—she is pleasant and well groomed. She
    smiles at you and does not appear depressed. When you ask her open
    ended questions she tends to ramble on and her answers are not
    consistent. She forgets your name and why she is talking to you. She
    reports no headache, weakness, or visual disturbances. She says she
    does not drink alcohol and is on no new medications
    Signs: She is fully alert and oriented to the place and time. There is no
    alteration in her level of consciousness. She thinks your screening
    cognitive tasks are silly. She can register 3 words but cannot recall any at
    5 minutes. She can count backwards from twenty by threes but says 12
    instead of 11 and gets stuck and frustrated and then will not finish the
    task as she is embarrassed. BP is 140 / 100
    Classification: Dementia
    Treatment: Refer for diagnostic clarification to determine the cause of her
    dementia. Given her age, the likeliest cause is dementia due to
    Alzheimers disease but could also be vascular dementia. Other reversible
    causes of dementia should be excluded including thiamine deficiency,
    vitamin B12 deficiency, hypothyroidism, neurosyphilis, dementia due to
    HIV/AIDS or dementia due to subdural haematomas

11. Same 72-year-old woman, brought back to clinic 6 months later.
    Assessment: Observe patient—she is irritable and confused. She is
    poorly groomed, picking at her skin and looks physically unwell. Her
    answers to your questions make no sense at all. She thinks she has been
    taken to a hotel and is scared of you.
    Signs: She is drowsy and disoriented. She does not know the date or
    time. Her level of attention fluctuates throughout the assessment. She
    cannot do any cognitive tasks. BP is 110 / 70 and her temperature is 39
    degrees.
    Classification: Delirium in a patient with known Alzheimer‘s Dementia.
    Delirium is likely due to an acute infection (pneumonia)


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    Treatment: Ensure safe environment. Give fluids and check glucose and
    give thiamine. Correct underlying medical disorder (treat the pneumonia).
    She may require a low dose of haloperidol (0.5 mg) to deal with
    symptoms of irritability, paranoia and confusion.

12. Man aged 27 years, involved in motor vehicle accident.
    Assessment: Clarify duration and relation to stressor
    Signs: anxiety linked to specific life-threatening event, flashbacks,
    avoidance of stressor
    Classification: Post traumatic stress disorder
    Treatment/management: Refer for psychiatric assessment/treatment;
    counsel on use of relaxation techniques to assist meanwhile

13. 47 year old man who has been a heavy drinker all his adult life
    Assessment: Observe patient—he is irritable, disoriented and confused.
    He looks physically unwell. (Mental state does not allow use of AUDIT or
    CAGE.)
    Signs: He does not know the date or time. He is shaking and tremulous.
    He is somewhat paranoid and seems to be talking to people who are not
    there. BP is 160 / 100, heart rate is 120, he is sweating profusely and his
    temperature is 37.5 degrees.
    Classification: Alcohol withdrawal delirium
    Treatment: Ensure safe environment. Give fluids and check glucose and
    give thiamine. He will require diazepam to help manage the withdrawal
    syndrome.

14. 45-year-old woman, on ART reporting for her regular check-up.
    Assessment: Clarify duration and any relation to stressor
    Signs: restless, agitated, anxious most of the time, poor appetite,
    disturbed sleep, difficulty concentrating, no specific stressor, deterioration
    over time
    Classification: generalized anxiety disorder, possibly depression
    Treatment/management: Counsel on managing anxiety; teach relaxation
    techniques; prescribe diazepam for 2 weeks; follow-up in 2 weeks and if
    no improvement, refer

15. 17-year-old boy, held up at gun-point on his way to the clinic a week ago.
    Assessment: Clarify duration and relation to stressor
    Signs: agitated, distressed; anxious, self-blame, disturbed sleep; specific
    recent stressor
    Classification: post traumatic stress disorder (possibly acute stress
    disorder)
    Treatment/management: Refer for psychiatric assessment/treatment;
    counsel on use of relaxation techniques to assist meanwhile


16. 26-year old woman, HIV positive, due to start ART.
    Assessment: Has features of both HIV-related cognitive impairment
    (dementia)—psychomotor slowing, memory impairment, wasting and very



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    low CD4 count, and of a major depressive episode (with psychotic
    features).
    Signs: physical signs: wasting, pain, low CD4 count, depressed mood,
    sleep, appetite and energy disturbance; anxious and negative self-
    defeating thoughts and thoughts of being better off dead. Some ideas of
    reference (people talking about her); possible hallucinations.
    Classification: HIV-dementia; major depression
    Treatment: refer for medical treatment (ART) and psychiatric treatment
    (antidepressant)

17. 28 year old woman known to be HIV+, due to start ART a year ago.
    Assessment: Observe patient—she is flat and slow in her speech and
    movements, she is oriented and not confused. She looks physically
    unwell.
    Signs: She is fully alert and oriented to time and place. Her speech is
    slow but logical. She is forgetful but can register 3 objects immediately
    and can recall 2/3 objects at 5 minutes. She takes a very long time to
    count backwards from twenty by one and cannot count backwards by 3.
    She takes a very long time to get from 20 to 17 and then forgets what she
    is supposed to do and gives up. BP is 120 / 70, and her temperature is
    37.5 degrees. She has no focal neurological signs and no neck stiffness
    Classification: HIV Associated Dementia
    Treatment: Provide support and reassurance and tell her that HIV
    Associated Dementia may improve with Antiretroviral therapy. She is
    referred for assessment for ART

18. Same 28 year-old woman, 4 weeks later.
    Assessment: Observe patient—she is flat and slow in her speech and
    movements, but on this visit she is also disoriented and confused. It is
    hard for you to wake her and she drifts off easily. She looks physically
    unwell and seems to have lost weight since you last saw her.
    Signs: She is drowsy and can‘t keep her eyes open. She can‘t stay awake
    long enough to answer your questions to check if she is oriented to time
    and place. BP is 100 / 60, and her temperature is 39.5 degrees. She is
    weak, complains of the light, and has a very stiff neck.
    Classification: Delirium in a patient with known HIV Associated Dementia.
    Since her CD4 is so low and she has signs of meningeal irritation you
    suspect her delirium is on the basis of a central nervous system
    secondary opportunistic infection—probably cryptococcal or tubercular
    meningitis. The delirium may also be due to other causes like dehydration
    causing metabolic abnormalities or even a drug ingestion or overdose.
    Treatment: Ensure safe environment. Give fluids and check glucose and
    give thiamine. Will require referral to establish the underlying medical
    disorder and treatment of the underlying cause will need to be instituted.
    Since she is so drowsy she will not likely need symptomatic management
    with haloperidol (0.5 mg).

    The patient is fortunate—she did in fact have cryptococcal meningitis and
    treatment with antifungal medications was started with good effect. Her
    delirium cleared and she was started on ART. She has had an excellent


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    response to the ART and her CD4 has gone up to 140 in four months.
    She comes to the clinic to thank you for all your help!

19. 18 year old woman, withdrawn and uncommunicative, talks to herself a
    lot
    Assessment: Exclude drug/alcohol use, HIV or other infection; assess for
    psychosis
    Signs: Possible auditory hallucinations and thought disorder, agitated,
    marked behaviour change (self-isolation)
    Classification: Probably psychosis (schizophrenia)
    Treatment/management: Refer for psychiatric assessment/treatment (use
    haloperidol if necessary to sedate patient during transfer), counsel sister




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