Ghana STG 2017 1

Republic of Ghana

Ministry of Health
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Standard
© 2017 Ministry of Health (GNDP) Ghana
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ISBN 978-9988-2-5787-3
For all enquiries write to the publishers:

GRvN}voDPbP}Puu~GNDPZ
Ministry of Health
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ii
Tableofonte
C nts
P( �� ˘]]
Alv}òPuv ��
˘]]]
Introduction �� 1
H}`}bR]b}}l ��
Pb]]vP(}NHIS]ubuv ��
N}b}v}br+vbb ��
Referral��
]}vb
A ��
Pb]}v`]vP �� æ
D}b]vPvu]}vb}vAPv}˙`]PR]vR]ov �� w
PRu}]P]ovvbDP A vE R}vP �� w
Iu}v}vb ��
Chatep rX Disorsofder theGatrs ointetina
s lTrcta �� 11
X D]R} ��
X R}]bD]bbvD]R} ��
X C}vb}v ��
ı
X PUoD]bb ��
æX Gb}r}b}RPoRG˘D]bb ��
æ
vX P]vO]P]vvP(}uROb}RPb ��
wX Hu}R}]b ��
ı
C tep rX
ha Disorsof der theLiver �� 33
X Au}]L]Ab ��
ıX Jv] ��
æ
X HbA ��
w
X CR}v]Hb ��
X HEvRo}R˙ ��
X Ab]b ��
v
X V}u]vP ��
æX H}ooo]v}u C �� æ
vX DPbvRL] �� ææ
C tep rX
ha NutritionalDisorsder �� 58
wX Mov]}v ��
æ
C tep rX
ha HaematologicalDisorsder �� 62
wX Avu] ��
v
X Bo]vPD]b}b �� væ
ıX S]loCooD]bb �� vı
X PobuCooM˙o}u �� w
X Llu] �� wæ
X Mo]PvvL˙uR}u �� w
C tep ræX
ha ImmunisableDissea �� 80
iii
Standard T G E
X Iuuv]b}v ��
X Mbob ��
æX Pbb]b ��
v X Tvb �� v
w X P}o]}u˙o]b �� ı
X D]RR] �� ı
ıX Yoo}`F �� ı
30. Haemophilus Influenzae˙D]bb �� ı
X Pvu}}oD]bb �� ıæ
X Hb �� ıv
X R}]bD]bb �� ıv
Chatep rvX ProblemsoftheNeorwb n~NeonateZ �� 97
X S]lv`}v �� ıw
æX N}voH˙}Po˙u] ��
vX N}voJv] ��
wX B]RIvi]b ��
X N}vo}viv]b ��
v
ıX Rv}ob}u ��
X W]oubTu} ��
Chatep rwX Disorsofder theCardiovcula sa rSystem ��113
X CRbP]v ��
X IbRu]HD]bb �� æ
X D˙bv} ��
X DV]vTR}u}b]b~DVTZ ��
æX Pou}v˙Eu}o]bu ��w
vX S}l �� ı
wX HF]o ��
X C}vPv]oHD]bb ��
ıX H˙˙v}'l ��

æX P]]b ��æ
æX H˙vb]}v ��
v
æX H˙vb]}v]vR]ovv}obvb �� æ
æX H˙vb]}v]vPPvv˙ �� æ
æX H˙vb]EuPv]b �� æ
ææX AR˙Ru]b ��æv
ævX RRu A F �� v
æwX D]]vbbvBol}b �� v
Chatep rX Disorsof der theRespirtor a ySystem ��167
æX C}uu}vC}o �� vw
æıX Pvu}v] �� vı
vX }vR]o B Ru
Ab �� wæ
vX }vR]b BA ��
vX CR}v]}vR]b B ��
vX }vR]b B ]b �� w
vX LvPbA �� ı
Chatep rıX Disorsof der theCentralNeouvr sSystem ��193
væX HR �� ı
vX S]b �� ıv
vwX E]ob˙ ��
vX TRUv}vb]}bPv ��
Chatep rX PsychiatricDisorsder ��207
vıX 'v}v A .]
D H˙]˙D]b}~ADHDZ �� w
wX TRo˙ A D]bPv �� ı
wX Pb˙R}Pv]S]b ��
iv
Tableofonte
C nts
wX Ivb}uv] ��
w X b]}v
D �� v
w X SR]}Rv] ��
wæX B]}oD]b} ��
v
wv X Ao}R}oW]RòS˙v}ub �� ı
w X Ao}R}o]Do]]uTuvb ��
w X Av˘]˙D]b}b ��
wıX
SbvUbD]b}b �� ı
Su X Ab D]b} ��
Chatep rX Disorsof der theSkin ��æ
]o B Sl]vIv(}vb ��æ
X B}]ob �� æ
X IuP} �� v
X Cooo]bvE˙b]ob �� ı
X Bo]Uo �� ı
æX Y`b �� æ
FvPoSl]vIv(}vb ��252
vX S.]oFvPoSl]vIv(}vb �� æ
wX P]˙]b]bVb]}o} �� ææ
V]oSl]vIv(}vb ��257
X HbS]uo˘Iv(}vb �� æw
ıX Hb}bZ Iv(}vb �� æı
ıX CR]lv}˘ �� v
N}vrS].Sl]vIv(}vb ��265
ıX LPCR}v]Uob �� væ
ıX P]b �� vw
ıX U] �� w
ıX RE˙RuvBoo}bR}v �� w
ıæX AvVoP]b �� wv

ıvX uE �� wı
ıwX Iv]P} ��
Chatep rX EndocrineandMetaolic
b Disorsder ��287
ıX D]bMoo]b �� w
ııX D]K}]}b]b �� ı
X D]b]vPPvv˙ �� ıw
X TuvrIvH˙}Po˙u] �� ı
X D˙bo]]u] ��
X G}] ��
X H˙}R˙}]]bu ��
æX H˙R˙}]]bu �� æ
vX vo A Ivb8]v˙ �� w
wX CbR]vP [bS˙v}u ��
X O`]PRvOb]˙ ��
Chatep rX Obtes tricCarendObtes tricDisorsder ��
ıX AvvoC ��
X H˙ub]bG]u ��
X H˙vb]}v]vPPvv˙ ��
X Proub] �� æ
X SPrEoub]vIuu]vvoub E ] �� v
X oub E ] ��
æX Mo]]vPPvv˙ ��
vX Avu]]vPPvv˙ ��
wX S]loCooD]bb]vPPvv˙ ��
X D]bMoo]b]vPPvv˙ ��
v
Standard Trtme
ae ntGuidelinesUwthEditionUw
ıX ]C D]bb]vPPvv˙ ��
X Jv]]vPPvv˙ ��
X P}brPuHu}RP ��
X P}brPuP˙˘] ��
ı
X AvoPb]]vL} ��
æ
X PuL}]vPuDo]˙ ��
æ
æX PuR}(RMuvb ��
æv
Chatep rX Gynaologic
ce alDisorsder ��358
vX D˙buv}R} ��
æ
wX A}}v ��
æı
X Av}uoVP]voBo]vP ��
w
ıX Av}uoVP]voD]bRP �� w
X L}` A A}u]voP]v �� wı
X FuoIv(o]˙ ��
X Mv}b ��
X ]v}u C }(RC]˘ �� v
Chatep ræX Disorsof
der theKidneyandGenitourinayr System ��388
X Go}uo}vR]b A ��
æX NR}S˙v}u �� ı
vX K]v˙ A Ivi˙ �� ı
wX CR}v]K]v˙D]bb �� ıv
X Avu]]vCR}v]K]v˙D]bb �� ıı
ıX U]v˙TIv(}v ��
X M]]vbvRK]v˙ ��
X C˙bA b �� v
X Bv]PvP}bH˙ob] ��
X ]o B P}bb ��
X S}oMbb ��
æX TREu˙S}u ��

vX P]]bu �� v
wX P}b]}URoVob �� w
X U]v˙TCoo] �� ı
ıX URoS] ��
æX Vb}u˙~MoS]o]b}vZ ��
æX E]]˙u} A r}R]b ��
æX TboT}b]}v~T}b]}v}(SuC}Z �� æ
æX F}v] [bGvPv �� w
æX BoCv �� ı
ææX C]v}u}(P}b ��
ævX oE D˙b(v}v ��
æwX MoIv(o]˙ �� æ
æX Hu] �� w
æıX U]v˙SR]b}b}u]b]b �� ı
vX Pb]bv}RvURoD]bRP ��
vX Rv}v}(U]v ��
Chatep rvX SexuallyTransmittedInfections ��
vX S˘oo˙Tvbu]'Iv(}vb]vAob ��
vX STIroURoD]bRP]vMob ��
164. Mycoplasma genitalum�� 443
væX STIroPb]bv}RvURoD]bRP ��
vX STIroVP]voD]bRP �� æ
vwX STIroL}À}u]voP]v]vW}uv �� w
vX STIroGv]oUo ��
vıX STIroS}oSòo]vP �� æ
vi
Tableofonte
C nts
wX STIroIvP]voB} . XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
�� æ
wX STIroGv]oWb �� æ
wX STIroAv}roRoS˙v}ub ��æ
wX S˘oo˙Tvbu]'Iv(}vb]vCR]ov �� ææ
wX STIroN}voC}viv]b~ORou]N}v}uZ �� ææ
MvPuv}(b].STIvSTI˙v}ub b ]vR]ov ��æv
wæX STIroURoD]bRPS˙v}u]vCR]ov �� æv
wvX STIroVP]voD]bRPS˙v}ub]vCR]ov �� æv
wX STIroL}À}u]voP]v}Po]IvGuu}˙D]bb
S˙v}u]vCR]ov �� æw
wX STIroGv]oUoS˙v}u]vCR]ov ��æ
wıX STIroAv}rRoRoS˙v}ub]vCR]ov �� æı
X HIVIv(}vvAIDS �� v
Chatep rwX HIVInfectionsandAIDS ��v
X HIVP}bE˘}bP}R˙o˘]b~PEPZ(}˘}bRoRb}vo
�� v
Chatep rX InfectiousDissande Infetas tions ��v
X F �� v
X To}b]b �� w
X DPb]bvo}b]b~DRrTBZ �� wv
æX T˙R}]F �� wı
vX Mo] ��
wX Uv}uo]Mo] ��
X SMo] �� v
ıX Mo]]vPPvv˙ �� ı
ıX Sb}voMo]CRu}v}v~SMCZ �� ı
ıX Mv]vP]b �� ı
ıX W}uIv(b}v~IvbvoZ �� ı

Chatep rıX yeE Disorsder ��503
ıX N}voC}viv]b �� æ
ıX X}RRou] �� æ
ıæX F}]Pv}˙]vR˙ �� æ
ıvX R˙E �� æv
ıwX Go}u �� æ
ıX C �� æ
ııX E˘}bK}R˙ �� æ
X S]bub �� æ
X S]loCooD]bbWRv}R˙ �� æ
X Ev}]vvu}o]]b}b`]R˙}uo]}vb �� æ
Chatep rX EarUNoseandThroatDisorsder ��515
X S]} �� ææ
X E]Po}hb
A �� æı
æX R}R˙vPobA �� æ
vX PR˙vP]bvT}vb]oo]b �� æ
wX S]vbA ]b �� æv
X Ob A M] �� æı
ıX CR}v]ObM] �� æ
X E]b˘]b �� æ
Chatep rX OralandDentalond C itions ��æ
X DvoC]b �� æ
X OoCv]]b]b �� ææ
X N}b A ]vPUoG]vP]]b �� æv
X ]o B Ev}]bvP}R˙o˘]b]vDvb˙ �� æ
vii
Standard Trtme
æX ]o
BA S]o}v]b �� æı
vX L`]P [bAvP]vlC]}rF]obA �� æ
w X CR}v]P]}}voIv(}vb �� æ
X M}RUob �� æ
ıX O}v}Pv]Iv(}vb �� ææ
X OoSu}bCoo]v}u C �� æ
X Tu}}ruv]oJ}]v˙b(v}vvub}˙ubo
˙b(v}v ��æı
X T]Pu]voNoP] �� ææ
Chatep rX DisorsOf der TheMuculos s keletalSystem ��552
X Ob}R]b �� ææ
X RRu}]R]b �� ææ
æX Jv]oI]}R]AR]b �� ææw
vX Bl]v ��
æv
wX F]}u˙oP] �� æv
X I]}R]]vGuu}˙u˙}R]b �� æv
ıX MvPuv}(RH}S`}oovJ}]v �� æw
X G} �� æw
X Pb}rP}~R}v}o]v}b]bZ �� æwæ
X S˙bu]ob˙Ru}bb �� æw
Chatep rX Trumaa AndInjuries ��582
X HIvi]b �� æ
X A}uv �� ææ
æX A}u]voTu �� æ
vX Co}bFb �� æı
wX OvFb �� æı
X D]bo}}vb ��æıæ
ıX }R}] A ]v(}vb �� æıw
X CR}v]Ob}u˙o]bvCR}v]SAR]b �� v

X Cooo]b �� v
X N}]vPFb]]b �� v
X HvIv(}vb �� v
X To}b]b]v}R}]b �� væ
æX R]lbvOb}uo] �� v
vX S˙ �� v
wX Ob}}}b]b �� vı
X S]lorooVb}r}ob]C]b]b �� v
ıX boA N}b]b �� v
æX Ob}Pvb]bIu( �� v
æX Bvb �� v
æX W}vb �� v
æX B]bvSvPb �� v
æX SR}l �� v
Chatep rX Geneal r Emeger ncies ��v
ææX AAooP]R}v~AvR˙o˘]bZ �� v
Chatep ræX AntibioticProphylaxisInSuger yr ��vw
ævX Av]}P}R˙o˘]b]vSP˙ �� vw
Chatep rvX ManagementofcuteA Pain ��651
æwX MvPuv}(P]v A �� væ
Chatep rwX ommon C Malignancies ��655
æX CvbB �� vææ
æıX GvoMvPuv}(P}]b}v]vP �� væw
Chatep rX Genealr ManagementOfPoisoning ��657
vX M]]vbUb]vREoo˙ �� v
viii
Tableofonte
C nts
Chatep rıX MedicinesUseInTheElderly ��662
Chatep rX LocalAnathe se ticgeA nts ��v
vX L}oAvbRAPvb ��v
Chatep rX StructuoaredAp chtotheSeriouslyIllChild ��666
vX S}R A }RS]}bo˙IooCR]o �� v
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TorP) To}(u]o]}vb(}b]]vP . XXXXXXXXXXXX �� XXXXXXX
TorP) D}b]vPvM]}vb}v}˙`]PR]vR]ov �� w
TorP) To}(]u}v}vbv(ovb ��
TorP) Abuv}(P}(R˙}v]vR]ov`]R]R} ��
TorP) Tuv˙Fo]TR˙rPovA �� v
TorP) Tuv˙Fo]TR˙rPovB �� w
TorP) Tuv˙Fo]TR˙rPovC ��
ToræP) Helicobacter pylori]}v E TR˙ ��
TorP) P}br˘}buvPuv}(RoR`}lbL}}vo
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ToærP) SRo(}}vIuuv]b}v}(R]ovvæ˙b ��
TovrP) M]vvvG]]uv ��
TowrP) Woo[bS}Iv}v(}VT D ��
TowrP) Woo[bS}Iv}v(}PE ��
w
TowrP) TuvG}`R(}u]ouvPuv}(}l b ��
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ıæ
TorP)RP]u(}uvP]vPD]K}]}b]b]vCR]ov ��
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TorP)R}uuvbRo(}AvvoV]b]b(}N}uoHoR˙
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æ
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TorP)D}bPP]ub(}M](]b}vvM]b}}b}o(}]}b
Pb}voPb ��
v
TorP)M]b}}b}oUbbvD}bP]vMvPuv}(PPvv˙
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TorP)SPb}(CR}v]K]v˙D]bb ��
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TorP)Cb}(MoIv(o]˙ ��
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TowrP)ORbo]vb(}HIV ��
v
TowrP) SvTuv~ st
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TowrP) SvTuv~vL]vTuvZ(}HIVrAIDS �� v
TowrP)SvTuv]vb]o}v]}vb(}HIVrAIDS �� v
TowræP)R}uuvM}v]}]vP}(DPT}˘]]˙HIVS}o}P˙}(
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vw
TorP)G]o]vb(}Ruv}(Rv`]R( �� w
TorP)D}b]vP(}TBM]]vb ��
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TorP)TuvP}}}o(}ORRb]bvT˙b �� w
TorP)D}b]vP}(S}vrL]vM]]vb �� wı
ToræP)bvA A=Au}]]v}ro]b(}uo}v~RP]uv(}
ONCAILYED DOSINGZ ��
TorvP)bvA A=Au}]]v}ro]b(}uo}v~RP]uv(}
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TorwP) bvA vAu}]]vF]˘D}bC}u]v}v~Sv
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TorP)uR A vLu(v]v~D}b]vPRP]uvZ �� æ
TorıP) D]R˙}u]b]v]vvP]]v~D}b]vPRP]uvZ �� æ
TorP)D}b]vPRP]uv(}Q]v]vIMIvi}v]v˙}vPCR]ov �� w
TorP)RobvA ~PrR(oTuv]vCR]ovZ ��
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ToırP)Suu˙}(R}uu}v˙b}(C}viv]bvR]
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Sv Tuv G]o]vb ~STGbZ ˙bb uoo˙ o}
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Uv}8]o ]}vb bR}o v} b R ]b R]PR
]bl}(u]b]v}vX
yy N}vr}]˙ ~Pv]Z vub P]v ]v R }}l v R˙
bR}oo`˙bb]vb]]vP
yy }]
A Rvvbb˙b}(]uo}]vbUXPXuPUv}XuPX
yy Qvb}(Pu}u}bR}o`]'vPX
yy QvbobbRvPubR}o`]'v]vu]oo]PubUXPXæ
uPUvv}XæPX
yy Qvb obb Rv uP bR}o `]'v ]v u]}PubU XPX
u]}PuUv}XuPX
yy WR ]uob v}]o } bR}o `]'v ]v (}v
}( R ]uo }]v`RR]b v} }R .PU XPX Xæ uoU v}
XæuoX

yy RM]}Pub[vRvv}Pub[bR}oNOT]XS]u]oo˙U
Rv]b[bR}oNOT]X
yy UbRuRu]oo]o][~uo}uLNOT Z ]vu~U}uZX
yy S }b v }b (v˙X Iv R b }( Rb ][U
u]v]uu }b ]vo bR}o b].U XPX R˙ rv Rb b
](}]v[X
yy SR v˙ } bo] } ]v]R vu }( ˙b }(
uv]X
yy W] ]}vbU (o˙ ]v EvPo]bR `]R} ]}vX I
]b }Pv]b R b}u Lv ]}vb b v Rb
]o ]v R b}v }v ]}vbX D} NOT b }R
]}vb
yy }]A }u]v}v PbU vobb R ]b b]Pv].v R
vP}b]vPo]vP]v}vb~XPXC}r]u}˘}oZX
yy }] A R b }( ˙u}ub uvb (} u]v} bo(ro]u]vP
}v]}vbX
yy }] A U`R}bb]oURb]]vP}(o}bXSvb}uu
vPvb]vPRvX
yy }] A uoo b]]vP ~}o˙Ru˙ZU b]oo˙ `Rv R
]Pv}b]b]bv}oX
yy }] A R}(
b Rvo}}(u]v]b}v˘`R
v
Introduction
R oU o]v]o ]v]}vb (} R]b }X Ub R }o }

`Rv}bb]oX
D}b]vPvu]}vb}vAPv}˙`]PR]vR]ov
TorP) D}b]vPvM]}vb}v}˙`]PR]vR]ov
AP B}˙`]PR]vlP
Children
˙b ı
w˙b
æ˙b
˙b æ
˙
vu}vRb wXw
u}vRb æXv
u}vR X
N`}v Xæ

TRb.Pbo}(oouvv}u]v(vbX}bA Pu˙]
]vu]v(vbX
PRu}]P]ovvbDP
A vE R}vP
TR o}uv }( v vb]o u]o }v]}v bR b
v` ˙u}u
b U b]PvU o}}˙ } }R b o}vU ]}}v }(
r˘]bvP u]o }v]}vU ]b]o]˙ } R ]vP } (}oo}`]vP
u]v]b}v }( u]]vo } ~oo}R] } RoZ } b }(
u]o ]U } R ol }( + }( R }U ]b }vb] v
b v R vb } }U `RR } v} }vb]
boo˙o}R}X
S}vv}bU }ov˙ }vP }( b vb ovP }
R b }( b]}v }vo˙ u]]vb v ]vbU }rRr}v
u]]vb v u]o ]b ]b v}` Pvoo˙ }vb] v}u
]v uv˙ }v]b (} RoR }(bb]}vob v }vbub o]lX
F} RoR }(bb]}vobU R v } } b }vb } Rb
}b]bob}u}ov}(bb]}vo}o]P}vX
AoR}PR u}b u]]vb vP} ]P}}b (˙ b u}v]}]vP
]vP o]v]o ]ob (} }o ]b P]v (} R] P]b}v
v b ]v v˙ }v˙U bR ]ob R b}u o]u]}vb ]vo]vP
R oo˙ buoo vu }( ]v]]ob ]v}oX P}brulvP
b P v u}v]}]vP v }vP vob }v }( obb
w
Standard Trtme
}uu}vo˙ v}vU }voo˙ b]}bbvb u}vP
oP }o}vX Oo u]]vb v ]bU `]R `R]R RoR
}vb u˙ R˘]v `]R bU v v`}vb `]R `R]R
R˙u˙v}UvooP]]b}vbb ]vob ]v]]obX
TR]b ]}v }( R SvTuvG]o]vbU o]lR]}b
]}vU ]vob }]b }( R GRv F}} v DPb AR}]˙ ~FDAZ
b }v }vP (}uX E˘ }]b }( R b }v
}vP(}uu˙}]v(}uRFDA}R}PR]bIvb}vo
C}v Pb}vb ]}b RoR (]o]b R}PR} R }v˙X
Pvb u˙ ob} } ]o˙ R}PR Pv S(˙ Cvb ]v
b]Pv }uuv]˙ Ru]b v}v`]X Ovo]v bu]bb]}v }(
}b ˙ }R RoR }(bb]}vob v vb v ob} }v
R}PRRS(˙WRS˙buR'PllX(PRvXP}XPRl}R'Pll
(PRvXP}XPRll}```X(PRvXP}XPRXAvru]o}(}u˙
ob} bv } R N}vo PRu}]P]ov Cv PXb(˙e
(PRvXP}XPRX A R}v oo } ıw } } bR} } æ
}ou(}v˙b]bvP]vPP(˙ b ]bbX
Ab]Pv]vP bo]˙ } R } v ]b ] } ˙
}uu]'}(˘b (}uob ]b]o]vb ]v u]]v v Ru˙
v }Rb bvvP R Ruo ]vb˙ v }vbu
]vbbU bo ˙ R FDAX TR }bb ]b v}v˙u}b v Rvo
`]RR]bb }v.vv]bo]vl}W}oHoROPv]}v
Ru}]P]ov˙bb uX
TR o˙ ]v.}v }( `v]vP b]Pvob (} o }

(}u b v }vP v Ru}]P]ov ]b vob

uo˙]vv}vb}(}boov˙}voRu}Ro]X
Important contacts
TorP) Table of important contacts and referral centres
Uv]lDuvlR(oCv Contacts
F}}AvDPbAR}]˙~FDAZ ræUrU
ær
bPA }vbP TOLLrFREEPæ~V}(}vl
Pob}v˙Pb }vb A]oZ
}RPRu}]P]ovUv]}(R HOTLINEPıırıUıırı
F}}vDPbAR}]˙~FDAZX F˘Prıwı
Wb]P```X(PRvXP}XPR
Eu]oP(e(PRvXP}XPR
T`]'PPR(ePRY(
WRbPvrıwvæ
SMSbR}}Pæ
F}}lPF}}vDPbAR}]˙rGH
N}voA]bC}v}oP}Puu~NACPZ rvwævlwllı
Wb]P```XPRvXP}XPR
Introduction
N}voMo]C}v}oP}Puu rvlv
Wb]P```XPRvRoRb]X}P l
uo]
N}voT}o}b]bC}v}oP}Puu rv
Wb]P```XPRvXP}XPR
N}voY`bC}v}oP}Puu rv
N}voBo]Uo C}v}oP}Puu rvlvw
F˘Prv
Wb]P```Xo]PRvX}P
E˘vP}Puu(}Iuuv]b}v rv
N}voAuovS] rvUrvæU
rvæı
N}voDPIv(}u}vRb}vC rvwææwUrvwææı
F˘Prvwææw
Wb]P```XPRvP]v(}u}vX}P
N}voP}]b}vbC}v}oCv rvUrææ
N}voBo}}S] rvwlrvw
Wb]P```XvbPRvX}P
GRvP}o]S] ıUıııUwrwæ

Wb]P```XPRv}o]X]v(}
Teaching Hospitals
C}bTR]vPH}b]o ræUrı
K}orBTR]vPH}b]o rvwæılvwlvwæ
K}u(}Av}l˙TR]vPH}b]o r
TuoTR]vPH}b]o wr
RP]}voH}b]ob
GRP]}vo
A H}b]o r
~R]PH}b]oZ
CvoRP]}voH}b]o rıw
~W]vvTuS]o]bH}b]oZ
V}oRP]}voH}b]o rvıılvlwıæw
UWbRP]}voH}b]o ırwlvlæıU
ræw
N}RvRP]}v wr~TuoTR]vPH}b]oZ
URP]}vo
bE H}b]o rv
ı
Standard Trtme
}vP
B rAR(}RP]}voH}b]o ærævlævlvUv
AbRvRP]}voH}b]o~Kub]S}RZ ærvwUrwvææ
WbvRP]}voH}b]o~E8Nl`vZ rærUrıU
ræw
vbE RP]}voH}b]o rl
Laboratory
N}voR(vL}}˙ rvwıvlrvı
GRvN}voDPbP}Puu
C}uuvbvbPPb}vbbR}obv}P
TRP}PuuMvP
GRvN}voDPbP}Puu
Ministry of Health
PXOXB}˘MBræUU A GRv
ToR}vvuP~Zrvwl
F˘vuP~Zrvı
ru]o
E PPvePRvX}P
Wb]P```XPRvX}P

Chapter
Disorsofder the
Gatrs ointetina
s lTrcta
8. Diarrhoea
D]R} ]b.vR
b bP}((vUo}}bU`˙}}ob b
}u}ub˙XD]R}u˙}uv]˙}u]vP X
Iv R]ovU R}uu}vbb ]b ]oX TR]b R(}boo˙
v}v}b]v]}bXOR]bbo]luo]Uvu}v]U
]v(}vb v ]v˙ ]v(}vbU u˙ b}] `]R
]R}XFo]o}b}bb ]lo˙]vR]bPP}}( b R]b]X
I(v}}U]u˙bo]vR˙}v U`R]Rv(oX
A }uo]v }( ]R} bR}o lv b]}bo˙X Ao`˙b bl
}R(v˙vR˘}(R}}ob b XG]]vPv]}b]voo
b}(]R}u˙`}bv}}o}vPR}v]}v˘]vb]o
]ubvb ~S b}v }v RCb[ o}`ZX Evub v o˘b
bR}ov}P]v}vb`]R]R}X
sueCa
]R} A ~AM`lbZ
yy Iv(}vb
yy V]oPXPX}]b Uv}}]b
yy ]o B PXPXSou}voo bXU SR]Poo UCu˙o} UE. coliU
Vibrio cholerae
yy P}}}oPXPX Entamoeba histolytica~u}]b]b Z
yy DPr]vPXPXv]]oo]vb
Chronic diarrhoea (> 2 weeks)
yy CR}v] ]v(}vbP XPX u}]b]b U o}b]bU }}v]b
]v(}vb`]RHIV
yy Fv}voPXPX]]o}ò˙v}u b
yy IvGuu}˙PXPXo}o]bU}Rv C [b]bb
yy Mob}}v˙v}ub b PXPXR}v]vb
yy Mo]Pvv˙PXPX}o}vv
yy Ev}]vPXPXR˙R˙}]]bu U]}v}u]v}R˙
yy DPr]vPXPXo˘bUNSAIDb
Symptoms
yy Fv`˙}}ob b
yy Bo}}}ub]vR}}o b
Standard Trtme
yy Pbv}((
yy Reduced urine output
yy Ab}]}u]vP
Signs
obA
yy Avu]
yy W]PRo}bb
yy Av}˘]
yy Ooob]}vbXPX}oobUv]]b]b
yy Sl]vob]}vbXPX˙Ruv}}bu
yy S]Pvb }( R˙}v ~˙ u}b uuvbU }v ]v bl]v
P}U]oo˙.ooAN}vb
b UR˙]U}boR˙}vb]}vZ
yy EvoPR˙}]
yy A}u]voubb
yy Roubb
B}˘rP) D]Pv}bob(}D]R}
yy D]R} WITH}u]vP Uo}`P(`]Rv}ub]v}}ob b P}vb] r
]o]v(}v
yy D]R} WITH }u]vP U (U }u]vo ubU o}} v ub ]v
}}ob
b P}vb]]o]v(}v
v*Diarhoea*v
yy D]R} WITHo}}vub]v}}o
b WITHOUT(P}vb]u} r
biasis
yy P}(b]R}bv~]`}}ob
b WITH
Z }u]vP : consider cholr
era
yy D]R} WITH˘bb]}u]vP ~b]oo˙](]vu}Rv}vuu
}(RR}bR}o}P}ZP}vb](}}}]b}v]vP
yy D]R} bvvP `]R }o vl} bl]v ob]}vbU `]PR o}bb X }
o}vP]}P}vb]HIV
yy D]R} ovvP `]R }vb}v ]v obP }vb] }ò uo]P r
nancy
TR(}oo}`]vPov}b bRP}(R˙}v in
children with diarrhoea:
TorP) Abuv}(P}(R˙}v in children with diarrhoea
Abuv}(P}(R˙}v ]vR]ov`]R]R}
A9DEHYDRATION AMæA9 ærA9 ANA9
Nil M]oru} Severe
LOOKTA
C}v]}v WooUo RbobbU LRP]U
irritable v}vb]}bUG}˙
Eyes N}uo Sunken V˙bvlvv

dry
M}Rv}vP Moist D˙ V˙˙
Chatep rP *Disorsof
der theGatrs ointetina
s lTrcta
Abuv}(P}(R˙}v ]vR]ov`]R]R}
A9DEHYDRATION AMæA9 ærA9 ANA9
Nil M]oru} Severe
Thirst D]vlbv}uoo˙U TR]b˙U]vlb D]vlb}}o˙
not thirsty Po˙
FEEL
Skin Goes back G}blbo}ò˙ Goes back very
]lo˙L L]vR]vP bo}ò˙L
]vR]vP ]vR]vP
CIDDE E
TRv I(RvRb I(Rv
Rbv}b]Pvb}( `}}u}b]PvbU Rb`}}u}
R˙}v ]vo]vPob b]PvbU]vo]vP
}vb]Pvvo]vU ob}vb]Pv
R]bb}u vo]vUR]b
R˙}v R˙}v
b
TRETME
A NTPLAN W]PRv W]PRvv W]PRvv
and use bTuv bTuv
TuvPovA PovB PovC
v*Diarhoea*v
(}u
A IvPMvPuv}(CR]oR}}IoovbbUWHO
Invtiga
se tions
yy FBC
yy Bo}}.ou(}uo]b]b
yy S}}o}v˘u]v}v
yy S}}o(}ovbvb]]˙
yy Bo}}vv]v
Trtme
ae nt
Tuv}ib
yy T}vR˙}v
yy T}oo}bG]
yy T} u]v]v v]}v ˙ vb]vP ]˙ ]vl ]vP
illness
yy T}u]v]vb}voR˙P]v
yy T}o]u]v]v(vP}Pv]bub`R}]
Non-pharmacological treatment
yy K}v]vPbb ov
yy Iu}b}voR˙P]vXPXRv`bR]vPL}]o
yy A G] ]vl r }o v ]vv}b b vbb˙ ~S
b}v}vRFo]uvPuv(}R]ov`]R]R}[Z
yy M]v]vv]}vv b }o
Standard Trtme
Pharmacological treatment
AX]o
B Pb}v]b ~(U}u]voubUo}}v
mucus in stools)
Note 1-1
N} v]}b ] (} b ]o Pb}v]b X A R˙ r
}v]bRu]v]uvX
st
L]vTuv
]v
E RvPPA
yy C]}G}˘]v U}oU
Adults
æuPR}o˙(}æ˙b
Children~(}ooR]oPP}bZ
æuP llPR}o˙(}æ˙b
nd
L]vTuv
]v
E RvPPA
yy (}˘]u
C UIVU
Adults
wæuPR}o˙
Children
æuP llP}˙`]PRR}o˙
v*Diarhoea*v
Neonates
AN˙bw V æuP llP}˙`]PRR}o˙
AM˙bw V æuP llP}˙`]PRR}o˙
Then
yy (}˘]u
C U}oU
Adults
æuPR}o˙(}ær˙bw
Children
r˙bV æuPR}o˙(}ær˙bw
r˙bV æ uP llP }˙ `]PR (} ærw ˙b ~u˘X
æuPR}o˙Z
u}vRbr˙bV uP llP }˙ `]PR (} ærw ˙b ~u˘X
æuPR}o˙Z
Note 1-2
Sbvb]}v v }vo˙ P]v} R]ov } u}vRbU R}`R IVv
P]v}v}vbX
BX Au}]˙bv˙ ~v
b (]o]vP}b}v}
u]]ouv(}]oPb}v]b within 2 days or
based on stool microscopy)
]v
E RvPPA
yy M}v]}o U}oU
Adults
uPR}o˙(}æ˙b
Children
Chatep rP *Disorsof
s lTrcta
r˙bV uPR}o˙(}æ˙b
rw˙bV uPR}o˙(}æ˙b
r˙bV uPR}o˙(}æ˙b
C. CholeraP}(b]R}~]`}}o b ZA=}u]vP
st
L]vTuv
]v
E RvPPA
yy TetracyclineU}oU
Adults
æuPvR}o˙(}˙b
Children
N}}uuv
Or
yy D}˘˙˙o]v U}oU
Adults
uPR}o˙(}˙b
Children
N}}uuv
Or
yy E˙R}u˙]v U}oU
Adults
æuPR}o˙(}æ˙b
v*Diarhoea*v
Children
AN˙bV æuPR}o˙(}æ˙b
vr˙bV æræuPR}o˙(}æ˙b
rv˙bV æuPvR}o˙(}æ˙b
u}vRr˙bV æuPvR}o˙(}æ˙b
NeonatesV XæuP llPvR}o˙(}æ˙b
D. Zincbouv}v(}]R}
]vE RvPPA
yy Z]vbouvU}oU
Adults
Not required
Children
ANvu}vRbV uP l˙(}r˙b
AMvu}vRbV uP l˙(}r˙b
Refealr Criteria
R(vb`R}(]o}]u}U}P`}bUb]R˙(}
]R}X R( oo vb `]R R}v] ]R} } b]o]b
(}(Ro}vvuvPuvX
Trtme
ae ntalgorithm
Fluid management for children with diarrhoea
uTvPoN}
R˙
Wv}v
A
yy CR]ov(o˙
b R}u
yy Ivbu}R}P]R}urbG]bo]l]Ùl}l}Ub}U
æ
Standard Trtme
ÙvOoRR˙}vSo~ORS ZX
yy ]bbB bR}oP]vu]ol
b vORS
yy G]buRbR]o`vb}(ooRG]b
yy CR]obR}o}vv}(
yy AblRu}R}v}RRoR(]o]˙](RR]oPb`}bU
bu}`˙}}ob
b U}u]bo˙U}ub˙R]b˙U
b}]vlb}}o˙}]bv}']v˙b
yy Ivbu}R}vR}`}v]R}
ORSvo˙}uuv (} b ]v u]o } u}]R}
Rbb}]uvPo}b}vv}v~o}`}bu}o]˙ZX
How to prepare ORS
ORSP D]bb}o R }vvb }( }v bR }( ORS ]v v uo }
uobv]vP}v˙}(ORSX
yy T} P v uoU b buoo ~ uoZ b}L ]vl }'ob } ]P
}'o
yy T}PuoUbLu]vo`}'o
TRR]o}obR}o]vlASMUCH}(]R b lbR`vbXI(R
R]o}u]bURu}RbR}o`]}u]vbvP]]P]vX
TorP) Tuv˙Fo]TR˙rPovA
v*Diarhoea*v
P
A ORSBb]Au}v ORS(}˙˘}}o
b
passed
AM˙b æuo}u} æWuo
W˙b uo}u} Wuo
AN˙b uo}u} Wuo
uTvPoR˙
u]o
}v
Wv}B u}
For the child with mild-moderate dehyd}v Uuse treatment Plan B
yy Child to be treated in the health facility
yy G]ORS }R.bR}bbR}`v]vRTo(}PovB
yy I(R]o}u]bU`]u]vbvP]v b
yy C}vv`]R}RG]bRR]o`]oo
yy Ivbu}R}}vv(]vP b ](R]o]b]vP
b
yy Ob}}ob
b bv}v˙
yy CRl(}b]Pvb}(`}bv]vPR˙}v
yy I(˙b}u+˙U]uvb}}uRG]RbvP]vb}}b
ORSvro
yy Rb}(b R˙}v LR}b
yy I(o]v]oRb b ]u}`]Rv}R˙}v rP}}ovA
yy I(R]boob u]oru}R˙}v ovB
yy I(}v]}v]b`}bv]vPrP}}ovC
v
Chatep rP *Disorsof
s lTrcta
TorP) Treatment by Fluid Therapy - Plan B

W]PR AMvlP vAMlP rAMlP WılP
AP U}u}vRb u}vRb} u}vRb} ˙b}æ
u}vRb ˙b years
Au}v ruo rwuo wrıuo ıruo
}(ORS
UbRR]o[bP}vo˙`Rv˙}}v}lv}`R`]PRXTR}˘]uu}v}(ORS
]~]vuovZ ob}oo˙uoo˙]vPRR]o[b`]PR~]vlP˙Z wæ
Treatment Plan R˙
}vCSW
yy A R]o `]R b R˙}v ]b Pv uv `]R IV
G]b]vR}b]o
yy I( R R]o v ]vlU P] ORS ˙ u}R `R]o R IV o]v ]b ]vP
set up
yy S IV G]b ]uu]o˙X G] uollP R]vP [b o b}o}v
}U](v}]ooUv}uobo]v}R}oouvG]~æPPZU
]]bR}`v]vRTo(}PovCo}`P
yy I(˙}vv}P]R}uvvvv}vbb }Pb]
U(}RoR(]o]˙Rv}b}X
v*Diarhoea*v
yy Rbb R R]o ˙ r R}bX I( R˙}v b ]b v}
]u}]vPU P] R IV G] u}]o˙ Rv b ]v R To
(}PovB
yy Aob}P]ORS ~}æuollP}˙`]PRlR}b}}v Z R b R]o
v]vlPboo˙LrR}b~]v(vbZ}WR}b~R]ovZ
yy Rbb v ]v(v L v R}b v R]o L R}bX Cobb](˙
R˙}v X TRv R}}b R }] ov ~AU U B } CZ }
}vvuv
yy R]o
Ab R}o˙XI(v}]u}]vP}R˙}v ]b`}bU]vb
drip rate
yy D} v}}b R IV G]b vo R R]o Rb v }b}]v
R ORS (} ob R} v R ]b ]u}uv ]v R o]v]o
}v]}v
yy C}vv ORS }v uv ov B v }vv } }b R]o
voR]oRbv}b]Pvb}(R˙}v URvu}}PovA
yy S]R} u˙ }uo]˙ ulG] o}bb
}uv] ˙ o}bb }( }bb]u ~R˙}lou]Z } }v R }R
RvU]u]vo(v}vo]vP}]}b]bvoo}}
}bb]u~R˙lou]Z
yy WRv R v ]b b]vP u}vb }( ]vU }o˙
]v]vPP}}vo(v}vU}bb b]u}v]v]vP(}}bbR
}}v b `v(bR(]b~XPXvvZ
yy I(R]bo]v]ovl}o}}˙]v}(R˙}lou]
b U
}bb]ubR}oP]v˙R]vv}b}b]vP}bb]u
Ro}] }vo˙ ]v R}b]oX P}bb]u }v]v]vP G]b bR b
w
Standard Trtme
Ro(vPRb }`
D [bb}o}v}R]vP [bo u˙
yy I(}bb]o]v(vbvR]ovbR}o}vv}}b
]vPR]}}(]R}
TorP) Treatment by Fluid Therapy - Plan C
P
A F]bP]uollP]vP TRvP]wuollP]vP
Iv(vb~AMu}vRbZ R} æR}b
Children
~u}vRb}æ˙bZ u]vb A*R}b
R}v](]oob]boo
b ˙`l}v}oX
Note 1-3
Avr]R}o u]]vb o]l M]b K}o]v U ]Rv}˘˙o l}]v U }]v U
o}u] bR}o v} b ]v R uv }( ]R} ]v R]ov v
o]lo˙ } } u} Ru Rv P}}X S]u]oo˙U v]} }vb `]R
l}o]v}v}(v}Ro]vRuvPuv}(]R}X
v*RotavirusDisseandDiarhoea*v
9. R}]b Disease and Diarrhoea

Rotavirus ]b R u}b }uu}v b }( b ]R} ]v ˙}vP
R]ovX I }vb (} u} Rv R] }( oo R}b]o]}vb }(
R]ov obb Rv æ ˙bX I }b ˙ }v `]R lb `v R
˙u}vRb~DurMRZXCR]ov]v(˙P}˙b
vr]v(}vb}uu}vX
sueCa
yy RotavirusPæ˙b}(}]b lv}`v}bANıA9}(oob
`}o`]
Symptoms
yy F
yy V}u]vP
yy P}(b`˙]R}
yy Thirst
Signs
yy Sunken eyes
yy D]u]v]bRbl]vP}
yy Ao}vb]}bvbbUv]vP}vRP}(R˙}v
Invtiga
se tions
yy }v D }( }]b vPv ]v }}o
b ˙ v v˙u ]uuv}b˙b
~EIAZ
Trtme
ae nt
Tuv}ib
yy C}}v}(G]vo}o˙.]b
Chatep rP *Disorsof
s lTrcta
yy Rouv}(}vrP}]vPG]o}bb
yy v]}v
A }vuov]}v
yy H}urbG]bXPXu]ol b U}]PbU}}v]vl
yy N]}vP(bv}o]vPR]b}UP]v˘
uo˙(}`lbLR]b}
AX ORS and Zincbouv}v
~Sb}v}vRD]R} [Z
Refeal
r Criteria
yy P}} b}vb } R˙}v }bb ~bb]vP u} }}ob
b Rv
]vl]vPZ
yy P}}]vl]vP
yy Bo}}]v}}o b
yy P}}(]vP
yy Ao}vb]}bvbbl}vob]}vb
yy D]R} v}u]vP }vv]vP(}AN˙b
N}r
v*Constiption
Pv}vP
T`}~}bZ }(
b R}]b ]vU P]vrv `lbU]b+]vv r
a *v
]vP }]b ]R}X TR v }b bR}o P]v ˙ v `lbU v v}
oRv`lbXR}]b]v]bv}`vo˙P]vb}(}v
]uuv]}v]vGRvX~Sb}v}vRIuuv]b}v[ZX
10. C}vb}v
Iv PvoU }vb}v (b } }ò u}uvb R
]v(v } }}ob
b R ]8o } bX TR ]b P ]v]]o
]}v ]v v}uo }ò R]bV R(} uRb]b bR}o o] }v
RvPb]vR}òR]X
D]R} ovvP `]R }vb}v u˙ ]v] oP }ò
v b]oo˙ ]v R}b P ˙b v }X Iv R]ov v R
oo˙UR]bu˙]v]R}v]}vb}v`]Rb]}b]R}X
TRR]ob}(o˘b]b˙}uu}v]vR}uuv]˙XTR]b
ub]b}P}}]R˙}lou]v]b}vbvbX
sueCa
Medical
yy D].]v]v}PRP
yy IPv}]vPRP}(XPX}]uu}]o]˙
yy H˙}R˙}]]bu
yy I]o}ò˙v}ub
yy H˙ou]
yy DPb XPX }]v U }]v U u}R]v U ]˙o] vbbvbU
ı
Standard Trtme
]b}˙u]
yy L˙}ò(}uR}v]o˘b]vo]vPRRo[}vb
yy Ll}(˘]b
yy DR˙}v v}v
b ~oo˙]vR]ovZ
Surgical
yy Gb}]vbvo}b}v
yy Avo.bvb }R]v(o]voob]}vb
yy ]v}u
C }(Ruvb]Pu}]}o}v
yy F}]Pv}˙]vRP
yy Po]ubbXPX.}]U(}b
yy APvPo]}v]v]uP}o}v
yy Pb}r}ò }b}v ~OP]o] ˙v}ub Z (}oo}`]vP ]uu}]o]˙
(}uv˙b
Symptoms
yy Iv]o]˙}u}}òb
yy Pbb]vPR}}ob b
yy Iv(vb]vP}(}}ob b
yy S]v]vP}}}ob b
yy Fo]vP}(]v}uo}v}(}ò
yy Iv]o]˙ } b GbU }o]l˙ }u]vo ]v `]R } `]R}
v*Constiption
}u]vP
a *v
Signs
yy Fv R]PR ]R }ò b}vb r b uRv]o }ò
}b}v
yy bv A }òb}vbro˙ b ]ob
yy S]Pvb }( ]}v]b ~Pvo]b vvbbU P]vP v }v
vvbbU(}]b}vZrbbPvPv}b}ò
Invtiga
se tions
yy D]P]o o ˘u]v}v ~ub ] } ]v oo vb `]R
]Pv}b
b ]b}(}vb}vZ
yy Stool for occult blood
yy Po]v}u]voXr˙~vb]vZ
yy P}}b}˙ l}}b]Pu}]}b}˙ l}o}v}b}˙ ~ub v} }v
](]vbvo}b}v]bZb
Trtme
ae nt
Tuv}ib
yy T}]v(˙}bb]ob}(}vb}v
yy T}o]}vb}v
yy ARv}Po˘]b
yy H]PR.]
yy A G] ]vl ~u]v]uu }( XL }( ` ˙ ]( v}
}v]v]}vb˘]bZ
Chatep rP *Disorsof
s lTrcta
AX MvPuv}(C}vb}v]vAob
st
L]vTuv
]v
E RvPPC
yy B]b}˙o U}oUruPv]PR
Or
yy SennaU}oUæruPu~u˘]uuwruP]o˙ZXD}bb
}wuPbR}o]]R}o˙
Or
yy Lo}b U}oUæruo]o˙vob}vbURvruo]o˙
nd
L]vTuv
]v
E RvPPC
yy B]b}˙o UoUuP]vRu}v]vP
Or
yy Glycerolb}b]}]bUoUPv]PR
Or
yy L]]8v U}oUruov]PR
Or
yy M]ol}(MPvb] U}oUæruo]vPobb}(ÙrR}o˙
v*Constiption
B. MvPuv}(C}vb}v]vCR]ov
L]vTuv
a *v
st
]v
E RvPPC
yy Lo}b U}oU
r˙bV æuoR}o˙
ær˙bV uoR}o˙
ræ˙bV æuoR}o˙
AM˙V XæuoR}o˙
Or
yy Glycerolb}b]}]bUoU
ræ˙bV Pv]PR
AM˙V Pv]PR
Or
yy B]b}˙o UoU
AN˙bV æuP]vRu}v]vP
AM˙bV }vu]o]}vo˙
Or
yy SennaU}oU
vr˙bV æruou
rv˙bV Xæruou
Note 1-5
D}v}buPvb]ubob]vvb`]R]u]vo(v}vX
Standard Trtme
Refeal
r Criteria
TR(}oo}`]vPP}]b}(vbbR}o(}P}v
b P
yy Pvb`]Rbv}òb}vbU}u]vP }v}b]vPGb
yy b]bC v}u]ouv
yy Av˙P]o b b
11. PUo Disease

Po u˙ }vo } Pb]X D}vo ob u}
}uu}v v } u} }Lv ]v ˙}vP obX Gb] ob usually
} L u]o PX Gb] ob bR}o lv b]}bo˙ b
R˙u˙uo]PvvX
Pobu˙o}o](Rv]vP}uo]}vb}(o]vPU
(}}vvPb]}o}b}vX
sueCa
yy Helicobacter pylori (H. pyloriZ]v(}v
yy E˘bb]}v
b }(Pb]]
yy Iv }}v }( R o]v]vP }( R }uR b v }vu
v*Petic
P]vb]Pb}v˙]vb]v
yy M]]vb XPX v}vrb}]o vr]vGuu}˙ Pb ~NSAIDb ZU
p UlcerDisse*a v
}}b}]b
Symptoms
yy E]b}] }u]vo ]v ~}Lv PP˙ ]˙ ]v]b}vb
vo](b˙oZ
yy M˙u]v}]b}u(}UPv`]vPUv]vPUooR}˙
severe pain
yy T˙]oo˙]v]b]vR]Pb]u}]PRR˙}R}v]u
yy Ob]}voo˙ R]PR R]v R vu b } o}` }`v }v
Ru]o]b
yy Iv }vo oU ]v ˙]oo˙ }ub }v `Rv R v ]b
RvP˙vu˙`lRv]vRu]o}(Rv]PRX
yy IvPb]oU]]b˙]oo˙`}bv˙(}}Uvu˙ r
o]˙}u]vP
yy Ibo]˙olo]bv(}}]v}voo
yy V}u]vP u˙}]v}R}vovPb]obXI]bboo˙
}uo]}v]v}voo~Pb]}o}b}vu˙ Z
bo(r]v]vPb]o}o]]v
In children
yy P]vu˙]ru]o]o
Signs
yy TRu˙v}}u]vob]Pvb
yy W]PRo}bb~b}uub]vPb]oZ
yy W]PRP]v~b}uub]v}vooZ
yy Tvvbbr]Pb]uU]PRR˙}R}v]u}u]o]oP]}v
Chatep rP *Disorsof
s lTrcta
Invtiga
se tions
yy Hu}Po}]v
yy H. pylori}}o b vPv
yy Ob}RP}rPb}r}v}b}˙~v}b}˙Z
yy B]uuo ~]vRbv}(v}b}˙Z
yy S}}o˘u]v}v~}˘o]vbvob]bZ
Trtme
ae nt
Tuv}ib
yy T}o]]v~˙bb]ZvPb]]}v b
yy To eradicate H. pylori if present
yy T}}u}Ro]vP}(Ro
yy To prevent recurrence of the ulcer
yy T}vvuvP}uo]}vb
yy Avoid alcohol and tobacco intake
yy }] A (}}bRPPR]v
yy Aoo˙v˘]˙ and stress
yy SP]o uvP (} R}v] b `]R b ]}] 'lbU
v*Petic
(]o u]o uv v }uo]}vb XPX (}}vU Pb]
p UlcerDisse*a v
}o}b}vvRu}RPZ
AX Dyspepsia
st
L]vuv
]v
E RvPPA
yy MPvb]u]b]o] U}oUæuoR}o˙~]vr`vuobv
u}}v}o˙bb]Z
Or
yy Aou]v]u R˙}˘]U }oU æ uP v R}o˙ ~]vr`v uob v
uZ
Note 1-6
}]
A l]vPv]b`]R]vR}b}(}}vu]vR]]}b~PPIbZXPX}u r
}oUb}u}oUv}}o
nd
L]vuv
]v
E RvPPA
yy Ou}o U}oU
Adults
uP]o˙(}`lbXR}b](o]bv}(oo˙RoX
BXNSAIDrbb}]}vo}Pb]ovPb}r}vo
erosions
]v
E RvPPA
yy Eb}u}o U}oU
Standard Trtme
Adults
Or
yy Ou}o U}oU
Adults
Or
yy Pv}}o U}oU
Adults
ruP]o˙(}`lbXR}b](o]bv}(oo˙RoX
C. Bleedingo ~u˙v]v]}v(}P˙
b Z
]v
E RvPPA
yy Eb}u}o UIVU
Adults
uP]o˙
Or
yy Ou}o UIVU
Adults
uPR}o˙(}}æ˙b
v*Petic
D. Helicobacter pylori Eradication

p UlcerDisse*a v
Mi}]˙}(vbbvvP`]R}voo]v(`]R
Helicobacter pyloriX]}v
E }( H. pyloribR}oR(}}vb]vP
r˙}b}(uv}vb]bvP}(PPI ob}u]v}v}(
`}}(Rv]}b]v]]vRoo}`X
ToræP) Helicobacter pylori]}v
E TR˙
Helicobacter pylori]}v
E R˙
PPI Av]}
Au}˘]]oo]v U Co]R}u˙]v U}o M}v]}o U
}o oral
Eb}u}o U}o PR}o˙ æuPR}o˙ rrrrrrrrrrrr
uPR}o˙
rrrrrrrrrrr æuPR}o˙ uPR}o˙
O PR}o˙ æuPR}o˙ rrrrrrrrrr
Ou}o U}o
uPR}o˙ æuPR}o˙ rrrrrrrrrr uPR}o˙
rrrrrrrrrr æuPR}o˙ uPR}o˙
O PR}o˙ æuPR}o˙ rrrrrrrrrr
Pv}}o U}o
uPR}o˙ rrrrrrrrrr æuPR}o˙ uPR}o˙
}]
A uvP]uvb]vo]vPAu}˘]]oo]v]vvb`]Rv]]oo]vooP˙
Refeal
r Criteria
R((}b]o]b`RvR]b(]o}( H. Pylori]}v
Chatep rP *Disorsof
s lTrcta
}](P˙
b ]b]v]}b X
12. Gb}r}b}RPoRG˘D]bb
Gb}r}b}RPoRG˘D]bb~GORDZ]bb˙lG}`}(
Pb] vl} }vo }vvb b R o}` }b}RPo bR]v
]v}R}b}RPb`]R}oR]vP}}u]vP X
TR]b]bb obb].]v}`}P}b}v
b v}b}˙.v]vPb
b v}vr}b] Pb}r}b}RPo ]bb ~v}vr}b] GORDZ v
}b] Pb}r}b}RPo ]bb ~}b] GORDZX F]o } u˙
bo]v}b}RP]b Uo}vU]bb vo˙v}]v}uX
sueCa
yy Ob]˙
yy Hiatus hernia
yy Ivb]vr}u]voXP b X]vPvv˙
yy L}vPub}(vb}Pb]
v*Gatrs oroeops hagealRefluxDisse*a v

yy APvb R b o}` }b}RPo bR]v b XPX
o}R}oU ]P'bU vR}o]vP]b ~XPX H˙}b]v ˙o}u] U
P}vRo]v }u] ZU }R Pb W M}R]v U D]u U
PR]]v vCo]u channel blockers
yy CR]ov`]RR}v]v}o}P]o]bb~XPXoob˙Z
Symptoms
yy Heartburn ~`}bvb `]R ]P}}b ˘]bU v]vP (}Ù o˙]vPV
o]˙v]bvb]hvP]PRZ
yy D˙bb]
yy o˙ E ˙b
yy R}bvov]Pb]]v~u]u]bvP]v}]b˙]vP
} vlU i`b v ubX TR ]v ]b `}b }v v]vP }`v XPX
`]vP
b Z
yy P]v}vòo}`]vP b
yy D]8o˙òo}`]vP
b
yy N}vo PP]}v ~`lb vb `]R }PR]vPU R}l]vP
v.oo]vP}(Ru}R`]RRbo][Z
yy Ru Ab ro]l~u˙`}bv]PRZ
In children
yy F]o}R]l(b]vP(}}
yy V}u]vP
yy C}PR]vP
yy F}(oPP]}v`R]Ru˙o}b]}vvu}v]
yy I}v.]v˙vu]
yy WR]vP
Signs
yy May be none
æ
Standard Trtme
yy E]Pb]vvbb}b]}voo˙
yy CRbb]Pvb~XPX`R]vPZ
Invtiga
se tions
yy Ob}RP}rPb}r}v}b}˙~OGDZU]XX Pb}r]vbvo
tract endoscopy
yy CRbXr˙}˘o}Rb
yy A}u]voob}v~}˘o}R]bbZ
yy B]uòo}` b `]RG}}b}˙~b]oo˙(o
b ]vR]ovZ
yy Ob}RPoHu}v]}]vP~]vbR]8o}]Pv}bZ
yy L}` }b}RPo bR]v uv}u˙ ~]v b R ]8o
}]Pv}bZ
Trtme
ae nt
Tuv}ib
yy T}o]˙u}ub b
yy T}v}uo]}vb
v*Gatrs oroeops hagealRefluxDisse*a v
Lifestyle changes:
yy EoR}(˙}Pb}bo}v]oo}`b
yy }] A bo]vP`]R]vR}bLvP
yy }] A }rvPvR˙uob(}u
yy }] A (}}bRPP˙u}ubb XPX('˙vb]˙(}}
yy }] A bu}l]vPvo}R}o
yy }] A N}vrS}]oAvrIvGuu}˙DPb~NSAIDb Z
yy Ev}Pu}˘]b
yy W]PR}v]v}`]PRv}b]v]]ob
yy }] A }bbU]vbò}}bo}R]vP
yy SP]o uvP Fv}o]}v ~(} b bU uv
(]obv}uo]}vbZ
AX N}vr}b]GORD
]v
E RvPPB
yy MPvb]u]b]o]U}oUæuoR}o˙~]v`vuobv
u}}v}o˙bb]Z
Or
yy Av]b }v]v]vP Aou]vu R˙}˘]U MPvb]u R˙}˘]U
S]uR]}vUCo]uoP]vb
Or
yy Ou}o U}oU
Adults
uP]o˙(}r`lb
Children
ANlPV uP]o˙(}r`lb
rlPV uP]o˙(}r`lb
ærlPV æuP]o˙(}r`lb
v
Chatep rP *Disorsof
s lTrcta
Or
yy Eb }u}o U}oU
Adults
uP]o˙(}}`lb
Or
yy R}o U}oU
Adults
uP]o˙(}}`lb
BXS}}bE ]GORD
yy Ou}o U}oU
Adults
ruP]o˙(}`lb
Children
ANlPV uP]o˙(}r`lb
rlPV uP]o˙(}r`lb
ærlPV æuP]o˙(}r`lb
Or
v*PainOriginatingfromtheOeops hagus*v
yy Eb}u}o U}oU
Adults
uP]o˙(}`lb
Or
yy R}o U}oU
Adults
ruP]o˙(}`lb
CXS}}bE ]GORD ~`]Ro}vPZ
yy Ubu]}vb]vS}vB}(}RSGORD[
Av
yy M}o}u] U}oU
Adults
ruPvrR}o˙
Or
yy D}u]}v U}oU
Adults
uPvrR}o˙
Refeal
r Criteria
R( b v} b}v]vP } R ubb } } R˙b]]v
} P]o
b b]o]bU b òo b b bU uv (]ob v
]v]]ob`]R}uo]}vbX
13. P]vO]P]vvP(}uROb}RPb
Ob}RPo ]v ]b boo˙ v]vP ]v o]˙ v vb }
o}o]b R]v Rvu
b X Ob}RPo ]v u˙ b}]`]R
]8o˙]vòo}`]vP
b ~˙bRP] ZXD˙bRP] }`bPPbRob
b ]U
w
Standard Trtme
`R]o R } b}o]b v v} ` bPPbb uRv]o }b}v ˙
u} } ]b X I u˙ b}uub }v(b `]R }R b }(
chest pain~Sb}v}vRCRbP]v [ZX
sueCa
yy I]}v}(R}b}RPou}b˙G˘}(R]]}vvb
}(R}uR
b ~Gb}r}b}RPoRG˘D]bb ~GORDZ
yy Ob}RPov]]b]b
yy Hiatus hernia
yy Achalasia
yy Sbu}(R}b}RPoubo]vb}vb}}b}vX
yy Ob}RPou}b
Symptoms
yy Retrosternal chest pain`}bv˙òo}`]vP
b ~]v`}b}vo˙]vP
Gu˙bPPbGORDZ
yy RPP]}v}(]vPbu]o
yy D]8o˙]vòo}`]vP
b
v*PainOriginatingfromtheOeops hagus*v
Signs
yy Uboo˙v}v
yy Pvu˙}b}o˙ b v`]PR]vRb}(GORD
yy S`]PRo}bbu˙bPPbu}}v]]b]b(}u]uuv
suppression
yy TRu˙}ov]]b]b]vR}( b }b}RPov]]b]b
Invtiga
se tions
yy B]uòo}`
b
yy Ob}RP}rPb}}v}b}˙~GIv}b}˙Z
yy Ob}RPouv}u˙ `RvRob]]bb
Trtme
ae nt
Tuv}ib
yy To relieve pain
yy T}]v.b
yy Bov(}}bvu]ol~u˙b}uubo]R]vZ
AX F}GORD
st
L]vTuv
]v
E RvPPB
yy Ou}o U}oU
Adults
uPR}o˙(}˙b
Or
yy Eb }u}o
Adults
Chatep rP *Disorsof
s lTrcta
ruP]o˙(}˙b
BXF}vbv}b}v]vP}u}v}R˙`]RPPI
]v
E RvPPB
yy Ou}o U}oUuPR}o˙(}˙b
Or
yy Eb}u}o U}oUruP]o˙(}˙b
Av
MPvb]u]b]o] U}oUuoR}o˙(}˙b
C. For oesophageal candidiasis
]vE RvPPA
yy N˙bv U}oU~b`]bR]vu}R(}ob u]vbvRvòo}`
b Z
Adults
UrvUv]bvR}o˙(}˙bw
Or
yy Fo}v}o U}oU
Adults
uPXb
Then
uP]o˙(}˙b
v*Haemorrhoids*v
Refeal
r Criteria
R(}b]o]b(}}v.u}v}(]Pv}b]bvuvPuvX
X Haemorrhoids
Hu}R}]b } S]ob_ voPU ]bo vo bR]}vb
](}uvP}P]vbU`R]R]u]o˙bvb`]Rvoo]vPX
F]brP Ru}R}]b u]v ]v R vo voX S}vrP
Ru}R}]b}obUb}vv}bo˙U`RbR]P
Ru}R}]b }ob v R } o uvoo˙ } u]v
}obuvvo˙voP]oo˙ b X
TRR]b}˙]b˙]u}vXTRv}(Ro]vPUb}]
]v v }R ˙u}ub
b Ro ]+v Ru}R}]b (}u }R
u}b]v]b}v]}vbXAo`˙b}]P]oo˘u]v}v}˘o
]v}u v }R }v]}vb `Rv v }uo]vb }( ]v }
o]vP(}uRvbXAo}lo}}U}o}}u]˘`]R}}ob b U
bR}o]bb]]}v}(o]vPR]PR]vRu}}o}vX
N} uv ]b ] (} Ru}R}]b R ˙u}u
b X
}] A Rb}(PbX
sueCa
yy Ivb ]vr}u]vo b XPX R}v] }PRU Pvv˙U
]vr}u]vo}o]u}b
yy E˘bb]]v]vP
b }}ob
b (}u}vb}v}]R}
yy Fu]o]o]b}b]}v
ı
Standard Trtme
yy CR}v]o]]bb`]R}oR˙vb]}v
yy Av}ou}b
Symptoms
yy PbbP}(]PRo}}(}v
yy N}u]˘`]R}}ob b
yy M˙˙b R}]o}ò}}vo˙(}v}vR}]oL
ov]vP
yy M}]]bRP
yy Sòo]vPvb
yy P]vo]]}v}]R~]b v]Z
yy D]b}u(}L}v]vP}òb
yy Avo]v~}b]vPv'l}(}ob`]RR}u}b]bU
}vPb}vv}uZ
yy S˙u}ub}(vu]
Signs
yy M˙ v}v ~]vb}v }( R vb v ]P]oo ˘u]v}v
u˙v}uoZ
yy Rvv (}ob }( bl]v ~bl]v PbZ bv ]v R }b]}v }( R
Ru}R}]bXS]v]vPu˙bR}`RRu}R}]b
v*Haemorrhoids*v
yy Sòo]vPRvb~]vR]PRu}R}]bZ
yy PooR}u}b]vvoRu}R}]b}vo˘u]v}v
yy S]Pvb }( }uo]}vb ~}(b o]vP `]R vu] }
Ru}RP] bR}lU }obU vPo}v b U R}u}b]bU ]v(}v
}o}vZ
yy Poo}
Invtiga
se tions
yy FBC
yy P}}b}˙ ~RP}ovb (}]Pv}b]bZ
yy S]Pu}]}b}˙ ~}˘o]v}u}(uZ
Trtme
ae nt
Tuv}ib
yy T}}vu]U](bv
yy T}o]˙u}ub b
yy T}v}uo]}vb
yy Ivb]vl}(G]v}PRP
yy }] A }o}vP]v]vP
b (}v
yy F} }ob Ru}R}]bU o] v }`v v oR (}}
v}(RXT˙Pvo]P]o}vLo]}v}(o}o
vbR uX I( R]b (]obU o˙ }o }ubbX S}v }(
Rvu˙]
yy F}]v(Ru}R}]bUùb]Rbrub˙
yy SP]ouvP
Chatep rP *Disorsof
s lTrcta
yyRvo]P}v(}}v b rPRu}R}]bX
yyHu}R}]}u˙(}R]PRu}R}]bX
yyHu}R}]b o}]vP ]vP Pvv˙ bR}o uv r
P}vbo˙bu}b`]oob}oLo]˙
AX WRvb}]`]R}vb}v
]v
E RvPPC
yy L]]8v U}oU
Adults
ruov]PR
Or
yy SennaPvobU}oU
Adults
bR`]R`Lb
B. When associated with local itching or discomfort
yy S}}R]vP Pv ~`]R } `]R} }]b
b Z U o] } ]vb r
oo˙U
Adults
Ovb}b]}˙R}o˙(}wr˙b
v*Haemorrhoids*v
C. For infected haemorrhoids
st
L]vuv
]v
E RvPPB
yy Gvu]]v UIVU
Adults
ruPR}o˙(}æ}˙bw
Av
yy M}v]}o U}oU
Adults
uPR}o˙(}æ}˙bw
nd
L]vuv
]v
E RvPPB
yy C]}G}˘]v U}oU
Adults
æuPR}o˙
vA
yy M}v]}o U}oU
Adults
uPR}o˙(}ær˙bw
L]vuv
]v
E RvPPB
yy Au}˘]]oo]v U}oU
Adults
æuPR}o˙
Standard Trtme
Av
yy M}v]}o U}oU
Adults
uPR}o˙(}æ}˙bw
D. When associated with anaemia
yy I}v}v ~(}b boRl(uZ ~S b}v }v RAv r
u][Z
Or
yy Bo}}vb(b]}v as indicated
Refeal
r Criteria
TRvbR}o(}(]o]˙`]Rb}b(}
vo]P}v}}uv](]v]X
v*Haemorrhoids*v
Chapter
Disorsof
der theLiver
8. Au}]L]Ab
Au}] o] b ]b }oo}v }( ˙]oo˙ }`v]bR }o}
G] ]v R o]U }]vP }Lv b b]vPo ubb ]v R ]PR o} v
}uo]}v }( ]vbvo ]v(}v `]R Entamoeba histolyticaX LvPU
R v ]v ]v(}vb v}uu}v boX Ob]}voo˙U
˙}Pv]bu˙Rb]u]oo]v]obv}vX
Tuv }( u}] b bR}o ]v] `]R b
Pv P]vbR}R}}](}u (}oo}`˙ ou]vo Pv}
o]u]v]vrou]vo˙bbX
sueCa
yy Entamoeba histolytica
Symptoms
yy R]PR}u]vo]v(o}R]Pb]uU]PRRb
}]PRbR}o
yy F
yy Malaise
yy S`b
yy C}PR
yy Hiccups
yy Av}˘]
yy W]PRo}bb
yy Jv] ~v}uu}vZ
yy C}vv]R}~obbRv}vrR]}(vbZ
Signs
yy LPvo]
yy Tvvbbvl}oP]vP]PR]v}bob
yy Jv]
yy Doovbb } b]}v }v R ]PR o}` Rb }vb `]R bo
]}vb
yy Au}]u˙u (}oo}`]vP˘vb]}v]v}RRb]˙
yy P]}v]b~v}uu}vZ
Standard Trtme
Invtiga
se tions
yy A}u]voob}v
yy CRbXr˙
yy FBC
yy ESR
yy S}}o˘u]v}v
yy A}u]voCTv b
yy S}o}P˙~u}]v}]bZ
Trtme
ae nt
Tuv}ib
yy To eradicate Entamoeba histolytica]v(}v
yy T}v(R}v b }(o]b
yy T}v(R}uo]}vb~XPX}(]v} b ooU
]]o}]}vobZ
yy TR b]}v u˙ ] ]v vb `]R }}
response to therapy
v*AmoebicLivs*ce rA v
st
L]vTuv
]v
E RvPPA
yy M}v]}o U}oU
Adults
uPR}o˙(}˙b~bbPvZ
Children
æuP llPR}o˙(}˙b~bbPvZ
Then
yy D]o}˘v](} U}oU
Adults
æuPR}o˙(}˙b~ou]voPvZ
Children
vruP llPR}o˙(}˙b~ou]voPvZ
nd
L]vTuv
]v
E RvPPA
yy T]v]}o U}oU
Adults
P}v]o˙(}æ˙b~bbPvZ
Children
AN˙bVæuP llP~u˘XPZ}v]o˙(}æ˙b~bbPvZ
Then
yy P}u}u˙]v U}oU
Adults
ruP llPR}o˙(}˙bw ~ou]voPvZ
Children
ruP llPR}o˙(}˙bw ~ou]voPvZ
Chatep rP *Disorsof
der theLiver
Refeal
r Criteria
Pvb`]RR b oP}v}b}v]vP}uv
`]oov}(}b]o]bX
9. Jv]
Jv] (b}˙oo}`]Puv}v}(bl]vUoubvRbo
as a result of elevated levels of bilirubin ]v o}}X I u˙ ]b]o `Rv
bu oob ˘ æ u]}u}olL ]v ob v u]}u}olL ]v
R]ovXTR˙u}ubb vb]PvbR}uv˙iv]}Lv}]
Ro(oob}Rvo˙]vPbX
Iv ob v R]ovU R˙]o]]vu] u˙ bo ]v R
encephalopathy ~Sb}vb}vRAvCR}v]Hb [vRH
EvRo}R˙[Z XJv] in neonates can result in kernicterus (bilirubin
encephalopathy}( bZ R}vbvb}(R˙]o]]vu]}v
R]v}(Rv`}v X~Sb}v}vRN}voJv] [Z
sueCa
Aob
yy Hb r ]oU o}R}o]U Pr]v ]vo]vP oo}R] v
Ro}vb
v*Jaundice*v
yy Hu}o˙b]b r]}bb]vo]vPuo]UGo}brvrPR}bR
D R˙}Pvb ~GvPD Z .]v˙ v b]lo oo ]bbU oo}R]
PbvRo}vb
yy CR}v] o] ]bb r }uvb ]R}b]bU ]o]˙ ]R}b]bU
R}v]RbUR}ooo]v}u
yy L] uo]Pvv]b r R}ooo ]v}uU ub o]
disease
yy H}vPb}v(}uR(]o
yy Gooo]bbr}vb b U]v(}vb
yy ]v}uC }(R}(vb
yy Su]
Children
yy Hu}o˙b]b rb]looo]bbUGvPD .]v˙UPb
yy Iv(}vb r uo]U RbU ]v˙ ]v(}vbU ˙R}] (
v}Ru]b ]oovbb
Pregnancy
(Sb}v}vRJv] ]vPPvv˙[Z
Neonates
~Sb}v}vRN}voJv] [Z
Symptoms
yy Yoo}`}Pv]bR]b}o}}v}(R˙b}bl]v
yy D˙oo}`]b}o}}v}(]v
yy IR]vP
yy Po}}obb
æ
Standard Trtme
Signs
yy Poo}~u˙]v]Ru}o˙b]bUR}v]]bb}uo]Pvv˙Z
yy SRulb~]v]}(R}obb]bZ
yy SPu }( R}v] o] ]bb ~XPX ou ˙RuU o]vPU
b]v]Z
yy H}uPo˙ ~u˙vZ
yy Sov}uPo˙ in portal hypertension
yy PooPooo
yy Ascites
yy Bo]vP ~RoRu}u U bPoo Ru}uU
Pb}]vbvoo]vPZ
yy HG~]v]}(o](]oZ
Invtiga
se tions
AobvR]ov
yy FBC
yy INR
yy S]lo]vPb
yy GvPD status
yy Bo}}.ou(}oov}uo]bUuo]b]b
yy L](v}vb
yy Uvo}o˙b
v*Jaundice*v
yy Hb vb ~HBbAPU HCV Av}˙U Hb A IPMU Hb E

IPMZ
yy Bo}}o
yy U]vo˙b]b
yy A}u]voob}v
yy A}u]voCTv b
Trtme
ae nt
Tuv}ib
yy T}]v(˙vb}(iv]
yy T}o]˙u}ub b b}]`]Riv]
yy T}v}uo]}vbb}]`]Rooob}(]o]]v
in the blood
AobvR]ov
~Sb}v}vRHvRo}R˙[UHb[Z
yy }] A o}R}ov}RR}}˘]Pvb
yy EvbR˙}v
AX CR}obiv] with severe pruritus`R]o]vbPvP(}
vo˙]vP}o}P˙
st
L]vTuv
]v
E RvPPA
v
Chatep rP *Disorsof
der theLiver
yy CR}ob˙u]v U}oU
Adult
PR}o˙~}b}b}vbv}ovPu˘XP v l˙Z
Children and Adolescents
rPR}o˙~u˘XP l˙Z
Refeal
r Criteria
R( vb `]R v˘o]v iv] } b]o]b (} (R
o}vvuvPuvX
10. HbA
Hb ]b .v b ]vGuu}v }( R o] v Rb uoo
bX I u˙bv b v ]oovbb `]R iv] v oo]
(v}vbXWRv˙u}ub b Ub]Pvb}o}}˙v}uo]bb]b
(}u}Rvvu}vRb]]b}vb]R}v]X
sueCa
yy V]bb~Hb AUU
B U
C DvEUYoo}`F XZ
yy DPb~oo}R]UovvRo}vbZ
yy Alcohol
v*AcuteHetitis
yy }]uuvA
ap
Symptoms
*v
yy R]PRR˙}R}v]o]v
yy F ~}]vP}`lb(}Riv]bZ
yy Malaise
yy Av}˘]
yy Nausea
yy V}u]vP
yy Yoo}`}l}o}]v
yy Po}}ob b
yy IR]vP
yy FP
yy Confusion
Signs
yy Jv]
yy R]PRR˙}R}v]ovvbb
yy H}uPo˙
yy ]˘]b Ab
Invtiga
se tions
yy FBC
yy L](v}vb
yy Hb vb ~HBbAPU HCV Av}˙U Hb A IPMU Hb E
IPMZ
yy AvvoAv}˙UAvrbu}}RuboAv}˙
w
Standard Trtme
yy A}u]voUob}v
Trtme
ae nt
Tuv}ib
yy T}]v(˙vo]u]vR]]vPb
yy T}o]˙u}ub b
yy Rest
yy H]PRo}]G]b~b]oo˙Po}b]vlbU(]i]Uo]PR}]PU
l}l}U]rÙubRlvl˙Z
yy Ivv}bG]b](}ouo
yy Av˙(}}RRvv}o
yy Avoid alcohol
yy S}~voPb]UG]ouvUX]b Z
Note 2-1
}]
A R}}˘]PbbRu}o
b vR]PR}bb}(v˘]}o˙rR˙ r
v}bX
Refeal
r Criteria
v*ChronicHetitis
R( vb `]R ]o˙ }Pbb]vP ˙u}ub

b v b]Pvb }
R˙b]]vb]o]bX
ap *v
11. CR}v]Hb
TR]b (b } R}v] ]vGuu}v }( R o] }( u} Rv v
u}vRb }vU `]R b]bvo˙ o o] (v}v bX CR}v]
Rb v }Pbb } o] ]R}b]bU }o R˙vb]}v `]R
Pb}]vbvo o]vPU R vRo}R˙ v R}ooo
]v}uX
Iuuv]b}v P]vbHb B]bv}`]oo(}R]ovv
R E˘v P}Puu }v Iuuv]b}v ~EPIZ X Aob ]v vu]
b]vo]vPGRvbR}o ]uuv]bP]vbHbB]v(}v
L ]v]o buv }( R] ]uuv}o}P]ob P]vP ]}b
˘}b}R]bX
L}vPru u}v]}]vP (} ]bb ]˙ v R}ooo
]v}uv]vP b `]Rb]˘ru}vRo˙Hb ]o
B DNAv.}vU
LFTbU }u]vo ob}v v oR (}}]v ]b uv}˙ (}
vb`]RR}v]RbBX
sueCa
yy Hb B]b~HBVZ
yy Hb C]b~HCVZ
yy Hb E]b~Pv}˙Z
Chatep rP *Disorsof
der theLiver
Symptoms
yy Uboo˙˙u}u b
yy M]ov}vrb].˙u}ub b
yy Recurrent fever
yy ARoP]
yy Malaise
yy Jv]
yy LRP˙
Signs
SPu}(R}v]o]]bb
yy Pou˙Ru
yy Co]vP
yy D˙v[b}v
yy P}voPuv
yy G˙v}ub
yy Tbo}R˙
yy Spider naevi
Signs of decompensated liver disease
yy Jv]
v*ChronicHetitis
yy Ascites
yy Encephalopathy
ap
yy P]Ro}u~R˙}ou]vu] Z
yy P lbl]v]b]vP~}Po}R˙Z
*v
Invtiga
se tions
yy FBC
yy LFTb
yy INR
yy HIV
yy Bbo]vAoRrF}r}]v
yy A}u]voob}vv b
yy L]]}b˙
CR}v]Hb B
yy Hb Bb(AvPv~HBbAPZ
yy HBIPG
yy Hb rBrrvPv~HBAPZAvrHB
yy Hb BV]oL}
CR}v]Hb C
yy Hb CV]b~HCVZv}˙vP
b
yy HCVRNA
yy HCVPv}˙]vP
Trtme
ae nt
Tuv}ib
yy T}v]b}Pb b b]}vv}uo]}vb
yy T}vRvRo}R˙
ı
Standard Trtme
yy T}]u}˙vR
b o](v}vR}PR]ob]}v
yy T}vvbu]bb]}v
yy Pv}v }( vbu]bb]}v } vb ~XPX } ˘b U v}
bR]vP}(}}RbRbvbRbUobUvobU}˙]]vPbU
'}}bUoo].}v
b bU]u]b]}vbXZ
yy L](b˙ol]˙]
yy S}blR}bR}ov]vP
b
AX CR}v]HbA B~HBAP}b]}HBAPvPZ
st
L]vTuv
]v
E RvPPA
yy PP˙oIv(}v o(r Uv}b
b U
Or
yy TenofovirU}oU
Or
yy EntecavirU}oU
nd
L]vTuv
v*ChronicHetitis
]v
E RvPPA
yy Lu]]v U}oU
ap
B. Decompensated liver cirrhosis/ Fulminant Liver failure from

*v
CR}v]Hb B
st
L]vTuv
]v
E RvPPA
yy TenofovirU}oU
Or
yy EntecavirU}oU
nd
L]vTuv
]v
E RvPPA
yy Lu]]v U}oU
CXPvb`]RCR}v]Hb B undergoing chemotherapy or
immunosuppressive treatment
st
L]vTuv
]v
E RvPPA
yy TenofovirU}oU
Or
yy EntecavirU}oU
nd
L]vTuv
]v
E RvPPA
yy Lu]]v U}oU
Chatep rP *Disorsof
der theLiver
Refeal
r Criteria
R( oo b }( R}v] Rb B ]v(}v } b]o]bU
b]oo˙ R}b `R} R (]o .bro]v vr]o R˙ } R
}vb
b }vr]oR˙}Ro]ro}uo]}vb
~XPX o] ]R}b]bU o] (]oU o] ubbU b]Pvb }( }o R˙vb]}vU
ascitesU ]Ro }uU R˙}ou]vu] ZX PPvv ]v]]ob
v vb `]R Rb B }r]v(}vb ~XPX HIV lHb CZ b òo
b R}b ]]vP Ru}R˙ } }R ]uuv}bb] R˙
bR}oob}(}b]o]bX
P}br˘}b uvPuv }( RoR `}lb L }}vo
˘}b}Hb B]v(}v
TorP) P}br˘}buvPuv}(RoR`}lbL
}}vo˘}b}Hb B]v(}v
HCWSb P}brE˘}bTbvP P}brE˘}bP}R˙o˘]b P}brV r
]v}v
Source HCW cHBIG HBV AvrHBb
Pv AvrHBb V]v}v
D}uv N}}v]
Responder
v*ChronicHetitis
~AND}bb
R]Z
ap
D}uv P}b] r §
HBIGT`] r No
*v
N}vr ~Ov
Responder Month
~ALANv AZ
D}bbZ
NP r N}A}vR]
Response P}b]l AMMIUluo §
HBIGOv Revaccinate Yes
Uvlv}`v Uvlv}`v
~ALAN
D}bbZ NP AMMIUluo None Revaccinate Yes
Any Result ANMIUluo N}}v]
Uv]vl P}b]l r HBIG}v C}uo Yes
Iv}uo Uvlv}`v V]v}v
V]v}v
NP r None C}uo Yes
V]v}v
HCWPHoR`}l
cHBIGPHb BIuuv}Po}o]vb}}vb}bb]o`Rv]v]~XvuollPIMZ
Note 2-2
AvrHBbT]bR}o (}uru}vRbLob}b}(HBV]v r
}v b]b rv u}vRb LHBIG }}]}v }( b]o˙ u]v r
]bAvrHBbX
Rb}vPb}v`]RAvrHBbANMIUluoL}u}HBV]v}v
doses
Standard Trtme
N}vrb}vPb}v `]R AvrHBb AM MIUluo L v } u}HBV] r

v}v}bbX
Note 2-3
AooHCWS`R}RAvrHbAMMIUluoUv]v}]v}uo]v r
}vv]v b ˘}b} b}v`R}]bHBbAPr}b]lvlv}`v
HBbAPb R}o vP} HBbAP v]vP
b b }}v b }bb]o L˘} r
vb (}oo}`vP b vu}vRbo~HBbAPA=AvrHBZX
AX CR}v]Hb C (Genotype 2 & 3)
st
L]vTuv
]v
E RvPPA
b U
Or
b U
Av
yy RibavirinU}oU
BXCR}v]Hb C~Gv}˙Z
L]vTuv
st
v*Hetic
]v
E RvPPA
a p Encephalopthy*

b U
Or
a

b U
v
Av
yy RibavirinU}oU
Refeal
r Criteria
R( oo b }( R}v] Rb C ]v(}v } b]o]bU
b]oo˙ R}b `R} R (]o .bro]v vr]o R˙ } R
}vb
b }vr]oR˙}Ro]ro}uo]}vb
~XPX o] ]R}b]bU o] (]oU o] ubbU b]Pvb }( }o R˙vb]}vU
ascitesU ]Ro }uU R˙}ou]vu] ZX PPvv ]v]]ob
v vb `]R Rb C }r]v(}vb ~XPX HIV lHb BZ b òo
b R}b ]]vP Ru}R˙ } }R ]uuv}bb] R˙
bR}oob}(}b]o]bX
12. HEvRo}R˙
TR]b }v]}v ]b }uo]}v }( ]R } R}v] o]
]bbXIbvb`]R]b}vov}b˙bb u(v}vU
}]v]o]˙}(Ro]}}˘](˙uu}v]v}RRu]obX
sueCa
yy V]oRb
yy Ao}R}o]Rb
Chatep rP *Disorsof
der theLiver
yy Cirrhosis of the liver
yy H}ooo]v}u
yy DPb XPX Ro}Rv U ]b}v]] U u}o }}bU Ro
}vb
yy F'˙o]}(Pvv˙
yy P]]vP(}b]vv`]Rr˘]bvPo]]bbP
yy F
yy Hypotension
yy Iv(}v
yy Fo]vo}o˙]uov~˘bb]}(b o}}]bZ
yy Sb
yy IvbPb}]vbvo~GIT}]v
Z o}XPXR˙GIT
o]vPUo}R}o]]vP
Symptoms
yy Jv]
yy Confusion
yy D]b }vb]}bvbb `R]R }Pbb b (}oo}`bP ]b}
}( boU R˙b}uv] v ]vb]}v }( bo R˙RuU R˙ v
voo˙}u
v*Hetic
yy Pb}vo]˙RvPb
a p Encephalopthy*
Signs
a
yy Cyanosis
v
yy F}Rb
yy S]Pvb}(R}v]o]]bb
yy N}o}P]ov}uo]bP
yy SR]u]uv
yy ]˘]b
Ab ~ G]vP u}Z ]v]b r}u v }vPo˙
b
b}bR]Pv}b]b}(vRo}R˙
yy Iv]o]˙}`}}vb}ibXPXær}]vb
yy Iv}}]v}v
yy LRP˙
yy Encephalopathy
yy GPM]o}v(b]}vU]]oUu}Uobb b
yy G P LRP] b}vbbU b ]vR]]}vbU ]b r
}]v}vUP]}vU]˘]bb
yy GPS}}b}boUPPbb]bU]v r
obRvul}v(b]}v
yy GPC}u
Invtiga
se tions
yy FBC
yy Bo}}Po}b
yy L](v}vb
yy Bo}}vo}o˙b
yy Hb Brb(rAvPv
yy Hb C screen
Standard Trtme
yy P}R}u]vu UINR
yy Iv(}v vb ~o}} oU ]v REU Rb XrR˙U ]Pv}b
b]Z
Trtme
ae nt
Tuv}ib
yy T}]v(˙v}]]vP(}b}uo˙
yy T}vo˙]vPb}(o]]bb
yy Po]vR}u }b]}v](v}vb]}b
yy M]v]v G] v o}o˙ ov ~}] R˙}v and
o}o˙v}uo]bbRbR˙}lou]Z
yy M}v]}uUobvb]}˙Uo}}U b
]obU]v}vo}}Po}bPoo˙
yy }] A o}R}oUu}o v}RR}}˘]Pvb
yy }] A b R b v}]]vb v Pb R ]u] R
}Po}v˙bb u
yy PvbbR}oNOTRR]}]v]vl]b
yy M]v]vv}]v]vl}(XrXæP llP˙
v*Hetic
yy Ev}P]vl}(R]PR}R˙]˙u}R}NG
a p Encephalopthy*
a
AX Mb}b }R˙}vbvv]}v
v
]v
E RvPPA
Adults
yy ˘}b
D saline ~ærA9˘}b]vXıA9bo]vZUIVUæuo R}o˙
~}]vP}]uvbZ
Av
yy H]PR }v˙ V]u]v B U IVU ~(}uo b `} b ]obZ Ov
]}(]ob]o˙~}Po}bIVb}o}vZ
Children
yy ˘}bD saline~XA9]vXA9bo]vZUIVU
Av
yy H]PR}v˙V]u]vB UIVU~(}uob`}]obb Z
BXMb}b o}ò}}uu}v]}vv}v
st
L]vTuv
]v
E RvPPA
yy Lo}b U}oU
Adults
S`]Rræuo~rPZUvrR}o˙
~R]`}b}u]v]vrbu]rb}o]}}ob
b ˙Z
Children and Adolescents
S`]RæruovrR}o˙
b ˙Z
Neonates
Chatep rP *Disorsof
der theLiver
S`]RXæræuovrR}o˙
b ˙Z
Or
yy Lo}b UoU
uo]o]vuo
w `~]ooo}}vRrZ R}
v r
o˙U]v]vRu(}rvu]vbX
b ˙Z
Av
yy M}v]}o U}oU
Adults
uPR}o˙
Children
æuP llPR}o˙
Neonates
ANlPV æuP llPR}o˙
rlPV wXæuP llPR}o˙
nd
L]vTuv
]v
E RvPPA
v*Hetic
yy R](˘]u]v U}oU
a p Encephalopthy*
Adults
ææuPR}o˙
a
Children
v
AN˙bV uPR}o˙
AM˙bV v}}uuv
CXHvRo}R˙ b}]`]Ro]vP~INR > 1.5
}oo}vAMæ˘ 9
/L)
AobvCR]ov~o]]b`]RHu}o}P˙Z
yy FbR(}vobu UIVU~(}INRANXæZ
Or
yy Poo}vvUIVU~oo}vAMæ˘ ı
lLZ
X
D Av]}}R˙o˘]b ]vHvRo}R˙ (associated with
]R}b]bvPb}r]vbvoRu}RPZ
Pvb]v`R}u}ou]v]b}v]bv}}bb]oU
]v
E RvPPA
yy C]}G}˘]v UIVU
Adults
uPrR}o˙~u]v]b}vu]vbZ
Or
yy L]˘}v
C UIVUP]o˙(}˙bw
Or
yy C]}G}˘]v U}oUæuPR}o˙
Or
yy N}G}˘]v U}oUuPR}o˙(}˙bw
æ
Standard Trtme
EXHvRo}R˙ ]]˙]o]v(}v
N}r
A ]Pv}b]b }( SBP ]b o]b
b R ]( R v}R]o }v ]v R b] G] ]b
AN æ oobluLU o bob }b] v P]oo˙
b ob ˘ r
oX
Pvb `]R b SBP bR}o b }v u]] v]}b ]uu] r
o˙Lb]G]]b}]vv]vPbobP
]v
E RvPPA
st
L]vuv
yy C ]}G}˘]v U IVU uP r R}o˙ (} ˙b ~} u]v]b
}vu]vbZ
Then
yy C ]}G}˘]v U}oUæuPR}o˙(}æ˙b
Note 2-5
}]
A ]vvb`]R ]}G}}]v}o}v R˙bSBP}R˙o˘]b }R]b r
}˙}(b]bvX
nd
L]vuv
yy (}˘]u
C UIVUPR}o˙(}˙bw
O
yy L]˘}v C UIVUP]o˙(}˙bw
v*Acite
s s*v
Refeal
r Criteria
R( vb ]( R }v]}v }b v} ]u}X Aoo R]ov `]R
RvRo}R˙ub(}b]o]bX
13. Ab]b
Ascites ]b R uo}v }( ˘bb G] `]R]v R ]}vo
]˙X
sueCa
yy P}oR˙vb]}v}v˙ b }o]]R}b]b
yy Renal failure
yy NR}˙v}ub
yy Cardiac failure
yy A}u]voo}b]b
yy Ivr}u]vo}o]uo]Pvv]b
Symptoms
yy A}u]vovoPuv
yy A}u]vo]b}u(}}]v
yy D]8o˙R]vP
Signs
yy D]bv}uv
v
Chatep rP *Disorsof
der theLiver
yy SR]L]vPoovbb
yy Fo]R]oo
yy A}u]vovvbb
yy S]PvbovP}Rvo˙]vPb~S}]b}vZ
Invtiga
se tions
yy FBC
yy BUEv]v C
yy LFTb
yy INR
yy U]vo˙b]b
yy A}u]v}ro]ob}v
yy CRbXr˙
yy D]Pv}bvb]b
yy Appearance and colour
yy Gu]v b
yy Coo}vv]+vo
yy B]}Ru]b˙XPXAou]v
yy M]}b}˙U o~`]R b] ]v}o}v }(}] v r
}]o}}o}'obZ
yy Acid fast bacilli
yy C˙}o}P˙
v*Acite
Trtme
ae nt
s s*v
Tuv}ib
yy T}o]˙u}ub b
yy T}]v(˙vuvPvo˙]vPb
yy b B
yy So]}v b AMP l˙
yy Fo]]}v b }AGXæLl˙
yy }] A NSAIDrb
yy Ao}R}ovv b
yy TR vb]b ~b]o }u]vo Z ]( b]b is tense
vl}R]bb]}˙ubbuv
Note 2-6
Ru}o}( }æo]b}(b]G]`]R}}v}u]v}oo}]]v(b]}v]b
(b bR}ru}}vvvo]lo˙}RRu}˙vu]}vbvbX
AX C}v}o}(b]G]uo}v
st
L]vTuv
]v
E RvPPA
yy SpironolactoneU}oU
Adults
æruP]o˙
w
Standard Trtme
Children
XruP llP]o˙
vA
yy F}bu] U}oU
Adults
ruP]o˙
Children
ruP llP]o˙
B. Massive ascites in liver cirrhosis with respiratory embarrassment
]]vPu}Rvæo]b}(G]]vP
st
L]vTuv
]v
E RvPPA
yy Sor}} Ruv ou]v b}o}v U IVU vr P o] }( b] G]
drained
Refeal
r Criteria
Pvb `]R R (}oo}`]vP }v]}vb ub ( }
b]o]bXP}}b}vb}]R˙}]r(}˙b]b U
}uo] ]R} b]b `]R b b}vv}b ]o
]}v]bUR}rvo˙v}u b UvRvRo}R˙X
Aob}(`Rvvvo˙]vPvv}
b ]v.X
v*Vomiting*v
X V}u]vP
V}u]vP v ]v˙ ]˙}(]bb}bb]vo]vP
Pb}]vbvoU v}o}P]U voU˙R]] b U]}boU v}]vU
]v v R +b }( PbX TR b }b }( }v ]v ]v(˙]vP
R vo˙]vP b ]b } ˙ } ]o o]v]o o}v v
uvPuv ovU o}}l]vP } (} R }o}P˙U }vbvb v
}vo}uo]}vb}(}u]vP X
S v}v}oo }u]vP v bo ]v b]Pv].v R˙}v
vo}o˙]uov}uv]˙vo}uo]}vbX
Avrub bR}o b] }vo˙ `Rv R b }( }u]vP
]blv}`vbR˙u˙o˙]Pv}b]bX
sueCa
yy D]b}b }( R Pb}r]vbvo ~GITZ v o]P ]vbvo
}b}vU oU vbU R}o˙bbU Pb}v]b U
Rb
yy N}o}P]o ]b}bP b ]vU u]P]vU ]b ]vv]o
~]
b XXu}bURu}RPVuv]vP]b ZVb]bU}l
b
yy Ev}]v v u}o]P ] l}]}b]bU u]U
R˙ou] U]vbvob}r}b}v
yy Pb˙R]]Pv˘]˙ Ub]}v Uu}}vo
b U
b ˙R}Pv]
b
}u]vP
yy DPbP v Ru}R˙U b]]v U oo}]v}oU ]P}˘]vU
Chatep rP *Disorsof
der theLiver
˙R}u˙]vUv}vobvbU}]}]b
yy Iv(}vbPuo]U]v˙]v(}vb
yy ]}b
C oPu˙}]o]v(}v
yy RvoPu](}u}R}v]l]v˙]bb
yy M]boov}bP Pvv˙U ˙o]o }u]vP ˙v}u
b U u˙}]o
]v(}vUo˙]vR]bU}bu]
Symptoms
V}u]vP may be associated with:
yy A}u]vo]v
yy D]R} PPb}v]b
yy A}u]vo]bvb]}vP}ò b }b}v
yy HeartburnPPb b }r}b}RPoG˘]bb
yy Chest pain
yy Jv] PR}r]o]˙]bb
yy VP} vv˙bPub Pob v}v]b
yy Av˘]˙
yy b]}v D
V}u]vP u˙R]Pv}bobXPXP
yy V}u]vP }((}}vob R}bo]PPb}b]b}Pb]r
}o}b}v
v*Vomiting*v
yy V}u]vP `]Ro}}P}b}RPoUPb]}}voob]}v
yy o˙ E u}v]vP}u]vP PPvv˙
yy Fov}u]vP P]vbvo}b}vUPb}r}o].bo
yy P}ioP](˙o}]v}b b ]b
Signs
yy A}u]vovvbb
yy DR˙}v ~ bl]v P}U ˙ }vPU R˙}vb]}vU
R˙]Z
yy A}u]vo]bvb]}v
yy Succussion splash
yy Jv]
yy S]Pvb}(]}v]b~}vvvbbU]P]]˙UP]vPZ
yy M]boov}bP XPX P} U v˙bPub U (}o v}o}P]o b]PvbU
KbbuoR]vP~u]U]l}]}b]bZ
Invtiga
se tions
yy FBC
yy BUEvv]v C
yy LFT
yy Bo}}Po}b
yy Suu˙ob
yy U]vRE
yy U]vPPvv˙b
yy GCE ~](u˙}]o]v(}vZb
yy A}u]voXr˙PIvbvo}b}v
ı
Standard Trtme
yy CRbE Xr˙P}ò(}}v`]R]v]RPu
Pb]bvV}u]vP :
yy UPb}r]vbvov}b}˙
yy Suo]uoo
yy CT scan of brain
Trtme
ae nt
Tuv}ib
yy T}]v(˙vRvo˙]vPb
yy T}vR˙}v vo}o˙]uov
yy T} u]v]v v]}v ˙ vb]vP ]˙ ]vl ]vP
illness
yy T}u]v]vb}voR˙P]v
yy T}o]u]v]v(vP}Pv]bub`R}]
yy M]v]v}oG]]vl~](}oZ
yy M]v]vv]}v
yy Povb}rPb]`Rvv
yy SP]o]vv}v]v]vb
b vo}b}vU]}v]b
v*Vomiting*v
AX SPPbAvrEub(}b]vM]P]v
]v
E RvPPB
yy M}o}u] U}olIVlIMU
Adults
uPR}o˙
Or
yy D}u]}v U}oU
Adults
uPUR}o˙
Children
AN ˙b ~B}˙ `]PR AH æ lPZV uP r R}o˙ ~u˘X uP
˙Z
u}vRr ˙b ~B}˙ `]PR AG æ lPZV æ u]}PubllP r
R}o˙~u˘Xwæu]}PullP˙Z
Or
Note 2-7
D}u]}vbR}obRo}`b+}b(}RbR}b}b r
b]o}vXTRu˘]uu}v}(uvbR}ov}˘˙bw ZX
Or
yy P}uR]vUIVlIM
Adults
XæræuPvrR}o˙bv~u˘XuP]vR}bZ
Or
yy P}uR]vU}oU
Children
æ
Chatep rP *Disorsof
der theLiver
r˙bV XæruPvrR}o˙bv~u˘XæuP
}bZ
AM˙bV N}}uuv
BX SPPbAvrEub(}b]vVboNb vV}u]vP
yy P}uR]vU}oU
Adults
ræuPR}o˙
Children
r˙bV XæruPvrR}o˙bv~u˘XæuP
}bZ
AM˙bV N}}uuv
Or
yy P}uR]vUIVlIM
Adults
XæræuPvrR}o˙bv~u˘XuP]vR}bZ
Or
yy C˙o]]v U}oU
Adults
æuPR}o˙bv
Children
vr˙bVæuPR}o˙bv~u˘XwæuP]vR}bZ
v*Vomiting*v
Or
yy C]vv]]v UIVlIMU
AdultsvR]ovAN˙b
uPR}o˙bv
Children
ær˙bV æuPR}o˙bv
AMæ˙bV v}}uuv
CX SPPbAvrEub(}b]vGb}v]b
Adults
uPR}o˙
Or
yy D}u]}v U}oU
Adults
uPUR}o˙
Children
AN ˙b ~B}˙ `]PR AH æ lPZV uP r R}o˙ ~u˘X uP
˙Z
u}vRr ˙b ~B}˙ `]PR AG æ lPZV æ u]}PubllP r
R}o˙~u˘Xwæu]}PullP˙Z
X
D SPPbAvrEub(}b]vP}brOV}u]vP
Adults
uPR}o˙
æ
Standard Trtme
O
yy C ˙o]]v U}olIVlIMU
Adults
æuPR}o˙bv
Children
vr˙bVæuPR}o˙bv~u˘XwæuP]vR}bZ
EX SPPbAvrEub(}b]vCRu}R˙rIv
V}u]vP
yy Ovvb}v UIVU
Adults
uP lXæuP llP~rRu}R˙Z]v(b}æu]vb
Children
ANvu}vRbV Xæ uP llP ~rRu}R˙Z ]v(b
}æu]vbURv v R}bL.b}bX~u˘
]bvuP l}bZ
Or
yy Ovvb}v U}oU
Adults
uPR}o˙
Children
r˙bV uP u]vb (} Ru}R˙U
v*Vomiting*v
RvuPR}o˙(}rR}bbv
AM˙bV v}}uuv
Or
yy GranisetronUIVU
Adults
uP lu]}PullP~u]vb(}CRu}R˙Z
Children
rv˙bV bubob
AM˙bV v}}uuv
Or
yy GranisetronU}oU
Adults
uPR}(}Ru}R˙URvuPR}bL}bb
Or
uPR}(}Ru}R˙
Children
N}}uuv
Or
yy ˘uRb
D }v U}olIVU
Adults
ruP(}Ru}R˙URvuPR}o˙(}u˙br
Children
N}}uuv
Or
yy L}u U}olIVU
Adults
æ
Chatep rP *Disorsof
der theLiver
XæruPvR}o˙]b
Children
Consult a specialist
FX SPPbAvrEub(}b]vPPvv˙
yy P}uR]v }oU}oU
ruPR}o˙bv
Or
yy P}uR]v UIMU
XæræuPR}o˙bv
Or
yy M}o}u] U}oU
uPR}o˙
Or
yy M}o}u] UIVlIMU
uPR}o˙bv
Refeal
r Criteria
R( oo vb ]v `R}u }u]vP b]bb } `R} bR}` b]Pvb }(
}Pbb]}v ]v ]bbUvb`]R v˘o]v }b]bv}u]vPU
v*Hetoc
v vb `]R b P]o b }( }u]vP (} b]o]b }
a p ellulacinoma
P]o
b buvvuvPuvX
rCa *v
15. Hepatocellular Carcinoma
H}ooo ]v}u
C ~HCCZ ]b ]u˙ uo]Pvv˙ }( R
o] oo v ub ]+v (}u uo]Pvv]b ob`R
R ubb] } R o]X H}ooo ]v}u }b u}
}uu}vo˙ ]v uv Rv ]v `}uv v ]b }Lv ]Pv}b ob ˙b
L o]b b Ruv }( R ]v]o b }v]}vX TR ]bb Rb
}} }Pv}b]b bovP (}u ub } o}oo˙ v ]bbX
C}uo]}vb ]vo o] (]oU ]o o]vP } u}
`]R o]vP ]v} R ]}vuX TR u} ]b }Lv b]bv }
Ru}R˙X vC P]b
b } v } Rb B v C
]v(}vbvo]]R}b]bv}voo˙Rov}(HCC
]vRo}vPuX
sueCa
yy Cirrhosis of the liver
yy Alcoholic liver disease
yy CR}v]RbB]b]v(}v
yy CR}v]RbC]b]v(}v
yy CR}v]˘}b}R]v}PvbXPXG}˘]v
Symptoms
yy Jv]
yy IR]vP
yy Av}˘]
æ
Standard Trtme
yy o˙
E ˙b
yy Fo]vP}(ubb]vR}uv
yy R]PR}u]vo]v
yy W]PRo}bb
yy Huub]b
yy A}u]vo]bvb]}v
yy B}v]v
yy D˙bv}
Signs
yy Jv]
yy CR˘]
yy H}uPo˙ ~]Pob(Uuoov}obUu˙vZ
yy Ascites
yy H]
Invtiga
se tions
yy FBC
yy LFTS
yy INR
v*Hetoc
a p ellulacinoma
yy SuAoRrF}}]v
yy Hb BrS(AvPv~HBbAPZ
yy Hb CAv}˙~HCVZ
rCa
yy CRbXrR˙
*v
yy A}u]voob}vv b
yy CTlMRIv b ~](ob}v]v}vob]Z
Trtme
ae nt
Tuv}ib
C
yy T}b(}}vo]o]˙
b
Poo]
yy To relieve pain
yy T}o]]b}u(}(}uP}bb]b
yy T}v}RvRo}R˙~Sb}v}vRH
Encephalopathy [Z
yy SP]ob}v}(v}vrubo}o]bob]}vb
yy Pvb]b(}vbb]b ~Sb}v}vRAb]b[Z
yy S}~uor]u]vbouvbZ
AX P]v}v}o]vvb`]RH}ooo]v}u
C
st
L]vTuv
]v
E RvPPB
yy Tu}o U }oU æ uP R}o˙ ~(R b }o} r
b]+Pu˘]uuuP]o˙Z
Or
æ
Chatep rP *Disorsof
der theLiver
yy MorphineboRU}oUæruPrR}o˙
Refeal
r Criteria
R( oo vb `]R b HCU
C b]oo˙ R}b `]R buoo
b}o]˙ob]}v~AMæuZ`R}u˙ }vb](}v}bo}R}o
]vi}v}P]ob b}vU}b]o]bX
16. Drugs and the Liver

DPrIv L] Ivi˙ ~DILIZ v } (}oo}`]vP R b }(
]˙ }( ]R b]}v } }rRr}v u]}vbX A R]PR
]v˘ }( b]]}v ]b }Lv vbb˙ ]v o]b
b R]vP R ]Pv}b]bX o˙E
}Pv]}v }( P }˘]]˙ ]b ]u}v } u] `]Rò }( R
}+v]vP PU buv }( ]˙ b v u}v]}]vP (} o]
(]oXDPr]vo]]vi˙v}brvv}]]}b˙vX
TR Rooul (} R uv }( DILI ]b o˙ `]Rò }( R
}+v]vPPX
sueCa
yy Aoo}R] Pb ~b]}vU }rRr}vU vbR
v*DrugsandtheLiver*v
PvbU XPXu}o Uvbb U ]b}v]] U Ro}Rv U u]}}v U
R]}]v U u]v U Rv˙}]v U v]]v U l}}v}o U
Go}˘]oo]v XZ
yy Ho}vb
yy D]˙bouvb
Symptoms
yy ˙u}u Ab
yy R]PRv]v
yy Nausea
yy Av}˘]
yy Malaise
yy LRP˙
yy P]b
Signs
yy Ob]}voo˙v}v
yy Jv]
yy SRulb
yy B]b]vP
yy ]˘]b Ab
yy Aouvob
yy S]Pvb}(r˘]bvPR}v]o]]bb
Invtiga
se tions
yy FBC
yy LFTS
yy BUEvv]v C
ææ
Standard Trtme
yy INR
yy SuPo}b
yy U]vo˙b]b
yy Hb vb ~AUU
B U
C EZ(}˘ob]}v
yy A}u]voob}vv b
Trtme
ae nt
Tuv}ib
yy T}]v(˙v`]R`R}+v]vPPv
yy T} } b P v } F}} v DPb AR}]˙ ~FDAZ
}uo˙
yy To assess severity of liver disease
yy T}u]v]bv}`Ro]o}(b]o
~Sb}v}vRHEvRo}R˙[Z
AX Drug-induced liver injury following paracetamol toxicity
st
L]vTuv
]v
E RvPPA
yy NrA˙o˙b]v
~S b}v }v RMvPuv oP}]Ru (} A Pu}o
P}]b]}v]vP[Z
Refeal
r Criteria
Aoo vb (]o]vP } ]u} } bR}`]vP }Pbb]}v ]v o] ]vi˙
b]`]Rò}(}+v]vPPbR}o(}b]o]bX
MvPuvoP}]Ru(}Pu}o
A Poisioning
B}˘rP) MvPuvoP}]Ru(}Pu}o
A Poisioning
Co]v]obv}v
Nauseav}u]vP }uu}vo˙˙u}ub
b
PvbRvo˙
b o}R]vi˙vRu˙˙u}u
b (}
R}bLv]vPb}v
IvbP}vb
Ivoovb`]Ru}o
b }˘]]˙U}]vR(}oo}`]vPP
Suu}o }vv}vUbo]vo](v}vb~ASTUALTU}o]o]]v ZU
PTvINR Uvo}o˙b
Ivoovb`]R]vv}vo
b }}bU}]vbubo]˙o
}vv}vUub Po}bUGCE UvPvv˙]vb `}uv}(R]o]vPP
TuvP]uv
S]`˙UR]vPUv]o}vbvbb˙
æv
Chatep rP *Disorsof
der theLiver
G]R}o ~ACZæP}ooovbbvvP`]R]vR}b}(
]vPb}vUvob}v]v]
b VCu˙
A (o
b (}}r]vPbvb˙}vR}b
T`]RNrA˙o˙b]v ~NACZI(P
• Suu}o }vv}v`vR}b}u}Lb]vPo
]vPb}v]b}RSuv_o]v}(Ruvv}u}Pu(}u}o
}]b}v]vP
• Suu}o }vv}v]bv]oo}`]oov}v`]R]vR}b}(
u}(]vPb}vvu}o]vPb}v]bb
• T]u}(]vPb}v]bvlv}`vvbuu}o oo]bPRv
u]}Puluo~vu]}u}olLZ
• TR]b]v}(v˙R}}˘]]˙`]RR]b}˙}(u}o ]vPb}v
• Pv}b}o]v]]v˘bb b]u}o ]vPb}vbU
vRb]bl(}b(}u}or]vR}}˘]]˙UvRub
u}o}vv}v]bPRvu]}Puluo~vu]}u}olLZ
OoD}b]vPO(NACP
• Oo}b]vP]bo(}v}vrPvvvb`]R(v}voGIvv}
]v}(R}}˘]]˙
• D}buP llPo}]vP}bU(}oo}`˙w}bb}(wuP llP˙R}b
• I(}u]vP }b`]R]vR}}(NAC}b]vPU(ooNAC}bbR}ob
rapidly as possible
• TR˙u˙u]v˙}vR}bL]vPb}v](Ru}o level
]bo}ù]}PubluoUvRv}bv}o}]v}(R}}˘ r
]]˙vu]vbo]v]oo˙òo
Ivv}b~IVZ}b]vP}(NACP
• Ivvb`]Rv}]}Ru]o]v}(o](]o~]XXUR}b`]RINR AMZUb
R}IV}}}oPæuP llPo}]vP}b}vu]vbU(}oo}`˙æuP llP
]v(b}R}bU`]RR.vouP llP]v(b}Ru]v]vPvR}b
• Ivvb`]R]}Ru]o]v}(o](]o~]XXUR}b`]RINR ANZU
u]v]bRR}IV}}}o~æuP llPo}]vP}b}vu]vbU
(}oo}`˙æuP llP]v(b}R}bU(}oo}`˙uP llP]v(b}R
v˘vR}bZ(}oo}`˙}vv}bIVNAC]v(b]}vvXæuP llPR}vo
INR]bAM
• IV}b]vP]bo]voob}(u}o }˘]]˙UbR}ob]vb
}(}o}b]vP]vvbvo}}o}oNAC~XPXU]vo}u]vP ZU
vb`]Ru]o}v]}vo]vPu]v]b}v}(}oNA~P
C U}}b]
]vPb}vUGIoZUvb`]Rb]Pv].vR}}˘]]˙~INR ANZUvPvv
vb
AvuR˙P
• M˙P]IVu}o}u]uPR}o˙
æw
Chapter
NutritionalDisorsder
17. Mov]}v
Mov]}v }b `Rv R]b .]v˙ ]v ]vl}( bvo
v]vb ~]XX }]vbU }R˙bU (bU ]u]vb v u]vobZX I ]b
u}b }uu}vo˙ bv ]v R]ov obb Rv . ˙bU oo˙ L
`v]vPXMov]}vR b ]v]]o[b]o]˙}.PR]bvb
]v(}vR˙]vb]vPRo]lo]R}}}(RvbvvP`]R
]R}U }u]vP U (U `}u ]v(b}vU vu}v]U o}b]bU
}bu] U]v˙]v(}vXIvobUuov]}v(vo˙
}b]vb}]}v`]RR}v]o}R}o]buX
P}]v vP˙ uov]}v ~PEMZU `Rv U
b bvb ]v
]+v(}ubbRbubub Ul`bR]}l} }ubu]rl`bR]}l}X
B]Rrb]vPU R}PR (u]o˙ ovv]vPU b òo b ˘ob] rb
(]vP(}}vu}vRbU(}oo}`˙Iv}}v}(`v]vP]
v u}vRb v }vv}v `]R }uo]uv˙ (}}b (} } ˙bU
u˙ Ro(o ubb ]v vvP uov]}v ]v ˙}vP R]ovX
Ev}P]vP ov ] (} R (u]o˙U ]vo]vP Pvv v
ovP`}uvUvv]}v}v]vbR}}obv]ooPbu˙Ro
Rov}(uov]}v]vR}uuv]˙X
sueCa
yy P}˙
yy Ivo]˙vl}v˙}((}}]vl
yy S}]ovPo
yy R}R}v]]v(}vb
yy Repeated diarhoeal illness
yy W}u]v(b}vb
yy HIV Uou}v˙o}b]bUubobUb]b
yy Chronic illness and cancers
yy Ao}R}o]bu~obZ
Symptoms
yy P}}`]PRP]v
yy W]PRo}bb~}}G'v]vP]v`]PR}vRR]oRoR}Z
yy B}˙òo]vP
b ~l`bR]}l} Z
æ
Chatep rP *NutritionalDisorsder
yy CR]oo˙bobb}(ol}(vP˙
yy D]b]vb]v(}}v}v]vPb
b
Signs
Marasmus
yy TR]v~uboolZ
yy P}u]vv}vb
yy HvP]vPbl]v(}obb]oo˙}R'}lb
yy Uvboo˙o
yy L}}lbo]lv}ouv
K`bR]}l}
yy TR]vv`bub
yy P+˙(voPb}}u
yy }`v]b B R}]bRR]
yy Fol˙bl]vbRb]oo˙}vRoPb
yy S}b}vR}u}bb}(R}˙]vb
yy Miserable and disinterested appearance
yy D]b]vb]v(}}
yy AvR}}u]ubuvb
M}Mov]}vA
yy M]UAuC]u(vPXærAMXæu
v*Malnutrition*v
yy W]PR(}APPAMrZrS}ANrZS}
yy W]PR(}H]PRPAMrZrS}ANrZS}
SMov]}v
A
yy M]UAuC]u(vPAMXæu~APvræıu}vRbZ
yy W]PR(}APPAMrZrS}
yy W]PR(}H]PRPAMrZrS}
Invtiga
se tions
yy FBC
yy Uvo}o˙b
yy Suou]v
yy U]vovbvb]]˙
yy Bo}}ovbvb]]˙
yy CRbXr˙
yy HIV vP b
yy Gb]oP(}](b]oo]
yy Sv (} }uu}v ]v(}vb bR b o}b]bU vu}v]U
]v˙]v(}vbUX~Sovb}vbZ
Trtme
ae nt
Tuv}ib
yy T}]v(˙vb}]]v(}vbv}uo]}vb
yy T}}G]vo}o˙]uovv}R}uo]}vb
yy T}}Rv]}vo.]v˙]vo]vPV]u]vA
yy T}vv˙vPP]b
yy T}o˙uvPR}v]]oovbb
æı
Standard Trtme
yy N]}voR]o]}v
yy OrvC
yy Mov}]bR R]ov `R} R U v } v}
R v˙ } u]o }v]}vU `R]R ]b u]b r
b]}vU bR}o uvP b }vb `]R R˙r}r
UbTRF}}~RUTF Z
yy IvrvC
yy u] A ooo˙
b uov}]bRR]ov`R}Ru] r
o}v]}vb]]vP]vv
yy S]o]b}vPRb
yy Fv(]vP`]RFwæ
yy Iv}R˙rT}rUbTRF}}rRUTF
yy P}Pbb]o˙v}oov(u]o˙uob
yy P]}v}(vbvP]b]vv]}v r
}v
AXV]u]vA bouv}v (children)
]v
E RvPPA
v*Malnutrition*v
yy V]u]vA U}oU
Children
AN˙V Uv]b]o˙(}˙b
vru}vRbV Uv]b]o˙(}˙b
AMvu}vRbV æUv]b]o˙(}˙b
Note 3-1
V]u]v A bouv}v bR}o P]v } o }˙ }bb U EXCEPT ](
RR]o]b}vRUTF u}]vP}WHOb].}vbU`R]Ro˙}v r
]vb]u]vAX
BXTuv}(vo˙]vP]v(}vb~R]ovZ
Ivvb
]v
E RvPPB
yy (}˘]u
C UIVUuP llPR}o˙(}rwR}b
Then
yy (}˘]u
C U}oU
u}vRbr˙bV æuP llPR}o˙(}ær˙bw
Ovb
]v
E RvPPB
yy Au}˘]]oo]v U}oU
ær˙bV æuPR}o˙(}˙b
ræ˙bV æuPR}o˙(}˙b
u}vRr˙V æuPR}o˙(}˙b
CXIuuv]b}v (children)
~S b}v }v RIuuv]b}v [ v N}vo E˘v P}Puu
v
Chatep rP *NutritionalDisorsder
}vIuuv]b}v~EPIZ P]o]vbZ
XD Tuv}(`}u]v(b}vb
~Sb}v}vRW}uIv(b}vb[Z
Refeal
r Criteria
R( } }] b]o]b (} uvPuv }( R vo˙]vP
bX Aob} ( } R} v CR]o HoR ~RCHZ v] (} (u]o˙
ovv]vPb]bvS}]oò(uv`]R]vRRoR(]o]˙U
]b]}P]}vX
v*Malnutrition*v
v
Chapter
HaematologicalDisorsder
17. Avu]
Avu] ]b .v b }vv}v }( Ru}Po}]v (}
RPv˘b }(R]v]]o~]XXo}`P lL]vouobUP lL
]vo(uobUP lL]vR]ovUvo}`XæP lL]vR`l b
}(o](ZXAvu]o`˙bRbbU`R]Rub]v.v}o˙
uvPX TR b ub ]vbP (} ]v]vP uvX
Iv v uPv˙U o}} buob ub lv (} ]vbP}vb (}
o}}vb(b]}vX
sueCa
N]}vou]}v]vv]u]v.]v˙
yy I}v
yy F}o]]
yy V]u]vB
Bleeding
yy H˙uvb}v
yy Hu}R}]b ~]obZ
yy Po
yy Iv(b}vbXPXR}}l`}uU]oR]
yy S}o]}Pvuo]Pvvu}bXPX}o}v]v
yy Hu}o}P]ouo]Pvv]bPXPXolu]
Haemolysis
yy Suo]
yy Sickle cell disease
yy GvPD .]v˙
yy H˙bov]bu
yy }]uuv
A
yy DPb
Bone Marrow Failure
yy D]bb]v.o}vXPXolu]Uo˙uR}uUo}b]b
yy Aob]W]u˙}}v˙
b XPX}˙}}˘]b
Chronic Diseases
yy K]v˙]bb
yy Tuberculosis
v
Chatep rP *HaematologicalDisorsder
yy H˙}R˙}]]bu
}]uuv
A D]bb
yy SLE
yy Pv]]}bvu]
Symptoms
yy ˙bE (P]o]˙
yy D]]vbb
yy SR}vbb}(R}v˘}v
yy Po]}vb
yy FbRo}}]v}}ob b
yy Bol˙}}ob b ~uovZ
yy Hu]
yy C}oro]l]v
Signs
yy Pou}buuvbvoub
yy AvPo}ub b
yy SS}}vbR_v]P.vPv}v]ob
yy SovUo]vo˙uRv}bu˙oo
yy S]Pvb}(R(]o~]vvu] b Z
yy Jv] ~]vRu}o˙b]bZ
v*Anaemia*v
yy PR] and purpura~}vu}`(]oZ
yy H˙]Puv}v}(oubvb}ob}((
Invtiga
se tions
yy FBC
yy Ro}˙}vvo}}.ou}uuv
yy S]lo]vPvb HBo}R}b]b](]v]
yy Bo}}.ou(}uo]b]b
yy K]v˙(v}vb
yy Su]}vUV]u]vB and folate levels
yy D]C}}u[bb
yy S}}o(}R}}l`}u}
yy Stool for occult blood
yy U]v(}bR]b}b}u}
yy S]o] b v]vP }v R b b XPX }v
u}` ˘u]v}vU vvo v}˙ ~ANAZ U
b v
o}`GIv}b}˙
Trtme
ae nt
Tuv}ib
yy T}vo˙]vPb}(vu]
yy T}}b Ru}Po}]voob}v}uo
yy T}ov]bR]}v}bb L}}v}(vu]]v]}v.]v˙
yy T} }b Ru}Po}]v } ˙b b oo ]v b]lo oo ]bb
vb
yy T}}vu] ]v}v ]u]v B v (}o.]v˙ v
v
Standard Trtme
u]v]vv}uooobR}PR}o](
yy A]b }v ov ]X RPo ]vl }( o(˙ (}}b b òo b
(bR(]bvPobUvbUo]UuUPPbU.bR
yy H]PR.]b}o]vP(}uRu}R}]b
yy SP]ouv
yy WRo]oXPXRu}R}]bUu}bUR˙bov]buX
AXI}v.]v˙
D Avu]
st
L]vTuv
]v
E RvPPB
yy F}bboR ~]}vR˙}bZU}oU
Adults
uP~væuPouvo]}vZR}o˙(}rvu}vRb
Children
AN˙bV uPR}o˙(}rvu}vRb
r˙bV uP]o˙(}rvu}vRb
ærw˙bV ruPrR}o˙(}rvu}vRb
r˙bV ærıuPrR}o˙(}rvu}vRb
AM˙V rvuPrR}o˙(}rvu}vRb
v*Anaemia*v
Or
yy F}b(u U}oU
Adults
uP~væuPouvo]}vZR}o˙
Children
rvuPouvo]}vllP˙(}rvu}vRb
nd
L]vTuv
]v
E RvPPB
N}r
Pvo]}vRbv}vP}}o]}v}vb˘]vR
b}(uob}}vX
Or
yy I}v}bb UIVU~bbo}`}ob]vi}v}ræu]vbZ
Adults
uP˙˙b(}æ}bb
Children
XæuP llP˙ `lb(} `lb~u˘X uP }bZUo r
ob}v}˙`]PRv]}v.]vRPH
Or
yy I}v ˘v U IVU ~b bo}` }ob } IM ˙ ]vuboZ ]v r
i}v
Adults
æruP]o˙bv
Children
v
N}}uuv
B. Vitamin B12 .]v˙
D
]v
E RvPPB
yy V]u]vB ~H˙}˘}}ou]vZ UIMU
Adults
uP˙}R˙(}v}bb
Then
uP˙u}vRb(}o](
Children
uPX
b
Then
uP˙u}vRb(}o](
CXF}o.]v˙
D
yy F}o]A] U}oU
Adults
æuP]o˙
Children
XæræuP]o˙
v*BleedingDisors*der v
X
D SS˙u}uAvu]
yy Bo}}vb(b]}v `]Rloob
Av
T(} ] (]o ]( b]Pvb }( ] (]oX ~S b}v }v
RH(]o[Z
Refeal
r Criteria
R(vb`]RRu}Po}]voobR}v}]u}L`}
`lb }v R } uv } `]R b vu] (}u v˙ bU
`R]R bU } b]o]bX Pvb `]R b ob vu]U
vu] } v}v}oo o]vPU ]vo]vP R˙ uvbo o}bbU
`}oob}](o}b]o]bX
18. Bleeding Disorders

Bo]vP ]b}b u˙ bv ]R } o} o]v o](X TR
o]vPu˙b}vv}b}(}oo}ù}P˙ b vu˙
}(o}}bobUoo]b}b}o}hvP(}.]v˙X
Pb ]b}b }( ˘bb] o]vP XPX (}oo}`]vP ]u]b]}vU (u]o˙
R]b}˙ }( o]vP v P R˙ u˙ ]u}v ob } R
]Pv}b]bX
TR 'v }( o]vP ]b Ro(o P] } ]b bX Iv oo
vob òo(bUo]vP]bboo˙]v}bl]vvu}bob(b
o]lR PubU v}bU Pb}]vbvo U `Rb ]v }Po}v (}
.]v˙~XPXRu}R]o]ZUo]vP]b]v} bo]lR]vU
i}]vbvubobX
væ
Standard Trtme
Iv v`}vb `]R ]u]v K .]v˙ ~`R]R ob } uoo
}Po}v (}.]v˙Z b}vv}b o]vP }b (}u]}b
b]bbRbRu]o]o}UPb}]vbvoUob v]vX
sueCa
yy Hu}R]o]
yy V}vW]oov]bb
yy L]]bb
yy V]u]vK .]v˙b]oo˙]vv`}vb
yy B}vu}`(]oXPXobvu]volu]
yy L}òo}v(}uv˙b
yy D]bbu]vIvboC}Po}v~DIC Z (}uv˙b
yy DP ]v r Ro }vbU b]]v U o}]}Po U `(]v U
]}˘v UR]v
Symptoms
yy S}vv}bo]vP(}uu}buuvb}b
yy ˙bE ]b]vPUo]vP(}u}].b
yy E˘bb]o]vP(}ub}]v]b]}vb
yy (}u D i}]vb(}uvi}]vob
yy Sòo]vPb]}(o}}}oo}v~b}u}bZ
yy P]vo]u]vPu}uv
Signs
yy Poo}
yy E˘bb]o]vP
yy L}o]bòo]vP b }o]vP]v}}˙bXPXJ}]vb
yy Tenderness
yy L]u]}v}(u}uvvi}]v(}u]b
yy P UR] UR˙u}b]b
Invtiga
se tions
yy FBCvo}}.ou}uuv
yy Poo}v
yy L](v}vb
yy P}R}u]vu UINRUoR}u}obvu
yy Bo]vP u
Trtme
ae nt
Tuv}ib
yy T}v}o]vP b
yy T}]v(˙v}vo˙]vPb
yy Ao˙ Po b b]vP vl} ] lb } u]v]u]b
o]vP`R}bb]o
yy S} v˙ vlPb b}vb]o (} o]vP } `R]R u˙
PPo]vP
yy E Ru}R]o]b }v R] ]bbU v}P]vP Ru }
v
u]v]u]b ur}v ]bU v } ]v(}u }}b }( R]
}v]}v(}v˙P]ob }
yy }]
A vvbb˙ ]vi}vb v P]o
b }b ]v oo vb
~b]oo˙UR}b`]R(u]o˙R]b}˙}(o]vPvv]bZ
yy PR˙b]}R˙ }v+i}]vb
yy SP˙
AX GvoMbbPG]ouv(}oo}`]vPo}} b
loss
S}]uCRo}] XıA9UIVU
Adults
~SS}v}vRSR}l[Z
Children and Neonates
uollP}obX
b
R](R]bv}o]v]o]u}uv
Av
yy Concentrated red cell transfusionUIVU
AdultsUChildren and Neonates
uollP(}R˘P lLRu}Po}]v]b
B. Bleeding due to underlying liver disease
st
L]vTuv
]v
E RvPPA
yy V]u]vK UIVU
Adults
æruPXb
Children
ræuPX b
Neonates~]b}(R]b}˙}(]u]vK ]vi}vZ
TuV uPX
b
PuV æu]}PubX
b
Av
yy FbRF}vPobu UIVU
AdultsUChildrenUNeonates
æruollP
CXHu}R]o]A
yy R}u]vvF}VIIIU]vv}bU
]vv}vo v] ]bb A9 }( F} VIII }v P ˙ lP
}˙`]PR
R]v]bAA}˙`]PR~lPZ˘b](}]b˘Xæ
~RbvZ
Or
yy Dbu}bb]v UIvvboUæu]}Pu˙b ]v}Rv}b]oU
R}o˙XM˙(}˙b
vw
Standard Trtme
D. Haemophilia B
yy R}u]vvF}IX
Au]v]b}v }( v]llP (} IX ~}u]vvZ Pvoo˙ ]v r
b(}IXoob˙}˘]uo˙XA9]vobvXwA9]v
R]ovAMæ˙b}(P
E. Von Willebrand Disease
yy Dbu}bb]v UIvvboUæu]}Pu˙b ]v}Rv}b]oU
R}o˙XM˙(}˙b
F. DIC
Tvo˙]vPbX
yy FbRF}vPobu
æruollP
Or
yy C}Po}v(} Uoovoo}vvb as needed
G. Thrombocytopaenia requiring platelet transfusion
yy PooC}vv
uollP~]bboo}v˙æ˘ılLZ
Pv}v}(o}o.]v}o˙b]b
yy Tv˘u]A] U}ovIVU
uP llP
Then
uP llP
Adults
uP}oR}o˙
nd
L]vTuv
]v
E RvPPA
Hu}R]o]A
yy P].(}VIII
yy CryoprecipitateUIVU
XærXlbllP
Haemophilia B
yy P].(}IX
yy FbR(}vobu
Refeal
r Criteria
R( oo Ru}R]o]b v oo vb `]R v˘o]v ]vP
o]vP ]b}b v R}b]]vPP˙
b } R R˙b]]v b]o]b
} Ru}o}P]b (} ]v]o buvU uv ov v bRo
}uRvb]]`X
v
19. Sickle Cell Disease

TR]b ]b v ]vR] ]bb R] ˙ R }bb]}v }( `}
v}uo Ru}Po}]vbU ob }v }( `R]R ]b Ru}Po}]v SX TR
]}b ˙bU ]vo]vP HBSS U HBSC v HBS WRobbu] X TR
}bb]}v}(}vv}uoRu}Po}]v~Ru}Po}]v}PR AZ `]R}v
v}uo Ru}Po}]v ~XPX AS } CZA }vb Ru}Po}]v}R˙
]vv}b]looo]bbX
TR b }( R `} Tb]loe } b] vb `]R b]lo oo
]bb ub }]X S]lo oo ]bb vb u˙ bv ]R
]vR˙b U b ]v]b}b `]R}uo]}vbXTR]b]b]b}uu}vo˙
b}r}ob]}v ]v ]b]bX OR ˙b }( ]bb ]vo Rb
˙v}ub UR˙rRu}o˙]b]bUob]b]bv}v b ]bbX
Ivb}r}ob]]bbR]b }ob]}v }( buoobob˙b]lo oob
b]vP ]v(}v v ]vV ]v A CRb S˙v}u ~ACSZ URv
bvb`]Rbv}vb}(}PRU]8o˙]vR]vPv(V]v
ob ]bbU ]v(}v `]R }]b b v b vu]
`]Ro}ò}˙}vV]v}v b ]bbRbovvo]
voP]o˙}]vP}(o}}oobX
v*SickleCellDisse*a v
Pvb `]R b]lo oo ]bb bR}o v}P } R
]}]Rlrbb]loooo]v]X
sueCa
yy IvR]v}(`}v}uoRu}Po}]vPvb(}u}RvbU
ob}v}(`R]R]bvSX
yy Crises are typically precipitated by:
yy }o`R
yy R˙}v
yy ]v(}v
yy R˙b]o˘}v
yy uvob
Symptoms
yy J}]vv}v]vUb]oo˙]vP}o`b}vb
yy ˙bE (P]o]˙
yy Poo}
yy Jv]
yy D]8o˙]vR]vP`]R}`]R}Rb]v
yy CR}v]oPo
yy A}u]vo]vUb]oo˙]vRbov]
yy S}vv}b ]v b }v `]R} ˘o b }bo ]v uo
vb~Sb}v}vRP]]bu [Z
Signs
yy Jv]
yy Poo}
yy H}uPo˙
vı
Standard Trtme
yy Sov}uPo˙ ~u˙bv]v}ovbZ
yy Oo } v ].}v
b ulb ˙ ]}vo RobU oo˙
}R}u]voòovi}]vb
yy Vv}bob
yy B}bb]vP
yy D˙o]b~Rvv(}}˙v}u
b Z
yy Gnathopathy
yy G}`Ro˙}ooUovl˙~ b Ru(v}][R]bZ
Invtiga
se tions
yy FBC
yy Bo}}.ou}uuv
yy Ro}˙}v
yy S]lo]vPb
yy Hu}Po}]vo}R}b]b
yy U]v˘u]v}v
yy CRbXr˙]vb}(CSA
yy Bo}}v]vClS`Rv]v(}vb
yy GvPD˙b
Trtme
ae nt
Tuv}ib
yy T}vRo}uv}(b]looo]bb
yy To relieve pain
yy T}]v(˙vuvPR]]vPb}(]bb
yy T}u]v]vP}}˙b Ru}Po}]v
b
yy T}vo}vPu}uo]}vbv}PvuP
yy T}uvPb]looo]bbv}uo]}vb}vo}
yy G}}R˙}vooub˙]vl]vP`lG]b
yy }]v A }(}uu}v]]vPb}(]bbRbuo]
~vbXZUR˙}v UbU˘bb]˘]bUv˘}b
}˘ub}(`R
yy M]vvv}(P}}v]}v
yy Co]v}v
yy PvolP]v}v
yy Gv}vboo]vP`]R}ov˙(u]o˙b]]}v b
yy Gvoo]lv}òP
Pharmacological Treatment
AXVb}r}ob]}v]v]bb
st
L]vTuv
]v
E RvPPB
M]o}u}]v
yy Pu}o U}oU
Adults
w
æuPrPvrR}o˙
Children
vr˙bV æræuPvrR}o˙
ræ˙bV ræuPvrR}o˙
u}vRbr˙V vruPvrR}o˙
Or
yy Pu}o UoU
Adults and Children
D}bb}
Or
yy I}(v U}oU
Adults
uPvrR}o˙
Children
vr˙bV ruPvrR}o˙
ræ˙bV ruPvrR}o˙
u}vRbr˙V v}}uuv
Or
yy D]o}(v U}oU
Adults
æuPR}o˙}uPR}o˙
Children
AN˙bV æuPR}o˙
AM˙bV v}}uuv
Or
yy D]o}(v UoU
Adults
uP]o˙}u˘]uu}(uP]o˙]v]]}bb
Children
wæruP]o˙
N}r
I( R ]v ]b v} }v}oo ˙ R ubb } `]R]v R}bU }vbo
b]o]bX PR]]v ]b v} o}vP R }uuv P }( R}]X M}R]v
u˙b]o]b}vbo}v]b]X
yy MorphineboRU}olIVU}vbob]o]b
C rX
}v
C}vP o}vPuNSAIDS ~(}u}Rv `} `lbZ XPX D]o}(v vI r
profenu˙vo
b ]u]uvUvPb]b
Av
yy ˘}b
D ]vS}]uCRo}] UIVIv(b]}vU
Adults
yy æA9˘}b
D ]vXıA9S}]uCRo}] rL]o˙
Children
yy æA9˘}b
D ]vXıA9S}]uCRo}] æuollP]o˙
w
Standard Trtme
Or
Adults
N}uoSo]v ovvP`]RæA9˘}b
D rL]o˙
Children
N}uoSo]v ovvP`]RæA9˘}b
D æuollP]o˙
B}˘rP) Fluid requirement in children according to age
AM˙ æuollP
˙ uollP
˙b uollP
˙b uollP
v˙b uollP
˙b ıuollP
˙b æuollP
˙b wuollP
SP]v
nd
L]vTuv
]v
E RvPPB
yy D ]o}(v b}]uUIMU
Adults
wæræuP]o˙]v]]}bb
Then
yy Codeine phosphateU}oU
Adults and Children}˙b
rvuPrvR}o˙
Or
yy Tu}o U}oUæruPR}o˙
vA
yy Bo}} vb(b]}v (packed cellsZ `Rv vU v} }vX
Tvb(b]}v`]oovbb˙](Ru}Po}]voo]bAMæP lL
B. Steady State
yy F}o]A] U}oU
Adults
æuP]o˙
Children
AN˙V æuP]o˙
AM˙V XæuP]o˙
w
C. Severe Disease
N}r
Pvb `]R b Rb ˙v}u
b bR}o R v Pv Rb
Xr˙Uo}}v]vClSUo}}(}P}]vPv}bbruR]vP
yy Au}˘]]oo]v A= Coov] A]U IVU X P v Pvo˙ vb(}
˙v
yy H˙}˘˙u] U Ab]]v U O]b v l} CR}v] vb(b]}v
R˙u˙bvb]o]b
XD Pv}v}(vu}}o]v(}vb
yy Pvu}}o}viP]v ~PCVZ]v}v ]v ]v(v˙U
}}bv˙b
Refeal
r Criteria
R( oo b]lo oo vb `]R o]vP ]v} R ˙U ]]buU
Ru] } vo ]bb v }l
b } b]o]bX TR bv }(
}b}u˙o]bU b v}b]b }( R R]U Rb ˙v}u
b and
b]bv iv] L ]v]o uvPuv b }uuv }
bR}oob}`v(o}b]o]bvX
v*PlasmaCellMyeloma*v
Pvb `]R CNS vbU v˘o]v R]PR `R] oo v oo
}vb ~u} Rv æ v æ ˘ ılL o˙ b ZU ]vo u}]
]vU ]bb } v bvu] ]v(]vP `]R R]
o]bbR}o(}b]o]bX
20. Plasma Cell Myeloma

Pobu oo u˙o}u ~]}bo˙ (} b uoo u˙o}u ZU
]bv+vPRobuoob]vR}vu}`XTRbv}uo
obu oob } ]v ]vb vub v } v}uo v}vr
(v}vo]uuv}Po}o]vbo]vP}]u]]o]˙}.PR]v(}vb
]v R v +U R˙]b}b]˙ v vo (]oX Iv R }v
u}` R ]vb obu oob bo ]v }v ]v v}uo o}}
oo }}v v }b]}v }( }v `]R bov ]Ro o}}
˙}v]bU}b}o˙ob]}vbUR}o}P]o(bvR˙ou] X
TR ]bb ]b}uu}vb]v R b]˘R v o}` R P}(
˙bX
sueCa
yy Uvlv}`v
yy P}vo]]vbP
yy CRu]ob XPX ]}˘]vbU (}uoR˙U v v]}vv (}v
]vb}ovbvov]vPPvb
yy I}v]]vP]}v
yy V]bbXPXHbV]b U]vbE rB UHIV UHb V]b
w
Standard Trtme
Symptoms
yy B}v]v
yy ˙bE (P]o]˙
yy E˘bb]`lvbb
yy Rv]v(}vb
yy B}v˙òo]vPb
b
Signs
yy Poo}
yy F
yy DR˙}v
yy B}v˙oub
yy PoP]
yy Pb]b
yy RvoIu]uv
yy Uv}}l(b
Invtiga
se tions
yy FBCvo}}.ou}uuv
yy ESR
v*PlasmaCellMyeloma*v
yy Bo}}Uo}o˙bUv]v
yy Pobuo]uoob
yy Su]]
yy B}vu}`b]
yy Sloo˙b ]vo]vPblooXr˙
yy Su}]voob
yy Su}]vo}R}b]b
yy U]vBvJ}vb}]v
Trtme
ae nt
Tuv}ib
yy T} R vu }( v}uo obu oob } v}uo v
reduce their rate of increase
yy T}vu]
yy To reduce bone pain
yy T}uvPR}o}P]o(
yy T}]u}}u]v]vP}}}vu]vovb]˙
yy T}]v(}vb
yy T}vvvo}uo]}vb
yy PvbbR}o]vlobo]b}(G]R˙R}PR}R
course of their disease
yy PR˙b]}R˙
yy OR}]b}b
w
AX T}vu}(obuoobv}(]vb
]oo
A b]o]vb}vo˙
B. To reduce bone pain
P]vo](~}]NSAIDSZ
C. To treat anaemia
Ploob transfusion and platelet transfusion`Rv]v]
X
D T}vvvo}uo]}vb
IVv}oG]b
EXT}u]Pu}o˙b]b
Allopurinol}u]Pu}o˙b]b
FXT}]v(}vb
~S}]b}vZ
Refeal
r Criteria
Aoo vb b } R obu oo u˙o}u bR}o
( } Ru}o}P]b b]o]b ˙ v (} (R
o}v v .v] uvPuvX Sbv (}oo}`r v
v*Leukaemia*v
}v˙R˙b]]vb]o]b`]RP]v(}uRRu}o}P]bX
21. Leukaemia
Llu] ]b v }( R o}} oobX TR `} u]v ˙b
}( olu]U `R]R o˙uR}] olu] v u˙o}] olu]X
R E ˙}(olu]vobb].b~`RRv(oob
bvo˙ ]ooZ v R}v] ~`R R v u˙ R v R}]vP
R ]bb (} u}vRb `]R} lv}`]vPZX TRb ]v ooU R u]v
˙b }( olu]P o˙uR}] olu] ~ALLZ U R}v] o˙uR}]
olu] ~CLLZ U u˙o}] olu] ~AMLZ v R}v] u˙o}]
olu]~CMLZ X
ALL ]b }uu}vb ]v R]ov b]oo˙ }˙bU CLL ]b }uu}vb ]v
Roo˙UAMLvCML}bbooPP}bv˘bb X
TR v}uo olu] oob b]oo˙ ]v olu]U .oo R
u}` vv R u}` (}u }]vP R v}uo o}} oob
]XX oobU `R] oob v oob o]vP } vu]U v}v]
vR}u}˙}v]Uo˙ b X
sueCa
yy Uboo˙vlv}`v
yy Associated factors
yy V]bb XPX Ruv T o˙uR}}R] ]b ˙ ~HTLVrZ v
]v
b ]b~EVB Z
yy CRu]ob XPX vvU ]vb]o b}ovbU ]bb ~o]v r
wæ
Standard Trtme
daneZU˙bU
yy DPbXPXol˙ovPPvbbRbuoRov
yy I}v]]vP]}v
Symptoms
Llu]
A
yy F
yy L˙uRv}òo]vP b
yy ˙bE (P]o]˙
yy B]b]vPvv]b
yy B}vvi}]v]v~b]oo˙]vR]ovZ
Chronic Leukaemia
yy ˙u}u Ab
yy PP]vP D bvb}v~oLb]}(}uvZ
yy ˙bE ˙b
yy L˙uRv}òo]vP b
yy W]PRo}bb
yy Gvo]]R
yy E˘bb]`vP b
yy P]]bu
yy H]vPo}bb
v*Leukaemia*v
Signs
Llu]
A
yy Poo}
yy F
yy Sl]vvu}boRu}RPb
yy GuR˙}R˙~AML˙b æZ
yy F]uU˙Uv}vrvo˙uRv}b~o˙uR}]olu]Z
yy Sov}uPo˙
Chronic Leukaemia
yy Sov}uPo˙
yy W]PRo}bb
yy Poo}
yy Gvo]o˙uRv}voPuv]vCLL
Invtiga
se tions
yy FBCvo}}.ou}uuv
yy B}vu}`b]
yy U]]oob
yy LDH
yy BUEvv]v
yy L](v}vb
yy Svb ~b]oo˙]volu]Z
yy LP(}CSF˙}o}P˙~b]oo˙]vo˙uR}]olu]Z
wv
Trtme
ae nt
Tuv}ib
yy T}]u(}]vALL]v}RR]ovvob
yy T}R]u]bb]}vv}o}vPP}}o]˙o](]vAML
yy T} ]u (} }uo Ru}o}P]o u]bb]}v } ]v
R]ooR]}b]CML
yy T} }v}o `R] oo }vbU˙u}ub
b v}o}vP P}} o]˙ }(
o](]vR]ooR]vPCML
yy T} }] b} uv ~]v o](U vb(b]}v b}U
]v(}vbU}vboo]vPZ
yy EvbP}}R˙}v
yy EvbP}}v]}vv(}}R˙P]v
yy EvbP}}}ovb}voR˙P]v
AX Tuv}(Rvò˙]Pv}bv
S}uv
yy P]vo](~}]NSAIDSZ
v*MalignantLymphoma*v
yy Ploob transfusion and platelet transfusion`Rv]v]
yy IVv}oG]b
yy Allopurinol}u]Pu}o˙b]b
yy Tuv}(]v(}vb
S].uv
yy ]oo
A b]o]˙vb}vo˙
Refeal
r Criteria
R(oovb}RRu}o}P]bb]o]˙v
(} }v.u}v }( ]Pv}b]b v b }( uvPuvX F}oo}`r v
}vv P]}vo v ˙ R˙b]]v v R ]bv P]v
}(Ru}o}P]bX
22. Malignant Lymphoma

TR]b (b } P} }( ]b}b R] ˙ uo]Pvv
}o](}v }( o˙uR}] b boo˙ bvvP b o˙uR v}
òo]vPb
b X TR ui} R]b}o}P]o ˙b ]bvP]bR ˙ R
bv } bv }( R RSvP ~RSZ oo X TR u]v P}b
H}Pl]v[b o˙uR}u ~RS oo bvZ v v}vrH}Pl]v[b o˙uR}u
~RSoobvZXN}P]b˘uoR}PRPvoo˙R]v]v}(v}vr
H}Pl]v[b o˙uR}u ~NHLZ ]vbb `]R P v ]uuv}bb]}v
`R]o H}Pl]v[b o˙uR}u ~HLZ bR}`b ]u}o lU ]v R R]b
R]PR]v]v]vRR]vvR b bX
Bl]' [b o˙uR}u U ˙b }( NHLU ]b }v }( R (bbP}`]vP
w
Standard Trtme
u}b lv}`v ]v uvX TR R o]v]o ]vb r R vu]U
b}] v ]uuv}.]v˙ b}] (}ubX TR vu] (}u ]b
(}v]v}]ovuo]vu]P]}vbo]lGRvv}uu}vo˙
bvb b i` òo]vP
b `]R o}}bv]vP }( R b}] RX Iv
GRvU ] ]b R }uu}vb R]oR}} uo]Pvv˙X I Rb l P
]v]vrw˙b`]Ruo}vvX
sueCa
yy OLvvlv}`v
yy Ab}]}o}P]oPvb
yy CR}v]vPv]uo}v b ˙ Helicobacter pylori]v(}v]v
Pb]o˙uR}u
yy V]bbXPXRb]bU]v b r]bUHTLVr
yy CRu]obXPX]bb UR]]b
yy W}}b
Symptoms
yy L˙uRv}òo]vP b `R]Ru˙`˘v`v
yy J`òo]vP b ~]vBl]'bZ
yy F
yy N]PR`bb
yy W]PRo}bb
yy ˙bE (P]o]˙
yy A}u]vo ]bvb]}vU ]vbvo }b}v ~]v }u]vo
o˙uR}ubZ
Signs
yy F]uU˙Uv}vrvo˙uRv}b
yy Sov}uPo˙
yy S]} v ˙v}u b ~]( ol˙ u]bvo ubb
bvZ
yy Poo}~](u}`Rbv]v}oZ
Invtiga
se tions
yy L˙uRv}]}b˙~}(b]Pv].vo˙voPv}Z
yy F]vvob]}v~]vBl]'bZ
yy FBCvo}}.ou}uuv
yy CRbXr˙U}u]voUSGUCTv b `Rvvbb˙
yy B}vu}`b]vR]v]}b˙
Trtme
ae nt
Tuv}ib
yy To provide a cure
yy T} }] b} uv ~]v o](U vb(b]}v b}U
]v(}vbU}vboo]vPZ
yy EvbP}}R˙}v
w
yy C}vboo]vPv}v
AX Hodgkin’s Lymphoma (HL) and Non-Hodgkin’s Lymphoma (NHL)
st
L]vTuv
]v
E RvPPA
S}uv
yy P]vo](~}]NSAIDSZ
yy Ploob transfusion and platelet transfusion`Rv]v]
yy IVv}oG]b
yy Allopurinol}u]Pu}o˙b]b
yy Tuv}(]v(}vb
S].uv
yy ]oo A b]o]˙vb}vo˙
Refeal
r Criteria
Aoo vb bR}o ( } Ru}o}P]b b]o]b
˙vX
wı
Chapter
ImmunisableDissea
æ
23. Iuuv]b}v
Iuuv]b}v P]vb ]v vo ]bb R}PR R
v}voE˘vP}Puu(}Iuuv]b}v~EPIZ]b}v}(Ru}b
+ ubb }( ]vP u}]]˙U ]b]o]˙ v u}o]˙ ]v R
}o}vUb]oo˙U]vR]ovX
GRv vo˙ Rb ~òZ ]vb ]v R ]uuv]b}v
bRoU vuo˙U GBC U }o }o]}u˙o]bU ]RR]U b]bU vbU
Rb U
B haemophilus influenzae ˙ U B vu}}bU }]bU
ubobU oo v ˙oo}` (X N` ]vb u˙ ]v} ]v
Rv(bR˙]b}v(}v+X
Iuuv]b}v ]b}uuv(}R(}oo}`]vPb}vbP
yy H]PR]blP}b~XPX]vP]b}l b }˙]}(]vP
˘}bZ
yy Y}vPR]ov
yy Elderly
yy TRuov}]bR
TRv bRo (}}v Iuuv]b}v (} R]ov v æ

˙b]bb(}oo}`bP
]v
E RvPA
ToærP) SRo(}}vIuuv]b}v}(R]ovvæ˙b
P
A V]v~D}bZ
BIRTH GCB ~XæuoIvuoo˙Z
P}o]}
[O[~}bD Ooo˙Z
v`lb SF]IvOv _~OPvrV]v Z~XæuoIMZ
Pvu}}o~PCVZ ~XæuoIMZ
P}o]}
[[~}bD Ooo˙Z
Rotavirus~R}]˘Z
Chatep ræP *ImmunisableDissea
P
A V]v~D}bZ
`lb SF]IvOv _~OPvrV]v Z~XæuoIMZ
PCV ~XæuoIMZ
P}o]}
R[~}b}oo˙Z
Rotavirus~R}]˘Z
`lb SF]IvOv _~OPvrV]v Z~XæuoIMZ
PCV ~XæuoIMZ
P}o]}
R[~}b}oo˙Z
ıu}vRb MeasleslRoo~XæuoSC}IMZ
Yoo}`F ~XæuoIMZ
u}vRb Measles~XæuoSC}IMZ
F] ]v Ov _ V]v } PvrV]v }v]vb D]RR] U Pbb]b U Tvb UHaemophilus
InfluenzaeBvHb BAvPvb]v}v]vX
MeasleslRoo]bbv}u]v
b ]vX
B}˘ærP) Notes on Vaccine use

yy W}vPuR}}(u]v]b}v8˙ b
yy I(Iuuv]b}v}b]b]vUbu`]RRbuv
}(]vUob`]R
b ]+vv
v*Immunistion
yy TR v} }v]v]}vb } R ]uuv]b}v }( R b]l
R]o](RlbR]bòov}PR}P}R}u
a *v
yy CR]ov `]R ]R} `R} (} }o ]vbP P]
}v[}vURvL`lbv}R]b}vP]v b
yy D}v[ P] OPV L æ ˙b ~]bb Po ]uuv]b}v
bRoZ
yy D}v[P]R}]˘}bb L`lbUv}bL`lb
Iuuv]b}v }(u]bP
yy C}vb]oou]b(}(oo]uuv]b}v}bX
yy S ]uuv]b}v ]v v u}vR L ]R ~L `lbZ
]b}(P}(u]˙XG]GBC }v]bRPX
yy Do˙OPV]vv}vov]b]vR]bbuooRv}(vb(}(
OPV]b}}R]bXHvP]OPV}v]bRP(}uvb˙
rv}`R]ooo
b }vu]bb]}vX
C}v]v]}vb}Iuuv]b}v :
yy Current serious febrile illness: delay vaccine
yy H]b}˙ }( b }v L ]}b }b ~XPX vR˙o
}vZr}]
yy }o]vP
E v}o}P]o ]bb ~XPX v}v}oo ]ob˙ Z r }]
`R}ooob]b]v
yy N} DPT } DPTlHBlH] } R]o `]R }vob]}v lbR}l `]R]v
˙b}(Ru}bv}b}(DPT}DPTlHBlH]
yy N} DPT } DPTlHBlH] } R]o `]R v }vob]}vb }
CNS]bb
Standard Trtme
yy Yoo}` ( ]v bR}o v} P]v ]( R ]b R]b}˙ }(
vR˙o˘]b `]R]vPb}v}(PP
yy Iv]]ob `]R ˙u}u
b HIV ]v(}v bR}o v} ] GBC
v ˙oo}` (]vb b]v Rb o]]vbXGBC ]v
vP]v]Rb]vRHIV]v(v`}v ]b˙u}u
b
L]]vbbR}ov}P]v}R(}oo}`]vPP
yy PPvv`}uvr(}]bl}(}Pv]+
yy Pvb`]Ruo]Pvv]bbXPXolu]UH}Pl]vb]bb
yy Mo]Pvv]bb}(Ro}v}Ro]o˙bb uU
yy Pvb `]R ]uuv b]}vU ]vo]vP S˙u}u HIV
vb
yy Pvb }v Ru}R˙ ~( (} v u}vRb L }]vP b
Ru}R˙uvZ
H}`P
yy Measles]vbR}oP]v}HIV }b]vbvR}PR
]]bo]]vbRv.}`]PRbR]bl
Refeal
r Criteria
R(oo}oubo} Iuuv]b}v} ]]]v } EPI
b]o]bX
v*Mesle
X Measles
a s*v
Measles ]b v ]v(}b ]bbU `R]R boo˙ }b ]v

R]ov `v v u}vRb v ˙b `R} Rv} v ]uuv]bU
}}uoR(oo]uuv]b}vbRoXI]bv˙}b}( b
ubob]v}v ı v u}vRbX TR}v]}v ]b˙ ]v(}b
(}u}˙bw (}U}æ˙bLUv}(RbRX
C}uo]}vb ]vo }b u] U `]R } `]R} (vbbU
}vR}vu}v]U }U ]R}U ]u]v A .]v˙ o]vP
} ˘}RRou] v o]vvbbU uov]}v v }v }( ov
o}b]bXS]}bo˙]ooubobvb]]vPu]bb]}vbR}o
]b}oX TR ]b v} b]. uv (} ubobX Av]}b v}
]U˘(}b}ub].}uo]}vbX
Measles ]Pv}b]b ]b u]vo˙ o]v]oX TR ]bb ]b v}` v}uu}v
}( b ]uuv]b}vXH}ÙR]PR]uuv]b}v}Pvb}
u]v]v} lR ]bb v }v}oX R} oo b} R
D]b]D]bbC}v}oO8(}}]}vX
useCa
yy Measles virus
Symptoms
yy Runny nose
yy C}PR
yy Red eyes
yy S}u}R
yy H]PR(Ubv(}RbRb
yy RbRrb}v(vvl
yy D ]R}
yy CR]o]bPvoo˙u]bo
Signs
yy F
yy C}viv]b
yy K}o]l b}b ~`R] P]vro]l b}b }v R o u}b ˙b
(}bRZ
yy RbRr]R˙UPvo]buo}ro
Invtiga
se tions
yy Uboo˙v}v
yy Measles]uuv}Po}o]vM~IPMZv}˙˙b ](]
Tuv}ib
yy T}o]˙u}ub b
yy T}u]v]vP}}v]}v
yy T}vv}uo]}vb
yy T]b}vP]vP(}(
v*Mesle
yy Ev}P}oR˙P]v`]R(vbo]vu}R`bR
a s*v
yy C}vv(]vP`]Rb}LR]PRo}](}}b
yy WbR˙b`]Rov`
yy D]b}Pb}(RbR]ub}vbl]v
AX F}]vv(
]v
E RvPPC
yy Pu}o U}oU
Adults
æuPrPvrR}o˙
Children
BX T}v˙}uo]}vb}V]u]vA .]v˙
]v
E RvPPA
yy V]u]vA U}oU
Children
AN˙V Uv]b]o˙(}˙b
vru}vRbV Uv]b]o˙(}˙b
AMvu}vRbV æUv]b]o˙(}˙b
CX F}uvPuv}(b}]]R}`]RR˙}v
~Sb}v}vRD]R}[Z
Standard Trtme
X
D F}uvPuv}(b}]vu}v]v}bu]
~Sovb}vbZ
EX F}o](}(bl]v]]}v
yy Cou]vo}}v ~o˙o]oo˙}R`R}obl]vZ
Refeal
r Criteria
R( vb `]R }uo]}vb bR b ol ~Ru}RP]Z
bRU ]} b U vu}v]U }u U P ]8o˙ ]v vP } ]vl]vPU
R˙}v }uov]}v}RR}b]oX
25. Pertussis
TR]b ]b R]PRo˙ }vP]}b ]o b]}˙ ]v(}v
}uu}v]vR]ovvobXTR]v}v]}]bwr˙bX
C}uo]}vb ]vo }vivo
b Ru}RPU }b u] U
v}U vu}v]U }vR]b]bU }v }( ov o}b]bU
R˙}v U (U }vob]}vbUo}obU v uov]}vX Au]
}R}b]o`Rv}uo]}vbbvX
Pbb]b v v ˙ R S.r]vr}v_ Iuuv]b}v
}uuv(}ooR]ov~Sb}v}vRIuuv]b}v[ZX
IvRv}(R]oo}]vPb]b(}]uuv]b}vUR
v*Petur sis*v
S.]v}v_]vbR}ooo b P]v}}P]vbR(}}R
]bbX
D]vP ]u]bU } `Rv R ]b o R]b}˙ }( }v ]v
R]o `]RRU}]v]}b u˙ Ro R ]} }(
]v(]˙ v vbu]bb]}vX Aoo b R}o } } R D]b]
D]bbC}v}oO8X
useCa
yy Bordetella pertussis
Symptoms
Ro C PRbPIv]or`lb
yy L}`P(
yy Nbo]bRP
yy M]o}PR
Paroxysmal phase: within the following 6-10 weeks
yy E]b}b }( ]}ov }PR v]vP `]R ]vb]}˙ `R}}
}}u]vP ~`R}}u˙bv]v]bvobZ
R}˙~}vobvZRbPv˘r`lb
yy Go}v]v}b}(}PR]vP
Signs
yy Apnoea~o}vPb]vR]vP}uu}v Z ]v]b
yy Cyanosis
Invtiga
se tions
yy FBCrR]PR}oo˙uR}˙}v
yy CRbXr˙~}˘o}Rb}(R}v]}PRZ
Trtme
ae nt
Tuv}ib
yy T}vbu]bb]}v
yy T}v}uo]}vb
yy F(vo˙`v}PR]vPbub
yy Ev}P}oG]]vl
AXPvbvo}b}vb`]R]v˙b}(}vb}(˙u}ub b
st
L]vTuv
]v
E RvPPA
yy E˙R}u˙]v U}oU
Adults
æuPvR}o˙(}˙bw
Children
r˙bV æræuPvR}o˙(}˙bw
r˙bV æuP}(bvb]}vvR}o˙(}˙bw
v*Petur sis*v
vu}vRbr˙bV æuP}(bvb]}vvR}o˙(}˙bw
AMvu}vRbV v}}uuv~]bl}(˙o}]
v}bb ]bZX
C}vb]T]uR}]ulSoRuR}˘}o ]vbX~So}`ZX
Or
]v E RvPPB
yy A]R}u˙]v U}oU
Adults
æuP]o˙(}˙b
Children
uP llP}˙`]PR]o˙(}˙b
~v}}uuv(}R]ovobRv b u}vRb
v }(
b ]bl
of pyloric stenosisZX
C}vb]T]uR}]ulSoRuR}˘}o ]vbX~So}`ZX
Or
]v E RvPPC
yy Co]R}u˙]v U}oU
Adults
æuPR}o˙(}˙bw
Children
wXæuP llPR}o˙(}˙bw
nd
L]vTuv
]v
E RvPC
yy T]uR}]ulSoRuR}˘}o U}oU
æ
Standard Trtme
Adults
vluPR}o˙(}˙bw
Children
luP llPR}o˙(}˙bw
B. OxygenR˙`Rv}˘˙Pv}v b AMıA9
yy O˘˙Pv U ]vvbo } ( ublU ~]( R v Rb ]8o˙ ]v
R]vP}]b˙v}bZ
Refeal
r Criteria
R(]v(vb`R}Rv]b}}(v}}˙v}b]bL]v]o
b]}v}b]o]bX
26. Tetanus
Tetanus ]b ]bb b ˙ ]uU `R]R }b
v}}˘]v b}vb]o (} R o]v]o (bX TRb ] o]
}u]vvo˙ ]v R b}]oU b} ] ]b ˙b } P R]b ]v(}v `Rv
l ]v R bl]v ]b v} ov }o˙X Tvbr}v `}vb ]vo
vbU v ]vi]bU } R}b }vu]v ˙ b}]oluvU b
`}vbUvR}b`]RuR]o]bvb }u}v(bX
TR b }( v}vrb]o]b ]vbuvb } b]vPb }v R u]o]o }
v*Tetanus*v
]b}b}b v}vovbXTR]v}v]}]br˙bX
Tetanus bR}o b u]o uPv˙X Tvb
]uuv]b}v]bRl˙(}v}v~Sb}v}vRIuuv]b}v [ZX
useCa
yy Clostridium tetani
Symptoms
yy D]8o˙}]v]o]˙}}vu}R
yy C}vb}v
yy S+}˙
yy Sbubr Rb ]v(o v ]PP˙ v}]bU ]PRo]PR}
}RVb}vv}b]vbX
Signs
yy Uu]o]bu˙]v(
yy Pbv}(`}v~u˙RRoZ
yy I]]o]˙
yy Cyanosis]vPbub
yy S}v]~u}l]vPZbu]o
yy L}li`~vv}}vRu}RZ
yy O]bR}}vb ~b+RlZ
yy R]P]}uvv+ b vlvo]ub
Invtiga
se tions
yy N}}v.u}˙~]Pv}b b ]b]bo]v]oZ
v
Trtme
ae nt
Tuv}ib
yy T}v(Rbub
yy T}o]u]v Clostridium tetani}}b (R}˘]v}}v
yy T}vo]b]ovP}˘]v
yy T}}]R˙}vvv]}v
yy T}}]b}oobub}uoo˙b
yy Ao`˙bu]b}(vb
yy M]v]vo]`˙
yy }] A v}]bU]PRo]PRvvvbb˙R˙b]o˘u]v}v}(R
v
yy Cov R ]v( u]o]b } `}v `]R b} v ` }
vbb}o}v~Sb}v}vRW}vuvPuv[Z
yy SP]o]uv}(R`}v`Rvvbb˙
AX ]}v
E }(]]vv]Pv}b}Rvb
st
L]vTuv
]v
E RvPPA
yy M}v]}o UIVU
v*Tetanus*v
Adults
æuPvR}o˙(}wr˙b
Children
ANu}vR wXæuP llPR}o˙(}wr˙
Neonates
AN˙bw V wXæuP llPR}o˙
AM˙bw V wXæuP llPR}o˙
nd
L]vTuv
]v
E RvPPB
yy Bv˙ov]]oo]v UIVU
Adults
æUv]bllPU b RvMUvR}o˙(}æ˙b
Children
æUv]bllPvR}o˙(}æ˙b
Neonates
æUv]bvR}o˙(}˙bw
v A
yy Gvu]]v UIVU~v}vb}vo˙ZUuP llPR}o˙
BX T}vo](]ovP}˘]v
]v
E RvPPB
yy HuvTvb Iuuv}Po}o]vUIM}IVU
Adults and Children
æv]bX
b
Neonates
w
Standard Trtme
æv]bX b
Av
yy Tetanus T}˘}]U IMU ~]vi ]+vb](}u Huv Tvb Iu r
uv}Po}o]v Z
Adults and Children
AN˙bV Xæ uo Xb R r `lb ~v }bZ v
vru}vRb~}bZ
AM˙bV }bb}(Pvov]v
]vob}((}`lb
C. To control spasms
]v
E RvPPC
Adults
yy CRo}}u]v UIMUæuPrR}o˙
Av
yy D ]u U IV } IMU ~˙ bo}` IV }( v} u} Rv æ uP l
u]vZUæruPrvR}o˙`Rv]
Or
yy PRv}]}v UIMU uPrR}o˙UPoo˙}v b
L}`lb
Children
v*Tetanus*v
yy CRo}}u]v U IM } }o ~] vb}Pb] ZU Xæræ uP

hourly
Av
yy D ]u UIVlIMlvb}Pb]lb}b]}˙UXuP llPrR}o˙
v
`Rv]~˙bo}ÌV}(v}u}RvæuP lu]vZ
Or
yy PRv}]}v U IM } }o ~] vb}Pb] TZU uP llP X
b U
RvXæuP llPR}o˙
Neonates
yy CRo}}u]v UIM}}o~]vb}Pb]ZUwXæuPR}o˙
Av
yy PRv}]o ~PRv}]}v ZU IM } }o ~] vb}Pb] ZU
uPX
b RvwXæuPR}o˙
N}vbr](bubv}}v}oo`]RR}uv
A
yy D]u UoUXæuP llPrvR}o˙`Rv]
B}˘ærP) TvbIuuv]b}v
yy S Iuuv]b}v (} ]bRP (}u R}b]o ]v oo vb b
vb]v(}v}bv}}]]uuv]˙P]vb(]b}b
yy Av o `R} Rb ] }o }( æ }bb }( vb }˘}] ]b o]lo˙ }
Ro](ro}vP]uuv]˙
B}˘ærP) TvbIuuv]b}v
yy A }b }( vb }˘}] ]v}vb bR}o P]v } v˙ ]}bo˙
v]uuv]b v }o Rv ˙b }( PX D}bP Xæ uoU IM }
SCU`lbv`lb~]u˙}bZ
yy I( }u}˙b~æ}u}˙b(}R]ovo}`Pæ˙bZR
obb]v]u˙}b}ob}}bUP]}}b}b}(Xæuo
yy Iv vbr}v `}vb b R ]u˙ }b ]v R v}vr]uuv]b
vXA}}b}bu˙ P]v](u}Rv.˙bRob
since the last dose
yy S]}b}(v}vovbbR}o(}oo}`Rv}uobRo(}SF]r
]vrOv_~Pvr]v Z
yy P]}bo˙v]uuv]bR]ovo}`RP}(˙bbR}o]
}bb}(æ]v]vob}((}`lbX
yy Cu]o]o}`]R]o b ]vbuvUov`]RuR˙ob]]~o r
}R}oZvov}
yy T}vvb ]vvb `]R }voo˙}vu]v`}vb ~ r
vb }v `}vZU }] `}v }]ovP ~S b}v }v
RW}vb[Zvob}}]vb}R˙o˘]b
yy TetanusIuuv]b}v ]vPvv˙~Sb}v}vRAvvoC [Z
Refeal
r Criteria
R(vb}b]o]b](bubvv}}v}ooX
v*Poliomyelitis*v
27. P}o]}u˙o]b
P}o]}u˙o]b ]b]o]bbU`R]R]b˙b (or}o}}or
}r}o vbu]bb]}vX Ivbv]˙ ]b}bo }( ˘ v b }( vb(
]vl]vP `}v] } R X b TR ]bb ]b R]b ˙
˙]vPPb}(G]o˙b]bU`R]R}uu}vo˙b]bbX
Po˙b]b}uu}vo˙+b}vo}ò]u v˙P}}(bloo
ubobU]vo]vPRubob}(b]}vvooob]vR]v
u˙+X
P}o]}u˙o]b ]b }uu}vo˙ ] ]v R]oR}}X TR ]v(}v ]b
}Lv bro]v]o v u˙ }vo˙ b u]o Gro]l]oovbbX Ovo˙ (`
}Pb
b }b o}o˙b]bXH}Ù]vi}vb]vP]}b}(
R (]o ]oovbb }]`]R v ]vb ]v]v }(o˙
}o]}u˙o]bX
P}o]}u˙o]b ]b vo ˙ Iuuv]b}v X Pv}v ]b ou}b
]v ]( }bb }( }o }o]} ]v P]v b ]v R EPI bRoX
Ro˙ V]vrAb}] Po˙ P}o]}u˙o]b ~VAPPZ u˙ } ]v
]]vb }( }o }o]} ]vb v R] v]uuv]b }vbX TR]b ]b
boo˙b}]`]R}o]}]b˙X
Note 5-1
Aoob}(}o]}u˙o]bbR}o }}RD]b]D]bbC}v}oO( r
.(}(}oo}`rX
ı
Standard Trtme
sueCa
yy P}o]}]b }˙b b U}
Symptoms
yy F
yy Headache
yy Sore throat
yy Muscle pain
yy Fo]o˙b]b
Signs
yy G] A o˙b]b}(+ubob
yy D]u]v]bR}bvuboG˘b
Invtiga
se tions
yy T`} (bR }}o b buob lv r R}b ~} bv }v ]
}RRP]}voPo]HoRR(vL}}˙(}}v.u}vZ
Trtme
ae nt
Tuv}ib
yy T}}]b}oov}b(}u]oovbb
yy T}}]}o]u]R˘v}(o˙b]b
v*Diphtheria*v
yy T}}]R]o]}v]vo˙b
yy b B
yy }] A ]vi}vb]vP(]o]oovbb]vR]ov
yy PR˙b]}R˙
yy P}]b]}v}(}]o]vb}]u}]o]˙
yy N}b].v]ouv
Refealr Criteria
R( oo vb `]R ]8o˙ ]v R]vP v òo}`]vPb (}
R}b]ou]bb]}vX
28. Diphtheria
TR ] b}vb]o (} R]b ]bb }b }˘]v R
uPbRuv}˙bv}PvbXI}uu}vo˙+bR}vb]ob
v b}uub R bl]vb]vP obX I ]b bu]vo˙ ˙b]}˙
}ob(}ub}v}b}vUvob}uu}vo˙ b R}PRbl]v}vX
Iv( vb u˙ } L ]v]o ˙u}ub b v b]Pvb }
o} b `lvbb v ] `]R]v vr ˙bX C}uo]}vb u˙
o}]vRo˙Rb}(R]b}b `lbobRv}uo b
RvR(]oUuP}ob}(RRU}b]}˙
}b}vo]vP}RX
ı
TR ]bb ]b v}` v}uu}v b }( ]uuv]b}vX H}Ù
R]PR ]uuv]b}v}Pvb} u]v]v}lR]bb
v}v}ob]RbR]PRu}o]˙X
Note 5-2
Aoo}(
b ]RR]bR}o}}RD]b]D]bC}v}o
b O8X
sueCa
yy Corynebacterium diphtheriae
Symptoms
yy Sore throat
yy L}bb}(
yy So]PR(
yy D˙bRP]
yy D]8o˙]vR]vP`]R}`]R}]} b
Signs
yy G˙]bR`R]uuv}R]vRR}v}v}vb]ob`]R]v
r˙b }( R }vb }(˙u}ub
b X Muv u˙ oU }u
P˙]bRPv}olX
Invtiga
se tions
v*Diphtheria*v
yy TR}lvbo`bb (}o(}]v˘bvo}b}vb
yy R`bb Lv]}uv}b~uvu˙v
}˘vZX
Trtme
ae nt
Tuv}ib
yy T}vo]bR+}(]ovPv}˘]vb(}R˙}u
.˘}Rb
yy T}}]b}b]}˙v(]vP`R]v]
yy T}]R}Pv]bu(}uRR˙v˘
yy To prevent spread
yy b B
yy F]vP˙vb}Pb](}vb`R}vv}òo}` b
yy S]]b}o}v}(vbb
AX Aoovbo]v]oo˙]Pv}b`]R]RR]
]v
E RvPPC
yy D]RR] v}˘]v UIV]v(b]}vU~(}oo}`]vPv]vuo}bb
}(Xuo}(]v]o}v}(v}˘]v]vS}]uCRo}] XıA9Z
Adults
U}Uv]b
Children
AN˙bV UrUv]b
ı
Standard Trtme
AM˙bV æUrUv]b
Note 5-3
R}vb }uu}v b} b]}v (]o]b bR}o ]oo ]uu] r
ately
Av
yy B Pv]]oo]v UIVU
v˙o
Adults
XPvR}o˙(}R}b
Children and Neonates
u}vRr˙bV æuP llPvR}o˙(}R}b
Then
yy A u}˘]]oo]v U}oU
Adults
PR}o˙(}æ˙b
Children
ær˙bV æuPR}o˙(}˙b
u}vRr˙V æuPR}o˙(}˙b
Or
yy A]R}u˙]v U}oU
v*YellowFever*v
Adults
æuP]o˙(}æ˙b
Children
uP llP}˙`]PR]o˙(}æ˙bX
N}}uuv(}R]ovobbRvvu}vRbb}(]bl
of pyloric stenosisX
BXAooo}b}vb
yy Au}˘]]oo]v U}oU(}˙b~(}b]vP}Z
Or
F}vb`R}u˙v}}ov]]oo]vbP
yy A]R}u˙]v U}oU(}æ˙b~(}b]vP}Z
Refeal
r Criteria
R( vb `]R o˙vPo }b}v } b]}˙ o˙b]b }
vENTb]o]bX
29. Yoo}`F
Yoo}` (]b b ˙ ]bvbu]'} uv ˙ b]b }(
u}b]}b ~ Aedes aegyptiZ (}u ]v( u}vl˙bX TR ]bb ]b v}
(}u
b b}v}b}vXCobb]o˙oo}`(]bboo˙(oX
AL R }vb }( ˙u}ub
b U R ]b ]( u]bb]}v }( r
R}bU(}oo}`]vP`R]RR˙u}ub b u˙`]RRo}uv}(
]Pb]]vUiv]Uvo]vb8]v˙U]}bo]vb]o]˙v
ı
o]vP(}u]}bb]b~XPXPubvvorvb]bZX
Yoo}` (]v}v ]b}P]vbR ]bb v vb
}˙v˙bXYoo}`(]v}v]b]uv
(}o(}uGRv}ob }v]bX
N}ær
Aoo b }( ˙oo}` (bR}o }} R D]b] D]bb C}v}o O( r
.X
sueCa
yy Yoo}`(]b
Symptoms
yy F
yy Mbo]vUoo˙lR
yy Headache
yy SR]]vP
yy L}bb}(
yy Nausea}}u]vP
yy D]R}
Signs
yy C}vPb}v}(R}viv
v*YellowFever*v
yy Jv]
yy Bo]vP (}u]}bb]b~R] UR˙u}b]b UXZ
yy R]PR}u]vovvvbb
yy S]Pvb}(vo(]o
Invtiga
se tions
yy U]vo˙b]br}]v]v]b}]o]v}Pvoob
yy L](v}vb
yy Bo}}Uo}o˙bvv]v
yy Bo}} buo (} ˙oo}` (]b}o}P˙
b ~ R RP]}vo Po]
HoRR(vL}}˙Z
Trtme
ae nt
Tuv}ib
yy T}}]b}(}RUvov]o}˙(]o
yy T}uvPo]vP]b}
yy I( ˙oo}` ( ]b b ]v vU u] ]uu]o˙ } v
]b}o}v`
yy Foob}uv(}R(]ovvo(]o
AX Av]oR˙
yy TR]bv}b].uv
ı
Standard Trtme
BXF}o]vPvb
yy FbR(}vobu
Refeal
r Criteria
R(}R}b]oU(o˙}v`]Rv]b}o}vv]X
30. Haemophilus Influenzae type b Disease

The Haemophilus influenzae ˙ ~H]Z ]u ]b v ]u}v
b }( ]v(}vb bR b ]o uv]vP]b U vu}v]U
]Po}hbv}bu] ]vR]ovobRv
b æ˙b}oXH]]b]bb
v}}uu}v˙}væ˙b}(PX
H] ]v(}vb vo ˙ R .r]vr}v ~vrZ ]v
~SEPIRSRo(}}vIuuv]b}v}(R]ovvæ˙b[ZX
sueCa
yy Haemophilus influenzae˙~H]Z
v*HaemophilusInfluenzaetypebDisse*a v
Symptoms
yy F
yy OR ˙u}ub b b}] `]R vu}v]U }b u] U
uv]vP]b Uu]b
Signs
~Sb]Pvbv˙u}ub
b }(Rb].]bb]v}Rb}vbZ
Invtiga
se tions
yy Cov bvb]]˙ }(}]}˙ G]b ~XPX b (}u R
]v b }b u] U }b]vo G] ]v uv]vP]b U
oob]]vu˙u Uo}}ZX
Note 5-5
Bo}} o ]b }vo˙ ov ]v ]vb] ]bb v `}o v} Ro(o ]v
v}uo]vu}v]bX
Trtme
ae nt
Tuv}ib
yy T}o]u]vR]
yy T}}]b}
yy R( } ov b}vb }v R bvvP ]oovbb XPX uv]vP]b U
vu}v]
yy R( } ov b}vb }v R bvvP ]oovbb XPX uv]vP]b U
vu}v]
Refealr Criteria
Aoo vb `R} (]o } bR}` ulo b]Pvb }( ]u}uv ]v
ı
˙b (}oo}`]vP P uvU } bv `]R }uo]}vb bR}o
((}R]PRrooX
31. Pneumococcal Disease

Pvu}}o ]bb bvb u} }uu}vo˙ b v}vr]vb]
]b]v b R(}u}(v}vru]vu}v]Uu]or]v(}vbU
b]vb]bU } }vR]bX H}Ù ] u˙ ob} uv](b b Ivb]
Pvu}}o D]bb ~IPDZ ]v R (}u }( vu}v] `]R u˙u
vl}u]}uv]vP]b bo}(Ru}Pv]X b Iv
o}]vP }v]bU v}vru] vu}v] b R ui}]˙
}(vu}}oRbXN]v˙]bv}˙b b Rv]v.X
Pvu}}o ]bb ]b +o˙ v `]R Pvu}}o
C}viPV]v~PCVZ vUv `lb(}]v(vbXPvu}}o
P}o˙bR]V]v~PPSVZ ]b}uuv(}b}vb}oRv
˙b `]R vo˙]vP u]o }v]}vb bR b S]lo Coo D]bb X
Aob `]R ]uuv}}u}u]b]vP }v]}vbU (v}vo } v}u]
bov]U }b]vo G] olbU } }Ro ]uovb bR}o ]
PCV(}oo}`˙PPSVX
v*PneumococcalDisse*a v
sueCa
yy Streptococcus pneumoniae
Symptoms
yy F
yy OR ˙u}ub b b}] `]R vu}v]U }b u] U
uv]vP]b Uu] b
Signs
yy Pob(} b]Pvb v˙u}ub
b }( R b]. ]bb ]v }R
b}vb
Invtiga
se tions
yy Cov bvb]]˙ }(}]}˙ G]b ~XPX b (}u R
]v b }b u] U }b]vo G] ]v uv]vP]b U
oob]]vu˙u Uo}}ZX
Note 5-6
Bo}}o]b}vo˙ov]v]vb]vu}}o]bbv`}ov}
Ro(o]vv}uo]vu}v]bX
Trtme
ae nt
Tuv}ib
yy T}o]u]vR]
yy T}}]b}
~S ov b}vb }v R bvvP ]oovbb XPX uv]vP]b U
vu}v]Z
ıæ
Standard Trtme
~S ov b}vb }v R bvvP ]oovbb XPX uv]vP]b U
vu}v]Z
Refeal
r Criteria
Aoo vb `R} (]o } bR}` ulo b]Pvb }( ]u}uv ]v
˙b (}oo}`]vP P uvU } bv `]R }uo]}vb bR}o
((}R]PRrooX
32. Hb
~S b}v }v RAv CR}v] Hb v D]b}b }( R
L] [Z
33. R}]bD]bb
~Sb}v}vRR}]bD]bvb D]R}[vD]b}b}(
RGb}]vbvoTZ
v*Hetitis
ap *v
ıv
Chapter
ProblemsoftheNeorwb n
~NeonateZ
v
X Sick newborn
TR u v`}v (neonateZ (b } ˙ ]v R .b u}vR }(
o](X A ]R oo RoR˙ v`}vb `]R }vP
b ˙X Av˙ ˙
}v]oo`]oobR}`b]Pvb}(}}]˙}u˙b]S]vP
b G_
} G}˙ ]v bX TR v`}v `]R }v } u}v}uo ]o
b]Pvb ]b vòoX TRb ]vo }o}U ]˙U uU b]}vU
RU o}} bPU ]v }U v}( }ò u}uvbU b]Pvb
}(]bb~]vZX
sueCa
yy B]RbR˙˘]
yy Pu]˙
yy N}vo]v(}vb
yy C}vPv]o uo(}u}vb XPX RU vo v}b˙bb uU}ò
X
yy B]R]vi˙
yy Mvo}v
b }voPb]]vPo}
yy M}o]XPXR˙}Po˙u]UR˙}ou]
Symptoms
yy Wl˙}]v]o]˙}˙
yy D]8o˙]vR]vP}v}vb }(R]vP~v}Z
yy Rb}vv}bu}uvb}]vP˙G}˙
yy Refusal of feeds
yy V}u]vP
yy A}u]vo]bvb]}v
yy Convulsions
yy Bo}}]v}}ob
b
yy Reduced urine output
Signs
yy R]b}˙u~ANwXæ£C˘]oo˙Z
yy L}`}˙u~AMvXæ£C˘]oo˙Z
yy Poo}
yy Cyanosis
ıw
Standard Trtme
yy Jv]
yy ˙]
B ~AMblu]vZ
yy Tachycardia~ANblu]vv Z
yy Huub
yy Rb]}˙]bb~ANRb
v lu]vURb]v`]vPZ
yy Rb]}˙AMRblu]v
yy Apnoea
yy A}u]vo]bvb]}v
yy }`bD ]vbb}v}vb]}bvbb
yy S]b
yy Tenderness of any part of the body
Invtiga
se tions
yy FBC
yy Rv}uo}}Po}b
yy Bo}}vo}o˙b
yy Bo}}ob
yy U]vo
yy S`}(v˙ob]}vb(}ovbvb]]˙
yy CRbXr˙
yy Po]v}u]voXr˙Uvb]v](]v]
v*Sickneorwb n*v
yy }bC ]voG]]}Ru]b˙vovbvb]]˙
Trtme
ae nt
Tuv}ib
yy T}]Pv}bvvo˙]vP}]o˙ b
yy T}]v(˙vPvo˙}R˙}Po˙u]
yy T}vuvv}PvuP
yy o]b Eb R]`˙UvbR]vPv]o}v~ABC Z
yy K˙ù]R`]v˙o}Rb}]vv]v}
]v
E RvPPA
AX Oxygen Therapy
yy O˘˙Pv ˙ ( ubl } vbo }vPbU r Llu]v ]( ]ooU
~u}v]}vu]v]v}˘˙Pv}v b `vırıæA9Z
B. Maintenance Fluid
yy ˘}b
D A9U IVU }v ˙ }( o]˙U }blu]vllP ~v uollP l
˙Z
yy N}uoSo]v XA9`]R˘}b
D A9~vræuollP l˙L˙
Z
CXC}}v}(H˙}Po˙u]
I(R˙}Po˙u]U}~Sb}v}vRN}voH˙}Po˙u][ Z
ı
Chatep rvP *ProblemsoftheNeorwb n~NeonateZ
D. For neonates having seizures (convulsions)
yy PRv}]}v UIVlIMUuP llPXb RvæuP llPR}o˙
E. To treat sepsis (other than cord sepsis)
yy Au]]oo]v UIMlIVU
Neonates
AN˙bw }(PV æuP llPR}o˙(}ær˙bw
AM˙bw }(PV æuP llPR}o˙(}ær˙bw
Av
yy Gvu]]v UIMlIVUuP llP]o˙(}˙bw ~]b}(PL
]RZ
Or
yy A u]]oo]v UIMlIVU
Neonates
vA
yy (}˘]u
C UIVUæræuP llP R}o˙(}˙bw ~]b}(P
L]RZ
F. For cord sepsis
v*Sickneorwb n*v
yy Co}˘]oo]v UIMlIVU
Neonates
AN˙bw }(PV æræuP llPR}o˙
AM˙bw }(PV æræuP llPR}o˙
vA
yy Gvu]]v UIMlIVU uP llP R}o˙(}˙bw ~]b}(P
L]RZ
G. For bowel related sepsis

yy Au]]oo]v UIMlIVU
Neonates
vA
yy Gvu]]v UIMlIVUuP llP]o˙(}˙bw ~]b}(PL
]RZ
vA
yy M}v]}oUIV~}Wu]vbZ
Neonate
AN `lb }Pb}vo PV æ uP llP b b]vPo o}]vP
}b(}oo}`LR}b˙wXæuP llP˙R}b
vr`lb}Pb}voPVæuP llPb]vPoo}]vP
}b(}oo}`LR}b˙wXæuP llP˙R}b
AM v `lb }Pb}vo PV æ uP llP b b]vPo o}]vP
ıı
Standard Trtme
}b(}oo}`LR}b˙wXæuP llP]o˙

Refeal
r Criteria
R( R v Pvo˙ } b]o]b (} (R ]vbP}vb
vuv](v}]u}uvLR}bX
35. Neonatal Hypoglycaemia

N}vo R˙}Po˙u] (b } v}u o}} Po}b oo
o}`Xvuu}olL]vRv`}v X
Ab R o]v]o b]Pvb u˙ ]oU } ]v bvU (} buoo }
b]l]b}]v(vb}(]u}RbRv}uo}}Po}boo
bR}o Rl ˙ R R}b (} R .b R}b vo ] ˙bb
}Xæuu}olL(}(RR}bX
N}voR˙}Po˙u]u˙bo]vR](v}}uo˙
v bR}o R(} uvP b b}}v b X b Sb(o b
uv bob ]v }u b}vbX T} v R˙}Po˙u]U
]vP
b bR}o v}P b}}v L ]RX I( R v}v is
vo } blU vb}Pb] u˙ b v ˘bb
v*NeonatalHypoglycaemia*v
u]olP]vXI(vo(b}v]v]U]vv}bG]bbR}o
]uu]o˙b X
sueCa
yy Pu]˙
yy Iv]vP}`R}v
yy ˙B }v}]u}R
yy Iv(}v
yy AbR˙˘]
Symptoms
yy I]]o]˙vobb bvbb
yy Tu}b
yy S`vP
yy S]b
yy LRP˙
Signs
yy S`vP
yy Tu}
yy Tachycardia
yy S]b
yy Uv}vb]}bvbb
Invtiga
se tions
yy Rv}uo}}Po}b~RBSZ
yy Ub]vPrb]Po}bu
yy CRl`]R]vR}bL]RvPoR}o˙]vob
in infants at risk
yy OR]vbP}vbv}vRvo˙]vP
b b
Trtme
ae nt
Tuv}ib
yy T}u]v]vo}}Po}boob`]R]vv}uoo]u]b
yy T}]v(˙vvo˙]vPb}(R˙}Po˙u]
yy T}v}uo]}vbXPX]vuP
yy Bo}} Po}b u}v]}]vP A* } R}o˙ ]v R˙}Po˙u] ]v(vb
vov}uooob']v
]v
E RvPPA
AXIv]ouvPuv
yy ˘}b
D A9UIVUuollPb}ob
BXM]vvvuv(}oo}`]vP]uu]o˙L]v]ouv
agement
yy So]v XA9 ]v ˘}b
D A9U vræ uollP l˙ v]vP }v R
P}(Rv`}v ~Soo}`ZX
v*NeonatalJaundice*v
TovrP) M]vvvG]]uv
˙D Pu Tu
vuollP l˙ æuollP l˙
ıuollP l˙ wuollP l˙
uollP l˙ ıuollP l˙
uollP l˙ uollP l˙
AHæ æuollP l˙ uollP l˙
CXA]}vouvPuv
Dvb}vRvo˙]vPbX
Refeal
r Criteria
R(} b]o]b](v}bv}b}v}uo˙]vb]}(
uvX
36. N}voJv]
Jv] in the neonate u˙ ]b]o `Rv R bu ]o]]v
oo ˘b u]}u}olLX N}vo iv] ]b ]u}v b
}(R}vbvb}(R˙]o]]vu}vR]v}(Rv`}v X
TR]b }v]}v ]b oo lv]b (bilirubin encephalopathyZ v u˙
R
b XIv(vb`R}b]u˙Rv]`]Roob˙U
vb}](vbbUuvo}vvu}}]v}}]v}vX
Standard Trtme
}˘]uo˙
A A9}(v`}vb`]ooiv]]vR.b`l}(
o](vu}b}(R]b]bR˙b]}o}P]oXTR]b}b}v˙vob}b
˙bXTR]biv]]bu]ovR˙u]vbRoR˙X
Jv] in the neonate ]b o]lo˙ } R}o}P]o ]( ] ]b bv
`]R]v R .b ˙ }( o](V } }viP ~]Z ]o]]v ]b u} Rv
u]}u}olLV}}o]o]]v]bu}Rvwu]}u}olL]vu
v u} Rv v u]}u}olL ]v R u ]v(vV } R v}v ]b
b]Pv].vo˙iv]˙}v˙b}Rbiv]`]R(X
E˘RvP vb(b]}v ]b R .v] uv (}
R˙]o]]vu] R Rb R R oo `R lv]b u˙
}X
sueCa
yy PR˙b]}o}P]o
yy Hu}o˙b]b rRRbb UABO ]v}u]o]˙UGvPD .]v˙
yy Bo}}˘b}vrRoRu}u UbPooRu}u
yy Sepsis
yy C}vPv]o]v(}vb
yy L]]bb
yy M}o]]b}brPo}bu]UR˙}R˙}]]bu
yy EvRv ˘ R ]o}v r GIT }b}vU ]v

(]vP
yy C}vPv]o(b}(]o]]v u}o]bu
yy u]ol bB oiv]
Symptoms
yy Yoo}`˙b
yy Yoo}`bl]vURvbv(
yy Po}}ob b ~]o]˙b]o]lo˙Z
Signs
yy Jv]
yy Yoo}`]Puv]vbl]v
yy Yoo}òubA=lr˙oo}`b}ob}((
yy Po}}ob b ~]o]˙b]o]lo˙Z
Invtiga
se tions
yy T}ov]bu]o]]v }vv}v
yy OR]vbP}vbo}` b Uvv}vPbv}vv
suspected cause:
o˙ E }vb~`]R]v.bR}b}(]RZ
yy Bo}}P}vRbb~RRZP}}(}R]v(vvu}R
yy D]C}}ubU b Iv]C}}ubU
b FBUC GvPD
yy Bo}}.ou(}oov}uo]bUuo]b]b
yy Cob }( o}}U ]vU v b]vo G] u˙ ]v] ˙ R
R]b}˙UR˙b]o˘u]v}v}]v]oo}}˙.v]vPb
P}o}vPiv]~L˙bZ
yy L]Fv}vb
yy TR˙}]Fv}vb
yy U]v(}]vPvbb
yy U]vRlEvClS
yy TORCH~}vPv]o]v(}vbvZb
yy HB
yy A}u]voob}vvb ~˘o]o]˙b]Z
Trtme
ae nt
Tuv}ib
yy To prevent kernicterus (bilirubin encephalopathyZ
yy T}vvo˙]vPb
yy PR}}R˙ ~Sv}o}`}vRPR}}R˙ [Z
yy E˘RvP o}} vb(b]}v ~S v} o}` }v RE˘RvP
vb(b]}v[Z
B}˘vrP) Phototherapy
PR}}R˙ is started if:
yy Jv] ]b]b]o}v˙
yy Jv] ]v}oboubvb}ob}((
yy Jv] ]vu]˙
yy AL˙Uuboo}(v}viP]o]]v ]bu}Rvwu] r
}u}olL]vu}u}Rvvu]}u}olL]vuv}v X
A R}}R˙ v] `]R o G}bv o]PRb ]b (X I( v]o r
oU `R] G}bv b u˙ bX TR ˙[b ˙b ub }
bR}o ˘u]v ]o˙ (} v˙ ]v(}vX C}vv]vP b ]vP
R]buXEvbG]]vlXPvR˙}Ru]}R˙Ru]X
PR}}R˙ bR}o}vvoov}viP]o]]v oobu]v r
o}`R}}R˙oob(}obR}bX
B}˘vrP) Exchange transfusion

Ubùo}}~w£CZU}bbruRP]vbuvov]v(vbu~v
uollP}rR}bZXM}v]}RUb]}˙U]o]]v and blood
Po}b oob ]vP R }X FR ˘RvPb u˙ v ]( R
]o]]voo}vvb}]bXS}R˘RvPvb(b]}v](RR
Gb˙u}Rvblu]vX
L}` oob }( ]o]]v than stated above should be considered for intervenr
}v˙R}}R˙}˘RvPvb(b]}v]vR(}oo}`]vPbPb]l}o}`
]R `]PR ]bU } (}oo}`]vP bR˙˘]U }o}vP R˙}˘u]U ]}b]b v
b]bX
S]vR]bv}˘b}u]vR]bl}(lv]b UvRvR
oo `R]R ˘RvP vb(b]}v ]b vbb˙U R (}oo}`]vP o }( Ru
Rb}(o
b bP]V
Standard Trtme
yy Su]o]]v }(u}Rvu]}u}olL]vu]v(vu}RvlP
yy Ivv`}vb`]PR]vPobbRvlPUbu]o]]v ˘]vPR(}oo}` r
]vP`}o]˘RvPvb(b]}v
yy AMlPrwu]}u}olL
yy rlPræu]}u}olL
yy C}HAMP lL}}]o]]v ANu]}u}olL
yy R]}Pbb]}v}(vu]]vbv}(b}o]vPiv]
yy Hydrops foetalis ~]b ]uu] ˘RvP vb(b]}v `]R l
cellsZ
AXTuv}(vo˙]vPb]b
~Sb}v}vRRS]lN`}v[Z
Refeal
r Criteria
R(]uu]o˙U oo ]b `R}o} iv] `]R]v R}b
}(o](}`R}R}o}vPiv]}]]]vX
R( oo vb ]]vP ˘RvP vb(b]}v } v }]
(]o]˙X
v*BirthInjuries*v
37. Birth Injuries

B]R ]vi]b ]vo ˘vb] bvuU
RoRu}u U bPoo Ru}RPU v ob]b v (bX
TR bv}v ]b v]vP }v ˙ v b] }( ]vi˙X E˘bb]
}vu˙bo]v]vi˙}RR]oo˘bvu˙b}]
`]R(}]vi˙}(RRub}bR}oi}]vX
sueCa
yy D]8oo]˙~]vo]vP]vbuvoo]˙Z
Symptoms
yy Sòo]vP}(R
yy Iv]o]˙}u}o]u}o˙
yy Poo}
Signs
E˘vb]CSvu
yy D]+b òo]vP
b }( RbvvP }( Ro b Ru˙˘v
beyond cranial suture lines
CRoRu}u
yy LPòo]vP b }(Ro b R]b]b }}vRo(v}bv}
˘v˙}vRu]o]v
SPooRu}RP
yy D]+bòo]vP
b }(Ro b `R]Ru˙bo]v]b}bR}(
the head and face
yy Severe pallor
yy Jv]
N]vi]b
yy bE Pob˙ r WR}o o]u }b v} u}X TR ]b u}uv
}vo˙]vR.vPb
yy Koul[b Pob˙ r F]vPb }( R + Rv } v} u} ~o`
RvZR]bu}uv]vRuv(}u
Fb
yy Ru}uv}(+o]u
yy Sòo]vP}(R+o]u
yy Av}uo}b]}v}(o]u
yy P]vvvvbb}vu}uv}(o]u
Invtiga
se tions
yy Hu}Po}]voo(}bPooRu}RP
yy Su]o]]v ](iv]
yy Xr˙}(ov]((]bb
Trtme
ae nt
Tuv}ib
yy T}(R b o]vP
yy T}}uo]}vb}(vu]viv]
v*BirthInjuries*v
yy T}rbo]bRvv}uou}uv]v+o]u
yy T}}u}v}uoRo]vP}((
Extensive caput succedaneum
yy Reassure parents
yy Lòo]vP
b o}v~b}vv}bb}o}v}r˙bZ
Cephalhaematoma
yy Reassure parents
yy Lòo]vP
b o}v~b}vv}bb}o}v`]RuZ
yy D}v}(}u]v]b]}vv]vP
yy PR}}R˙ ](iv]
Subgaleal Haemorrhage
yy PR}}R˙ ](iv]oob]R]b~Sb}v}vRN}vo
Jv] [Z
Nerve injuries
yy PR˙b]}R˙
Fractures
yy M˙]bo]vvP
AX CRoRu}u and Subgaleal haematoma
T}o]vP
]v
E RvPPA
æ
Standard Trtme
yy PR˙}uv]}v ~V]u]v K ZU IMU uPX
b v ](˙]
dose at birth
T}}Avu] ](HAMPulo
yy Bo}}vb(b]}v UæruollP
Refeal
r Criteria
R(}b v}]b]o]b(]o]˙X
38. N}vo}viv]b
N}vo }viv]b } }RRou] v}v}u ]b v
ov}viv]b]vPR.bu}vR}(o](XI]bboo˙}v
(}u]v(Pv]o}vb b }(Ru}RX
Cov]vP }( R v}v [b ˙b ]uu]o˙ L ]R v R
o]}v }( A9 ˙o]v }]vuv ]v} R ˙bU ]b + ]v
vvP R }v]}vX TR]b ub ]uouv b }o]˙ ]v oo
RoR(]o]b]v`R]RR]oo]]bvlvX
sueCa
v*Neonatalonju
yy Neisseria gonorrhoea
yy Chlamydia trachomatis
yy Staphylococci
c nctivitis*v
yy Streptococci
yy HbS]uo˘]b
yy CRu]oXPXb]ov]
Symptoms
yy ˙E ]bRP
yy Sòo]vP}(R˙o]b
Signs
yy ˙E ]bRPU`R]Ru˙ov
yy Rvbbvòo]vP
b }(R}viv
yy Ouvvbb}(R˙o]b
Invtiga
se tions
yy C}vivo`bb (}Gu]v]vP
b vo
Trtme
ae nt
Tuv}ib
yy T}R]v(}v
yy To prevent blindness
yy CovR˙o]b(vo˙~˙R}b`]R Z }'}v`}}o]
]v]o
b bo]vb}o}vXIvRbv}(]o
b bo]vb}o}vUb
}]o`RRbvoL}}}o
v
AXTuv}(˙
]v
E RvPPB
yy L]}v
C UIM}IVUæuP llPX
b ~u˘XæuPZ
Or
yy (}˘]u
C UIMUuP llPX
b
Av
yy E˙R}u˙]vU}oUXæuP llPvR}o˙(}˙b
vA
yy CRo}uRv]}o ˙}bUXæA9o]}R˙˙ R}b
(}R}b~Lov]vP`˙]bRPrbo]v]]P}vZ
Then
yy C Ro}uRv]}o ˙}bUXæA9o]}R˙vR}o˙
vA
yy C Ro}uRv]}o ˙}]vuvUA9o]}R˙v]PR
B. Treatment of mother
]v
E RvPPA
v*Neonatalonju
yy L]}v
C UIMUæuPXb
Av
c nctivitis*v
yy E˙R}u˙]vU}oUæuPvR}o˙(}˙bw
C. Treatment of mother’s partner(s) for gonorrhoea and chlamydia
yy L]}v
C UIMUæuPXb
Or
yy .˘]u
C U}oUuPX b
Or
yy C]}G}˘]vU}oUæuPX
b
Av
yy D }˘˙˙o]v U}oUuPR}o˙(}˙bw
Or
yy T˙o]vU}oUæuPvR}o˙(}˙bw
Or
Or
yy A]R}u˙]vU}oUPX b
Refeal
r Criteria
R(oov}vb`]R}vo]v}ouvv}v}vo
b
}vi]b v} b}v]vP } uv } ]]]v v } v
}RRou}o}P]bX
w
Standard Trtme
39. Rv}ob}u
Rv}ob}u ]b }vPv]o uo]Pvv u} }]P]vvP (}u
R v }( R ˙X TR]b u} u˙ R]˙U oo˙ R
]oo (}u `R]R (}ub } A9 }( bX M}b u}b R}`
b}]~b}vv}bu}vZXTR]b]bRR]}uu}vbv
bv u}vPb R]ov ]v GRvX M}b R]ov bv (} .
˙b }( PX I o˙ }b ]v }o R]ovX TR }Pv}b]b `]R o˙
bv}v ]b ˘oov `]R ıæA9 Rv }( o}vP u X TR ]b
R]PR}(o}uv}(u}b}(}R}Pvbo]vo](]vR
R]˙(}uX
sueCa
yy Gv~}A9}(bZ
yy S}]~]v}vA9}(bZ
Symptoms
yy WR]U bR]v˙ b} ~ol}}]Z ]v R ]oU ob} lv}`v b R [b
˙G˘]bboo˙R.b˙u}u
b ]vu}bvb
yy Squint~b]bub Z
yy V]boo}bb
v*Retinoblatoma
yy P}]vP˙oo
yy Redness of the eye
s *v
Signs
yy bv A G˘
yy Tu}]vRv}v(v}b}˙
yy V]}bRu}RPvvoRuv}v(v}b}˙
yy Ivb]v}o~Po}u b Z
yy O]oooo]b
Invtiga
se tions
yy Uob}vv b }(}]
yy HCT}MRIv b
yy Luv(}}b]voG]˙}o}P˙
yy B}vu}`b]
Trtme
ae nt
Tuv}ib
yy T}R b }Pbb]}v}(Ru}
yy T}v]bv}( b u}
yy T}R]o}vPu
yy T} }] b} v oo] ]v v
disease
yy Evo}v}(R+˙]b]vRo˙Pb b
yy P}bR˙]vb}v
yy LbR˙(}(}o}v}o
yy R]}R˙(}o}o}(
b Ru}
yy C}vboo]vP}Ro}`]R˙R}o}P]o
b ]u}(R]bb
AXIv}ov˘}ov}ob}u
CRu}R˙
]v
E RvPPA
yy V]v]bv UIVU
yy EtoposideUIVU
yy C}ov UIVU
Or
yy V]v]bv UIVU
yy EtoposideUIVU
yy C˙o}R}bRu] UIVU
BXvA ]bb`]R]vv]oubb
Poo]`]R]vv}R˙u}u
b }v}o
~Sb}v}voo]Z
CXF}uv}(}u]vP
v*Retinoblatoma
]v
E RvPPA
yy M}o}u] UIV}}oUru]}PullPR}o˙
Or
s *v
yy GranisetronUIVUu]}PullP~u˘XuPX Zb
M˙R}o˙](vbb˙
Or
yy GranisetronU}oU
u]}PullP~u˘XuP`]R]v
Z R}(}}(b uv
Then
u]}PullPR}o˙(}}æ˙b
Or
yy Ovvb}v UIVU
Adult
æuP luXb
RR}o˙](vbb˙
Children
r˙bV uPX b ~]uu]o˙(}Ru}R˙Z
Or
yy Ovvb}v U}oU
Adult
uP R}o˙U u]v]b u]vb (} R b}( Ru} r
therapy
Children
r˙bV uPrR}o˙}æ˙b
ı
Standard Trtme
D. For treatment of febrile neutropenia
yy L]˘}v
C UIVUuP llP]o˙
Av
yy Gvu]]v UIVUæuP llP]o˙
Av~](oob (]oLR}bUZ
yy Co}˘]oo]v UIVUæræuP llPvR}o˙
Av~](oo
b (]oLæ˙bUZ
yy Fo}v}o U}oUuP llP]o˙
E. For treatment of anaemia and thrombocytopenia
yy Bo}}vo}}}vb(b]}vb
~Sb}v}vRBo]vP]b}b[Z
Refeal
r Criteria
AoovbbR}o(}˙vRv+o˙
v}ob}uX
X Wilms Tumour
W]oub u} ~vR}ob}u Z ]b uo]Pvv u˙}vo u}
}( vo bX I ]b R (}R }uu}vb v u}vPb R]ov
v*WilmsTumour*v
]v GRvX A} A9 }( R]ov `]R W]oub u} bv (} æ

˙b}(PXIvbvb}}vLo]˙XIu˙ b}]`]R
}vPv]o v}uo]b bR b Ru]R˙}R˙ and the absence of the
iris (aniridiaZXW]oubu} Rb ˙P}}}Pv}b]b`]Rv}A9
Rv}(o}vPruX
sueCa
yy S}]Pvu}v
Symptoms
yy V]b]ov}oo}u]voubb
yy F
yy Bo}}]v]v
Signs
yy A}u]vo ubb ~o `]R } v }
]bbu]v}vZ
yy Hu] ~u}b}]}u]}b}]Z
yy Hypertension
yy Ab}]}vPv]ov}uo]b
Invtiga
se tions
yy A}u]voob}vv b
yy A}u]voCTv b
yy CRbXr˙
yy FooBo}}C}v
yy Bo}}UUo}o˙bvv]v
Trtme
ae nt
Tuv}ib
yy T}}]vo}vPu
yy T}}]b}voo]
yy NR}u˙
yy R]}R˙}brbP˙(}vb
AXPr}uv
st
L]vTuv
]v
E RvPPA
yy V]v]bv UIVU
Av
yy Av}u˙]vD UIVU
Av
yy D}˘}]]v UIVU~](bv}(ubbZ
BXP}br}uv
]v
E RvPPA
v*WilmsTumour*v
yy V]v]bv UIVU
Av
yy Av}u˙]vD UIVU
Av
yy D}˘}]]v UIVU~v]vP}vP b v]blP}˙Z
Or
yy C}ov UIVU
yy EtoposideUIVU
yy D}˘}]]v U IVU C˙o}R}bRu] IV ]v }u]v}v ~F} R]PR ]bl
u}bZ
CXF}uv}(}u]vP
]v
E RvPPA
yy M}o}u] UIV}}oUru]}PullPR}o˙
O
yy GranisetronUIVUu]}PullP~u˘XuPX Zb
M˙R}o˙](vbb˙
O
yy GranisetronU}oUu]}PullP~u˘XuP`]R]v Z R}(}
}(
b uv
Then
u]}PullPR}o˙(}}æ˙b
O
yy Ovvb}v UIVU
Adults
æuP luX
b
RR}o˙](vbb˙
Standard Trtme
Children
r˙bVuPXb ~]uu]o˙(}Ru}R˙Z
O
yy Ovvb}v U}oU
Adults
uP R}o˙U u]v]b u]vb (} R b}( Ru} r
therapy
Children
D. For treatment of febrile neutropenia
yy L]˘}v
C UIVUuP llP]o˙
Av
yy Gvu]]v UIVUæuP llP]o˙
Av~](oob (]oLR}bUZ
yy Co}˘]oo]v UIVUæræuP llPvR}o˙
Av~](oo
b (]oLæ˙bUZ
yy Fo}v}o U}oUuP llP]o˙
E. For treatment of anaemia and thrombocytopenia
v*WilmsTumour*v
yy Bo}}vo}}}vb(b]}vb
~Sb}v}vRBo]vP]b}b[Z
Refeal
r Criteria
Aoo vb bR}o (} b]o]b vb (} }]
uvX
Chapter
Disorsof der the
Cardiovcula
sa rSystem
w
X Chest Pain
CRb ]v ]b }uu}v v }uo]v v ub b
u]o uPv˙ vo }v }R`]b b R ob o](r
Rv]vPvo˙]vPbXTR}]}]˙]b}˘o}}uo˙
b]}b ] v v}vr] bX A P}} R]b}˙ v
˘u]v}v]b˙Ro(o]vR]bv}X
sueCa
Common Cardiac
yy SoAvP]v
yy C}}v˙A S˙v}u
yy P]]b
Non-cardiac
yy Gb}r}b}RPoG˘]bb
yy Pou}v˙Eu}ob~PEZ
yy Pvu}v]
yy PUo
yy Ob}RPobu
yy Poo+b]}v
Others to consider
yy A}]bb}v
yy Mitral valve prolapse~}Roo}ouZ
yy C}}v˙b}bbu
yy Sickle cell diseaserRb˙v}u b
yy Hiatus hernia
yy Ob}RPo`]Ru]bv]b
yy B]o]˙]bb
yy C}b}R}v]b
yy N}}}ubb]}v
yy Cardiac neurosislDC}b[b˙v}u b
yy Hb}bZ
Standard Trtme
Symptoms
Myocardial A} P]]b Po]P]v P Musku-
Ischaemia D]bb}v pain lo-skeletal
pain
Quality of CbR]vPU T]vP Sharp Sharp Bv]vP Sharp or dull

P]v PRUR˙
}vro]l
S]}(P]v Central Central Central Av˙`R]v Central Av˙`R
anterior anterior chest on chest
chest òo
R]}v T}R}U Bl Uboo˙v} Uboo˙v}v To throat T}ub
iÙub} ]}v occasionr or around
v}`R ally chest to
back
E˘ r E˘}vU None o˙]vPb]vU E˘ Spicy Pbb
]vPF}b v˘]˙ U by inspirar (}}U on chest
cold }vU}PR]vU alcohol }u}]vP
neck
Ro]]vP RbU None S]hvP None Bov Rb]}v
F}b nitrates (}` food and }(u} r
antacids uv
Associated NauseaU SR}lU F Uv C}PR U Bo}vPU Pvo}}lb
features }u]vP U ˙v}b]bU viral illness Ru}˙b]bU `]v òo
v*Chets Pain*v
`vP
b U `vP
b U]PR dyspnoea
˙bv}U oLuBP and shock (in
shock ]+vU ubb]PEZ
v`}
PP]}v
uu
Signs
yy SR}lUoo}U`vP b rMIUD]bbvPv˙buUPE
yy D˙bv} rMI`]RLVFUPEUPvu}v]
yy Bo}}b
yy N}uo}R]PR
yy L}`rbPPb]}Pv] b bR}l
yy D]+vANuuHP`vubbPPb}b ]bb}v
yy PobrR]PRUo}`}v}uoVPo}]Po
yy Mubr}vb]ooR]bb
yy P]]orbPPbb]]b
yy UvoRb˘vb]}vrvu}v]vvu}R}˘
yy RlbvRb}vbrvu}R}˘
yy }vR]oB R]vPrvu}v]
yy Poor}vb]vu}v]UPE
yy A}u]vo~]Pb]vvb Z brPUo D]bb
yy G]vPr(}oU]}v]b
yy R}òb}vbro˙Iob
yy CRbòovvbbrubo}rbloob
Invtiga
se tions
~Sb}vb(}b].]b}v]}vb
b Z
Chatep rwP *Disorsof
der theCardiovcula
sa rSystem
Trtme
ae nt
Tuv}ib
yy S˙u}uo](}(Rb]v
yy Rbvb }u]v]u]bv˘]˙
yy Tuv }( vo˙]vP b ~S b}vb (} b]. ]bb
}v]}vbZ
~Sb}vb(}b].]b}v]}vb
b Z
~Sb}vb(}b].]b}v]}vb
b Z
Refealr Criteria
Pb]bvv˘o]vRb]v X
X Ischaemic Heart Disease

IbRu] R ]bb ]b }v]}v `R˙ R ]b
o}} bo˙ } R R uboX I }u]bb }( ob vP]v }]b
v*IschaemicHetar Disse*a v
vR}}v˙˙v}ub
b X
STABLEANGINAPECTORIS
So vP]v }]b ]b ]v } ]b}u(} R }b ]v R
(}v }( R RbU v u˙ ] } R vlU bR}obU i` } ubX
The chest pain ]b ˙]oo˙ ]v ˙ ˘}v } u}}vo b v
o] ˙ b } Po˙˙o ]v]X Iv]]ob `R} ˘]v ob
vP]v}]bR]PR]bl}(o}]vP}}v˙˙v}ub b
} R 'lX R]bl (}b ]vo ]b uoo]bU R˙vb]}vU
]P' bu}l]vPU obu o]] v}uo]bU }b]˙U (u]o˙ R]b}˙ }(
R ]bb vb]bvo˙ oulb }( ]vGuu}v bR b
Cr}]v X
R]bl (}b (} R]b }v]}v ]vo }b]˙U ]b uoo]bU
R˙vb]}vUbu}l]vPUR˙o]]u]X
sueCa
yy Atherosclerosis`]Rv}`]vP}(R}}v˙o}}bob
yy Sbub}(R}}v˙]b
Symptoms
yy Central or precordial chest pain
yy M˙]]v}RoLuUvl}i`
yy Relieved by rest
yy Ro]˙Po˙˙o]v]
Signs
yy N}˙]ob]Pvb
Invtiga
se tions
yy roGCE
æ
Standard Trtme
yy ]C v˙ubPv]vl]vbrMB~CKrMB Z and troponins
yy Bo}}Po}b
yy Bo}}o]]}.o
yy FBC
yy CRbXr˙
yy Stress ECG
yy R}]}PR˙
E
yy C}}v˙vP]}PR˙
Trtme
ae nt
Tuv}ib
yy T}u]v]u]b˙u}ub
b
yy T}v}Pbb]}v}}}v˙˙v}ub
b
yy T}]v(˙vuvPu}].o]bl(}b
yy T}]u}o]˙}(o](
yy vE vb
yy HoR˙o](b˙ou}].}vb
yy D]
yy E˘]b
yy W]PRuvPuv
yy R}v]vo}R}o}vbu}v
yy }]
A }]bu}l]vP
AXTvPRRb]v
]v
E RvPPA
yy Glyceryl trinitrateUbo]vPoUæu]}PuX
b Rv]b
Av
yy AspirinU}oUuPX
b RvwæuP]o˙
Or
yy Co}]}Po U}oUuPX b RvwæuP]o˙
Av
yy AtenololU}oUæruP]o˙
Or
yy B]b}}o}o U}oUæruP]o˙
Or
yy MetoprololU}oUæruPrR}o˙
Note 7-1
}]
A o}lb ]v }vR]o Ru
b U ˙]U v R˙}vb]}vV }]
v}o}o]vR(]oX
O
yy Vu]o U}oUruPR}o˙
v
der theCardiovcula
sa rSystem
Note 7-2
}]
A ]v˙]UR˙}vb]}vv]vvbo˙}vro}lb
yy Ou]b}]v]uv(}R˙vb]}v
yy Ou]b}]v]uv(}]buoo]b
yy Ubvbb }v}uoo}}o]]b}Poob
B. If beta blockers or verapamil are contraindicated
yy Ib}b}]]v] U}oUuPrR}o˙
Refeal
r Criteria
R(R(}oo}`]vPvb
yy TR}b`]Rv}b]Pv].v]u}uv]v˙u}ub
b LR]v]o
uv}
yy TR}b`]R`}bv]vP]bl(}b
Flowchatr
F]PwrP) Fo}`RPAvP]vP}]b
CUTE
A ORONA
C RYSYNDROME
A C}}v˙ S˙v}u ~ACSZ ]b u R b]b ˙u}ub
b
bovP (}u b u˙}]o ]bRu]X TR ]bRu] u˙U
} u˙ v}U o } u˙}]o ]v(}v ~R 'lZX CSA ]b obb].
w
Standard Trtme
b ST bPuv o}v }v v o}]}Pu ~STrbPuv o}v
u˙}]o ]v(}v r STEMI Z } v}vrSTrbPuvo}v u˙}]o
]v(}v ~NSTEMI Z v vbo vP]v ~v CSA `]R} o}v }(
] v˙ubZX TR ]bl (}b (} CSA ]vo } R}b (}U v
]vo]}b]b}b}(Uob vP]v}]bX
R]bl (}b (} R]b }v]}v ]vo }b]˙U ]b uoo]bU
R˙vb]}vUbu}l]vPvR˙o]]u]X
sueCa
yy Atherosclerosis}}b}v}(R}}v˙o}}bobo]vP
}}v]vo}}bo˙}RRubo
Symptoms
yy Chest pain
yy Sudden onset
yy V˙]vP P }Lv b v b] b PRvbbU
R]vbb}}vb]]vvX
yy Pb]bvP(}u}Rvu]vb
yy N}o]˙}b Po˙˙o]v]
yy M˙]}RoLuURvl}i`
yy Nausea
yy V}u]vP
yy SR}vbb }(R } (P ~R]b u˙ R }vo˙bv}v ]v
]bvRoo˙Z
yy L}bb}(}vb]}bvbb
Signs
yy Restlessness and apprehension
yy E˘bb]`vPb
yy P]Ro}vo˙v}b]b
yy Pobu˙R˙U(bU]PoUbo}`}v}uo
yy Bo}}u˙ b R]PRUo}`}v}o~(}oo}`]vP˘vb]
uP}RuboZ
yy B]oo]}vb]vRRb~`]RoLv]o(]oZ
yy Pbv}(R]}(}RRb}v~bPPbbR(]oZ
yy Confusion in the elderly
Invtiga
se tions
yy SvoGCE
yy ]C v˙ubPCKrMB U}}v]vb TvI
yy M˙}Po}]v
yy Suo]]}.o
yy CRbXr˙
yy Rv}uo}}Po}b
yy FBU C SR
E
yy Su]]
yy Bo}}Uo}o˙bvv]v
yy Cr}]v
der theCardiovcula
sa rSystem
yy R}]}PR˙
E
yy C}}v˙vP]}PR˙
Trtme
ae nt
Tuv}ib
yy To relieve distress and pain
yy T}o]u]]v(b]
yy T}vv}uo]}vb
yy T}]b u}oo]vP
yy T}vr]v(}v
yy T}]v(˙vuvPu}].o]bl(}b
yy T}]u}o]˙}(o](
yy Rbvb vv}P]vb R.bR}b
yy Ev}P}v b }(bu}l]vP
yy Evb`]PR}v~]v}`]PRv}b]v]]ob]v
Z R
o}vPu
AXIv]ouv}vu]bb]}v
]v
E RvPPA
yy O˘˙Pv U]vvboU˙(ubl}vbovvo
Av
yy AspirinU}o~RòZUuPX b
Av
yy Co}]}Po U}oUuPX b
Av
yy Glyceryl trinitrateUbo]vPoUæu]}PuX b
Av
yy MorphineUIVUæruPX b
Av
yy M}o}u] U IVU uP Xb ~} v }u]vP induced by
u}R]v Z
BXM]vvvuv(}oo}`]vP]uu]o˙L]v]o
treatment
yy AspirinU}oUwæruP]o˙]v.v]o˙
Av
yy Co}]}Po U}oUwæuP]o˙~vb`R}]bo]b}v
R˙`]oo]uv(}}u}vRbZ
CXAv}Po}v
yy Ev}˘]v USCUuP llP~v]bllPZR}o˙
X
D Pv}v}(]R˙Ru]bv}v}(u˙}]o
workload
yy AtenololU }oU ær uP ]o˙ ~}] }vo˙ ]( ro}lb }v r
ı
Standard Trtme
]v]Z
Or
Or
Av
yy L]b]v}]o U}oUXæruP]o˙
Or
yy L}bv U}oUæræuP]o˙
Or
yy CandesartanU}oUrvuP]o˙
And
Ivvb`]RSTEMI :
yy F]]v}o˙ Pvb u˙ P]v b (b]}v R˙ ]v vb
bvvP`]RSTEMI vb]o]bX
yy MvP}uo]}vbbRou}v˙
b }uU]}Pv]
shockv]R˙Ru]b
yy MvP R˙Po˙u] `]R ]vbo]vX CRvP ] vb
]}bo˙}v}oR˙}Po˙u]Pvb}]vbo]v
EXL}vPruuv~b}v˙v}vZ
yy AspirinU}oUwæræuP]o˙]v.v]o˙
Av
yy AtenololU }oU ær uP ]o˙ ~}] }vo˙ ]( ro}lb }v r
]v]Z
Or
Or
F. To prevent cardiac remodelling and improve survival
yy L]b]v}]o U}oUXæruP]o˙
Or
yy L}bv U}oUæræuP]o˙
Or
yy CandesartanU}oUrvuP]o˙
Note 7-3
}]
A ]vR]]}b
CEA vAvP]}v]v}o}lb]vvb`]RBPAM
uuHP
G. To stabilise the clot and reduce blood cholesterol levels
yy }bA v U}oUruP]o˙
Or
yy R}bvb U}oUruP]o˙
Or
der theCardiovcula
sa rSystem
yy S]ubv U }oU r uP ]o˙X Svb ]v] ]b

of lipid levels
HXT}]u}}}v˙]o}vvu˙}]o`}lo}
yy Ib}b}]]v] U}oUuPrR}o˙
IXC}v}o}(R˙vb]}vvR˙Po˙u]U](bv
~S}]b}vbZ
Refeal
r Criteria
Aoovb `]R bCSA ]vPvGCE X I(GCE ]b v}
]oo}vv}]vU(]uu]o˙}R]PR(]o]˙X
Pvb `]R }v.u STEMI in any facility should be referred
Pvo˙ } PR˙b]]v S]o]b } ]}o}P]bC (} (b]}v R˙
~Lv]v]o}o}b}(uP}(b]]v ZX
ORvb`]RNrSTEMI vvbovP]vbR}o(
} R˙b]]v b]o]b } ]}o}P]b L R ]v]o uvPuv
}X
X Dyspnoea
D˙bv} ]b v v}u(}o `vbb }( }v[b }`v R]vPX
v*Dyspnoea*v
I ]b }Lv R u]v ˙u}u
b }( ]}ou}v˙ ]bb oR}PR R
]+vo ]Pv}b]b ˘vb ˙}v Rb `} ˙bb ubX D˙bv} }(
bv}vbbR}obu]ouPv˙X
sueCa
yy Cardiac
yy HF]o
yy C}}v˙HD]bb
yy VooHD]bb ru]ov}b
b ]bU}v}b
b ]b
yy ]C AR˙Ru]b
yy P]]o+b]}v
yy Respiratory
yy Pvu}v]
yy Pou}v˙Eu}ob~PEZ
yy Ob ovP ]bb r CR}v] Ob Pou}v˙ D]b r
b~COPDZ URu
Ab
yy Rb]ovP]bbrIvboovP]bbP˙}Pv]
.}o˙b]vPo}o]bvR}}voovP]bb
yy Pvu}R}˘
yy Poo+b E ]}v
yy CRb òo (v}v o]u]}v r u˙}R˙U v}R˙U l˙R} r
scoliosis
yy OR
yy Avu]
yy Pb˙R}Pv]R˙vo}v
yy A]}b]brXPXu]UD]K}]}b]b UP}}b
Standard Trtme
yy F}]Pv}˙b]}v
yy Mbb]}u]vo]bvb]}v
Symptoms
yy Rob B bvbb
yy Quality
yy }vv}b}]vu]'v
yy ˘}vorbPPb]}ou}v˙b b
yy }b]}vo r bPPbb }˘˙buo v}vo ˙bv}U } r
thopnoea and a cardiac cause
yy v}vorbPPb]b }}vR]oRu b
yy T]ub]v}vbrv~Z}o}vPbv]vP~R}v]Z
yy }v D }(]b}~bZ
yy u]vb } R}b r bPPbb RuU vu}R}˘U o r
u}v˙ }uU vu}v]U ou}v˙ }uU v r
R˙o˘]b
yy `lb } u}vRb r bPPbb oo +b]}vU ]]o
+b]}vU ou}v˙ .}b]bU ovP vU v PEU
] (]oU vu]U v}ubo ]bbU r
culosis
yy ˙brOPD C UovP.}b]b
yy Associated features
v*Dyspnoea*v
yy }PR~bPPbR b (]oUvu}v]Z
yy buURu}˙b]b
yy `R~bRuUR(]oZ
yy vlo}u~RUl]v˙Uo]Z
Signs
yy F rvu}v]Uob}uu}vo˙
b PE
yy Poo}rvu] b R(]oUPEUu˙}]o]v(}v
}]}Pv]bR}l
yy S`vPrR(]oUvu}v]UPEUu˙}]o]v(}v
yy Co]vPr]v(}vbU˙v}}vPv]oR]bbUovP.}b]b
yy CyanosisrR˙}˘]XPX]vOPD C UR(]oUPEUvu}v]X
yy P]Ro}urRUo]}vo(]o
yy WRrR(]o}}vR]oRu b
yy oB bRRbrOPD C
yy Ascites r ]U voU Pb}]vbvoU R } ]vr}u]vo
lesion
yy Pobr(b~bPPbR˙R˙Ru] b UPE}Z bo}`~˙R˙Ru]Z
yy Bo}}rb u˙R]PRUv}uo}o}`
yy HuubrooR]bb
yy ORb]Pvbr(b}(vu}v]Uvu}R}˘Uoo+b]}v
Invtiga
se tions
yy FooBo}}C}v
yy UUEo}o˙bUv]v C
yy CRbXr˙
der theCardiovcula
sa rSystem
yy ECG
yy Pob}˘]u˙
yy PlG}ùbuv
yy ]C v˙ubU T}}v]v TU CKrMB ]( ]bRu] R ]bb ]b
suspected
yy R}]}Pu
E
yy LvPFv}vTbb~b]}u˙Z
yy CTou}v˙vP]}Pu(o
b (}}v.u]vPPE
Trtme
ae nt
Tuv}ib
yy Tvo˙]vPbrov b Rb
yy M]v]v}˘˙Pv}v b }ıæA9r}v](R]bvo˙]vP
OPD
C UbRbvbvv}vR˙}˘]]
yy Bb}vvo˙]vPbX~Sovb}vbZ
yy Bb}vvo˙]vPbX~Sovb}vbZ
v*DepVeinThrombosis~DVTZ*v
Refealr Criteria
R(}Rv˘oo}(](vv} b ]v.
X Deep Vein Thrombosis (DVT)

D V]v TR}u}b]b ~DVT Z ]b }uu}v ]bb oR}PR }Lv
˙u}ub X TR ]vb }( R o}` o]ub + u}b
}uu}vo˙U R}u}b]b u˙ + }R b]bU ]vo]vP R
o]ubU]vv]ovbovRv]]vbXC}uo]}vb]voou}v˙
R}u}u}o]bu U`R]Rvo](rRv]vPXI]bR(}bvo
}Ro]ouR}(}o]b b R]vPRVT
D ]bl}(vbv}
l}b }]}R˙ouvvbb b˙XC}uu}v
]bl (}b (} VT D ]vo }b]˙U bu}l]vPU }o}vP ]uu}]o]˙ ~XPX
U
b o}vP Ro G]PRbZU ui} P˙ b XPX }R}]U }u]vo
v o] P˙ b U Pvv˙ v R ]u U L vb
b}vU uo]Pvv]bU ]vR]o}} ]b}bU }b}Pv R˙ v
u]o }v]}vbU XPX }vPb] (]oU u˙}]o ]v(}vU
vR}˙v}ub U}lb U˙bb u]ob˙Ru}bbX
Iv b }( }v.u VT
D U uv `]R v}Povb ub v}
o˙vvbb]o˙vobbRb]Pv].v}v]v]}vb}
R] b R b v ]vo oU b o] ]bbU
oUo]vP]b}bUvR˙vb b ]}vX
sueCa
yy SPv}v}(o}}]vR]v
yy Ivb]b}b]˙}(o}}
yy IvGuu}v}(Ro}}bob]vPuP
Standard Trtme
Symptoms
yy Sòo]vP}.uvbb}(+o]u~boo˙v]ooZ
yy P]v]vR+o]u
yy Mild fever
Signs
yy Sòo]vP}(+o]u
yy D]+voùR
yy Tenderness
yy Redness
yy P]hvP}u
yy P}u]vvb.]o]vb
B}˘wrP) Well’s Scoring for DVT probability
TR Woo[b }]vP
b ˙bb u (} VT
D }]o]˙ }i.b o]v]o b]]}v }(
VT
D ]blv}]b]](}]v]vPuvX
TRbv }bv }( R o]v]o (b o}` }u} P]
rbvP}]o]˙ }b (} R o v `R]R ]b b } ]}] r
b]vbP}vvuvX
yy Po˙b]bUb]b}v}R}]vP b }(o}`˘u]˙~}]vZ
yy Rvo˙ ]v ~u} Rv ˙bZ } ui} P˙
b `]R]v b
`lb~}]vZ
yy L}o]vvbb]v]v˙bb u~}]vZ
yy Sòo]vP}(voP~}]vZ
yy Co(òo]vP
b uPRv}RoP~ubuo}`R]o
}b]˙Z~}]vZ
yy P]hvP}uP]vR˙u}u b oP~}]vZ
yy C}ooov}v]}bb.]o]vb~}]vZ
yy vA }v`]R]vvu}vRb~}]vZ
yy Aov ]Pv}b]b u} o]lo˙ Rv VT
D ~Bl[b ˙bU ooo]bU ubo
uPU b.]o v}b R}u}b]bU }b Ro] ˙v}u
b U ]vP]vo
o˙uRv}R˙U˘vov}b}ubb]}vZ~r}]vbZ
TowrP) Woo[bS}Iv}v(}VT
D
rP}]vbP H]PR}]o]˙}(VT
D
rP}]vbP Moderate probability
rrP}]vbP L}`P}]o]˙
L}`}]o]˙PDrD]ub ]b}uuvXL}`rb}]o]˙}u]v`]RvP r
DrD]ubvoo˙ob}VT
D X
M}} H]PR P}]o]˙P DrD]ub `]R ]}vo D}ol}ubb]}v ob}v
vb ]b}uuvX
Invtiga
se tions
yy DrD]ub
yy D}oob}v
yy TR}u}R]o]vb XPX}]vU
C }]vSoob~]vvb`]R
vVT
D Z
yy FBC
der theCardiovcula
sa rSystem
Trtme
ae nt
Tuv}ib
yy T}vo}}P}vvou}v˙u}o]bu
yy To prevent recurrence
yy }]v A }(}o}vPuv˙vR˙}v
yy }]v A }( ˘bb u}vb }( }+U v o}R}oU b]oo˙
}vo}vPi}v˙b
yy Ivb`]vl]vPo}vPi}v˙b}]}b}(]uu}]o]˙
yy RPo˘]b]vPo}vPi}v˙bXPX}]vP b }v}i}v˙b
}lòl}u}]vP}}vov]vPo}vPG]PRbvoP
G˘]vP˘]bb`R]ob
yy }] A }bb]vPoPb(}o}vP]}b}vo}vPi}v˙b
yy Ub}(ob}ubb]}v}l]vPbb
AXVT
D Prophylaxis
st
L]vuv
]v
E RvPPA
yy HeparinUSCU
Adults
æUv]brR}o˙
Children
u}vRr˙bVæv]bllPR}o˙
nd
L]vTuv
]v
E RvPPA
yy Ev}˘]v USCU
Adults
uP]o˙
Children
u}vRbr˙bVæu]}PullPR}o˙~u˘uPZ
ru}vRbV wæu]}PullPR}o˙
B. DVT Treatment
st
L]vTuv
]v
E RvPPA
yy HeparinUSCU
Children
u}vRr˙bVæv]bllPR}o˙
Or
yy HeparinUIVU
Adults
v]bllPX
b }vv`]Rv]bllPlR}
Or
æv]bllPUSCU}vv`]Ræv]bllPR}o˙
æ
Standard Trtme
Children
r˙bVwæv]bllPX
b }vv`]Rv]bllP lR}
u}vRr˙Vwæv]bllPX b }vv`]Ræv]bllP lR}
Neonates ~u ˙ZV wæ v]bllPX
b }vv `]R æ v]bllP l
hour
Neonates ~AM æ `lbZV æ Uv]b llP X
b }vv `]R æ v]bl
lP lR}
nd
L]vTuv
]v
E RvPPA
yy Ev}˘]v USCU
Adults
XæuP llP~æv]bllPZ]o˙
Children
u}vRbr˙bV uP llPR}o˙
ru}vRbV XæuP llPR}o˙
NeonatesV XæruP llPR}o˙
Or
yy Do]v USCU
Adults
uP llP~u˘X}(Uv]bZ]o˙
Children
r˙bV v]bllP }v ]o˙ ~u˘ U v]b
]o˙Z
u}vRr˙bV v]bllPR}o˙
NeonatesV v]bllPR}o˙
And
yy W(]v U}oU
Adults
L}]vPD}b
YA D DOSE INR
uP r
uP r
æuP CRlINR
N}wr
W(]v]bv}}P]v]vPvv˙X
C}vv æ uP ]o˙ INR vo P INR }( } ]b R]X AL R]b R
o}` u}oo `]PR R]v ]b }b v u]vvv `(]v dose of
Xæ uP } æ uP ~b}u vb u˙ ] wXæ uPZ ]b }vv P] oo
ub˙PINR}(}X
L}vPruuv]b}vv}v }( `(]v (}R}b]˘ u}vRb
]( R ]bl (} ]b u}˙ } vlv}`vX RvVT
D v uvv ]bl
(}bbRbR}u}R]o]u˙]o}vPruv}Po}v X
v
der theCardiovcula
sa rSystem
Refeal
r Criteria
R(}R˙b]]vb]o]b(}uvPuvvu}v]}]vPX
æX Pulmonary Embolism
Pou}v˙Eu}o]bu~PEbobZ (}uR}u]U}Lv(}uR
]vb}(Ro}ò]ub}o]bU`R]Rvb}]R]PRR
]v} R ou}v˙ boX LP u}o] u˙ b }b}v }
o}} G}` v bo ]v o](rRv]vP R˙}˘] v R]PR u}o]˙X PE
bR}oR(}uvPbu]ouPv˙X
TR]bl(}bvuvPuv(}PEb]u]o}R}b(}VT
D X
~Sb}v}vRDVT[ZX
sueCa
~Sb}v}vRDVT[Z
Symptoms
yy D˙bv}
yy Po]]v
v*Pulmonayr Embolism*v
yy C}PR
yy Hu}˙b]b ~}ou}v˙]v(}vZ
yy Pb˙v}U˙v} b }}oob~ubb]PEZ
yy Uv]ooòo]vP
b }(o]u
Signs
yy Tachypnoea
yy Tachycardia~u˙Po}]PoZ
yy Bo}}rb o}`lv}o~bPPbbubb]PEZUv}uo}
R]PR
yy Poo+b]}v
yy L}`}˘˙Pv}v b }vob}˘]u˙AMıA9
yy Poo
yy Cyanosis
yy Uv]ooo˙`}oovb o(}R]PR}(VT D
B}˘wrP) Well’s scoring for PE probability

yy S˙u}ub}(VT
D ~}]vbZ
yy N}ov]Pv}b]b'˘o]vbR]oovbb~}]vbZ
yy Tachycardia`]RobAN~Xæ}]vbZ
yy Iuu}]o]}v~ANAA˙b}Z P˙
b ]vR]}b(}`lb~Xæ}]vbZ
yy P]}R]b}˙}(VT
D }ou}v˙u}o]bu~Xæ}]vbZ
yy Pbv}(Ru}˙b]b~}]vZ
yy Pbv}(uo]Pvv˙~}]vZ
w
Standard Trtme
TowrP) Woo[bS}Iv}v(}PE
S}ANvP H]PR}]o]˙
S}ANAAvAMAAvP Moderate probability
S}AMP L}`P}]o]˙
L}`}]o]˙PDrD]ub ]b}uuvX
M} } H]PR P}]o]˙P DrD]u b `]R ]}vo CT Pou}v˙ vP]}Pu ]b r
}uuvX
Invtiga
se tions
yy CRbXr˙
yy ECG
yy DrD]u
yy CTPou}v˙vP]}Pu
yy R}]}PR˙
E
yy D}oUob}v}(R+o]uvo]b
yy FBC
Trtme
ae nt
Tuv}ib
v*Pulmonayr Embolism*v
yy T}]o]b
b ]}rb]}˙(v}v
yy T}v(Ro}(}u}vvu}o]b}v
yy T}vvvo}uv}(ou}v˙R˙vb]}v
yy Eo+oP}v]oo}`](VT D present
yy Ao˙}ubb]}v}l]vPb
b rL]vb]b](VT
D present
yy SP]oRv]bXPXu}o}u˙U]v(]}vo.obX
AXCo]v]ob]]}v}(ou}v˙u}ob
st
L]vTuv
]v
E RvPPA
yy O˘˙Pv U ˙ ( ubl } vbo }vPb } ] v}vrR ubl
~l}˘˙Pv}vb ANıæA9Z
Av
yy MorphineUIVUæruPX b
Av
yy E v}˘]v USCU
Adults
Or
yy Do]v USCU
Adult
uP llP~u˘XUv]bZ]o˙
der theCardiovcula
sa rSystem
yy W(]v U}oUb]uov}bo˙~NOT]vPvv˙Z
Adults
L}]vPD}b
YA D DOSE INR
uP r
uP r
æuP CRlINR
Note 7-5
C}vv æ uP ]o˙ INR vo P INR }( } ]b R]X AL R]b R
o}` u}oo `]PR R]v ]b }b v u]vvv `(]v dose of
Xæ uP } æ uP ~b}u vb u˙ ] wXæ uPZ ]b }vv P] oo
ub˙PINR}(}X
L}vPruuv]b}vv}v}(`(]v (}R}b]˘u}vRb](
R]bl(}]bu}˙}vlv}`vXRvu}o]bubvuvv
]bl(}bbRbR}u}R]o]]bo}vPuv}Po}v X
Refeal
r Criteria
R( oo vb `]R b ou}v˙ u}o]buU `R
(]o]b v]oo (} }v.u}vU } R˙b]]v b]o]b }
v*Stroke*v
]}o}P]b(}˘uvPuvL]o]b
b }vX
vX Stroke
A stroke v .v b bv Po}o } (}o v}o}P]o
.] bovP (}u b}vv}b Ru}RP } ]v(}v }( R
vo v}b ˙bb uU `]R }i ]v }( v ]v(}v }
Ru}RPU ]b }( R }v }( o]v]o ˙u}ub b X A CT }
MRIvb ]b]}ulR]Pv}b]bv˘o}R]vv]o
ob]}vbR}obvb]u]oo˙X
A Tvb]vIbRu]'lA ~TIA Z U }v R }R RvU ]b vb]v
]b} }( v}o}P] ˙b(v}v b ˙ (}o ]vU b]vo }U }
vo]bRu]XTR]bv}}i]v}( ]v(}v]vR
+P]}v}(]v}vX
Iv obU R˙vb]}vU ]bU ˙bo]]u]U ]o .]oo}v
v bu}l]vPU ]vb R ]bl (} }lbb X Iv R]ov b]lo oo ]bb
v˙v}R]b]u}vb ]bl(}b(}}lb
b X
PvbbR}o]oo˙Ruo]b]o]v˙X
sueCa
yy oC ]v(}v
yy TR}u}b]b}(obo
yy Eu}o]bu(}u]bvb]~XPX]o.]oo}v Z
yy IvoRu}RP
yy SRv}]Ru}RP
ı
Standard Trtme
Symptoms
yy Wlvbb}(}vb]}(R}˙]vo]vPR(
yy Iv]o]˙}]b(}ub]hvP}o˙]vP}b]}v
yy Sv(ool}oob
yy L}bb}(bR
yy L}bb}(]b]}v
yy SRRvl}vl]v~bRv}]Ru}RP Z
yy Uv}vb]}bvbb ]vb}uvb
yy S]b
Signs
yy Po˙b]b}(o]u
yy F]oo˙b]b~o}`Ro(Z
yy Iv]oG]]˙}(o]ubUo]˙ b v˘PPG˘b
yy Hu]v}] ~o}bb}(}vrRo(}(]bo.oZ
yy Hu]rvbRb]~o}bb}(bvb}v}(}vrRo(}(}˙Z
yy E˘vb}ovb}vb
yy D˙bR] l˙bRb] ~o}v}(bRZ
yy Nl+vb b b~]vRv}]
b Ru}RP Z
Invtiga
se tions
yy FBU C SR
E
v*Stroke*v
yy Bo}}Po}b
yy Suo]]}.o
yy Bo}}Uo}o˙bvv]v
yy U]]
yy ECG
yy CTv b lMRI}(RR
yy CRbXr˙
Trtme
ae nt
Tuv}ib
yy T}o]u]R}(]vuP
yy T} } vb (}u R vPb }( v}vb]}bvbb v
]uu}]o]˙
yy T}vb]}v
yy T}Rvo˙]vPb](}bb]o
yy T} ]v(˙ v uvP u}].o ]bl (}b ~R˙vb]}vU R]PR
R}ob}oU]buoo]bXZ
yy T}]vbub}b ]u}(v}vo}˙
yy T} b} v R]o] vb `R} b] `]R b]o
disability
yy T}u]v]u]b+b b }(PR˙
yy Au] v u}v]} vb ]o b]Pvb v v}o}P]o b]Pvb
(vo˙~R}o˙Z
der theCardiovcula
sa rSystem
yy o]b
Eb R]`˙]vv}vb]}bvb
yy Sòo}`]vP]v b v]PR}b]}v~bræuo}(`Z
yy Ivb vb}Pb] b o˙ b }bb]o (} (]vP v
u]}vb ]v v}vb]}b vb } R}b `]R òo}`]vP
b
]8ob}vb]}v
yy Nb]vRoo}b]}v`]Rb}v]vP`Rvbb˙
yy Eo R }( } Pb } ]vv]o
pressure
yy Pvb}b˙Pov]vP~˙R}bZ]v
yy M]v]vR˙}v
yy K v ov v ˙ ˙ (v b }( vl]v }U
]bU }v}u R b ]X URo R bR}o
used only if absolutely necessary
yy SR˙b]}R˙b}}vob
AXIv(S}lb vTIA s
st
L]vTuv
]v
E RvPPB
yy AspirinU}oU
Adults
uPX b
v*Stroke*v
Then
wæuP]o˙
Children
ANv˙bV ub bo}b
AMv˙bV v}}uuv
Av
yy }bA v U}oU
Adults
ruP]o˙
Children
N}}uuv
Or
yy R}bvb U}oU
Adults
ruP]o˙
Children
N}}uuv
B. Haemorrhagic Stroke with evidence of cerebral oedema present
st
L]vTuv
]v
E RvPPB
yy MannitolUIVU
Adults
XærP llPvR}o˙~}P llP}bZ
Standard Trtme
Children
u}vRr˙bVXærXæP llP OrXærwXæuollP}(A9b}o}v
~S uv G}`R (} u]o uvPuv }( }l
b
o}`Z
CXC}v}o}(}ru}]]b~XPXR˙vb]}vU]bXZ
~S}]b}vbZ
Refeal
r Criteria
Pvb `]R `}bv]vP ˙u}ub
b v b]Pvb bR}o Pvo˙
( (} b]o]b o}v v X Aoo ob vb `]R
v}o}P]o.]bbR}o(}bRR]bU}}vo
R]b}R˙b]}R]b}] b X
Flowchatr
v*Stroke*v
F]PwrP) Flowchart: Stroke
TowrP) TuvG}`R(}u]ouvPuv}(}l
b
History and Iv(˙]bl(}bUb]v˘v}(R}l
b
˘u]v}v C}vb]b}b}(u}o]bu
IvbP}vb FBUC U]vRlEUBUEUA=U
C FbvPPo}bUFbvPR}ob}oU
CTSvUCXRUGCE
H˙}v A]u]vP(}}ou]~XærL˙}vPZ
Ubv}uobo]v}˘}bbo]v
}]
A ˘}bæA9}A9vobbR˙}Po˙u]X
der theCardiovcula
sa rSystem
TowrP) TuvG}`R(}u]ouvPuv}(}l
b
Stress ulcer G]}}vu]vR]]}
}R˙o˘]b
Glucose control KRBS~rZuu}olL
M˙v]vbo]vbo]]vPob }}v}o}bouv}o
u]}vb~}]}ou}u]v](]Z
P˙˘] I(ANwXæ}CuvP`]RPou}o }}v}o˙˘]
C}vb]b}~RbU]vUuo]U}RZvuvP
}]vPo˙
Bo}}b OLv]bb]bo}(}l
b vu˙oo˙'o
b
uvPuv `]Rv}}vXI(ANluuHP]u(}Po}v
}(v}u}RvA9}R}bXC}vvrb}l
u]}v](]v]XDONOTUSESUBLINGUALNIFEDIPINEX
Sv}v]vBPvo}˘vb]}v}(}l
b X
Tuv}(]v(b Start aspirinuPb}}vb]v(]v.]~}ol
NGZ](v}}v]v]}vbXR}b}wæuP]o˙L
`lUv}vb](Rvroou]}vX
]o
A F]]oo}v C}vb]R˙Ru}v}o(}}vbVv}Po}v
M}]o]b}v}( o˙
E (o}(oovb}RR˙b]}R]b~v](
v*Stroke*v
vb v}vb]}bZ
Ab]}v L}}l(}b]Pvb}(R]bPoo˙~]b]vPb]}˙U
vu}v] R˙]URbb]PvbZXT`]RIVAu}˘]]oo]vA=Coov]
A]vIVu}v]}o(}.bR}bRv]`
VT
D vPou}v˙ P}R˙oR]v if infarct detected on CT scan
u}o]bu
S]b Tu]vb]b}}}ob
b XRPov}vobv](
u}Rv}vb]}b
CRvP]v}vb]}b UPvo˙}vb]}bb]]o]bbRbVo}ul
level R˙}Po˙u]lu}o]lPbRvb
R]b]vPICP NbPbRUIVuvv]}oA=lr˘uRb
D }v
as required
H]PRR}ob}o SR]PR}bvbb P]o]vb
b
Standard Trtme
wX Heart Failure
TR]b]b}v]}v]v`R]RRR]bvo}}
] }U v ]v b} }]vPU ]b vo } u R }˙ [b u}o]
]uvbX TR ] ˙b(v}v u˙ }u]vvo˙ ]v}o R
oL } R ]PR v]o ]v]]oo˙ } }R v]ob b]uov}bo˙X
TR]bob]buB]v]oF]o~BVFZ }C}vPb]C
F]o~CCFZ X
TR(v}voobb].}v}(R(]ob]vPRN`Y}lH
Ab}]}v~NYHA ZCobb].}v ]bb]]vRoo}`X
TowrP) N`Y}lHAb}]}v~NYHAZCobb].}v(}H
Failure
CLASSI N}o]u]}v}(R˙b]o]˙XO]v˙R˙b]o]˙}bv}
vb (PUo]}vU}˙bv}
CLASSII So]PRo]u]}v}(R˙b]o]˙XC}u(}oU
b }]v˙
R˙b]o]˙bob]v(PUo]}v}D˙bv}
CLASSIII Mlo]u]}v}(R˙b]o]˙XC}u(}oU
b bo]PR
]˙b(PUo]}v}˙bv}
v*Hetar Failure*v
CLASSIV Uvo}˙}v˙R˙b]o]˙`]R}]b}u(}X
S˙u}ub}(]]vb8]v˙bvX b I(v˙R˙b]o
]˙]bvlvU]b}u(}]b]vb
sueCa
yy S˙bu]]oR˙vb]}v
yy RRuR]bb
yy ]}u˙}R]b
C
yy Svu]
yy IbRu]R]bb
yy TR˙}}˘]}b]b
yy C}vPv]oR]bb
yy Pou}v˙]oR˙vb]}v
yy ]C R˙Ru]
Symptoms
LLHF]o
yy RobB bvbb
yy Ov˘}v
yy Ovo˙]vPG~}R}v}Z
yy v]PR
A ~}˘˙buov}vo˙bv}Z
yy ˙bE (P]o]˙
yy C}PR `]R(}R˙o}}rb]vbu
yy WR]vP
R]PRHF]o
yy Sòo]vP}(R(vo}`˘u]b~u˙bv]vR]ov
o}`vu}vRbZ
yy A}u]voòo]vPb
der theCardiovcula
sa rSystem
yy R]PRR˙}R}v]o]v(}uvvoP]vPo]
Signs
LLHF]o
yy Tachypnoea
yy Tachycardia
yy Bbo]}vb
yy Goo}R˙Ru
yy D]bo˘
yy ]C uu
yy Rhonchi
R]PRHF]o
yy Tachycardia
yy P]hvPo}u~u˙bv]vR]ovo}`vu}vRbZ
yy Ascites
yy TvUbu}}RUb}LR}uPo˙
yy R]biPov}bb
yy Goo}R˙Ru
yy ]C uu
In children
yy F]o}R]
v*Hetar Failure*v
yy D]8o˙]v(]vP
Invtiga
se tions
yy FBC
yy ECG
yy CRbXr˙
yy Bo}} U o}o˙b v v]v v GFR ~bu
Po}uo.o}vZ
yy L](v}vb
yy FbvPo}}bP
yy FbvPo]]b
yy R}]}PR˙
E
yy TR˙}](v}vb
yy ]C v˙ubU](u˙}]o]v(}v]bb
yy C}}v˙vP]}PR˙
Trtme
ae nt
Tuv}ib
yy T}o]˙u}ub b v]u}o]˙}(o](
yy T}R]]vPb
yy T}}uo]}vb
yy T}vv}(˙u}ub b
yy T}v(}R}b]oru]bb]}vb
yy T}u}o]˙
yy Reduce salt intake
æ
Standard Trtme
yy R`]PR]v}`]PRv}b]v]]ob
yy Avoid alcohol
yy }] A }]bu}l]vP
yy Ev}Pu}˘]b
yy ~}vo˙
bB ]vR(]o}˘}vb}(R}v]R
(]oZ
yy P}]v
AXR
A (]o r]v]ouv
L]vTuv
st
]v
E RvPPA
yy O˘˙Pv U˙vbovvo}(ubl](R]bR˙}˘u]~SO
AMıA9Z
And
yy F}bu] UIVU
Adults
ruPULu]vb](vbb˙
Children
r˙bV ruPR}o˙bvbb˙
u}vRr˙bV Xær uP llP R}o˙ ~u˘ uP l
v*Hetar Failure*v
lP l}bZ
BXR
A (]o ru]vvvuvL]o]b
b }v
yy F}bu] UIVU
Adults
ruPR}o˙
Children
lP l}bZ
CXR
A (]o rvv}]u}]vPL]v]ouv
yy F}bu] ~Fbu]ZUIVU
Adults
ruPR}o˙
Children
lP l}bZ
Av
yy MorphineUIVU
Adults
æruPbo}ò˙
Children
N}}uuv(}R]b}v]}v(˙
b ]bv}òoo]b
b R
Av
v
der theCardiovcula
sa rSystem
yy M}o}u] UIVU
Adults
uP}v}u]vP
Children
Not required
X
D R
A (]o rv]u}]vPL]v]ouv
yy F}bu] U}oU
Adults
ruPR}o˙
Children
XæruP llPrR}o˙
EXR
A (]o rv`]R(b]o.]oo}v or in sinus
R˙Ru`]R˙bb }o]˙b(v}v
]v
E RvPPC
yy D]P}˘]v U}oU
Elderly
æu]}PubR}o˙(}rR}b
Adults
æu]}PubR}o˙(}rR}b
Then
v*Hetar Failure*v
æu]}Pub]o˙
Then
æu]}Pub]o˙
ChildrenAN˙b
XæruP]v]]}bb}R}b
Then
vXæræu]}Pu]o˙
Childrenr˙b
ru]}PullP]v]]}bb}R}b
Then
ru]}PullP]o˙
ChildrenAM˙b
ru]}PullP]v]]}bb}R}b
Then
ru]}PullP]o˙
Neonates~(oouZ
u]}PullP]v]]}bb]vR}b
Then
ru]}PullP]o˙
Neonates~AMXælPZ
æu]}PullP]v]]}bb]vR}b
Pu
æu]}PullP]o˙
Then
æu]}PullP]o˙
w
Standard Trtme
FX R
A (]o rvb]v]}Pv]bR}l (adult
˙bb }o]o}}AM
b æuuHPZ`]RR˙}vb]}vv}
hypoperfusion
yy D}u]v UIV]v(b]}vU
Adults
Xæru]}PubllPu]v
Note 7-6
GCE bR}o u}v]}}vv}bo˙b ]v}}] Pvbvb r
R˙Ru]bvu˙}]o]bRu]
GXP}R˙ov}Po}v against venous thrombosis
yy Ev}˘]v USCU
Adults
Children
yy Iv(˙ v ~]( }bb]oZ ]]vP b bR b
R˙vb]}vUu˙}]o]v(}vUvu]}R˙}}˘]}b]b
v*Hetar Failure*v
HXS˙u}uHF]o
st
L]vTuv
yy F}bu] U}oU
]v
E RvPPC
Adults
ruP]o˙
Children
ruP llP]o˙
Av
yy L]b]v}]o U}oU
~}vo˙`Rv˙bb }o]o}}AN
b uuHPZ
]v
E RvPPA
Adults
XæruP]o˙
Or
yy Ru]]o U}oU
~}vo˙`Rv˙bb }o]o}}ANb uuHPZ
]v
E RvPPA
Adults
XæruP]o˙
Av
yy CarvedilolU}oU
]v
E RvPPA
Adults
XærXæuPR}o˙~u˘]uuæuPR}o˙Z
der theCardiovcula
sa rSystem
Or
yy B]b}}o}o U}oU
]v
E RvPPA
Adults
XæruP]o˙
Or
yy MetoprololU}oU
]v
E RvPPA
Adults
æruP]o˙
IX Pvbv}}ovPCE]vR]]}b
A ~oL]b]v}]o or
Ru]]o with the following in the 1st line treatment above)
yy L}bv U}oU
]v
E RvPPA
Adults
æræuP]o˙
Or
yy CandesartanU}oU
]v
E RvPPA
Adults
v*Hetar Failure*v
rvuP]o˙
JX Pvb`]R(b]o.]oo}v or in sinus rhythm with systolic
˙b(v}vV
A
yy D]P}˘]v U}oU
]v
E RvPPB
Elderly
æu]}PubR}o˙(}rR}bU
Then
æu]}PubR}o˙
Adults
æu]}PubR}o˙(}rR}bU
Then
æu]}Pub}v]o˙
Children
æu]}PubllPR}o˙
KXS˙u}uvbU]vb]}(R}u]}vb
Av
yy SpironolactoneU}oU
]v
E RvPPA
Adults
æræuP]o˙
Refeal
r
Aoo vb ub ( } b]o]b `Rv o]v]oo˙ ob
ı
Standard Trtme
(} R ]v.}v vuv}( R vo˙]vPb }( R R
(]ov(}o}vPruu]vvvR˙X
Flowchatr
v*CongenitalHetar Disse*a v
F]PwræP)Flowchart: Heart Failure
X Congenital Heart Disease

C}vPv]o uo(}u}v }( R RU }uu}vo˙ ( } b
SH}or]vrH _U ]b ] }uu}v uo(}u}v `]R v ]v]v }(
} }( o] ]RbX TR `} u]v P}b }( }vPv]o R
]bb vuo˙U ˙v} v ˙v}X TR ˙v} ˙b ]vo
v]o ob (U ]o ob (U v b ]}bb
b òo b } v}b
b ]bU ou}v˙ v}b
b ]b v }}v }( R
}X TR ˙v} ˙b b}] `]R u]˘]vP }( }˘˙Pv
o}} `]R }˘˙Pv o}} v ]vo To}P˙ }( Foo} ~TOFZ and
Tvb}b]}v}(RG]bA ~TGAZ X
o˙
E }Pv]}v }( R b]. ˙ v }] u]o }
P]o
b ]vv}v ]b ]u}v ]v ]u}]vP R o]˙ }( o]( v
]vPu}]]˙(}u}uo]}vbX
sueCa
yy I]}R]
yy Gv~R]PR]bl`]R]vb]vPuvoPZ
der theCardiovcula
sa rSystem
yy Mvo]v(}vb}]b]vb o˙Pvv˙Uv}o˙oo
yy Maternal diabetes
yy Ao}R}oUbu}l]vPUvb}(Pb]vPo˙Pvv˙
yy E˘}b}Xr˙bv}R]}v]vPo˙Pvv˙
yy Pu]˙
yy MooPvv˙
Symptoms
A˙v}
yy ˙bE (P]o]˙
yy Rob B bvbb
yy P}}(]vP lIv}v}(bl]vP]v]b]vP(]vP
yy P}}P}`R
yy C}o`b }v(}R
yy P+˙˙o]bU`}oov b (~R}ÙRbv}uu}v]v]v(vbZ
yy D]bv}uv
yy E˘}vu˙o}Rb]vbU˙v} b }bvR
C ˙v}
yy Aoo˙u}ub b }(˙v}R]bbUobR(}oo}`]vPP
yy Bo }vP v .vPv]ob ~˙v}b]bZ ]R } }u]vP `}b
`]R˘}v]v}oR]ov
yy ShvPob ub]vPo˙]v}ob
Signs
A˙v}
yy S]Pvb}(R(]o(}u}}obb ]}vbP
yy C}o`˙ b bl]v
yy P+˙˙o]b
yy D]bvvl]vbvvlo}u~]v
yy }oR]ovZ
yy Tachycardia
yy Tachypnoea
yy WlR˙ob
yy ]}uPo˙
C
yy Goo}R˙Ru
yy ]}vb C UR}vR]
yy H}uPo˙
yy Huu~v}o`˙bbvZ
C˙v}
yy S]Pvb}(R(]ob}Uob
yy F]vPo]vP
yy Cyanosis ~o}` ]Ro }˘˙Pv }v b ub ˙ ob
}˘]u˙Z
yy Huu
yy H˙˙v} 'l ]XX b]}˙ ]bb `]R v]vP
˙v}b]bUo}bb}(}vb]}bvbbv}vob]}vb
Standard Trtme
Invtiga
se tions
yy FBC
yy CRbXr˙
yy ECG
yy R}]}PR˙
E
Trtme
ae nt
Tuv}ib
yy o˙ E }Pv]}v}(R}ou
yy P}uuv}(R(]o
yy o˙ E P]o
b }}v](]v]
yy Pv}v}(v}]b
yy EvbP}}v]}vUP}}}ovvoR˙P]v
yy }] A ˘bb]R˙b]o˘}v~v}(˙vbvRbZ
AXS˙u}u}vPv]oR]bb
]v
E RvPPC
yy O˘˙Pv U ˙ ( ubl } vbo }vPbU Llu]v ]( ]ooU

~u}v]}}˘˙Pv}vb Z
Note 7-7
F}vb]vR(]o}`]RR˙˙v}'l
BXTuv}(R(]o]v˙u}u
b }vPv]oR]bb
~Sb}v}vRHF]o[Z
CXT}]u}o}}G}`]v}RovPb(}vb`]RTo}P˙}(
Fallot
yy P}v}o}o U}oU
Childrenu}vRr˙b
XæruP llPvrR}o˙~u˘XæuP llP]o˙Z
Neonates
XæruP llPrR}o˙~u˘XuP llPR}o˙Z
yy P}v}o}o Ubo}ÌV`]RGCE u}v]}]vPU
Childrenu}vRr˙b
ær u]}PullP vr R}o˙ ~u˘X u]}PullPZ
˙vrR}b](vbb˙
Neonates
ær u]}PullP ~u˘X u]}PullPZ ˙
hours if necessary
X
D C}vPv]oR]bb`]RR˙˙v}'l
~Sb}v}vRH˙˙v}'lA [Z
der theCardiovcula
sa rSystem
Refeal
r Criteria
R( oo R]ov `]R }vPv]o R ]bb } ]]
]}o}P]b } ]]]v (} (R o]v]o buv v
uvPuvX
ıX H˙˙v}'l
TR]b]bo](Rv]vP]]]uPv˙X
I boo˙ }b ]v ]v(vb `]R l ]v]v `v v v
u}vRbX]bb A }u˙o}o]uvbbUb]bU}bo
]v}vRXSoobu˙](~ru]vbvZ bo(r}
}u˙}Pb}b U b o](rRv]vP]b}XP}u}Pv]}v
˙vbvu]o+ b ]b]u}vXTR'l]b}Lvo˙]vR
u}v]vP`]Rv}vb}vXIu˙]](}oo}`]vPRU
˙}o}vP˙]vPU(}vUR˙}v U(]o]oovb}b ]v}v
}(vbRb]X
sueCa
yy C}vPv]oR]bXP b XTo}P˙}(Foo}Uou}v˙v}b
b ]bU
v*Hypyacer noticttaa ck*v

}o }o ]PR v]oU ]b] b]U E]bvuvP
˙v}u
b
Symptoms
yy I]]o]˙v}o}vP˙]vP
yy ]D R]vP
yy Ivb]˙ b }(˙v}b]b
Signs
yy Tachycardia
yy S˙b}o]uu
yy C}u
yy Convulsions
yy Hu]b]b
Invtiga
se tions
yy FBC
yy CRbXr˙
yy ECG
yy R}]}PR˙E
Trtme
ae nt
Tuv}ib
yy T}}Pv]bR}ouo˙
yy T}b}b}v
yy T}}u}o]vPuv]vR˙}˘] b
yy T}v}uo]}vbvR(}uR˙}˘] b
yy H}o]vlvRb}b]}v~RvbZ
Standard Trtme
yy TR } }vb ]vb ]Ro bo b]bv v Ro
}˙v}b]bX
AXAooR]ov`]RR˙˙v}'l
]v
E RvPPC
yy O˘˙Pv ~A9ZU˙(ubl}vbo}vPbU
Llu]v~u}v]}]vP}˘˙Pv}vb ]( }bb]oZr}oovb
}R˙}˘]
Av
yy XıA9N}uoSo]v }R]vPb[L UIVUuollPU}u]vb
then assess response
Av
yy Morphine boRU bo}` IV ~(ZU } IMU ]( IV o]v v} b] r
oUru]}PubllPX
b
BXF}vb`]R}}b}vb}}ubbUA
yy P}v}o}o U}oU
Childrenu}vRr˙b
æu]}PullPR}o˙~u˘XæuP llP]o˙Z
v*Hypyacer noticttaa ck*v
Neonates
æu]}PullPR}o˙~u˘XuP llPR}o˙Z
CXT}}]}b]b]v˙v}vb`]Rv}]u}uvL
u]vb}(}uvUA
yy S}]uB]}v UIVU
F}ooPP}b
ruu}ollP
Note 7-8
EuPv˙P]o
b bRvu˙]
X
D M]vvvuv}vv'lbv]vP
surgery
yy P}v}o}o U}oU
Childrenu}vRr˙b
XæruP llPvrR}o˙~u˘XæuP llP]o˙Z
Neonates
XæruP llPrR}o˙~u˘XuP llPR}o˙Z
yy P}v}o}o Ubo}ÌV`]RGCE u}v]}]vPU
Childrenu}vRr˙b
ær u]}PullP vr R}o˙ ~u˘X u]}PullPZ
˙vrR}b](vbb˙
Neonates
ær u]}PullP ~u˘X u]}PullPZ ˙
hours if necessary
der theCardiovcula
sa rSystem
Refeal
r Criteria
H˙˙v}'l ]bv]v]}v(}o˙P˙
b XR(Pvo˙
}]]b]o]b}]}R}]P}v
b
50. P]]b
P]]b ]b ]vGuu}v }( R ]]uX I u˙ ˙U
.]v}bU+b]}}vb]XIu˙}R}v]~ANu}vRbZX
sueCa
yy V]o
yy ]o
B
yy Tuberculous
yy FvPo
yy RRu(
yy P}br]}}u˙
yy P}bu˙}]o]v(}v
yy Uu]
yy }]uuv
A ]bb
Symptoms
v*Pericarditis*v
yy R}bvo } oL }]o Rb ]v ~`}bvb `]R o˙]vP }`v
v]u}b`]Rb]hvPvov]vP(}`Z
yy Po]}v
yy FP
Signs
yy F
yy Malaise
yy M˙oP]
yy P]]o(]}v
yy FbvPoR
yy D]bvRb}vb~](R]boP+b]}vZ
Invtiga
se tions
yy FBCvSR E
yy ASO
yy roGCE
yy CRbXr˙
yy R}]}Pu
E
yy Chest CT scan
Trtme
ae nt
Tuv}ib
yy To relieve pain
yy T}vo˙]vPb
yy T}v]u}v
æ
Standard Trtme
bB
P]]}vb]b~] nd
]`RvR]b]u}vUoP
}˙u}u
b ]]o+b]}vZX]v
E RvPPB
AX]]b
A
st
L]vTuv
]v
E RvPPB
yy I}(v U}oU
Adults
ruPvrR}o˙
Children
wr˙bV uPvrR}o˙
rw˙bV uPvrR}o˙
r˙bV æuPvrR}o˙
vru}vRbV æuPR}o˙
rvu}vRbV æuP llPvrR}o˙
Av
yy ColchicineU}oU
v*Hypteer nsion*v
Adults
XæuPR}o˙
Children
N}}uuv
Or
yy Pv]b}o}v U }oU ~b] } }vv b ]bb v
u]]]bZ
Adults
uP]o˙(}˙bv}+
Children
uP llP]o˙(}˙bv}+
B. For treatment of underlying cause
~S}]b}vZ
Refeal
r Criteria
R( oo vb } ]}o}P]b
C (} (R o}v L R
]v]o uvX Pvb `]R oP +b]}vb } ] u}v
]Pv]]}vb]bvR}]}PR]P]vv
R˙bR}o(]uu]o˙X
51. Hypertension
Hypertension } RR]PR o}} [b ]b v ]vb ]bl }(
o˙R(}u}l
b UR'lUR(]ovl]v˙(]o](]]b
v}o˙v}o˙}v}ooXO`]vP}R]bUR(}bub
v
der theCardiovcula
sa rSystem
}v `Rv } ]v] uvU R Rv R}` R˙vb]}v bR}o
.vX
S]v R }Lv v} b]. ˙u}ub b b}] `]R
R˙vb]}vUR]bRv(}Poo}}~B b Pv]vP
Zb
]vRo}o}v(}o˙}vX
Iv R Pvo o }o}vU uv ub ]v]
BP }( lı uuHP } R]PR (} ]v]]ob o}` v ˙b }( PU v
ælı uuHP } R]PR ]v R}b } v ˙bX F} ]v]]ob `]R
]b uoo]b } v}vr]b `]R CR}v] K]v˙ D]bb ~CKD ZU
uv (} R˙vb]}v ub ]v] BP }( lı uuHPU
]b}(PX
IvRui}]˙}(vb`]RR˙vb]}vUv}b].vo˙]vP
]bb ]v.~]u˙R˙vb]}vZXIvRb]v]]obU]vb]vP
PU (u]o˙ R]b}˙U ˘bb }˙ `]PRU ol }( R˙b]o ]˙ v
˘bb] o}R}o ]vl u˙ }bb]o ]b}b]vP (}bX Iv }
A9}(}(b R˙vb]}vURu˙vvo˙]vPl]v˙]bbU
v}]v ]b}U vo ˙ v}bb ]b } }}v }( R }
~b}v˙R˙vb]}vZX
Ov ]Pv}b]b }( R˙vb]}v ]b uU R ]v]]o bR}o
o } ˘o }v˙
b b v } ]v(˙ }R ˘]bvP
v*Hypteer nsion*v
]}bo ]bl (}b XPX ]bU ˙bo]]u]U R˙]u]U
X
B}˘wrvP) ]}b
C oR]blF}b
yy P A ~uvAHææ˙bV`}uvAHvæZ
yy Fu]o˙ R]b}˙ }( u]}bo ]bb ~uv P AM ææ ˙bV
`}uvPAMvæZ
yy D˙bo]]u]
yy Ob]˙ ~BMIAHlP lu Z
yy D]buoo]b
yy Su}l]vP
yy Pob~]vb Roo˙ZAHvuuHP
yy M]}ou]v]}}]v]
yy LLv]oR˙}R˙
yy LL vo vR o}l v }R o}]}PR] (b bPPb] r
}(]bRu]R]bb
yy P]}b}l b }vb]v]bRu]'l
yy P]o]o]bb
yy Heart failure
yy Coronary artery disease
yy Chronic kidney disease
yy vA v}R˙PRu}RPb}˘bU]oo}u
sueCa
yy P]u˙R˙vb]}v
yy Secondary hypertension
yy K]v˙orCKD U}o˙˙bl]v˙]bb
yy Ev}]v r R}R}u}˙}uU CbR]vP [b˙v}u
b U C}vv[b
˙v}u
b UR˙}R˙}]]bu UR˙R˙}]]bu U}uPo˙
w
Standard Trtme
yy Vborvo˙v}b
b ]bU}}v}(R}
Symptoms
yy Uboo˙v}v
yy Ob]}voo˙U
yy Headaches
yy Po]}vb
yy D]]vbb
yy ˙bE (P]o]˙
Signs
yy Bo}}AHb lıuuHP
yy D]bo˘
yy S]Pvb}]vvP}b].b(}}v˙
b R˙vb]}v
Invtiga
se tions
yy FBC
yy U]vo˙b]b
yy Bo}}Uo}o˙bvv]v
yy Bo}}Po}b
yy Suo]]b
yy Su]]
v*Hypteer nsion*v
yy CRbXr˙
yy roGCE
yy Uob}v v b }( l]v˙b v vob ~]v b }v˙
b
R˙vb]}vZ
yy R}]}Pu
E
Trtme
ae nt
Tuv}ib
yy T}o}}oob b }}uuvPbP
yy AMlıuuHP(}Po}`v˙bU]bUCKD
yy AMælıuuHP(}P}v˙b
yy T}uvP}ru}]}v]}vbXPX}b]˙U]bUo]]bX
yy T}v]}boU}bovvo}uo]}vb
yy T} }u} R o](b˙o RvPb XPX bu}l]vP }v
b U
PoR˙b]o]˙U}v]voR}R}o]vl
yy T}]v(˙vuvP}v˙ b R˙vb]}v}]o˙
yy Reduce salt intake
yy Rv]uo(]vl
yy EvbPo(]vPo]vl
yy W]PR}v]v}bv}`]PR]v]]ob
yy RPo˘]bXPX]blòl]vP(}u]vbub`l
yy R}v]vo}R}o}vbu}v
yy }] A }]bu}l]vP
der theCardiovcula
sa rSystem
AXTuv}(R˙vb]}v
st
L]vTuv
]v
E RvPPA
B}˘wrwP) N}b}vvrR˙vb]u]]vb
Av˙}(R.obb}(ui}vR˙vb]Pbv b .bro]v
uvXTRbP
yy TR]]D]b
yy Co]u CRvvoBo}lb
yy AvP]}vb]vC}vvPEv˙uIvR]]}b
yy AvP]}vb]vR}Bo}lb
yy ro}lb
B
Iv R Pvo ol }o}v R]] ]b } o]u Rvvo o}lbU

]R b u}v}R˙ } ]v b}u }u]v}v R˙U ]b (oX AvP]} r
vb]v}vvPv˙uIvR]]} v}
b }uuv.bb ro]vPb(}
v}uo]R˙vb]}v]volvbX
Do R˙ bR}o b o] `Rv R o}} b ˘b
luuHPX
A]}vo vrR˙vb] Pb bR}o b ]( P o}} b
v*Hypteer nsion*v
oob v} R]X Ar}v Pb bR}o R}bv (}u .bro]v R}]b
]vP]vu]v}uoo]vP]v]}vbv}v]v]}vbX
C}uoo]vP]v]}vb(}RR}]}(vR˙vb]b
yy LLv]oR˙}R˙PrI CEA }ARBU(o˙CB Auo}]]v
yy M]}ou]v]PrI CEA }ARB
yy Rvo˙b(v}vPrI CEA }ARBVC}vr](GFRAMæu]vluo`]R}vo
ouvR˙
yy P]}b}lb PAv˙}(R.bro]vPbUb]oo˙rI CEA
yy C}}v˙ ˙ ]bb ~AvP]vlM˙}]o ]v(}vZP rI CEA } ARBU B r
ro}lUCBX
yy H(]oPrI CEA }ARBU]} C rboBrBo}lbr]b}}o}oUu} r
}o}oU]o}oVL}}]bUS]}v}o}v]vvR(]o
yy P]Ro˙]bbPU CB rI CEA }ARB
yy D]buoo]b PrICEA }ARB
yy ]o
A .]oo}vPARB}rI CEA }Bro}lb
C}uoo]vPC}v]v]}vb
yy GoutPTR]]]b
yy ro}lb
B PRuAb UvVA o}l
yy CBPH(]o
yy rI
CEA }ARBPB]oovo˙v}b
b ]bvR˙lou]
TR]]D]b :
yy Bv}GuR]] U}oUXæuP]o˙
Or
yy H˙}Ro}}R]] U}oUXæuPræuP]o˙
AvlO
ı
Standard Trtme
Calcium Channel Blockers:
yy Auo}]]v U}oUæruP]o˙
Or
yy NifedipineU}oUruPR}o˙
AvlO
A vP]}vb ]vr}vvPv˙u~ACEZ]vR]]}b
yy L]b]v}]o U}oUæruP]o˙
Or
yy Ru]]o U}oUXæruP]o˙
Or
A vP]}vb ]v}o}lb
yy L}bv U}oUæruP]o˙
Or
yy CandesartanU}oUruP]o˙
Or
yy Vobv U}oUrvuP]o˙
AvlO
Beta-blockers:
v*Hypteer nsion*v
yy AtenololU}oUæruP]o˙
Or
Or
yy MetoprololU}oUæruPR}o˙
Or
yy CarvedilolU}oUXæræuP]o˙
Or
yy Lo}o U}oUruPR}o˙
nd
L]vTuv
]v
E RvPPC
Cvoo˙vPPvb
yy MethyldopaU}oUæuPrPrR}o˙
AvlO
Vasodilators
yy H˙o]v U}oUæræuPR}o˙
AvlO
AoRro}lb
yy P}b]v U}oUXæuPrR}o˙v]vb]vPPoo˙}u˘X
}b}(uP
AvlO
Ao}b}vvP}v]bb
yy SpironolactoneU}oUæræuP]o˙
æ
der theCardiovcula
sa rSystem
Refeal
r Criteria
R( R (}oo}`]vP P}]b }( R˙vb] vb } v
appropriate specialist:
yy TR}bv}R]]vPRPo}}~B b Poo Z Lob
u}vRb}(uv
yy TR}b }v R } u} vrR˙vb] PbU ˙ R }} BP
control
yy TR}b`]R`}bv]vP}(BP}(``lb}u}vRb
yy TR}b`]Robuv]voob}Ro]u]}(v}uo
yy TR}b`]R]buoo]b
yy TR}b `]R uoo ]bl (}b ~]bU ˙bo]]u]U }b]˙U
(u]o˙R]b}˙}(R]bbZ
yy TR}b v} }v ]b R b]bvo˙ o}` }bb]u }v
repeated blood tests
yy AooR]ovU˙}vPobvPvv`}uv`]RoBP
Flowchatr
v*Hypteer nsion*v
F]PwrP) Flowchart: Hypertension
æ
Standard Trtme
52. Hypertension in children and adolescents

Hypertension ]v R]ov ]b .v b v P ˙bb }o] vl}
]b}o] o}} b R ]b AH ıæR vo (} PvU PU v
R]PR }v } u} b }b]}vb lv ]v R ]PR u ~]v ]`
}(}bb]]o]˙}(}}v}(}ZXAv}]+b]R}b
`}R]b~A0}( Z RovPR}(Ru~`vbR}ovo}`vZ
v]o]vPR`R}ouUbR}obX
IvPvoU o}}b}(ANlwuuHP]vR]ovPræ
˙bvANæluuHP
vw ]vR}bPvr˙bvu}Rvl
uuHP]v}obvb]b}vb]v}uov`}o](o
}Uvo}v˙]]]vX
M}b }obv v R]oR}} R˙vb]}vU b]oo˙ ]v ]v(vb
v ˙}vP R]ovU ]b } }v˙ b b ~S b}v }v
RH˙vb]}v ]v Aob[ZX A}obvbU R}Ù u˙ R o˙ }vb
]u˙R˙vb]}vX
v*Hypteer nsioninchildrenandadolecents
sueCa
yy RvoXPXR}v]˙o}vR]b UR˙}vR}b]b
yy VboXPX}}v}(}Uvo˙v}b b ]b
yy Ev}]v XPX R}R}u}˙}u U CbR]vP [b ˙v}u
b U vo
disorders
s *v
yy Ob]˙
yy P]u˙R˙vb]}v
Symptoms
yy Chest pain
yy Headaches
yy D˙bv} }v˘}v
yy E˘bb]`vP b
yy LPòo]vP b
yy Po]}vb
yy Hu]
yy Uv}vb]}bvbb (hypertensive encephalopathyZ
Signs
yy BPANlwuuHP]vR]ovPræ˙b
yy ANælwvuuHP]vR]ovPvr˙b
yy ANluuHP]v}obvb
yy S]Pvb}]vvP}b].b(}}v˙ b R˙vb]}v
Invtiga
se tions
~Sb}v}vRH˙vb]}v ]vAob[Z
Trtme
ae nt
Tuv}ib
yy T}o}}~B b P}Z P}(AMıæRvo(}PU
Pv v R]PR ]v R bv }( v }PvruP ~} AM ıR
æ
der theCardiovcula
sa rSystem
vo](v}PvuPbvZ
yy T}v}uo]}vb
yy T}uvPvo˙]vP}v˙ b b
yy T}v}P`]PR}v]v}bv}`]PRR]ov
yy TRo](b˙oRvPb
yy `]PR}v}o
yy Po˘]b
yy o}`(]vl
yy o}`b}]u]
yy Po(]vPo]vl
]vE RvPPA
AvP]}vb]vr}vvPv˙u~ACEZ]vR]]}b
yy EnalaprilU}oU
Children
v*Hypteer nsioninchildrenandadolecents
r˙bV ]v]oo˙ Xæ uP ]o˙ ~]vb } u˘X r
uP]o˙]vr]]}bbZ
u}vRr˙bV ]v]oo˙ u]}Pub lP ]o˙ ~]v r
}b u˘XuP llP]o˙]vr]]}bbZ
Neonate
u]}PullP]o˙~]vb}u˘Xæu]}PullP]o˙]v
s *v
r]]}bbZ
D]b
yy Bv}GuR]] U}oU
Children
r˙bV XæuP]o˙
r˙bV æru]}PullP]o˙
u}vRr˙bV æru]}PullP]o˙
Beta blockers
yy P}v}o}o U}oU
Children
r˙bV rvuPR}o˙
u}vRr˙bV æu]}PuruP llPR}o˙
NeonateV æu]}PullPR}o˙
O
yy AtenololU}oU
Children
XæruP llP]o˙~u˘XuP llP]o˙Z
Calcium channel blockers
yy NifedipineU}oU
Children
r˙bV æruPR}o˙
u}vRr˙bV r u]}PullP R}o˙ ~u˘X
uP]o˙Z
æ
Standard Trtme
Or
yy A uo}]]v U}oU
Children
r˙bV æruP]o˙
u}vRr˙bV r u]}PullP ]o˙ ~u˘X uP
]o˙Z
Vasodilators
yy H˙o]v U}oU
Children
r˙bV æuPR}o˙]vb}bou˘Xær
uPR}o˙
u}vRr˙bV æræ u]}PullP r R}o˙ ]v r
vbb b˙}u˘XwXæuP llP]o˙~v}˘]vPuPZ
Neonate
æræ u]}PullP r R}o˙ ]vb b vbb˙ } u˘X
ruP llP˙R}b
IVU æræ u]}PullP ]o]v uo v}uo bo]v P]v }
u]vbU Rv r u]}PullP rv R}o˙ ~u˘ uP llP
]vR}bZ
v*Hypteer nsioninPrgna
AvP]}vb]vr}o}lb
yy L}bv U}oU
Children
e ncy*v
Iv]o}bV XwuPllP]o˙~u˘XæuPZ
M]vvv}bV XuPllP]o˙~u˘XuPZ
Refeal
r Criteria
Refer all cases of hypertension in children to a specialist for
]vbP}vv(RuvX
53. Hypertension in Pregnancy

~S b}v }v RH˙vb]}v ]v PPvv˙[ v ROb]
vOb]D]b}b[Z
æX Hypertensive Emergencies
A R˙vb] ]b]b ]b b v }voo˙ o]( Rv]vP
]vb ]v o}} b ~BPZ `R]R u˙ bo ]v v }l b U
Rv}]
b Ru}RP U b]b ~R˙vb] vRo}R˙ ZU
R 'lU ]bb}v }( }U R (]oU vo uP }
oub] ~]vP Pvv˙ZX TR vo˙]vP b u˙ ]u˙
R˙vb]}vV R}Ù }v˙ b b }( R˙vb]}v ub
˘oX
IvovbR]b}Lv}b`]RBPANluuHPU`R]o
]vR]ovR]bu˙}o}`BPoobX
æ
der theCardiovcula
sa rSystem
TRb vb v (o ˘u]v}v } ˘o P }Pv
uPX R] }}v }( o}} b `]R (o u}v]}]vP }
}]]]}b}]b]v]}v}PvuPX
Symptoms
yy Headache
yy Chest pain
yy Shortness of breath
yy Nausea
yy V}u]vP
yy Confusion
yy S]b
yy Uv}vb]}bvbb
Signs
yy So˙oo}}~(} b PZ
yy Uv}vb]}bvbb
yy S]b
yy Nl]P]]˙
yy LvP]}vb
v*Hypteer nsiveEmeger ncies*v

Invtiga
se tions
yy CRbXr˙
yy roGCE
yy FBC
yy U]vo˙b]b
yy Bo}}Uo}o˙bvv]v
yy ]v B CTv b ~(}}lb Z
yy CRbCTv b `]RvP]}PR˙~(}}b ]bb}vZ
yy ]C v˙ubP v]v l]vbrMB ~CKrMB Z U bu b
vbu]vb~ASTZUbuoR˙}Pvb~LDHvZ }}v]vb
~(}}}v˙˙v}ub Z
yy R}]}PR˙
E
Trtme
ae nt
Tuv}ib
yy T} o]u] (R }Pvro}uo]}vb ˙}v}oo}v
}(BP
yy T}}v}ovbvo˙vb]b](bv
yy T}uvP]v.P}PvuP
yy Strict bed rest
]v
E RvPPA
yy Lo}o UIVU
Adults
ræuPX b ~}u]v]}Z
ææ
Standard Trtme
Ru]v]vobU](vbb˙U}u˘X}(uP
Children
r ˙bV r uP X
b ~} u]v ]}ZX R æ
u]v]vobU](vbb˙~u˘XuPZ
u}vRr ˙b ~˙ IV ]v(b]}vZV ]v]oo˙ ær u]}Pu llP
}˙ `]PR l R} ib ]vob }( ob æ u]vb r
}]vP}b}vbXM˘XuPllP lR}X
Note 7-9
M}v]}BP˙æu]vb(}oo}`]vPR]vi}v(}ooPP}bX
Lo}o
Cb ]vi}vb](BPAMlıuuHPvl}obAMBPM
v ]vobU
~(}R]ov}vbo]]]vZ}`R]vPv}vR}bbu}bX
Or
yy H˙o]v UIVU
Adults
æruPbo}ò˙~} u]v]}ZU]o`]R uoN}uo
Saline~XıA9ZX
Rru]v]vobU](vbb˙
Children
r˙bV æruPXb
R˙rvR}bU](vbb˙
v*Arhythmias*v
u}vRr˙bV ræu]}PullP
R ˙ rv R}bU ]( vbb˙V u˘X uP llP ]o˙ ~v} ˘ r
]vPvuP˙Z
AMu}vRV ræu]}PullP
R˙rvR}bU](vbb˙Vu˘XuP llP]o˙
Note 7-10
M}v]}BP˙æu]vb(}oo}`]vPR]vi}v(}ooPP}bX
D} v} b R}rvP v](]]v ~XPX bo]vPoZ ]v R uvPuv }( R˙ r
vb] ]bb b ] o}`b R BP }} ]o˙ v u˙ b ]bRu] }(
]o}PvbX
Refeal
r Criteria
R(oovb}R˙b]]vb]o]b(}(Ro}vX
55. AR˙Ru]b
AR˙Ru]b ]b}b }( ] U R˙Ru v }v}vX
TR˙ v obb]. b ˙R˙Ru]b ~R AM v u]vZ
vR˙R˙Ru]b~RANu]vZX
˙R˙Ru]b
B include sinus bradycardiaU b]vb b v
]}v]o o}lbX TR R˙R˙Ru]b v (R obb].
]v} v]o
b v v]o R˙Ru]bU b }v R] b]
}( }]P]vX TR˙R˙Ru]b ]vo ]o .]oo}v U ]o G' U
}˘˙buo v]o
b R˙]U v]o R˙] v
v]o.]oo}vX
æv
der theCardiovcula
sa rSystem
P]}}Puv}(]b R˙Ru]Uro
GCE ub }v } }v.u R R˙Ru v}uo]˙X I ]b vP}b
} b v vR˙Ru] P `]R} }]vP vGCE X R(˙u}u
b
vb } R}b]o ]uu]o˙X TR R}] }( P uv vb
}vR˙}(R˙Ru]v]˙ b }(˙u}ub
b X
sueCa
yy RRuR]bb
yy ORooR]bb
yy Hypertensive heart disease
yy IbRu]R]bb
yy TR˙}}˘]}b]b
yy H˙}R˙}]]bu
yy ]}u˙}R]b
C
yy C}uoRo}l
yy Eo}o˙v}uo]boo˙R˙}lou]
yy P]]o]bb
yy DPb
yy Su}l]vPUo}R}oU}+UUX
yy Pou}v˙u}o]bu
yy P}b]P˙ b
v*Arhythmias*v
yy I]}R]
Symptoms
yy Po]}vb
yy D]]vbb
yy CRb]b}u(}l]v
yy FP
yy D]8o˙]vR]vP
yy Sudden collapse
yy Sudden death
Signs
yy Pob
yy Ru˙(bUbo}`}v}uo
yy RR˙Ru
RPo RPoo˙]Po IPoo˙]Po
Sinus tachycardia Supraventricular or ]o
A .]oo}v
Sinus bradycardia ventricular ectopic ]o
A G'~`]R]o
C}uoRo}l beats ]}rv]oo}lZ
Supraventricular tachycardia Moov]o
b }
Vv]oR˙] ventricular ectopic beats
yy Pob .] ~]o (b Rv ]o ob V bv ]v
(b]o.]oo}v }G'Z
yy H˙}vb]}v}o}}u˙ b v}o
yy S]Pvb}(R(]o~u˙bvZ
æw
Standard Trtme
Invtiga
se tions
yy roGCE
yy Suo}o˙b~]vo]vPuPvb]uUo]uZ
yy TR˙}](v}vb
yy CRbXr˙
yy Auo}˙GCE ~H}oZ
yy R}]}PR˙
E
Trtme
ae nt
Tuv}ib
yy To control ventricular rate
yy T}}b b]vbR˙Ru
yy T}o]˙u}ub b
yy T}]u}(v}vo]˙vo]˙}(o](
yy T}v}b}]}uo]}vb
yy T}Rvo˙]vP}v]}vXPXR˙}}˘]}b]b
yy To prevent stroke}˙bb u]R}u}u}o]bu
yy T}u}]]˙vu}o]˙
yy RbR b v
v*Arhythmias*v
yy }] A ˘bb]]vl}( o}R}oU}+} v}b bu}l]vP ~](

Rb}bb]o]]vP(}bZ
yy MbbP}(R}b]vb}v}vb](}(`}vb b XTR]bu˙
u]vv'l}(}˘˙buov]o b R˙]
yy Electrical cardioversion
AXFb]o.]oo}v }]oG' -for rate control
st
L]vTuv
]v
E RvPPA
yy AtenololU}oU
Adults
æruP]o˙
Children
r˙bV æræuP]o˙
u}vRr˙bV XæræuP]o˙
Neonates
Refer to a paediatrician
Or
yy B]b}}o}o U}oU
Adults
XæruP]o˙
Children
Safety not establised in children
Or
yy MetoprololU}oU
æ
der theCardiovcula
sa rSystem
Adults
æruP}R}o˙]o˙~u˘XuP]o˙Z
Children
r˙bV æuP}R}o˙]o˙~u˘XuP]o˙Z
AM˙bV (}]]]v
Note 7-11
}]
A ](ro}lb}v]v]XPX}vR]oRu
b UR˙}vb]}v
O
yy Vu]o U}oU
Adults
ruPvrR}o˙~u˘XuP]o˙Z
Children
Note 7-12
}]
A b]vvbo˙}vro}l
nd
L]vTuv
]v
E RvPPA
yy D]P}˘]v U}oU
v*Arhythmias*v
Adults
æræu]}Pub]o˙
Children
BXFb]o.]oo}v }]oG' -for rhythm control
TR]b]b]}}b b]vbR˙RuX
R( } ]}o}P]bU R˙b]]v b]o]b } ]]]v b
}]X
C. Paroxysmal supraventricular tachycardia
st
L]vTuv
]v
E RvPPA
yy AtenololU}oU
Adults
æruP]o˙
Children
r˙bV æræuP]o˙
u}vRr˙bV XæræuP]o˙
Neonates
Or
yy B]b}}o}o U}oU
Adults
XæruP]o˙
Children
Safety not establised in children
æı
Standard Trtme
Or
yy MetoprololU}oU
Adults
æruP}R}o˙]o˙~u˘XuP]o˙Z
Children
r˙bV æuP}R}o˙]o˙~u˘XuP] r
o˙Z
AM˙bV (}]]]v
Note 7-13
}]
A ](ro}lb}v]v]XPX}vR]oRu
b UR˙}vb]}v
Or
yy Vu]o U}oU
Adults
Children
N}wr
}]
A b]vvbo˙}vro}l
v*Arhythmias*v
nd
L]vTuv
]v
E RvPPA
yy D]P}˘]v U}oU
Adults
æræu]}Pub]o˙
Children
X
D Pv}v}(}l b or systemic thromboembolism in atrial
.]oo}v }G'
PvbbR}oP]vo}vPruv}Po}v X
~S }}vb (} o}vPru v}Po}v ]v b}v }v RDVT [}
RPou}v˙Eu}o]bu [Z X
Refeal
r Criteria
R(oovb}]}o}P]bUR˙b]]vb]o]b}]]]v
(}(Ro}vvuvPuvLR]v]ouvX
Aoo˙u}u
b vbU b òo b R}b `R} vv} RvGCE
}v}]vU}`R}bv`]RR(]oUbR}o(
]uu]o˙X
Flowchatr
v
der theCardiovcula
sa rSystem
v*AcuteRheumaticFever*v
F]PwrıP)Fo}`RPAR˙Ru]b
56. RRu
A F
A Ru ( ]b v ]oovbb b ˙ v ]uuv}o}P]o
}v } P} A }}ob ]v(}v }( R R}X TR }vb }(
˙u}ub
b }b r `lb L v v } ]vo˙
R} ]v(}vX TR ]bb }b u]vo˙ ]v R]ov v }obvb
`]R l P }( æræ ˙bX A Ru ( }Lv bob ]v
obvP uP } R ob o]vP } R R}v] (}uU `R]R ]b
lv}`vbRuR]bbX
Iv]]ob`R}RRRu(]}bo˙u}
o]lo˙}Rbv]b}bXTRbvbu˙b(R
RouPXF}oo}`]vPuv}(v]b}U}v˙ b
}R˙o˘]b bR}o }vv (} u]v]uu }( ˙b L R
v]b}}( Ru(}voP ˙b~`R]R
]b o}vPZX F} R}b `]R b Ru R ]bb }v˙b
}R˙o˘]bbR}o}vv]v.v]o˙X
RRu R ]bb ]b v ]u}v b }( R (]o v
u RX Iv GRvU Ru ( u˙ u]u] uo]U
typhoid feverv}R(]o}v]}vbU`R]oRi}]v˙u}ub b u˙
u]u]b]looo]bbX
J}vb]]]bb(}]Pv}b]b}(Ru(X
v
Standard Trtme
B}˘wrP) J}vb]](}]Pv}b]b}(RRu
A F
F}]Pv}b]b}(]v]oRu(P
]v
E }(]vPP}}}o
Ab ]v(}vU
And
ui}]]
O
ui}]]}vvu]v}]]
F}]Pv}b]b}(vRu(P
]v
E }(]vPP}}}o
Ab ]v(}vU
And
ui}]]
O
ui}]]}vv}u]v}]]
~S˙u}ub
b vS]Pvbo}`(}ui}vu]v}]]Z
sueCa
yy G}}}o
Ab ]v(}v
Symptoms
yy F
yy Malaise
yy J}]v ]v `R]R u}b (}u }v i}]v } v}R ~lvbU vlobU
`]bbUo}`bZ
yy Po]}vb
yy ˙bE (P]o]˙
yy Chest pain
yy Skin rash
yy Av}uo}˙u}uvb~R}Z
Signs
yy FAN£C~u]v}]]Z
yy S]vPoi}]vvvbbv}òo]vP b ~u]v}]]Z
yy R] R ~ AN lu]vZU uuU R (]oU ]]o
~bPPb]bb Z~ui}]]Z
yy Skin rash
yy Sv}bv}ob}}v˙}u]vvb
Invtiga
se tions
yy FBC
yy SR E AN}Cr}]vANuP lL ~u]v}]]Z
yy S]lo]vPb
yy CRbXr˙
yy TR}`b (}o
yy Avrb}o˙b]vO
yy roGCE ~}o}vPPR]vo(}Pru]v}]]Z
yy R}]}PuE ]v}(]b~ui}]]Z
v
der theCardiovcula
sa rSystem
Trtme
ae nt
Tuv}ib
yy T}]}}o b R}]v(}v
yy T}b]vGuu}˙b}vb
yy T}vv ]b}b }( Ru (v (R R
ouP
yy T}R(]o](}r˘]bv
yy b B
AXTuv}(RRu A F
st
L]vTuv
]v
E RvPPC
yy BvR]vv˙ov]]oo]v UIMU
AHlP}˙`]PRV UUUb]vPo}b
AMlP}˙`]PRV vUUb]vPo}b
Or
yy PRv}˘˙uR˙ov]]oo]v ~Pv]]oo]vV ZU}oU
Adults
æuPR}o˙(}˙b
Children
vr˙bV æuPR}o˙(}˙b
Or
yy E˙R}u˙]v U}oU~(}vbooP]}v]]oo]vZ
Adults
æuPR}o˙(}˙b
Children
r˙bV æuPR}o˙(}˙b
Av
]v
E RvPPB
yy AspirinU}oU
Adults
rı uP rv R}o˙ vo i}]v˙u}ub
b o]U v Poo˙
`]R`}r`lbX
Children
u}vRr˙bV æ uP llP v R}o˙ vo i}]v˙u}ub
b r
o]UvPoo˙`]R`}r`lbX
Or
]v
E RvPPB
yy I}(v U}oU
Adults
v
Standard Trtme
Children
ræuP llPvrR}o˙~u˘XuPlP]o˙Z
BXTuv}(RRu A F `]R]bC
Ab]vRuv}}v[A }
Av
yy Pv]b}o}v U}oU
Adults and Children
uP llP]o˙(}`lbvRvPoo˙}+˙ræA9
`l(}r`lbX
CXTuv}(RRuA F with Heart Failure
Ab]vRuv}}v[A }
Av
Tuv(}R(]o~Sb}v}vRH(]o[Z
X
D S}v˙v}v~}R˙o˘]bZ}(Ru(v
RuR]bb
st
L]vTuv
yy BvR]vv˙ov]]oo]v UIMU
v*DizzinesandBlackouts*v
AHlP}˙`]PRV UUU
AMlP}˙`]PRV æuP~vUUZr`lo˙
nd
L]vTuv
yy PRv}˘˙uR˙ov]]oo]v ~Pv]]oo]vV ZU}oU
Adults
æuPR}o˙]o˙
Children
vr˙bV æuPR}o˙
ræ˙bV æuPR}o˙
Or
yy E˙R}u˙]v U}oU~(}vbooP]}v]]oo]vZ
Adults
æuPR}o˙
Children
r˙bV æuPR}o˙
r˙bV æuPR}o˙
r˙bV æuPR}o˙
Refealr Criteria
R(oovb}]]]vUR˙b]]vb]o]b}]}o}P]b
bvbb˙(}(RuvPuvX
57. Dizziness and Blackouts

D]]vbb ]b v}vb]. u R (b } v}uo bvb}v
}( }˙ }]v}v } }b]}v ]v bX TRb ]vo (o]vP }(
vb]vbbU o]PRrRvbb v P} X Pvb }Lv .v Rb
v
der theCardiovcula
sa rSystem
bvb}vb ]8o } b]X D]]vbb ]b ou}b o`˙b b}]
`]R }R ˙u}ub
b U R(} (o R]b}˙ v (}b R˙b]o
˘u]v}vbR}o(}u]voo}b ]v(˙RbX
L]l ]]vbbU Sol}b _ ]b PU b] u ]uo˙]vP
]R o}vb]}bvbbU ]bo ]bv } bvb}v }( (oo]vPX
(o A R]b}˙Uoo˙(}uv˙r`]vbbU]bbvoX
Episodes of transient disturbance of consciousness and falls are
}uu}v o]v]o }oubX I ]b boo˙ }bb]o } ]bvP]bR `v
.~b]ZUv]b}}((]vvPv}R˙b}('l(}uR
R]b}˙P]v˙RvvR}v}(v˙`]vbbX
sueCa
Cardiovascular
yy Vb}Por~(]vvPZ
yy P}boR˙}vb]}v
yy Ru}RPA
yy ]C R˙Ru]b
yy S}v}b b ]b
yy C}uoRo}l`]RS}lbrAub'lb
yy V}rb]o]vb8]v˙
Cerebral
yy Tvb]vIbRu]'lbA ~TIA Z
yy Stroke
yy Epilepsy
Others
yy DPr]v
yy Svu]
yy H˙}Po˙u]
yy Middle ear disease
yy Mv][b]bb
yy Conversion disorder~H˙b]o(]vvP lH˙vo}vZ
Symptoms
yy L]PRrRvbb
yy L}bb}(}vb]}bvbb
yy Svb}(u}}v}b]vv]vP}(}˙
yy Uvb]vbb
yy Nausea
yy V}u]vP
yy Tinnitus
Signs
yy S`vP~bPPbb}Po]b}lR˙}Po˙u]Z
yy Tachycardia}˙]~bPPb]R˙Ru]Z
yy Hypotension
yy P}boR˙}vb]}v
yy Poo}
væ
Standard Trtme
yy N˙bPubU ˙b]}R}l]vb]bU ˘] U R˙}}v]U ˙bR]
~bPPboo
b bZ
yy F}ov}o}P]ob]PvbbPPb}l b UTIA
Invtiga
se tions
yy TRb˙v]vP}vRb
yy FBC
yy Rv}uo}}bP
yy Xr˙}(]ob]v
yy ECG
Trtme
ae nt
Tuv}ib
yy T} ]v(˙ v }]o˙ uvP R }bb]o vo˙]vP
b~bZ
yy P}boR˙}vb]}vr]ù]}vb
yy H˙vo}v˙v}u b rR]vP}v}o˘]b
yy C}vbo]vP
yy Cervical collar
yy M}o]o]oo}`b
yy TRvo˙]vPbX~S}]b}vZ
Refealr Criteria
R(vb } R˙b]]v b]o]b (} o}v ]( R b ]b
]8o } u]vX I( R b ]b ]v.U ( } R }]
b]o]b(}(Ro}vvuvPuvX
v
Chapter
Disorsof
der the
Respirtor
a ySystem
58. Common Cold

TR]b ]b bo(ro]u]vP ]v(}v }( R b]}˙ U
oo˙ R vb}R˙vPo u}b v b]vbbX I ]b }vP]}b
v b ˙ ]}v }obU b òo b (}u Rvb v }v
`]R }vu]v b(bX TR ˙u}ub
b b}o `]R} v]}
uvUboo˙`]R]v`lX
I(RR}o[obo}vP
b Rv`lvR]bb]bv(v
}PRU ]Pv}b]b}(]vGvu˙ }vb]XW]R]vGvU(U
˙bb u] ˙u}ub
b v }b}v u} }v}vX S}v˙
]o ]v(}v u˙ b}] `]R ov RoPu } }+vb]
vbo]bRPv(X
Ob]}voo˙U R }uu}v }o ]b }uo] ˙ }b u] and
R˙vP}}vb]oo]bUoo˙]vR]ovU]v`R]R}v b bR}o(
}R}]b}vb(}uvX
sueCa
yy Rhinoviruses
yy Corona viruses
yy Rb]}˙S˙v˙oV]b~RSVZ
Symptoms
yy Rvv˙v}b~R]v}RZ
yy Sv]vP
yy Nbo}vPb}v
yy Mild fever
yy Headaches
yy Sore throat
yy Muscle aches
yy C}PR
yy FP
yy Malaise
Signs
yy L}`P(
yy Nbo]bRP
vw
Standard Trtme
yy Nbou}bv]vP
yy W]vP}(˙b
Invtiga
se tions
yy N}]vbP}vb]
Trtme
ae nt
Tuv}ib
yy T}o]˙u}ub b
yy Rb}o}v}(]v(}v]vRbR}b}bb]ou
yy Rest
yy Ev}PG]]vl
yy GPoolùbob}o}v
yy Su]vRo}v
AXUv}uo]}uu}v}o
st
L]vTuv
]v
E RvPPC
yy Pu}o U}oU
v*Commonold
Adults
ærPvrR}o˙
C *v
Children
ræuP llP l}bvrR}o˙
Av
yy S}]uCRo}] XıA9Uvbo}bU
Adult and Children
}bU]v}Rv}b]oUR}o˙}o]}vPb}vvbb b˙
Or
yy X˙o}u}o]v UvboU
Adults~XA9}vZ
r}bR}o˙]v}Rv}b]o
Children~XæA9}vZ
ANu}vRbV r}bR}o˙]v}Rv}b]o
Av
yy ]]v
C U}oU
Adults
uP]o˙
Children
AN˙bV uP]o˙
vr˙bV æuP]o˙
rv˙bV XæuP]o˙
v
Chatep rP *Disorsof
der theRespirtor
a ySystem
Or
yy C Ro}Rv]u]v uoU}oU
Adult
uPR}o˙
Children
vr˙bV uPvrR}o˙]o˙~u˘XuP]o˙Z
rv˙bV uPvrR}o˙~u˘XvuP]o˙Z
r˙bV v}}uuv
Note 8-1
Av]}bv}]v](}}uu}v}oX
Refeal
r Criteria
R(}b RubobU]vGv}}uo]}vb}
]]]v}R˙b]]v(}uvPuvX
59. Pneumonia
Pvu}v] ]b v ]v(}v }( R ovP b b ˙ ]}b
]U ]bb } (vP]X Iv.}v }( R b }Pv]bu v
Pbvb]]˙vP b ]bRl˙}}uvXH}Ùb
v*Pneumonia*v
}( R b]}b v }( R ]v(}vU v]} uv bR}o
]uu]o˙
b b}vlv}òP}(Ru}b}ob
}Pv]bu v R v]}b b (} ]buvX L}o lv}òP }(
P b]bv 'vb ob} lv ]v} }vX Tuv u˙
u]v]v } RvP b }v o bob v buv }( R
v[b b}vb } ]v]o uvX Iv R v R R ob }(
o}} } bu } vPU u]] uv ]b }vv `]R
o]v]ob}vbbP]X
TR]˙ b }(R]oovb]bb l˙(}]vR]b]}v(}u]bb]}vU
vRR}]}(.b}}v b ro]vuvX
B}˘rP) S]˙}b (}}uuv]˙]vu}v]~CURBrvæZ
S]˙}b u˙}v
b R(}oo}`]vPUb]Pv]vP}v}]v}R}(R
(}oo}`]vP(}b~u˘]uuæ}]vbZV
yy C}v(b]}vUobb bvbbU}˘bb]}`b]vbb
yy Bo}}UN]}Pv~ANwuu}olLZ
yy Rb]}˙~AHu]v]vobUvAHæ]vR]ovZ
yy L}`BP~S˙b}o]BPAMıvl}]b}o]BPAMvuuHPZ
yy PvbR˘ub}(PU~AMæ˙}AHvæ˙Z
rV}vb]R}uuv
rV}vb]bR}]vvR}b]o]b}v
ANVu]v}vb]]vvb]
vı
Standard Trtme
B}˘rP) S]˙}b (}}uuv]˙]vu}v]~CURBrvæZ

Iv Rbvv˙}( R(}oo}`]vP ]}vo (}bUoob}( vu}v]
`}o`vR}b]o]b}vX
A]}vo(}b
yy C}˘]bvP]bbRbR}v]ovP]bbUR(]o}vo]b r
ease
yy E˘vb]]bbUuooo}b]v}o
yy L}`}˘˙Pv}v b SO UAMıA9}v}}u]
yy Severe tachycardia
sueCa
Community acquired pneumonia
yy Streptococcus pneumonia
yy Streptococcus pyogenes
yy Haemophilus influenza
yy Klebsiella pneumoniae
yy M˙}obuvu}v] and Legionella pneumophila (tend to occur
]v]u]bZ
yy Staphylococcus aureus ~]v R]ov L ]o ]oovbb o]lubobU ]v
]b}]vRoo˙]vPRG[]u]bZ
Ab]}vvu}v]
v*Pneumonia*v
yy Av}] vl} Pu vP }Pv]bub ~bb}] `]R

b]}vXPX}lb Ub]bUv}vb]}bvbbZ
Hospital acquired pneumonia
yy GurvP]XPX Pseudomonas aeruginosa
yy MRSA~MR]]oo]vb]bvZ
yy VRSA~Vv}u˙]v b]bvZ
yy Staphylococcus aureus
Others
yy Pneumocystis jiroveci vu}v] v }R (vP] ~]v
]uuv}}u}u]bbXPXRu}o}P]ouo]Pvv]bUHIV l
AIDS Z
yy V]bb
Symptoms
yy F rbR}R]b}˙
yy P}}PR
yy Sur˙b }o}}]v b U˙oo}`]bRUPv]bR
yy Po]Rb]v r`}b}vR]vP}}PR]vP
yy Rob B bvbb
yy S`vP
yy Muscle aches
yy Eoo˙v]uuv}}u}u]bvbu˙Ru]v]uu}v}
˙u}ub
b
Signs
yy R]R]vP
w
Chatep rP *Disorsof
der theRespirtor
a ySystem
yy GvvP~]vR]ovZ
yy Ub }( b}˙ ubob }( b]}v v G]vP }( R vbo
uP]vb
yy L}`Rbòo]v`]vP~]vR]ovZ
yy Rb]u}uv}(R+b]}(RRb~}]vZ
yy F
yy Rapid pulse rate
yy Bo}}u˙ b v}uo}o}`
yy S]Pvb}(}vb}o]}v}oo+b]}v}vRb˘u]v}v
yy Rbobbvbb}}v(b]}vU}`b]vbb
yy L}ò}}}˘˙Pv}v b ˙ob}˘]u˙AMıA9
omp
C lictionsa
yy Poo+b]}v
yy LvPb
yy Eu˙u
yy P]]o+b]}v l]]b
yy Pvu}R}˘ oo˙ Staph. aureus ]v(}vU Pneumocystis
jirovecivu}v]
yy Mv]vP]b
yy Su]`]Ruo}Pv(]o
v*Pneumonia*v
yy Aob]}˙]b˙v}ub ~ARDSZ
Invtiga
se tions
yy FBC
yy Cr}]v ~CRPZ
yy CRbXr˙
yy SuPu]v b vovbvb]]˙
yy Z]RorNobv]v b (}]r(b]oo]~}˘oTBZ
yy Bo}}ovbvb]]˙
yy Bo}}vo}o˙b
Trtme
ae nt
Tuv}ib
yy T} ]v(˙ vb P ]bl `R} ] ]vrR}b]o
uvPuv
yy T}oo]˙u}ub b
yy T}v]R]v(}v
yy T}vvl}uvP}uo]}vb
yy Nb]v}u(}o}b]}vUboo˙`]RR]b
yy S}vP]vP}}v}o(Ub]oo˙]vR]ovAMæ˙b~`R}
]bl}((]o}vob]}vbZ
yy }o A R˙}v~](]v}oZ
yy Chest physiotherapy
w
Standard Trtme
AX Auo}˙vPo}`]˙ b }b AM~b}Z
st
L]vTuv
]v
E RvPPA
yy Au}˘]]oo]v ~Au}˘˙]oo]v U Z }oU
Adults
PR}o˙(}˙bw ~R]PR}bZ
Children
ær˙bV æuPR}o˙(}˙bw
ræ˙bV æuPR}o˙(}˙bw
vu}vRbr˙V æuPR}o˙(}˙bw
Av
yy A ]R}u˙]v U}oU
Adult
æuP]o˙(}˙bv
Children
uP llP]o˙(}˙bv
Or
yy E˙R}u˙]v U}oU~](v]booP]}v]]oo]vZ
Adult
v*Pneumonia*v
æuPvR}o˙(}˙bw
Children
r˙bV æuPvR}o˙(}˙bw
vu}vRbr˙bV æuPvR}o˙(}˙bw
nd
L]vTuv
]v
E RvPPA
yy (}˘]u
C U}oU
Adults
æuPR}o˙(}˙bw
Children
u}vRbr˙bV uP llP l˙ ]v `} ]] }bb (} w
days
AN˙bV æræuPR}o˙(}˙bw
Or
yy D}˘˙˙o]v U}oU
Adults
uPR}o˙(}wr˙bv]vP}v]˙
b
Note 8-2
N} }uuv ]v Pvv˙U ovP u}Rb v ]v R]ov AM ˙b
}(PX
w
Chatep rP *Disorsof
der theRespirtor
a ySystem
BXH}b]o]bvPS]˙}b UAH}`]R]}vo(}b
buv}v}
yy O˘˙Pv U˙(ubl}vbo}vPbU
Adults and Children
M]v]v}˘˙Pv}vb ANıA9
Av
yy IV G]b b v}uo bo]v v ˘}b bo]v } o ub
insensible loss
Av
yy Pu}o U}oU
Adults
æuPrPvrR}o˙
Children
Or
yy Pu}o suppository
Adults and children
doses as above
v*Pneumonia*v
Av
yy A u}˘]]oo]v A= Coov] A] U IVU ~RvP} }o}`Rvv
]u}bZ
Adults
XPR}o˙(}wr˙b
Children
u}vRbr˙bV uP llP R}o˙U u˘X X P R}o˙ (}
wr˙b
AMu}vRbV uP llPR}o˙(}wr˙b
Av
yy A ]R}u˙]v U}oU
Adult
æuP]o˙(}r˙bw
Children
uP llP}v]o˙(}r˙bw
Or
yy A]R}u˙]v UIVU
Adult
æuP]o˙(}˙b
R}}o]R}u˙]vU`Rvo]v]oo˙ob }}uo˙bw
}( uvX ~S b}v }v uv (} uo}˙ vb
}ZX
Children
IV}v}}uuv]vR]ov(}vu}v]uv
w
Standard Trtme
Note 8-3
A]R}u˙]v ]v(b]}vbR}ov} P]v]vbR}Rv R}XIbR}ov}
P]vbvIV}ob}bv]vubo]vi}vX
nd
o]vuv
]v
E RvPPA
yy L]˘}v
C UIVU
Adult
P]o˙(}wr˙b
Children
AooPbæuP llPR}o˙~u˘XwæuP llP]o˙Z
Av
yy A]R}u˙]v UIV~b}Z
CXTuv(}b]}vvu}v]
st
L]vuv
]v
E RvPPB
yy L]˘}v
C UIVU
Adult
P]o˙(}wr˙b
Children
AooPbærwæuP llP l˙]v]]R}o˙}bb
v*Pneumonia*v
Or
yy Au}˘]]oo]v A= Coov] A] U IVU ~RvP} }o}`Rvv
]u}bZ
Adults
XPR}o˙(}wr˙b
Children
u}vRbr˙bV uP llP R}o˙U u˘ X P R}o˙ (}
wr˙b
AMu}vRbV uP llPR}o˙(}wr˙b
Or
yy C]}G}˘]v UIVU~}u]v]b}vu]vbZ
Adults
uPrR}o˙(}˙bw
Children
uP llP~u˘XuPZR}o˙(}˙bw
Av
yy M}v]}o UIVU
Adults
æuPR}o˙(}˙bw
Children
Or
yy Co]vu˙]v UIVU
Adults
rvuPvR}o˙(}˙bw
w
Chatep rP *Disorsof
der theRespirtor
a ySystem
Children
rvuP llPvR}o˙(}˙bw
Refeal
r Criteria
R(} R ]]]v } R˙b]]v b]o]b ]( v} ]u}uv
}b ~]XX (u]vb R]PRUv]boo b RobbU } Xr˙b
bR}`}uo]}vb}v}b}o}vZX
60. }vR]o
B Ru
Ab
Ru
Ab ]b R}v] ]vGuu}˙ ]bb }( R }vR]o ]`˙bU
`R]Ruv](bbv]b}b}(`RU}PRURbPRvbb
v bR}vbb }( RU `R]R ]b boo˙ b]o `]R uvX I
]b R]b ˙ ]vb bvb]]˙ } uv˙ v]}vuvo PvbX
Ru Ab ]b ]o v u˙ b}] `]R b}vb o]l R ]v˙
b}v } Ru'vX }vR]o B Ru
b }b oo Pb lb ]v
R]oR}}X I ]b obb]. b v ooP] ]bbU v u˙ b}]
`]Rb}vo}(u]o˙R]b}˙}(ooP]R]v]b ~R˙(ZUu or
ooP]}viv]bX
C}uo]}vb }( Ru b ]vo vu}u]bvuU
v*Bonc
r hialthma
vu}R}˘Uv}b b uR˙buvvu}v]X
sueCa
As *v
yy AooPvb XPX R}b b u]U }l}R }]vPbU PbbU }oov
vv]uoR]
yy Ev]}vuvo (}b XPX ] }oo}vU o]u RvPbU }vP b
bvbvbu}l~]vo]vP]P'bu}lv(ubZ
yy V]o]v(}vb
yy E˘]b
yy Eu}}vbvR˙vo}v
yy DPbXPXb]]v UNSAIDSvro}lbbR}v}o}o
b
yy O}vo ˘}b } ]vb]o Ru]obU b v P
uv(]vP
Symptoms
yy Episodic breathlessness
yy T]PRvbb}(RRb
yy C}PR r}Lvv}vo
yy WR
yy N}vo ˙u}ub b X Av˙ }( R } ˙u}ub
b `l]vP R
vv]PR
Signs
yy Tachypnoea~(bR]vPZ
yy Ub }( b}˙ ubob }( b]}vV vl vl} }u]vo
ubob
yy RR}vR]l`R
wæ
Standard Trtme
yy S]Pvb}('lb
yy Iv]o]˙}}uo(oobvvb]v}vR
yy R] ob AN lu]v ]v ob v }obvb } ANl
u]v]vR]ovræ˙b
yy R]b]}vANlu]v]vobv}obvb}}AN
ælu]v]vR]ovræ˙b
yy PlE˘]}˙Fo}`R~PEFRZ]bAMæA9}(˘
~(}PU˘b vR]PRZ
yy S]Pvb}(o](rRv]vP'lP
yy Cyanosis
yy Pob}˘b b
yy S]ovRb}vbo}v
yy }`bD ]vbb}}v(b]}v
yy E˘Rb}v
yy Pl E˘]}˙ Fo}` R ~PEFRZ obb Rv A9 }( ˘
value
yy SOobbRvıA9}v}}u]
Invtiga
se tions
yy N}]vbP}v]]vu}bb
yy FBU C u]oo˙R]PR}b]v}R]o}v
v*Bonc
yy CRbXr˙~}vo˙(}R˘ob]}v}(}R]Pv}b}b }uo]}vbZ
r hialthma
yy S]}u˙ r}v]vFEVvFEVlFVC}`]Rb]]o]˙
As *v
u}vb L }vR}]o} b ~ v}uo b]}u˙

`v'lb}bv}˘oRu
b ZX
yy Tbb(}}˙rbl]v]l}b b].IPE(}}uu}vooPvb
yy S}}o˘u]v}vU˘oRou]vR]b]b
Trtme
ae nt
Tuv}ib
yy T}o]}vR}bbu
yy T}v}uo]}vbvv
yy T}vo˙]vP]vGuu}v}]v(}v
yy }] A lv}`v ]PPblooPvbU bR b b ~b u]Z `R
possible
yy }] A bu}l]vP
yy }v E }vRu
b bo(uvPuvU]bvRv]
AXE˘}v
A }(Ru Ab PIv]oMvPuv]vR
Community
]v
E RvPPC
yy Sou}o ]vRoU b]vP b] u }b ]vRo ~MDIZ
`]Rb
Adults and Children
G] r +b ] b v ubl ]( v ~XPX V}ou Or
wv
Chatep rP *Disorsof
der theRespirtor
a ySystem
}Ru
A U}oPobu]vo`}'oZ`]RRv
l]vPrRbLR+X
RL˙æru]vbu˘]uu}bbX
I(R]bv}]u}uvblRoR(]o]˙`]Rv r
o]bX
BXM}
A lSE˘}v}(Ru Ab PIv]o
Management in Hospital
st
L]vTuv
]v
E RvPPA
yy O˘˙Pv
˙B vbo}vPbrvLlu]v
Or
Fubl rLlu]v
Or
N}vrRubl ræLlu]v
Av
yy Sou}o Uvo]bU
Adults
XæræuP]v]oo˙Læru]vbURv˙rR}b
v*Bonc
vo]u}
r hialthma
Children
XæræuP˙rR}bvo]u}
As *v
And
yy I}]u}u] Uvo]bU
Adults
æu]}PurvR}o˙
Children
vr˙bV æu]}PurvR}o˙
ræ˙bV æu]}PurvR}o˙
~u˘X}b(}R]ov]buP lR}bZ
And
yy H˙}}b}v UIVU
Adults
uPX b RvuPvR}o˙voo]v]o]u}uv
Children
r˙bV uPvrR}o˙
u}vRr˙bV ruP llPR}o˙
Then
CXM}
A lSE˘}v}(Ru
Ab : Maintenance
Treatment in Hospital
yy Sou}o Uvo]bU
Adults
XæræuP˙vR}bvo]u}
Children
w
Standard Trtme
XæræuP˙vR}bvo]u}
Av
yy I}]u}u] Uvo]bU
Adults
æu]}PurvR}o˙
Children
~u˘X}b(}R]ovuP lR}bZ
N}r
F}R]ovAM˙b`]R˙u}ub
b }vb]V
I}]u }u] U æ u]}Pu ˙ r u]vbU (} R
.bR}bURvrvR}o˙bvbb˙
Av
yy Pv]b}o}v U}oU]v]o}bP]v}vu]bb]}vvbvo˙
P]vbu}v]vP}bX~Ov}vv]b}o}vU}b IVR˙}} r
soneLR}bZ
Adults
ruP]o˙(}˙bw voob XT}+}b}]}}(
`lb](vRbv}vo}vPu}]b b X
v*Bonc
Children
r hialthma
ruP llP(}ræ˙b
As *v
X
D M}
A lSE˘}v}(Ru
Ab : Maintenance
Tuv]vH}b]o~`Rv]boo b ]bL
b r
]v]o}bb}(vo]bbou}oZ
yy Au]v}R˙oo]v UIVU
Adults
æuPbo}`]vi}v}u]vb
R L u]vb `]R }vv}b ]v(b]}v ˙ (b}U ](
vbb˙Uv}˘]vPXæuP llP lR}}R}b
Or
yy Au]v}R˙oo]v UIV]v(b]}vUæuP]væuo}(æA9˘}b D }XıA9
S}]uCRo}] UvR}o˙(}R}b
Children
æ uP llP } u]vb b o}` ]v(b]}v } ˙ (b} uP l
lP lR}~u˘XæuPZ
EXCR}v]Ru
Ab rIv]ouvPuv
]v
E RvPPA
yy Sou}o U]vRoU
Adults and children
u]}PuU+bb}Lvbv
Av
~I(]vRoSou}o ]bvu}Rv}v]o˙Z
yy Bb}v] U]vRoU
Adults
w
Chatep rP *Disorsof
der theRespirtor
a ySystem
u]}Pu~}v+R}o˙Z
Children
AN˙bV u]}Pu~}v+R}o˙Z
AM˙bV u]}Pu~}v+R}o˙Z
Or
yy Fob}v UIvRorMDIU
Adults
æræu]}Pu~+bR}o˙Z
Children
æu]}Pu~+bR}o˙Z
Or
yy Bo}ub}v ~Bo}uRb}v ZU]vRoU
Adults and Children
u]}Pu~+bR}o˙Z
FXCR}v]Ru
Ab - Maintenance treatment
yy Sou}o U]vRoU
Adults and children
u]}PuU+bb}Lvbv
Av
v*Bonc
yy Fob}v lSou}oU]vRoU
r hialthma
AdultsvR]ov}æ˙b
lærælæu]}PuV+R}o˙
As *v
Or
yy Bb}v] lF}u}}oU]vRoU
Adults
vlXæu]}Pu~r+bR}o˙Z
Children}æ˙b
lXæu]}Pu~r+bR}o˙Z
Av
yy MontelukastU}oU
Adult
uP]o˙
Children
}æuPPvob]o˙
vA
yy Pv]b}o}v U}oU
Adults
r uP ]o˙ v ]o }`v bo}ò˙ } r `l ]} } o}`
u]vvv]o˙}b}(æuP]o˙X
Children
uP llP]o}+˙æuP˙R]˙U]vP}æruP]o˙
}ov]o˙Uo}`b}b}bb]o`]R}}}l]vP'lb
wı
Standard Trtme
Note 8-5
R]ùv˙rvu}vRb`]R]`}]vP
b }`vuv](
o]v]b˙u}u
b r(}Rbu]v]uo˙u}ub
b ~AMrubu}vRZX
Aoo vb `]R R}v] Ru
Ab bR}o ] }vv}b }v v
}vboo]vP˙Ru]ouX
Refeal
r Criteria
Iv ˘}vU ( vb ]( v} ]u}]vP } ]o˙
]}vPL]v]ouvPuv}b]o]bX
Aoo ]bRP o]vb bR}o (}oo}` `]R]v }v `l v
(}b]o]bo]v](}}vvX
F} R}v] Ru b ( vb `]R b]bv ˙u}ub
b }
b]o]b o]v] ]v P]}vo } ˙ R}b]oU v vb `R} R
v˘}vb`]R]v(`˙bl`lb}(R}R(}
b]o]bv]`}(R]uvX
Aob} ( `Rv v ]b u} Rv }v }b }( }o
v]b}o}v]vu}vRbX
61. }vR]b
BA
TR]b (b } v ]vGuu}v }( R }vR]o u}bX I ]b
v*Acuteonc
Br hitis*v
}Lv (}v ]v b}]}v `]R b]}˙ ]v(}vX M}b

b } v} ] v]}bU R}Ù R˙ u˙ b] ]( R
v[b SPO ]b obb Rv ıA9 } ]( R ]b v vo˙]vP }ru}]]˙
o]l uov]}vU ubobU ]lbU vu]U ]b uoo]bU R}v]
}vR]b}HIV lAIDS X
sueCa
yy V]bbXPXIvGv]b UC}}v]b ~}uu}v}oZ
yy ]B XPX Streptococcus pneumoniaeU H. influenzaUMoraxella
catarrhalisU Staph. aureus ~vb } b }br]vGv Rb
]v(}vbU]vo]vP}vR]bZ
Symptoms
yy D˙}PR
yy Su}}v
yy Sore throat
yy Po]Rb]v
yy L}`P(
Signs
yy F
yy Rhinorrhoea
yy RR}vR]~`RZ
yy ]}vb C ~Z
Invtiga
se tions
yy FBC
Chatep rP *Disorsof
der theRespirtor
a ySystem
yy SuovPu]v b
yy Su AFBb ~ buobZ (} o}b]b ]( ˙u}ub
b R ob
u}Rv`lb
yy S]vbXr˙(}R]v}b]vb]b~`]R}bvbo]}bb Z b]ob
(}}o}vP}PR
Trtme
ae nt
Tuv}ib
yy T}o]˙u}ub
b
yy T}]o b ]v(}v](v˙
yy b B
yy OoG]b}lòoR˙
yy Hu]].]}ub ]vRo}v](vbb˙
AXUv}uo]]v(}vb
st
L]vTuv
]v
E RvPPC
yy Pu}o U}oU
v*Acuteonc
Adults
Br hitis*v
æuPrPvrR}o˙
Children
Or
yy Pu}o UoU
Adults
æuPrPvrR}o˙
Children
BXUv}uo]]v(}vbr(}]]vP}Rb˙}PRb
yy Guaifenesin}v]v]vP˘}vU}oU
Adult
ruPR}o˙~u˘XXP˙Z
Children
AN˙bV ruPR}o˙~u˘XXP˙Z
vr˙bV ruPR}o˙~u˘XXP˙Z
ræ˙bV æruPR}o˙~u˘XvuP˙Z
vu}vRbr˙bVæræuPR}o˙~u˘XuP˙Z
Or
yy S]uoo]vb U}oU
Adults~o(}uo}vZ
æuovrR}o˙
Standard Trtme
Children~]](}uo}vZ
u}vRr˙bV XæræuovrR}o˙
Or
yy CarbocysteineU}oU
Adult
ærwæuPvrR}o˙
Children
ræ˙bV vXæræuPvR}o˙
AM˙bV v}}uuv
CXUv}uo]]v(}vbr(}v}vr}}˙}PR
yy ˘}uR}Rv
D }v]v]vP}PR}vb
Adult
ruPvrR}o˙
Children
wr˙bV æuPvrR}o˙~u˘XvuP˙Z
rv˙bV wXæuPvrR}o˙~u˘XuP˙Z
AM˙bV v}}uuv
Or
yy Codeine}v]v]vP}PR}vb
Adult
v*Acuteonc
wXæruPrvR}o˙bv~u˘XuP˙Z
Br hitis*v
Children
wr˙bV rXæuP llP˙]vrv]]}bb
~u˘XvuP˙Z
rv˙bV rXæuP llP˙]vr]]
v }b~u˘
b XuP
˙Z
AM˙bV v}}uuv
X
D F}}uo]]v(}vb`]R}ru}]]b}}v˙
b
]o]v(}v
st
L]vTuv
]v
E RvPPC
yy Au}˘]]oo]v ~Au}˘˙]oo]vZU}oU
Adults
æuPR}o˙(}ær˙bw
Children
vr˙bV æuPR}o˙(}˙bw
AM˙V vXæuPR}o˙(}˙bw
Or
yy Au}˘]]oo]vA=Coov]A] U}oU
Adults
PR}o˙(}ær˙bw
Children
AN˙bV OvælæoR}o˙(}˙bw
r˙bV æuo}(læwbvb]}vR}o˙(}˙bw
r˙bV æuo}(lbvb]}vR}o˙(}˙bw
Chatep rP *Disorsof
der theRespirtor
a ySystem
u}vRbr˙VuP llP~}(u}˘]]oo]vZR}o˙(}˙bw
AMu}vRbV æuP llP~}(u}˘]]oo]vZR}o˙(}˙bw
F}R]ov}oR}b}(R}v]}]v]v( b r
}vb~}vR}vu}v]Z
Or
yy E˙R}u˙]v U}oU~(}]v]]obooP]}v]]oo]vZ
Adults
æræuPvR}o˙(}˙bw
Children
r˙bV æræuPvR}o˙˙bw
r˙bV æuPvR}o˙˙bw
vu}vRbr˙bV æuPvR}o˙˙bw
Or
yy A]R}u˙]v U}oU
Adults
æuP}v]o˙(}˙b
Children
uP llP}v]o˙(}˙b
Av
v*Chroniconc
yy O˘˙Pv
˙B vbo}vPbUrvLlu]v
Br hitis*v
Or
FublUrLlu]v
Or
N}vrRublUræLlu]v
Refeal
r Criteria
R(oo}uo]b}(}vR]b}b]o]bX
62. CR}v]}vR]b
B
TR]b]bR}v]]vGuu}v}(R}vR]ou}b}]]vb
bR b }} bu}lX I }b L R P }( ˙b v ]b }(
R˙v}u
b }(R}v]}bou}v˙]bb~COPD ZXTR]b
}Pbb]`}bv]vP`]RPUvoo˙bovP]vR}v]b]}˙
(]oXI]bPP˙v]ov]o]v(}vbX
O˘˙Pv R˙ ]v Rb vb ub P]v `]R }v }
v }v ]}˘]v}v } b]}v }( b]}vX H]PR
G}` b u} R vo R˙}˘] ] R u]v]vb b]}˙
+}vvRu(oX
sueCa
yy C]P'bu}l]vP
yy Ivb]ob
yy CRu]o]]vb
yy IvRobu}l(}ub}(]}ubb(ob~PXR}oU`}}Z
Standard Trtme
Symptoms
yy SR}vbb}(RUoo˙}v˘}v
yy WR
yy F
yy C}PR `]R}}v}(bu(}u}b}(R˙
yy Iv( ˘}v b}] `]R ]vb v˙ }( R]l
ovbu
Signs
yy May be none
yy oB Rb
yy Pbo]R]vP
yy Co]vP
yy Cyanosis
yy Ivbb]}˙
yy Ub }( b}˙ ubob ]XX vl vl} }u]vo ubobU (}
R]vP
yy Hyperresonance on percussion and loss of cardiac dullness
yy WR}R}vR]
v*Chroniconc
yy RPlE˘]}˙Fo}`R~PEFRZ
Invtiga
se tions
Br hitis*v
yy FBC
yy S]}u˙ UbR}`b ovP}oubUoo˙FEV`R]R]b
v}b}br}vR}]o}u]v]b}v
yy CRbXr˙
yy SuovPu]v b
Trtme
ae nt
Tuv}ib
yy T}u]v]u]b}}b }PR
yy T}v}u]v]u]b`RvbR}vbb}(R
yy T}v˙}(bu}
yy T}v]v(˘}vb
yy Su}l]vP}v b
yy PR˙b]o˘]b
yy G}}v]}v
yy Ub}((ubl]vR]PR]bl}}vb
AXSoR}v]}vR]b
]v
E RvPPB
yy Sou}o U]vRoU~]MDIZ
Adults
u]}Pu~+bZrvR}o˙]b
Chatep rP *Disorsof
der theRespirtor
a ySystem
Children~˙vo]b}vZ
XæræuPrvR}o˙]b
vA
yy T]}}]u U]vRo~˙}`]vRoZU
Adults
u]}Pu~+bZ]o˙
Children
AN˙bV u]}Pu~+bZ]o˙
AM˙bV v}}uuv
Av
yy Fob}v lbou}oU]vRo~]Ro}MDIZU
Adults
læ u]}Pu } ælæ u]}Pu } ælæ u]}PuU
+R}o˙
Children
r˙bV læu]}PuU+R}o˙
AM˙bV (˙
b v}o]b
b R
Or
yy Bb}v] l(}u}}oU]vRo~]Ro}MDIZU
Adults
v*Chroniconc
vlXæu]}Pur+bR}o˙
Br hitis*v
Children
AN˙bV vlXæu]}Pur+bR}o˙
AM˙bV 8˙v}o]b
b R
BXCR}v]}vR]b`]R]v(˘}v
]vE RvPPC
yy O˘˙Pv
˙B vbo}vPbUrvLlu]v
Or
FublUrLlu]v
Or
N}vrRublUræLlu]v
Av
yy Sou}o Uvo]bU
Adults
XæræuP]v]oo˙Læru]vbURv˙rR}b
vo]u}
Children
XæræuPrvR}o˙
vA
yy I}]u}u] Uvo]bU
Adults
æu]}PurvR}o˙Uvo]u}
Children
æ
Standard Trtme
~u˘X}b(}R]ovuP lR}bZ
Av
yy A u}˘]]oo]v ~Au}˘˙]oo]vZU}oU
Adults
æuPR}o˙(}wr˙b
Children
vr˙bV æuPR}o˙(}wr˙b
ræ˙bV æuPR}o˙(}wr˙b
AM˙V vXæuPR}o˙(}wr˙b
Or
yy E˙R}u˙]v U}oU
Adults
æuPvR}o˙(}wr˙b
Children
r˙bV æræuPvR}o˙wr˙b
r˙bV æuPvR}o˙wr˙b
vu}vRbr˙bV æuPvR}o˙wr˙b
Or
yy A]R}u˙]v U}oU
v*Chroniconc
Adult
Br hitis*v
æuP]o˙(}˙bv
Children
uP llP]o˙(}˙bv
Or
Adults
PR}o˙(}wr˙b
Children
AN˙bV OvælæoR}o˙(}wr˙b
r˙bV æuo}(læwbvb]}vR}o˙(}wr˙b
r˙bV æuo}(lbvb]}vR}o˙(}wr˙b
u}vRbr˙VuP llP~}(u}˘]]oo]vZR}o˙(}wr˙b
AMu}vRbVæuP llP~}(u}˘]]oo]vZR}o˙(}wr˙b
Av
yy Pv]b}o}v U}oU
Adults
ruP(}˙bw
Then
uP]o˙(}æ˙bU uP]o˙(}æ˙bUæuP]o˙(}æ˙bX
T]o}`v}r`lbv}b X
Children
ruP llP(}ræ˙bXT]o}`v}r`lbv}b X
Av
yy AcetylcysteineU}oU
v
Chatep rP *Disorsof
der theRespirtor
a ySystem
Adults
uoR}o˙(}ær˙bw
Children~]](}uo}vZ
æruoR}o˙(}ær˙bw
Or
yy CarbocysteineU}oU
Adult
ærwæuPvrR}o˙
Children
ræ˙bV vXæræuPvR}o˙
AM˙bV v}}uuv
Refeal
r Criteria
R( oo vb v} ]u}]vP }v ]v]o uvPuvU `]R
˘}vUv]v(˘}vb}]o˙]}vP}
b]o]bX
63. Bronchiectasis
Iv }vR]b]bU R u]u v buoo b] }vR] v
}vR]}ob uPX TR] ]o] ]Ro]u ]b }˙ b ˙
v*Bonc
r hiectasis*v
]vGuu}vv]vP b U`R]R]v]]}b˙o}(]v(}vv(R
]vPb ob}uvv]o}vv}vR]oòoR]lv]vPXTR
ubo]v]vP}(Rb]`˙b}u}o}v]˙]vPv
}]}b u}vb }( ov v }Lv }+vb] buX TR ]bbU
]( v} ]b R] ˙ (v ]v( ˘}vb `]R
}Pbb]o˙`}bv]vPovP(v}vX
sueCa
yy CR]oR}}vu}v]XPX`R}}]vP}PRU}bubob
yy P}brou}v˙o}b]b
yy CR}v]R]v}b]vb]b`]R}brvbo]
yy Ru Ab vOPD
C
yy F]}b]vPovP]bb}(v˙bXPXRu}]ovP]bb
yy Iuuv.]v˙bXPXHIV ]v(}vUPuuPo}o]vu]
yy IvR] ]b}b XPX ˙b .}b]bU ]u˙ ]o]˙ ˙bl]vb]
bR}o}vb]]v˙}vPR]ovbvvP`]R}vR]b]b
Symptoms
yy Pb]bv}PR}uv˙u}vRb
yy C}]}bovbu`R]R]bb}uub}+vb]
yy Hu}˙b]b ]v}}vR]}(b]vP˘}vb
yy Ivu]'v˙bb u]˙u}ub
b r(Uv]PR`bb v`]PRo}bb
yy Chest pain
yy D]8o˙]vR]vP
Signs
yy W]PRo}bb
w
Standard Trtme
yy F
yy Co]vP
yy Doob]}vv}
yy }vR]o
B Rb}vb
yy C}b]}vb
Invtiga
se tions
yy FBU C SR
E
yy Suovbvb]]˙UPu]v b
yy SuAFBb
yy CRbXr˙
yy CT scan of the chest
yy Pob}˘]u˙
Trtme
ae nt
Tuv}ib
yy T}]v(}v
yy T}]buov
yy T}u]v]u]}PRvbu}}v
yy T}v˘}vb
yy T}]Pv}bvvo˙]vP]b}b
v*Bonc
r hiectasis*v
yy CRb R˙b]}R˙ r P}bo ]vPU Su ov

techniques
yy R]vP B ˘]bb
yy Iu}v]}v
yy Ev}PG]]vl
yy Ev}PR˙b]o˘]b
AX]v(
A ˘}v
st
L]vTuv
]v
E RvPPC
Adults
PR}o˙(}W˙b
Children
AN˙bV OvælæoR}o˙
vr˙bV æuo}(læwbvb]}vR}o˙
rv˙bV Xæuo}(læwbvb]}vR}o˙
u}vRr˙VXæuollP}˙`]PR}(æl
bvb]}vR}o˙
AMu}vRV XæuollP}˙`]PR}(æl
bvb]}vR}o˙
Av
yy A]R}u˙]v U}oU~(}vbooP]}v]]oo]vUP]vbu}v} r
R˙Z
Chatep rP *Disorsof
der theRespirtor
a ySystem
Adults
æuP}v]o˙(}vr˙b
Children
uP llP}v]o˙(}vr˙b
Refeal
r Criteria
R(oob} b]o]b(}}v.u}vv(R
uvPuvX
vX LvPbA
A ovP b ]b .v b v}b]b }( R ou}v˙vR˙u
v (}u}v }( ]b }v]v]vP v} b } ov G]U
boo˙ b ˙ u]}]o ]v(}vX Av]} uvPuv bR}o
}vb]b}}vb]]b]Pv}bU`R]o`]vP}v.u}v}(R
}Pv]b
b uvub}vv(}rv`lbX
sueCa
yy Ab]}v}(]v(}vb
b }(}u
b Ru}Rv
b]}˙]vRv}vb]}b}bu]r}vb]}bvXPX]v
o}R}o]bU]obUvbRb}vovb
v*Lungs*ceAb v
yy F}]Pv}˙b]}vXPX]vRovUvbU.bR}v
yy Ivo˙ ]o vu}v] b]oo˙U Pu
vP ] o]l Klebsiella pneumoniaeU v rRu}o˙
streptococci
yy Staphylococcus aureusb]vPuooovPb
yy PvovP]vi˙
yy Po}b}v}(v]`˙˙u}}o˙uRv}
yy S u}o] (}u }R ]v(b }( R }˙ XPX ]PRb]
]ov}]b
yy }vR]b
B ]b
yy Iv(oo]vR}v]ovP]bb
Symptoms
yy F `]R`]vP]vP
b ub
yy C}PR U } }( }]}b u}vb }( ov (}o buoo]vP
bu
yy Hu}˙b]b
yy Chest pain
yy Rob B bvbb
yy ˙bE (P]o]˙
Signs
yy F
yy Tachycardia
yy Tachypnoea
yy CRbòovvbb
yy Doob]}vv}
ı
Standard Trtme
yy D]u]v]bRRb}vb
yy Ivb}ob}vv
Invtiga
se tions
yy FBC
yy Suovbvb]]˙UPu]v
b
yy SuAFBb
yy CRbXr˙
Trtme
ae nt
Tuv}ib
yy T}]v}oo}v b
yy T}vo˙]vP]v(}v
yy T}]b}b]vP}v]}vb
yy Chest physiotherapy
yy Iu}v]}vob
yy EvbG]]vl
yy SP]o]vP}(b
v*Lungs*ceAb v
AXIv]ouv
st
L]vTuv
]v
E RvPPB
yy Co}˘]oo]v UIVU
Adults
æuPvR}o˙(}`lb
Children
ær˙bV æuPvR}o˙(}r`lb
ræ˙bV æuPvR}o˙(}r`lb
AM˙V vXæuPvR}o˙(}r`lb
Av
yy Au}˘]]oo]vA=Coov]A] UIVU
Adults
XPR}o˙(}`lb
Children
u}vRbr˙bV uP llPR}o˙Uu˘XXPR}o˙
AMu}vRbV uP llPR}o˙(}r`lb
Av
yy L]˘}v
C UIVU
Adult
P]o˙(}`lb
Children
AooPbærwæuPllP˙]v]]R}o˙}bb(}`lb
Or
yy Gvu]]v UIVU
Adults
ı
Chatep rP *Disorsof
der theRespirtor
a ySystem
ruPR}o˙(}˙b
Children
r˙bV XæuP llPR}o˙(}˙b
AM˙V XæuP llPR}o˙(}˙b
Av
yy M}v]}o UIVU
Adults
æuPR}o˙(}`lb
Children
wXæuP llPR}o˙(}`lb
Or
yy Co]vu˙]v UIVU
Adults
rvuPvR}o˙(}`lb}voo]v]o]u}uv
Children
rvuP llPvR}o˙(}r`lb
BXC}vv}vuv
yy Foo}˘]oo]v U}oU
Adults
æuPvR}o˙(}`lb
v*Lungs*ceAb v
Children
ær˙bV æuPvR}o˙(}`lb
ræ˙bV æuPvR}o˙(}`lb
AM˙V vXæuPvR}o˙(}`lb
Av
Adults
PR}o˙(}r˙bX
Children
u}vRr˙V XæuollP }˙ `]PR }( æl bv r
b]}vR}o˙
AMu}vRV Xæ uollP }˙ `]PR }( æl bv r
b]}vR}o˙
Av
yy Co]vu˙]v U}oU
Adult
uPvR}o˙(}˙b
Children
ANu}vRbVæruP llP l˙U]v]]}bbU
~M]v]uu}brv}obbRvuP l˙Z
Refeal
r Criteria
R( } b]o]b } R]PRroo (]o]˙ ]( R ]b v} o]v]o
ı
Standard Trtme
]u}uv`]R]vR.b`lb}(]v]vPv]}R˙X
v*Lungs*ceAb v
ı
Chapter
Disorsofder theCentral
Neouvr sSystem
ı
65. Headache
Headache]b˙b }vU]bouvU]vGuu}vUbo
bu } ]bvb]}v }( R ]v bvb]b ]v R R } vlX
HRbRv`]v}vbvoo˙]+v(}uv˙Rv
Rb ˘]v ]}bo˙ }uu}vo˙ ˙u}u b }( b]}b ]oovbb
v R(} uv }u o}vX TR ]]vP (}bU
b}]˙u}ub
b v o]v]o.v]vPb }v˘u]v}vU}PR`]R
Rbob}(}]]vbP}vbUv}]P]}Rb
}(RRRX
sueCa
A
yy SRv}]Ru}RPv}R}bo]bb
yy Iv(}vbXPXuo]U˙R}]( U]o]v(}vb
yy Mv]vP]b }vRo]b
yy Oo]b}b~Po}uU]]bU(}bZ
yy P}brb]b
yy P}brouv
yy Hypertensive encephalopathy
Subacute
yy Lb]}vb}(Ru]o~}bu] Uub}]]bZ
yy Ivv]oubb~u}Uob Ru}uUbZ
yy I]}R]]vv]oR˙vb]}v
yy T]Pu]vovoP]
yy P}brRvoP]
yy Severe hypertension
yy Atypical facial pain
yy M]}v
yy P}bu
yy G]voou}o]b
Chronic
yy M]P]v
yy Cluster headache
yy Tension headache
ı
Standard Trtme
yy Cervical spine disease
yy S]vb]b
yy Dvo]bb
yy Pb˙R}Pv]b
Symptoms
yy V]boXPXR}}R}]UGbRb}(o]PRUG}b
yy XP A X]boU]}˙UPb}˙Uo
yy }uv˙]vP
A (bXPXvbU}u]vP U(U}oob
yy S]}(]vXPX}]]oU}oUv]ooU]oo
yy CR]bbXPXobvPUR}]vPUbRUoo
yy Ro]]vP}˘vP(}bXPX}PRU}]bUo˙]vPG
Signs
yy Uboo˙v}v
yy L}ovvbb
yy F
yy Nl+vb b b
yy P}b]Kv]Pb
yy Markedly elevated blood pressure
yy }`b D ]vbb
yy E˘bb]o]u}v
v*Hechead *v
yy C}vivovbb
yy P]oo}u
yy F}ov}o}P].]XPXv]ov.]URu]b]b
Invtiga
se tions
yy FBC
yy ESR
yy SlooXr˙
yy C]oXr˙
yy Xr˙}(Rvbob]vbb
yy Luv~uv]vP]b URv}]
b oZ
yy ˙E b~}v}u˙U(}vU(v}b}˙Z
yy v]o C CTv b }MRI](`v
Trtme
ae nt
Tuv}ib
yy To relieve pain
yy T}]v(˙vvo˙]vPb
yy T}v}uo]}vbovP}Rvo˙]vPb
yy T}]u}o]˙}(o](
yy Ro˘}vRv]b
yy Avoidance of stress
yy Pb˙R}R˙
yy Iv.}vvo]u]v}v}(]PP(}b
ı
Chatep rıP *Disorsof
der theCentralNeouvr sSystem
AX˙u}u
bA uv}(RRb
st
L]vTuv
]v
E RvPPB
yy Pu}o U}oU
Adults
æuPrPvrR}o˙
Children
Or
yy D]o}(v U}oU
Adults
æuPR}o˙}uPR}o˙
Children
AN˙bV æuPR}o˙
AM˙bV v}}uuv
Or
yy I}(v U}oU
Adults
v*Hechead *v
uPvrR}o˙
Children
vr˙bV ruPvrR}o˙
ræ˙bV ruPvrR}o˙
u}vRbr˙V v}}uuv
Or
yy Tu}o U}oU
Adults
æruPrvR}o˙~u˘XuP]o˙Z
Children
AN˙bV æruPrvR}o˙
AM˙bV v}}uuv
BXP}R˙o˘]b(}M]P]v headaches
st
L]vTuv
]vE RvPPB
yy P}v}o}o U}oU
Adults
Iv]oVuPR}o˙Uu]vvvVruPR}o˙
Children
Iv]oVruPR}o˙Uu]vvvVruPR}o˙
Refeal
r Criteria
R(vUvb}o]vP}v˘o]vRRb}b]o]b
(}o}vv}]uvPuvX
ıæ
Standard Trtme
66. Seizures
A b] ]b o]v]o v b ˙ vb]v ]bv }(
]v (v}v } v v}uo }˘˙buo v}vo ]bRP ]v
R ]vX I( Rb ]b}b v `]R} v ]v.o bU
R˙ }uu}vo˙ b] b ]ob˙ X TR u b ]ob
]b b (} b]bU `R]R } `]R} R v P]v]vP
}vb]}bvbb `v 'lbX ~S b}v }v RE]ob˙ and Status
]ob[ZX
TR o]v]o bv}v vb }v R }( R]v +X
Pvbu˙b}uubb]R`v]vPb]Pvob~u}}u
}ZU`R]RR˙˘]v(}RvX]o A b]}v
˙`]vbb]bl˙X
GvovbRb]vvo}vu˙]]vb
v`RR]PR}bb}(v}vobvb]X
sueCa
yy C}vPv]oUvo}]vo]vi˙
yy FbU b]oo˙ ]v R]ov P v u}vRb } v ˙b ~(]o
convulsionZ
yy oC uo]
v*Seizs*ure v
yy Iv(}vbXPXuv]vP]b UTBUHIV Ub]vR]v

yy M}o] bP R˙}Po˙u]U R˙}ou]U R˙}vu]U
R˙}bu}o]U b u]UR(]o
yy I]}R]]ob˙ ~Sb}v}vRE]ob˙ [Z
yy oub E ]
yy Vbo ]bbP R˙vb] vRo}R˙ U }l
b U u˙}]o
]v(}v
yy S}˙]vPob]}vbPu}}uo(}u}vb}(R]v
yy Hu
yy DPbv}˘]vbPo}R}oUvbbvbUu}v]}oUPv
o}R}o`]Rò
yy DPv]bbXPXuv
yy Pb˙R}Pv]P~Sb}v}vRPb˙R}Pv]S]b [Z
Symptoms
yy L}bb}(}vb]}bvbb
yy T}vP]vP
yy F}u]vPRu}R
yy Iv}vvv}(}}o b vl}]v
yy A ~u˙ ]vo vP b P (o]vPU b}u}bvb}˙
uv](b}vb r ]boU }o(}˙U Pb}˙ } ]}˙ XPX vPb
buooblGbR]vPo]PRbZ
yy Mbo`]R]vPvu}uvb`R]Ru˙(}o}Pvo]
yy ALb]URvu˙}v(b~}br]o}v(b]}v}Z
u˙bo(}b}uu~}br]oboZ
ıv
Signs
yy }}u A }`]R}ubu~o]bul]vPU]l]vP]ubZ
yy Mbo`]R]vPvu}uvb`R]Ru˙(}o}Pvo]
yy P}br]obo
yy P}br]o}v(b]}v
yy T}[bo˙b]b (strokero]l`lvbbZu˙o˙}
yy E˘u]v (oo˙ (} ]v }( v}o}P]o o}o]]vP b]PvbU
}vPo}vv]v}(u}R(}}Rb
of the body
Invtiga
se tions
yy FBU C SR
E
yy Bo}}Po}b
yy BUE
yy Co]u
yy LFTb
yy CRbXr˙
yy Eo}vRo}Pu~EGE Z
yy CTv b ~RZ
Trtme
ae nt
Tuv}ib
v*Seizs*ure v
yy T}}b Rb]
yy T}vo˙]vPb
yy T}v]vi˙
yy M}bR}ibU.X`˙(}uv]vPb]b
yy Evbo}R]vP}vRvl]bo}}b
yy EvbR]`˙]boU`]}b}vv˙}vb b }}u]b
(}uRu}R}v}bX
yy D}v}(}b}}v}}vPb}]v}u}RJ
yy Ru}(obR](bv
yy AL }vob]}vb bU v R v ]v} bu]r}v }b]}v
˙ v]vP R v }v R b]U `]R }v oP v v R }R
oP]PR
b
yy M}v]}.b~.bRZ
AXS]b
A ~]uu]uPv˙ubbZ
st
L]vTuv
]vE RvPPA
yy O˘˙Pv
˙B vbo}vPbUrvLlu]v
Or
FublUrLlu]v
Or
N}vrRublUræLlu]v
ıw
Standard Trtme
Av
yy L}u Ubo}ÌVU
Adults
uP b ]vPo }bU }v L u]vb ]( vbb˙X
G]v]v}oP]vbo}ò˙}ræu]vbX
Children
r˙bV uP b b]vPo }bU }v L
u]vb](vbb˙XG]v]v}oP]vbo}ò˙}ræu]v r
bX
u}vRr˙bV u]}PullP ~u˘X uPZ b b]vPo
}bU}vLu]vb](vbb˙X
NeonatesV u]}PullP ~u˘X uPZ b b]vPo
}bU}vLu]vb](vbb˙X
Or
yy M]}ou UIVU
Adults
æru]}PullPUu˙˙ræu]vb]b
Children
u}vRr˙bV ]v]oo˙ ær u]}PuU (}oo}` ˙
(}oo}` ˙ }vv}b ]v(b]}v }( v u]}PullP R}X M˙
]vb ˙ v u]}Pu llP R} ˙ æ u]vb vo b] r
}v}oo
b X~u˘Xu]}PullPR}Z
v*Seizs*ure v
NeonatesV ær u]}PullP (}oo}` ˙ }vv r

}b ]v(b]}v }(vu]}PullP R}XM˙]vb˙vu] r
}PullPR}˙æu]vbvob]b}v}ooX
~u˘Xu]}PullPR}Z
Or
yy M]}ou UoU
Adults
uP
RLu]vb](vbb˙X
A R] }b ub v} P]v b}}v Rv R}b L R b r
}v}bX
Children
vu}vRbr˙bV ræu]}PullP~u˘Xb]vPo}b
uPZ
RLu]vb](vbb˙X
R] A }bubv}P]vb}}vRvR}b v LR}v b
}b]vR]ovAMlPX
nd
L]vTuv
yy D]u UIVU
Adults
uPbo}ò˙}ru]vb~}˘]uo˙XæuP˙ b r
}vbZ
Children
ru]}PullPbo}ò˙}ru]vbX
TR]bu˙u]vbo](R.}vvbX
Or
ı
yy D]u UoU
Children
AN˙bV XuP llP
vr˙bV XuP llP
rv˙bV XæuP llP
u}vRr˙bV XæuP
NeonatesV XærXæuP
TR]bu˙ u]vbo](R.}vvbX~u˘X
uPZ
Note 9-1
I(o(}uo}v]bv}]uu]o˙]ooU`R]vio(}u
]o˙ ]v} ˙]vP
b v u]v]b ] ]v} R u ~L u}]vP R
voZX
BXI(b]b}vv~SbE]ob Z
yy PRv˙}]v UIVU~`]RGCE u}v]}]vPZ
Adults
æ uP llP bo}ò˙ v} P Rv æ uP lu]vX ~u˘X P
o}]vP}bZU
Then
M]vvvUuPvrR}o˙
Children
v*Seizs*ure v
r˙bV]v]oo˙UuP llPbo}ò˙v}PRvæuP l
u]vX
Then
M]vvvUæruP llP]o˙~u˘XuP]o˙Z
ru}vRb
v V]v]oo˙UuP llPbo}ò˙v}PRvuP l
lP lu]vX
Then
M]vvvUXæræuP llPR}o˙
NeonatesV ]v]oo˙U uP llP bo}ò˙ v} PRv uP l
lP lu]vX
Then
M]vvvUXæræuP llPR}o˙
Note 9-2
M˙]b R˙Ru]b](P]v(bRvæuP lu]vX
C}vırX
N u]˘ Rv˙}]v `]R æA9 ˘}b
D U } u]v]u]b R ]bl }( ˙boo]b}vX
IvbURv˙}]vub]vN}uoSo]v X
Or
yy PRv}]}v UIVU
Adults
r uP llPU }b u]v ]vob ]( vbb˙ ~u˘X
}o}buP llPZ
Then ~bvPR}bL]v]o}bZ
ıı
Standard Trtme
XærXæuP llPrR}o˙
Children
u}vRr˙bV uP llPv}u}RvuP llP l
u]vXRLæu]vb](vbb˙X
Neonates
Iv]oo˙UæruP llPX b
M˙ }b }( ær uP llP u]v ]vob ~u˘X }o
}buP llPZ
Then ~bvPR}bL]v]o}bZ
ruP llPR}o˙
Refeal
r Criteria
I( b]bu]v v}v}oo `]R]v u]vb L R˙ PvU
( ]uu]o˙ (} b]o]b 'v}vX N} R }˘˙Pv}v bR}o
}vv]vPvb(X
67. Epilepsy
Epilepsy ]b ]b} }( R vo v}b ˙bb u ~CNSZU `R]R ]b
R]˙b}vv}bvb]b}Rvv˙}R
b]bXE]ob˙ ]bv}òbb].bGvo]~}v]Uo}v]UbvU
}v]}u˙}o}v]Z`]Rvo}bb}(}vb]}bvbb}F}oX
v*Epileysp *v
T]}voo˙U b]vPo b] Rb v P b v ]v]}v

(} ]vbP}v v buvU v} (} P uv vobb R
]ubvb}(Rb]vbb]]X
DPuvbR}o]vo˙}vb]L`}b]bU}
](R}v b b](}oo}`bo}bo˙(}uR.bXTR˙}(Pb
vb}vR˙}(b]X
DP uv }( ]ob˙ bR}o P] ˙ R (}oo}`]vP
Pvo ]v]obX BP]v `]R b]vPo P R o}`b }bP vP
v ]vb }b Poo˙ } R o]u] }( }bP vP } vo
b]r+bU](b]bv}}v}ooX
Sbvo˙U ]( b]b oo
b u]v v}v}ooU RvP }
]+v P ˙ Poo˙ ]vP R }b }( R ]v]o Pv `R]o
b]uov}bo˙]v}]vPRv`}vXTR]bboo˙lbr`lbX
T˙ R b Pb ]v R]b (bR]}v ]( v} o]v]o b}vb ]b
}bU(}b}vP}P}u]v}vbX
Av}vobv Puvv }oo˙ `]R`v ~Poo˙Z
]vv`]R]ob˙ }vo˙Lr˙b]r(]}vL
(ooo}vv]bb]}v`]RRvX
Pvb `]R ]ob˙ should be advised not to drive a vehicle if
v} . } b]r(U `]u b o}vU `}l R]PRbU }
uR]vbU}}l˙}v.o}vUv}]vPbo}R}o˘bb]o˙X
sueCa
yy I]}R]
Symptoms
~Sb}v}vRS]b [Z
Signs
~Sb}v}vRS]b [Z
Invtiga
se tions
~Sb}v}vRS]b [Z
Trtme
ae nt
Tuv}ib
~Sb}v}vRS]b [Z
~Sb}v}vRS]b [Z
AXMvPuv}(E]ob˙ rGvo]
A b]b
yy PRv˙}]vUIVU
Adult
ræuP llPX b }ru]vb
Then
uPvrR}o˙PRN
Children
v*Epileysp *v
ræuP llP
Or
yy PRv}]o ~]o˙ZUIMU
Adult
vruPv]PR
Children
XæræuP llP]o˙˙bo}ÌV}}o
Or
yy Cu]v
Adult
ruP}v}R}o˙
Then
IvbPoo˙}XrXPrR}o˙
Children
u}vRr˙bV XæræuP llPv]PR}R}o˙
Ivb`Rvvbb˙
Then ~u]vvvZ
æuP llPrR}o˙
Or
yy S}]uo} ~R}o˙Z
Adult
vuP~u˘XPZ
Children
AN˙bV vuP~u˘XPZ
u}vRr˙bV ræuP llPU]o˙}`}]]}bb
Then ~u]vvvZ
Standard Trtme
æruP llP]o˙]v`}]]}bb
Or
yy Lu}]P]v
Adult
æræuPR}o˙
Children
æræuP]o˙
Or
yy Lu
Adult
æræuPR}o˙
Children
æræuP]o˙
BXMvPuv}(E]ob˙ rGvo]bvb]
yy S}]uo} ~rR}o˙Z
Adult
vuP~u˘XPZ
Children
AN˙bV vuP~u˘XPZ
Then ~u]vvvZ
v*Epileysp *v
æruP llP]o˙]v`}]]}bb
Or
yy R}b
E ˘]u] ~]o˙Z
Adult
æuP R}o˙U]vb˙æuP˙ær˙bw }rXæP]o˙
]v`}]]}bb
Children
ANv˙bV æuP R}o˙U]vb˙æuP˙
ær˙bw }rXæP]o˙]v`}]]}bb
u}vRrv˙bV æuP llP~u˘XæuPR}o˙Z
CXMvPuv}(E]ob˙ rF}ob]
yy Cu]v U}oU
Adult
ruP}v}R}o˙U
Then
IvbPoo˙}XrXPrR}o˙
Children
u}vRr˙bV XæræuP llPv]PR}R}o˙X
Ivb`Rvvbb˙
TRv~u]vvvZ
æuP llPrR}o˙
Or
yy S}]uo} ~rR}o˙Z
Adult
vuP~u˘XPZ
Children
AN˙bV vuP~u˘XPZ
Then ~u]vvvZ
XæræuP llPR}o˙
Note 9-3
WR]oobo}òb}vb(
Aoo vb `]R ]ob˙ bR}o ] }vv}b }v v }vboo]vP
˙RPRu]bX
Refeal
r Criteria
R(oovb`]R]vob]b}Rb]o]b
68. TRUv}vb]}bPv
Uv}vb]}bvbb ]b}uu}vo]v]o}ouvu˙b}]
`]R]b}(
b ob }Pvb]vR}˙XTR}(
b v}vb]}bvbb
]b }Lv v} ]uu]o˙ ]vU v ˙bb u }R } ]b
]Pv}b]bvuvPuv]bR(}]u}vXO]v]vP R}}PR
v*TheUnconsciousPatient*v
R]b}˙(}u}uv˙]vPobU(]vbvR}o]]bbvoX
sueCa
yy Iv(}vbXPXuv]vP]b Uouo]
yy H˙}Po˙u] ~]bro}o}R}o]vZ
yy D]l}]}b]b
yy SR˙vb]}v`]RvRo}R˙
yy }bC oA]v~CVAZ}}lb
yy DP ]vPb}v } }}b XPX o}R}oU bo]˙obU ]bU
cocaine
yy Eo}o˙]uov
yy Epilepsy rb]ob
yy H]vi˙
yy Mi} }Pv (]oXPX R(]oUvo (]ov u˙}]o
]v(}v
yy H˙}˘](}uvu]b
yy P}]b}v]vPXPXl}bvU]bb UR]]b
Symptoms
yy Dvb}vRvo˙]vPb~S}]b}vbZ
Signs
Invtiga
se tions
Tests depend on suspected cause
yy FBC
yy BF(}MPb
yy Bo}}Po}b
yy Uvo}o˙b
Standard Trtme
yy L](v}vb
yy Bo}}ovbvb]]˙
yy U]vovbvb]]˙
yy ECG
yy T}˘]}o}P˙PPvb Uo}R}ooob
yy Luv
yy Head CT scan
Trtme
ae nt
Tuv}ib
yy T}b}o](vo}vb]}bvbb]bP]v
yy T}v}uo]}vbXPXb]}vUR˙}˘]
yy T}u]vRvo˙]vPbvuvP]}]o˙
yy EvbR]`˙]bvvo}(}vbb
yy E˘u]vv]o] b R]ob]v](v˙R]b}˙}b]Pv}(]vi˙
yy R]b C vu}v]}]v}](vbb˙
yy PoRv]v }b]}v R`}ovb]}v]vb
}(}u]vP }bvNG](v}}v]v]}vb˘]b
ToırP) G]}Ru}o}P]ouv}(Rv}vb]}bv
C}uo]vb D]Pv}b]b A}v
H]b}˙}(]bUb H˙}Po˙u] ~S}v
b }vRH˙}Po˙u][ Z
}(}ovr]}
]vPb}v}(o}R}o
H]b}˙}(]vPb}v}( DP}}bXPX S}b]}v
u]}v~ob} Alcohol
o]]ZXTRu˙
buoo}(o}R}o}}R
substance on breath
IV˘}b
D A9æruo
}vR˙}Po˙u]XIv
R}v]o}R}o]bXPIV
˘}b
D ˙IVlIMTR]u]v
uPIVURværuPIMvo
P]vb}vb]}bvbb
Pu}o SNr˙o˙b]v (as
]v]o}`Zv(
IV}vv}b]v(b]}vP
B}˙`]PRANlPP
uo}(˘}b
D æA9P]v}
æu]vUF}oo}`˙

æuP llP]væuo}(˘}b
D
æA9}R}bX
Then
uP llP]væuo}(˘}b
D
æA9}vR}bX
CR]ovAMlPP
æuP llP]vuollP}(˘}b
D
æA9P]v}æu]vX
F}oo}`˙æuP llP]vwuol
lP}(˘}b
D æA9P]v}
R}bX
TRvuP llP]vuo}(
˘}b
D æA9}vR}bX
Pbv}bv D]l}]}b]b ~S}v
b }vDKAZ
}(R]b}˙}(]bV
}o˙]U}o˙]b]X
H˙vo}vU
Po}vb}(]oovbbU
]v}(]v(}v
U]vbPvl}v
}b]
Bo}}Po}bAN
uu}olL
H]PRrP(U Mv]vP]b T`]R}]v]}b
b]bURRU vvruo]ovo]R
vl+vb
b bUo ]Pv}b]b}v.uX
}vb]}bvbX
b Cerebral Malaria ~S}]b}vZX
History of previous E]ob˙ G]D]u UIV~bo}ò˙}
b]bUvb }vb ru]vbZU}}b]b
}(}vob]}vbV`]R} v}vv}`]R
b
`]R}]v}vvvX vr]oPuvX
~S}]b}vZ
Pv`]Rbv Stroke Check blood pressure and blood
onset of paralysis of one Po}bX~S}]}v
b Z
b]}(}˙X
Pv`]R Hypertensive Check blood pressure
R˙vb]}vU vRo}R˙ I(ANluuHPUP]}o}
RRbUb]b vovrR˙vb]}
BPPoo˙
Sudden onset associated Syncope Uv}vb]}bvbb ]bboo˙](X

`]R]R˙Ru] P}u`lv]vP}bX
}u}}vo]b]bX M}v]}]ob]PvbUGCE
Reassure
æ
Standard Trtme

H]b}˙}(]vi˙U} HIvi˙ To}vbUS]o]bC]o
o}R}o]buUb]Pvb}( spine
u Xr˙bloo(}(bUH
CT scan
History of heavy alcohol HF]o MvPbR
]vPb}v}uv˙ encephalopathy
˙bX
H]b}˙}(iv]
vPo}vb}(
RvPb]vbvb}]u
D]R}b]bU}o Shock ~S}]b}vbZ

ouu˙bl]vU`l H˙}}ou]
pulses Hu}RP]
]}Pv]
C
S
~S}]b}vZ
Refeal
r Criteria
R( } b]o]b (} (R .v] uvPuv ]( v}

b}v]vP}vb ubb}(b]}vX
v
Chapter
PsychiatricDisorsder
69. 'v}v
A .]
D H˙]˙D]b} ~ADHD )
'v}v
A .]
D H˙]˙ D]b} ]b R u}b }uu}v
v}R]}o ]b} +vP R]ovX I u˙ bv ]v ]v(v˙
v v }vv ]v} oR}}X I +b ærA9 }( R]ov v vo˙
Rubuv˙ b }˙bP]ob b XNo˙Ro(RR]ovbvvP`]R
ADHD u˙ob}Rvb}]ov]vP}ouX
TR u ]b }uu}vo˙ o] `}vPo˙ } R v}uo R]o `R} ]b
o`˙b }v R P} v v b]b oo b X R}Pv] b }( R˙]˙
]v R]ov ]vo v}uo ]}vU }}u } vbuo}v }
˘bb]]v b Uov]vP]8obUbuUob]bvPb
o]lo}vuURv}]}vvRv˙}]v X
ADHD ]b ob} `}vPo˙ '] } }} vvPU }} uR TVU
}}bR}}obU}}R}uv]}vuvU˘bbP}(}}ooP]bX
N} b]. b }v.u ]Pv}b]b }( ADHD X A (oo R˙b]o v
v}o}P]o ˘u]v}v ub }v ]v oo bX TR R]}o
.]bv˘bR b }vb]Pv}b]b}(ADHDubvb
]vuoohvPb b bRbR}uvbR}}oX
sueCa
yy Uvlv}`v
yy Related factors:
yy Hereditary
yy Iuov}(v}vbu]'b
Symptoms
yy Iv'v}v
yy R]o}Lv(]ob}.v]bRR]vPbR}bRb
yy }Lv}bv}bu}o]bv
yy Rb]8o˙}vvvP}vbR}}o`}l
yy Iuob]]˙
yy R]o}Lv(} b R]vl]vP
yy R]b}Rb`Rvb
yy ]v]o]˙}`](}R]b}Rv]vPu
yy vPPb ]v vP}b ]b `]R} }vb]}v }( R
consequences
w
Standard Trtme
yy Rb]8o˙}Pv]]vP`}l~R]bv} }}Pv]]u] r
uvZ
yy H˙]˙
yy R]o]b}}ob R]vPb}v
yy olb]vbbvo˙U
yy PPob b }b]oo
b blv.Pb
yy D]b]o]˙]b]v˙
yy v}o]bv]vP`Rvb}lv}
yy v]vo]v}v}˙u
yy v}]vPo}`}l]vvvo˙
yy ]b}Pv]
Signs
yy S]u]o}˙u}ub b }
Invtiga
se tions
yy Uboo˙v}v
v*AttentionDeficitHypctiv
Trtme
ae nt
Tuv}ib
yy T}R˙]˙
aer ityDisorder~ADHDZ*v
yy T}]u}'v}v
yy T}]u}}uo]v}]vb}v
BR]}uvPuvRv]br]v E RvPPA
yy A obb Ro ]v obb} b] `]R R]o v (}b'v}v} bR}}o
`}l
yy PvvPob}b Rovb}
yy Db]b(}uv]R˙b]o]vv}vbXPXv]vP
st
L]vTuv
]v
E RvPPA
yy MethylphenidateU}oU
Adults
uPrR}o˙~u˘XvuPZ
Then
Ivb`lo˙˙æruPU](vbb˙U}u˘X}(uPR}o˙
Children
vr˙bV XæræuPR}o˙
Ivb`lo˙˙æruPU](vbb˙U}u˘X}(uPR}o˙
rv˙bV XæuPR}o˙
Ivb`lo˙˙XæuP]o˙}u˘X}(XuP llP](vbb˙]v
}]]}bbX
AM˙bV v}}uuv
Or
yy }u}˘vA U}oU
Adults
Chatep rP *PsychiatricDisorsder
uP}v]o˙(}˙bw
Then
Ivb}]vP}b}vb}u˘X}(uP
Children
ANv˙b~`]PRANwlPZVuP}v]o˙(}˙bw
Then
Ivb}]vP}b}vb}u˘X}(uP
ANv˙b~`]PRAMwlPZVæu]}PubllP]o˙(}˙bw
Then
Ivb}]vP}b}vb}u˘X}(XuP llP]o˙
AMv˙bV v}}uuv
nd
L]vTuv
]vE RvPPB
yy Iu]u]v U}oU
Adults
wæuP]o˙
Then
Ivb}æuP]o˙](vbb˙~u˘XuP˙Z
v*ThecuteA lyDisturbedPatient*v
Children
vr˙bV ruPR}o˙
Refeal
r Criteria
R( } o]v]o ˙R}o}P]b
b (} R]} uvPuvX Av
}}vo R]bU u]o RU bR R]b (}oo}`]vP
vbbuvX
R(}b]o]b](R]bv}o]v]o]u}uvLu}vR
}(R}}uuvR˙X
70. TRo˙
A D]bPv
TR o˙ ]b v bvb ]v v ˘]U P] }
PPbb] X
b TR u˙ ob]}vb v o RvPb o]l
Roo]v}vb R }`Rou R vX D]b}]v}v v o}v
]v }vb]}bvbb }Lv }u]vv `Rv R b ]b }Pv]X TR
vbboo˙}PR]v]v b ˙u}Rv}vb}v}˙
R }o]X TR}v]}v ub Pb v uPv˙ b]v (`
}voo˙
b (oX
sueCa
~Fv}vo
A ZPb˙R]]D]b}b
yy Mv]}R˙}uv]
yy SR]}Rv] and like states
yy OR˙R} b ]b}b
yy AP]b]}v
yy Acute psychosis
~OPv] A ZPb˙R]]D]b}b
ı
Standard Trtme
yy T}˘] ˙R}b
b ]b }v˙
b } P ]v}˘]}v ~uRu]vbU
cocaineUu]iv UR}]vXZ
yy Av}uo}v}o}R}o]Iv}˘]}v
yy Ao}R}o]W]RòS˙v}u~o]]uuvbZ
yy Iv(b XPX ˙R}]U uo]U uv]vP]b U HIV U vRo]bU
Rb
M}o]
A D]b}b
yy H˙}Po˙u]
yy Thyroid disease
yy P}R˙]
Others
yy Hu
yy SoRu}u
Symptoms
~Sovb}vb(}˙u}ub
b }(b].]b}bZ
yy Sleeplessness
yy RbobbvbbrP]}v}uv
yy Tol]vP ˘bb]o˙ v o}o˙U } o}` }vU bRU v
u]vb}ub
yy D]b]vR]]R]}}bR
yy H]vP}b]vPS]uP]v˙ _}o}}ibX
yy E˘bb]}v }( (U v b]]}vU ]v}] P]o } ]
beliefs
yy vbDb b
Signs
~Sovb}vb(}b]Pvb}(b].]b}bZ
yy EoU]]oUvP˙}bu}}
yy PR˙b]oPPbb]}vUP]}v}obb bvbb
yy Ll}(]vb]PR
yy Pb}b bR
yy H˙]˙}u}}]˙
yy D]b]vR]]}vrb}]ov˘o b
yy Dob]}vb }(PvUP]o}v}]
yy A]}˙Roo]v}vb
yy V]bo Roo]v}vb ~b]oo˙ ]v }˘]U ]v(}b v `]Rò
Zb b
yy F ~]v(}v]}vbZ
yy }`b D ]vbbUo}vb]}bvbb~u]vo˙]vo}R}o`]RòZ
yy D]b}]v}vv}v(b]}v~u]vo˙]vo}R}o`]RòZ
yy S`vP
yy Tu}b~u]vo˙]vo}R}o`]RòZ
Invtiga
se tions
yy Uboo˙v}v
yy U]v vb ~(} vbb o]l uRu]vbU }]v U R}]vU
vv]bZ
yy FBU C R]D]Pv}bTb (}uo]b]b~`RvR]b(
v]v(}vb
b Z
yy Rv}uBo}}SP
yy Bo}}o
Trtme
ae nt
Tuv}ib
yy R]v]o]b}vr}ou}`vRv]lo˙ b }bb b]o
b]vPR(bb Pb]oo`]R}vbb]o˙]v]vPbo
yy T}vo˙]vPb
yy Rb]vv`Rvvbb˙`]R}b]vP]vi]b
yy Tol}Rv]v.ub]vPuvv
yy }] A o}vP]}b}(b]ovb]oo˙]vv}]vb
yy Ru}v}b `˙v˙}+vb]`}vb}v}}vvX
]v
E RvPPC
yy L}u UIVlIMU
Adults
ruPX b
R}vLu]vb](vbb˙X
Children
AN˙bV æu]}PuruP~u˘XuPZ
AM˙bV æu]}PuruP~u˘XuPZ
Or
yy HaloperidolUIMU
Adults
ræuPX b u˙]vrR}b~u˘XuP˙Z
Children
r˙bV ræuPrR}o˙]b
vr˙bV r uP r R}o˙ b ] ~u˘X Xæ
uP llP˙Z
AMæ˙bV v}}uuv
Note 10-1
PvbR}o`]R
b }}ob}}vb}bb]o
Then
yy HaloperidolU}oU
Adults
ræuPrR}o˙~u˘XuP˙Z
Children
AN˙bV ræuPrR}o˙]b ~u˘XuP
˙Z
r˙b~ærlPZV XærXæuP˙~u˘XXæuP˙Z
AM˙bV v}}uuv
Or
Standard Trtme
yy CRo}}u]v UIMU~(}˙P]vbZ
Adults
æræuPX b Lru]vb](vbb˙
Children
r˙bV æræuPvrR}o˙
vr˙bV æ u]}PullP vr R}o˙ ~u˘X wæ uP
˙Z
rv˙bV æ u]}PullP vr R}o˙ ~u˘X uP
˙Z
Note 10-2
NP]Ro}}u]v]vv}bo˙JIu˙o}R˙}vb
b ]}vX
Or
yy Oov]v UIMU
Adults
r uP X b bv }bb }( uP u˙ P]v R}b
L ]v]o }bU ]( vbb˙ v R}b L v }b ~u˘X
uP˙Z
Children
N}}uuv
Or
yy Chloral hydrateU}o}oU
Adults
æuPrP
Children
r˙bV æuPrP
u}vRr˙bV ræuP llP~u˘XPZ
NeonateV ræuP llP
Or
yy D]u UIVU
Adults
uPbo}ò˙}ru]vb~}˘]uo˙XæuP˙ b r
}vbZ
Children
TR]bu˙Lu]vb](vbb˙~u˘uPZ
Or
yy D]u UoU
Children
AN˙bV XuPllP
vr˙bV XuP llP
rv˙bV XæuP llP
u}vRr˙bV XæuP
NeonatesV XærXæuP
TR]bu˙Lu]vb~u˘uPZ
Note 10-3
I(o(}uo}v]bv}]uu]o˙]ooU`R]vio(}u
]o˙ ]v} ˙]vP
b v u]v]b ] ]v} R u ~L u}]vP R
voZX
D]u IV ub u]v]b `]R ]( R b }( R ]b r
v]bR}PR}}Pv]X
Refeal
r Criteria
R(ooo˙]bvb}b]o]bX
71. Psychogenic Seizures

Pb˙R}Pv] b]b } b} b]b v}vr]o b]bU
`R]Ru]u]]ob˙ oo˙Rvvo˙]vP˙R}o}P]o
b bX
Ivvb `]R R]b (}u }( ]b}U Ru˙ R]b}˙ }( R˙b]oU
˘o
b } ˙R}o}P]o
b bX TR ˙u}ub
b u˙ ]] ˙
b v R b]Pvb }Lv ]o v u˙ ]vo b]bv }
˙ }v]vP }v ˘u]v}vX TR ]Pv}b]b ]b R]PR oo }(
b]]}vb]v]]b}Lv]8o}(}u b ]ob]bv
u˙U]v(}r˘]b`]R]ob˙X
v*PsychogenicSeizs*ure v
Symptoms
yy Rv}v]o}v]ro]lb]b
yy 'lbA boo˙ } }vo˙ `Rv 'v}v }( }R }o v
'
yy Pvb Ro˙ P ]viU v `Rv R˙ (oo ~vo]l ]v
b]bZ
yy TRbvPo]u}uvb}uu}v]vPSb]_'lb
yy T}vP]vPU](]}b]bboo˙R}(R}vP]vb}(
Rb]bb]vb]b
yy M˙R]v˙]v}vvvb]vv}uob]b
Invtiga
se tions
yy Su}ov
yy EEG
Trtme
ae nt
Tuv}ib
yy T}}b b]b
yy T}}b v}uo˙
yy Rbvbb UP]vbX
yy C}vboo]vP
yy Pb˙R}R˙
yy Avr]ou]]vb } v} } Rv˙ v.]o+
}v(v˙}('lb
Standard Trtme
Refeal
r Criteria
R(oob(}o}v˙˙R}o}P]b
b }˙R]]b
b X
72. Insomnia
Ivb}uv] ]b .v b bi } }( ]8o˙ `]R bo
]v]}vU }vU }vb}o]}vU } o]˙ R }b b]
}}v]˙(}boUvRbob]vb}u(}u}(˙u
]u]uvX Ivb}uv] ˙u}ub b } ] }uu}vo˙ ]v R Pvo
}o}vX R]bl (}b (} ]vb}uv] ]vo ]vb]vP PU (uo ˘b U
}ru}]]b}bbRu]o b U˙R]]b Uvb bUvbR]L
`}lXPvb`]R˙R]] b vR}v]]v]b}bRoo˙
R]PRb}(]vb}uv]X
sueCa
yy BR]}o r bv]vP u} u ]v ]v v +} } SR _
on sleep
yy Stress
yy LvR]b`R]R}v}vRvbo
yy C}Pv]]b}}vb~XPX](}v}bv}boR}PR}Rv]PRU
}vRbv}boooZ
v*Insomnia*v
yy M]]vb~XPX(}uv}(}uu}v}oUR˙vb]}vURu b Z
yy +]vC r}v]v]vPPb~XPX}+UZ
yy W]Rò (}u o}R}o v }R Pb }( b ~XPX }]v U
u]iv UuRu]vbZ
yy M]o }v]}v ~XPX bo vU ]`˙ }b}vU o]
]bbUvo]bbUR˙}]]b}bZ
yy Pb˙R}o}P]ovv]}vuvo(}b
yy OR˙R]] b ]b}bbRbv˘]˙ vu}}]b}b
yy To~b]oo˙}bbu}vbo]vP}ioPZ
yy SR]L`}l
Symptoms
yy P}o}vPPu(}(oo]vPboro}vPRvu]vb
yy T}obouobbRvvXæR}b
yy D]8o˙(oo]vPbo
yy Fv`lv]vPb
yy D]8o˙v]vP}bo
yy A`lv]vP}}o˙]vRu}v]vP
yy SoR}bv}(oob U(bR]vP}}b
yy Av]vP }} bo R}b (} uU v }u]vP u}
ovv˘]}bbu}Rb
yy ˙u D +b}(}}boP
yy FPvbo]vbb
yy M}}]bvbv}Pv]]8ob
yy P}} o]˙ }( o]( ~`}bv ˙ ]vb}vo ]8obU }
}]v}(˙]bZ
yy E˘}v }(}ru}]}v]}vb bR b]}v U R]PR
o}}Ub X
yy ˙D r}r˙]]o]˙
B}˘rP) H]b}˙l]vPvbuv}(vb`]RIvb}uv]
yy R]}v
C }( R bo]vP v]}vuv ~}RlU o]PRllU ] r
lv}]b˙U}}uuUo}vl vUTV }vl}+ZUv[b b
}(u]v~bo˙bX`]`lUo˘bXv˘]}bZ
yy Iv(˙vPvPR]}bv}Pv]}bb
yy AbSorWlSRo`]Rbo]˙P u}(oobo~boo r
v˙ZUvu}(`lv]vPbUWluALSoOvb~WASOZUbo
}v
yy Assess
yy R]vP B robo]b}b~bv}]vPUPb]vPU}PR]vPZ
yy Soou}uv]b}b~l]l]vPUobb bvbbZ
yy Pb}uv]b~R]}b}}o]}vZ
yy C}ru}] u]olv}o}P]o ]b}b ~G˘U o]}vbU b]bU
RRbZ
yy ORR˙b]obvb}vbvu}}vbb}]`]R`l(ovb~b b R
b]vUobb bvbbUv˘]˙ U(b}vUbvbbZ
˙u
AbD A]bv˙u
D Fv}vP
yy N]vP~(v˙l˙UubU}ov˙l]v}ov˙Z
yy W}l ~`}l ubU `}l ˙ bR b ]]vP } `]R vP}b }vb r
v*Insomnia*v
vbU]boUlb}vb]]o]bZ
yy L](b˙o~bv˙lUR}u}vUo]PR˘}bU˘]bZ
yy To~b]oo˙}bbu}vbZ
yy Qo]˙}(o](v˘}v}(}ru}]]b}b
Invtiga
se tions
yy FBC
yy BUEvv]v
yy LFTb
yy Bo}}Po}b
yy TR˙}](v}vb
Trtme
ae nt
Tuv}ib
yy R}v}(`l]vP˙u}ub b
yy Iu}uv}(˙u(v}v
yy R}v}(]bb
yy Tuv}(}ru}]}v]}vb
yy Suob}v}oR˙ ~}]uovP
b bov]}vuvbbR
bo]vPo]PRbUTVv]}}vZ
yy Ro˘}v]v]vP
yy C}Pv]BR]}TR˙
yy }]v A }(˙rubo
yy }]v A }( ˘bb] uov
b }vbu}v r u ~XPX
æ
Standard Trtme
}+UUo}R}oXZ
st
L]vTuv
]v
E RvPPC
yy L}u U}oU
Adults
ruPu
Children
N}}uuv
Or
yy T]}ou U}oU
Adults
Eoo˙V æræu]}Puu
AMv˙bV æræu]}Puu
Children
N}}uuv
nd
L]vTuv
]vE RvPPB
yy MelatoninU}oU~oo˙(}R]ovZ
Adults
ræuP]o˙UrR}b(}u~u˘XuPZ
v*Dsion*
epr
Children
v
u}vRr˙bV ruPu
Ivb](vbb˙Lr`lb}rvuP]o˙~u˘XuPZ
Or
]v E RvPPB
yy Au]]˙o]v U}oU
Adult
æræuPv]PR(}`}`lb
Children
N}}uuv
Refeal
r Criteria
R(} o]v]o˙R}o}P]b
b (} R}bvb `R} } v}b}v
} R }uu}v v}vrRu}o}P]o v Ru}o}P]o ]vv}vb
(} }Pv] R]} R˙X R( vb `]R vo˙]vP R˙b]o
}b R}]b]o]bbX
73. Depression
b]}v
D ]b u}} ]b}U `R]R u˙ } ]v oo P P}bU
oR}PR R ˙u}ub
b u˙ ]+ ]v R]ovX I ]b oo˙ }uu}v
}v]}v v Rb vv˙ }X S}u +b}vb u˙ v
}}R]}o]b}U]v`R]RbU]b}b}(uv] }X
Co]v]oo˙ b]Pv].v b]}v U ob} oo ui} b]}v U ]b
v
`] b }uu}v ]v `}uv b ]v uvX Mv˙ + ]v]]ob bl
Ro(}ub]]ov]}voRobXF}P}}}}}v}(R}b
`R}P}}R}b]obUR]}v]}v]bv}}Pv]bX
b]}v
D ]b b]Pv].v b }( u}]]˙ oo } R `}o
v u}b }o `R} 'u } (oo˙ b }uo b]] R
depressionXOvbR}ov}]bu]bb}l(}Pvuvb b u
˙ vb bR b SI `v } ]_U So]( ]b v} `}R o]]vP _U } SI u
( `]R o](_X Aoo b }( 'u b]] bR}o ( }
˙R]]b
b L ]v]o uvPuv }( R bvvP }uo]}v XPX
bo(r]vG]]vi]b}}]b}v]vPX
Recurrent depression } v]}o b]}v ]b ]+vo˙
~`]R vbbvbZ (}u ]}ob]}vU `R]Rb}vb u}}
u}}]o]b
b X
TR]Pv}b]](}ui}b]}v relies on the presence of
ob.~æ}( Z R˙u}ub b o]b]vRb}v}v˙u}ub
b o}Ù
˘]v˙˙(}ob`}`lbX
Iv R uv }( b]}v U u˘]uu }oo }bb }(
vbbv u]}vb ub P]v (} ob v `lb (}
]]vPou]}v]bv}+X
ALv ]b} }(b]}v Uuvub }vv (}
obvu}vRbUbR]bR]PR]bl}(ob`]R]vR]b]}X
v*Dsion*
epr
Avbbvb ub }b ]uu]o˙ ]( uv] `]vP b
}bX Pvb `]R b]]o vv]b ub u]' v l
v
vo}b}b}vX
sueCa
yy Gv
yy Fu]o]o
yy Ev]}vuvo
yy Pb˙R}b}]o(}b
yy Ev}]v]b}bXPXR˙}R˙}]]bu UCbR]vP [b˙v}u
b
Symptoms
yy bu}}
D U}Lv}b(o]vPR}}(b}b[
yy L}bb}(]vb}ol}(ob]vR]vPb]}bo˙}(]vb
yy S]Pv].v`]PRo}bb}`]PRP]v
yy Ivb}uv] }bo]vP}}uR
yy Pb˙R}u}}P]}v}}v
yy FP}o}bb}(vP˙
yy Fo]vPb}(`}Robbvbb}˘bb]P]o
yy Iu]R]vl]vP
yy P}}}vv}vV
yy ]v]b]vbbV
yy `}˙]vP˘bb]o˙
yy Moo}]o˙}uo]vb
yy S]]o]b}R}PRb}(R
w
Standard Trtme
yy Hoo]v}vb }ob]}vb}(u}]Rub]vb
In children
yy Tv˙}(bo}P}}bR}}o
yy P}}bR}}o(}uv
yy B`hvP]v]}bo˙R˙ [R]o
yy OR]}UPPbb]}v}.v
yy I]]o]˙
yy RvPb
A
yy S}u}(RRo [˙u}ub
b o]b}
Signs
yy bu}} D
yy ]v E }(`]PRo}bb}`]PRP]v
yy AP]}v}}v
yy Hoo]v}vb
Invtiga
se tions
yy FBC
yy BUEvv]v C
yy FBS
yy TR˙}](v}vv}b}ooob](]v]
yy Au]v]b v] b o b }( b]}v bR b R PHQ
v*Dsion*
~vRoR}vv] b ı]uo b Z
epr v
Trtme
ae nt
Tuv}ib
yy T}˙u}ub b
yy T}v]b}v}v}uoo](R}uU`}l}bR}}o
yy To prevent suicide
yy C}vboo]vP
yy Pb˙R}R˙ Ub].oo˙C}Pv]BR]}TR˙
yy Electroconvulsive therapy
st
L]vTuv
]v
E RvPPA
yy Fo}˘v U}oU
Adults
uP}v]o˙(}r`lbU
Then
Ivb](vbb˙}u˘X}(uP
Children
r˙bV uP}v]o˙(}r`lb
Then
Ivb](vbb˙}u˘XuP}v]o˙X
AM˙bV v}}uuv
N}r
Ub`]R}v]vR]ov`]R]ob˙ XS}](b]}bX
Or
yy SertralineU}oU
Adults
æuP}v]o˙U
Then
Ivb](vbb˙˙]vuvb}(æuP]vob}(ob
`lU}u˘X}(uP]o˙X
Children
r˙bV æuP}v]o˙
Then
Ivb](vbb˙˙]vuvb}(æuP]vob}(ob
`lU}u˘X}(uP]o˙X
vr˙bV æuP]o˙U
Then
Ivb](vbb˙}æuP]o˙L`lX
FR]vb](vbb˙]v}( b æuP]vob}(ob
}v`l}u˘X}(uP]o˙
AMv˙bV v}}uuv
Or
v*Dsion*
epr
yy C]o}u U}oU
Adults
v
uP }v ]o˙U ]vb ]( vbb˙ ]v b }( uP ]o˙U
]vob}(r`lUu˘XuPX
Children
AN˙bV uP}v]o˙U
Then
Ivb ]( vbb˙ } uP }v ]o˙ ]v R v]vPU } r
`lb~u˘X}(uP}v]o˙Z
AM˙bV v}}uuv
Or
yy Iu]u]v U}oU
Adults
æræuP}v]o˙~o˙v]vPZU
Then
Ivb˙æuP˙ræ˙b}u˘X}(æuPX
Children
N}}uu
Or
yy Au]]˙o]v U}oU
Adults
Then
Ivb˙æuP˙ræ˙b}u˘X}(æuPX
Children
ı
Standard Trtme
ANv˙bV æræuPR}o˙
AMv˙bV v}}}uuv
AXMvPuv}(vb`]Rb]}v ]]vPv]PR}v
b
yy L}u U}oU
Adults
ruPrR}o˙Uu˘XuP]o˙
Children
r˙bV XæuP llPR}o˙Uu˘XuP]o˙
Or
yy D]u U}oU
Adults
æruPvrR}o˙
Children
r˙bV uPR}o˙
ær˙bV æuPR}o˙
Refeal
r Criteria
R(vb`]R˙]o}vbo˙u}ub
b UR˙b]o}R}]
(bU v R}b `R} } v} b}v } vrbbv
uv`]R]vu}vRbU}˙R]]bb UbR}oR]ovb
}b+(}ub]}v X
v*Schizophrenia*v
Pvb ]]vP C}Pv] BR]} TR˙ should be referred

}˙R}o}P]b
b X
wX Schizophrenia
SR]}Rv] ]b }o˙ R u}b b v }voo˙
]bo]vP (}u }( uvo ]oovbb ]v ˙ }uuv]˙ `}o`]X I u˙
bv b v } R}v] ]oovbbX TR o]v]o (b ]vo
R]b R}b][ } RvP[ ˙u}ub b U ]}}v ]v b}]oU
`}l } ]vb}voo}vbR]b v}vv ]v }( ]b
R]}(}obvu}vRbX
TR o]v]o (b u˙ vu}b v v RvP } uX
Pb˙R}b]b b}] `]R vb b v u}} ]b}b `]R
˙R}
b (bu˙u]u]bR]}Rv]X
F} R]b ]oovbbU (` }o u˙ } }uoo˙ L v
]b}}`}XTuvub}v b ˙u}ub
b bvXA
.v]]Pv}b]bvo]b b Ruv}(uvov]b]b
} ˙ ˙R]]b
b X Tuv (} ]b}b v b ˙
˙R]]b
b v(}oo}ùv}vv˙u}bRoRP]bX
Tuvub(}obu}vRbLu]bb]}v}(˙u}ub b (}
.b]b}XH}Ùo](o}vPuv]b}o˙RP˙ b
}}]vX
S] +b bR b ˘r˙u]o }vb ~bo}`vbbU }}o]vPU
+vbb bU u}bU ]P]]˙U ubo bub ]vo]vP }vP l]vP b
}U vl v]vPU XZ } vb˙R}b u˙ } b]oo˙ `Rv
u]v]b R]PR }bbX TRb b }vb v v
}uvP`]RvR}o]vP]PvbU`R]Rubb]vPo˙b
R˙u˙}v]}Ro}uv}(v}Rvb Uoo
] ˙bl]vb]U ]v R o}vP uX ~S b}v }v RAiv Tuv[
o}`Z
sueCa
yy LPo˙vlv}`v
yy P}bb]ob}]}vbP
yy B]}rGv~}}`]R}u]vv}}v]v b }bZ
yy B]}rPb˙R}b}]ou]vvbVPv]b}b]}v}o
`]R b ~}v}u]U ]b (u]o˙ v]}vuvbU XZ
B]R (b ]v ]v b}] `]R b}v }( ]RU }bb]o
]o]v(}vbUX
yy Ev]}vuvo]PPb
yy Ioo]]Pb~u]iv UuRu]vbXZ
SymptomslSigns
RP}b][˙u}ub b
yy Hoo]v}vb ~XPXR]vP}]bZ
yy Dob]}vb ~bo](b`R]Rvv}vb Z
v*Schizophrenia*v
yy Iv}RvbR}]oo}P]o]˙
yy O}]b}Pv]bR]}
yy Pvo]bR]b}RR}PRb}v}oo˙}b](}b
RNP[˙u}ub b
yy P}˙ }( bR } }vv }( bR ~(` `}b } `]R o]'o
vb Z
yy Apathy
yy Rb}]o}v}`]Rò
yy Fo'v+~bR}`]vPo]'o(]o˘bb]b}vbbZ
yy Dob]}vb
yy M˙}˙ b UbRvb b]]}vU}}oo˙]U
o]l]vP }v}oo } ]vP u } (o u}}vb } bvb r
}vb
yy Gv]}b ob]}vb u˙ ob} } `]R} R o
u}}bv]vuv]vb
yy Hoo]v}vb
yy }uu}vo˙]}˙~u˙]v}ov˙}(R}RbvbbZ
yy A]}˙ Roo]v}vb }( uoo }]b }uuvvP }v r
vb[}vbUP]vP}Rvou}b]Pv}b
yy M}} ]b}b o]l}b]vPU˘]uv}}b u˙ }
v}bvo(}]Pv}b]b
Invtiga
se tions
yy Uboo˙v}v](}]Pv}b]b
yy Tb}b o}}Pv]b}(˙R}b b ]b
yy Bbo]v(ooo}}}vUo}}bPUo]]bUo]vl]v˙(v}v
Standard Trtme
bU(}}bb}(P]]vPuv
yy F}Oov]v and RisperidoneUvbR(bvPo}}bP r
Uo]]}.obUo]vl]v˙(v}v]b }
ob`]˙X
Trtme
ae nt
Tuv}ib
yy T}}o]bR˙u}ub b
yy T}}b (v}v]vP}Ru˘]uuoo}bb]o
yy To reduce the chances of recurrence
yy T} u}v]} o}} Po}bU o]]}.obU o]v l]v˙ (v}v
ob`]˙(}vb}v}ov]vv]b]}v
yy S}˙R}R˙ b
yy RR]o]}v
yy Fu]o˙R˙
yy Pb˙R}}v } bU }bU uvU b] +b v
obv}v
yy BR]} TR˙ XPX b}]o bl]oob ]v]vPU }Pbb] ubo
o˘}vU}]vPbl]oobUX
v*Schizophrenia*v
st
L]vTuv
]v
E RvPPA
AX MvPuv}('lb
yy Oov]v UIM}}oU
Adults
æruPX b
Then
æruP]o˙Uu˘XuP]o˙
Children
AN˙bV æruPXb
Then
æruP]o˙Uu˘XuP]o˙
AM˙bV v}}uuv
Or
yy CRo}}u]v UIMU
Adults
æræuPvrR}o˙UibvP}u˘X}(uP]o˙
Children
r˙V æræuPvrR}o˙UibvP}u˘X}(uP]o˙
vr˙bV æu]}PullPvrR}o˙}u˘X}(wæuP]o˙
rv˙V æu]}PullPvrR}o˙}u˘X}(uP]o˙
Or
yy CRo}}u]v U}oU
Adults
æuPR}o˙}wæuPv]PR
Then
Aib}]vP}b}vb}wæruP]o˙
Children
AN˙bV æuPR}o˙}wæuPv]PR
Then
Aib}]vP}b}vb}u˘X}(wæruP]o˙
vr˙bV uPR}o˙
Then
Aib}]vP}b}vb}u˘X}(wæuP]o˙
rv˙bV æu]}PullPrvR}o˙
Then
Aib}]vP}b}vb}u˘X}(uP]o˙
Or
yy HaloperidolUIMU
Adults
ræuPX b
Then
RrR}o˙}]vP}b}vbU}u˘]uu}(uP]o˙
Children
vr˙bV ruPrR}o˙]b
v*Schizophrenia*v
AMv˙bV v}}uuv
Or
yy HaloperidolU}oU
Adults
XæræuPrR}o˙]o˙
Then
æruPrR}o˙~u˘X}(uPZ
Children
AN˙bV XæræuPrR}o˙]o˙
Then
æruPrR}o˙~u˘X}(uPZ
r˙b}}˙`]PRærlPVXærXæuP]o˙
Then
Ivb˙XæuP]o˙˙ær˙bw
AM˙bV v}}uuv
B. Maintenance
yy RisperidoneU}oU
Adults
ruPrR}o˙~bo}`}bvib]o˙}]vP}
vb}vbZ
Or
yy Oov]v U}oU
Adults
æruPUu˘XuP]o˙
Standard Trtme
Children
AN˙bV æruPUu˘XuP]o˙
AM˙bV v}}uuv
Or
yy Ro}}u]v
C U}oU
Adults
æuPR}o˙}wæuPv]PRUib}u˘X}(uPR}o˙
Children
r˙bVæuPR}o˙}wæuPv]PRUib}u˘X}(
uPR}o˙
AM˙bV v}}uuv
Or
yy HaloperidolU}oU
Adults
ruPR}o˙Uib}u˘X]o˙}b}(uP
Children
r˙bV ruPR}o˙Uib}u˘X]o˙}b
}(uP
r˙bV æ u]}Pub R}o˙U ib }
u˘X}(æuPR}o˙
v*Schizophrenia*v
CX M]vvvuv(}vb`]Rv}R}v]
]oovbb~}}vbZ
yy FoRv]v decanoateUIMU
Adults
æuPu}vRo˙
Children
N}}uuv
Or
yy FovR]˘}o v}UIMU
Adults
G]}bb }(æruPUvLob˙bw UP]
uPu}vRo˙
Children
N}}uuv
X
D Aivuv(}uvPuv}v}v}(vb˙R}
Pb]+b
yy T]R˘˙Rv]˙o ~BvR˘}o ZU}oU
Adults
XæræuPvrR}o˙u˘XuP]o˙
Children
vr˙bV XæruPrR}o˙U
Then
Ivb˙r˙bw ˙uP]o˙}]vP}b}vb
Or
yy Bv}]v ~Bv}]v Z }oU
U
Adults
ruPrR}o˙
Children
AN˙bV ræu]}PullPrR}o˙
Or
yy ]]]vB U}oU
Adults
uPR}o˙U
Then
ib}uPR}o˙}uPR}o˙X
Children
v}}uuv
Or
yy B]]]v Ubo}ÌVlIMU
Adults
XæræuPib}u˘X}(uP]vR}b
Or
yy Bv}]v UIVlIMU
Adults
r uP bo}ò˙ } r u]vbU ]( ˙u}ub
b b]b L
rR}b
Or
v*Schizophrenia*v
yy D]u U}oU
Adults
æruPvrR}o˙
Children
r˙bV uPR}o˙
ær˙bV æuPR}o˙
Or
yy D]u UIVU
Adults
ær uP bo}ò˙ } r u]vb ~}˘]uo˙ Xæ uP ˙
}vb
b Z
Children
TR]bu˙u]vbX
Or
yy P}uR]v R˙}Ro}]U}o}IMU
Adults
Xæræ uP ]v]oo˙U u˙ }b ]( ˙u}ub
b b]b L v
hours
Children
ANv˙bV vXærXæuP
Then
R}bLvR}b
AMv˙bV v}}uuv
Refeal
r Criteria
R(oovb}˙R]]b
b Lv]b}](uv
æ
Standard Trtme
`b]v]`]R}˙R]]b
b [bb]b]}vX
L]l`]b ( oo vb `]R v ]b}b v R}b
`R}b ˙u}ub
b vv} }v}oo } ˙R]]b
b (} (R P
uv}Eo}}vob]TR˙X
75. Bipolar Disorder

B]}o ]b} ]b (}u }( u}} ]b}X TR u (b }
}v]}v ]v `R]R vb ˘]v u}} `]vPb b `v R `}
˘ub}(b]}v vuv] XB]}o]b}]b(}]v}o
o] b uv]rbb] ]oovbbX I ]b ]u}v } v} R R
+v boo˙ bvb `]R }v }u]vv u}} b
uU]Rb]}v}uv]X
A b]vPo uv] ]b} v R]b}˙ }( b]}v qualify for
obb].}v]}ob ]b}XvA ]b}}(b]}v`]R}
b uv] ]b} ]b v} ]Pv}b b ]}o ]b}X R
b]]b}b]Pv}bvb b]}vX
sueCa
yy LPo˙vlv}`v
v*BipolarDisorder*v
yy P}bb]ob}]}vbP
yy Tvv˙}v]v(u]o]b
yy Gv(}b
Symptoms
yy Pb]bvo˙ ou}}Pr R}]U˘vb]vbbU (o]vP RR]PR[
or irritable
yy O]˙
yy Tol]vP(bv˘bb]o˙
yy Gv]}bo]ub
yy Reduced sleep
yy Rlobbv]vPv]vP}o˙Pv}b
yy S˘ovb}]o]b]vR]]}v
yy A]}˙ Roo]v}vbU ]v b ~vb u˙ R }]bU
}Lv]v(}]vPR]Pv]}bo](bZ
yy Uvb]]}v~v}]Zu˙˘]b
yy Iu]iPuv
Signs
yy None typical of bipolar disorder
yy Su˙u}ub b }
Invtiga
se tions
yy Uboo˙v}b].]vbP}vb
yy Ro˙UR˙}}˘]}b]b u˙u]u]uv] vub˘o
v
Trtme
ae nt
Tuv}ib
yy T}˙u}ubb }(uv] or depressionU`R]R]bbv`]R
current episode
yy T}Roo}(]˙]vuv] }uvPob
yy T}ou}}}v}uo]v b b]}v
yy T} }o]bR ˙R} b ˙u}ub
b ~ob]}vb v Roo]v}vbZU ](
present
yy Pb˙R}R˙
yy Pb˙R}}v
AXMvPuv}(Ruv]v
yy RisperidoneU}oU
Adults
ruPrR}o˙U}u˘X}(uP]o˙
Children
AN˙bV æu]}PubX b
Then
v*BipolarDisorder*v
Aib ]o˙ ]v b }( æ u]}Pub r uP ]o˙ } u˘X }( v
uP]o˙
AM˙bV v}}uuv
Or
yy Oov]v U}oU
Adults
æræuPrR}o˙}u˘XuP]o˙
Children
r˙bV XæuP]o˙U}u˘X}(uP]o˙
AM˙bV v}}uuv
O
yy HaloperidolU}oU
Adults
æruPR}o˙}u˘X}(uP]o˙
Or
yy CRo}}u]v U}oU
Adults
æuPR}o˙}wæuPv]PRU
Then
Ivb˙æuP]o˙}æruPR}o˙
Or
yy S}]uo} U}oU
Adults
ærwæuPR}o˙~}v}ooob(oZ
Children
AM˙bV v}}uuv
w
Standard Trtme
Or
yy C u]v U}oU
Adults
ruPR}o˙~}v}ooob(oZ
Children
AM˙bV v}}uuv
BXMvPuv}(b]Pv].vo˙PPbb]v
~Sb}v}vRTRo˙A D]bPv [ZX
C. Management of the depressive phase
yy Lu}]P]v U}oU
Adults
æuP]o˙(}`lb
Then
Ivb ˙ æ uP ˙ `lb } u˘X }( uP ]o˙ b r
quired
Children
AM˙bV v}}uuv
Av
yy L}u U}oU
v*BipolarDisorder*v
Adults
ruPrR}o˙Uu˘XuP]o˙
Children
r˙bV XæuP llPR}o˙Uu˘XuP]o˙
Or
yy D]u U}oU
Adults
æruPvrR}o˙
Children
r˙bV uPR}o˙
ær˙bV æuPR}o˙
Note 10-5
TR v}]]vb `]R`v b b}}v b R v ]b ouU R]b
bR}o}v˙bo}ò˙]vPR}bX
X
D M]vvvuvPuvL}v}o}(RRb
yy L]R]u U}oU
Adults
rvuPvrR}o˙~u˘XuP]o˙Z
Children
r˙bV rvuPR}o˙~u˘XuP]o˙Z
vr˙bV æruPllPR}o˙
AMv˙bV v}}uuv
Note 10-6
L]R]u oobbR}ou}v]}R}bL}bU`]`lo˙vo}v r
]}v]o]b
b bURv}v˙u}vRX
Or
yy S}]uo} U}oU
Adults
ærwæuPR}o˙~}v}ooob(oZ
Children
AM˙bV v}}uuv
Or
yy Cu]v U}oU
Adults
ruPR}o˙~}v}ooob(oZ
Children
AM˙bV v}}uuv
Refeal
r Criteria
R( oo vb b+]vP .b ]b}U v} b}v]vP }
v*AlcoholWithdal
uvL}vu}vRvooR]ov}˙R]]b b X
76. Ao}R}oW]RòS˙v}ub
w r Syndome
TRb } (}oo}`]vP bv `]Rò (}u o}R}oX TR˙
r s*v
}Lv bv } R}b L R ob ]vlU u˙ o] v
`}b `v } R}b L }vbX TR]b }uu}vo˙ }b
]v vb u]' } R}b]o (} }R }oub XPX ]b]vP (}u
]vb } R˙b]o ]oovbbU `R]R lb Ru (}u ]vl]vPX TR
bv}v]b(}uu]v]uou}b}}( b (ooro}`vP]}v
v}v(b]}vU`R]R}voo˙(oX
sueCa
yy A }vb } b]Pv].v }v ]v o}R}o ]vl ]v v
]v]]o`]RR˙]vl]vP}uv˙u}vRb}˙b
M]v}W]Rò Alcoholic Hallucinosis Ao}R}o]S]b
Ovb }R}bL rRbL}v b wrR}b
v LR
ob]vlUu˙ }(]vl]vPvPvoo˙ ob]vlu˙
o]XPlb }bb `]R]vR}b o]X
`vrR}b
S˙u}ub Shaky hands Svb}v}(}ib vb Pvo]b
Headaches ò]vP}v}˙ b]b]v
Ivb}uv] chronic alcoholic
M]ov˘]˙ SS]vP _}ibv}oo˙
NauseaU present
V}u]vP SH]vP _v}]bb}}]b
S`vP v}}˙obvRX
ı
Standard Trtme
M]v}W]Rò Alcoholic Hallucinosis Ao}R}o]S]b

S]Pvb Ivbob The vivid hallucinar Pvo]b
Raised blood pressure }vb}]vo ]bb
}vb]}bvbbX
PobUBo}}Pbvb
b]}v`]R]v
v}uoo]u]b
Trtme
ae nt
Tuv}ib
yy To stabilise pulse and blood pressure
yy T}vR˙}v
yy T}bvvP}v]}vbo]luo]X
yy T}o]]vUu}bvb]b
yy T}}b Roo]v}vb
yy Sit or lie in a quiet place
v*AlcoholWithdal
yy PR˙b]o ]vb b u˙ ] u}]o˙ (} ˙ P]

vb
yy Ev}P]vl}(G]bvb }o}vR˙}v
w r Syndome
st
L]vTuv
r s*v
]vE RvPA
yy HaloperidolU}olIMU
Adults
æuPR}o˙]b voRoo]v}vbbX
Children
Refer to specialist
Or
yy Oov]v U}oU
Adults
æruPR}o˙~u˘X}(uPR}o˙Z
Children
AN˙bV XæræuPXb
Then
M˙]vb}uP~u˘XæuPR}o˙Z
Refealr Criteria
R(oovb`]Ro}R}o`]Rò˙v}ub
b }˙R}o}P]b
b
}˙R]]b
b XAob}(ooR]ov}]]]vX
77. Ao}R}o]Do]]uTuvb
TR]b ]bRu}bu`]Rò˙v}u
b XIboo˙br
˙bL]vl]vP}bb XOvPUR˙v}u b obb˙b u˙
}vv (} uR o}vPX W]R} P}} b} v
uvUDo]]uTuvb~DTZ ]bb}]`]Rb]Pv].vu}o]˙X
R]bl(}b]voo}vPR]b}˙}(R˙o}R}obU]}bR]b}˙
}(TD U}vv]oovbbUb]Pv].vo}R}ooo]vP`]RòUo}vP
}vb]vob]vl~}R}bZvP}˙bX
sueCa
yy Sv `]Rò }( o}R}o (}u o}vPru R}v] b }(
alcohol
Symptoms
yy Restlessness
yy SRl]vP}(RvbU`R}oo]ub}}˙
yy S`vP
yy Confusion
v*AlcoholicDeliriumTremens*v
yy Iv}]R]}
yy Uv]voo]P]obR
yy M]b]v.}v
yy S]vP}ol]vP}]uP]v˙}ib
Signs
yy Tu}b
yy Pb˙R}u}}P]}v}}v
yy S`vP
yy V}u]vP
yy D]b}]v}v
yy Ivu]'v ]boU o } ]}˙ Roo]v}vb } ]oob]}vb
~V]bo Roo]v}vb (vo˙ }( buoo }ib } (]PRv]vP
Rv]uob[}vòobXZ
yy F AN£CX
yy PobANblu]vUBo}}PbAN b vluuHP
Invtiga
se tions
yy FooBo}}C}v
yy L]Fv}vTbb
yy Sv(}uo]v}uu}v]v(}vb
Trtme
ae nt
Tuv}ib
yy T}o]P]}vvouv
yy T}}G]vo}o˙]uov
yy T}v}uo]}vbo]lb]bUo}uv}(uvb]v
encephalopathy
yy T}v}uvPR}uo]}vb](bv
Standard Trtme
yy Sob]}v}(Rv
yy Ao]}v}(]vb
b bvbb˙
yy Pb˙R}R˙ v˙R}}v
b
]v
E RvPPA
AXF}}v}o}(b]b
yy L}u UIVUIM}}oU
Adults
˙bD }P ruP}v]o˙
˙bD væP ruP}v]o˙
Or
yy D]u U IVU ~u]v]b bo}ò˙r} r u]vbU }˘]uo˙
XæuP˙}vb b Z
Adults
˙D P ruPvR}o˙
˙D P ruPR}o˙
˙D P ruPR}o˙
v*AlcoholicDeliriumTremens*v
˙D P æruPR}o˙
˙D æP æruPR}o˙Rv}b
Note 10-7
I]b}b P]v}]]vbbvRRv}v .˘}bbR r
oX
W]RR}o ]( v ]b bo } Rb bo bRU ˘] U v˙bPub or over
X
b
Or
yy C Ro}]}˘] U}oU
Adults
æruPR}o˙]b ~u˘XuPZ
Av
yy TR]u]v U}oUIM}IVU
Adults~}oUIMUIVZ
uP]o˙(}˙b~(}v˙IVGo}bo}Z
vA
yy F}o]A] U}oU
Adults
uP]o˙bv
vA
yy ˘}b D saline~æA9Po}b]vXıA9bo]vZUIVU
Adults
As necessary
BXF}vb`]Rb]bv}}v}oo˙v}]]vbo}v
yy L}u UIVUIM}}oU
Adults
˙bD }P ruP}v]o˙
˙bD væP ruP}v]o˙
Or
yy D ]u U IVU ~u]v]b bo}ò˙r} r u]vbU }˘]uo˙
XæuP˙}vb b Z
Adults
˙D P ruPvR}o˙
˙D P ruPR}o˙
˙D P ruPR}o˙
˙D P æruPR}o˙
˙D æP æruPR}o˙Rv}b
Av
yy PRv}]}v Ubo}ÌV}IMU
Adults
XærXæuP llPR}o˙
Refeal
r Criteria
R(vb`R}b˙u}ub
b ]8o}}v}o`]R]v˙b
}`R}u]vP]b]]vP P]v} uP]u`]R]v
v*AnxietyDisors*der v
R}b}b]o]bX
R( vb } ˙R]]b
b } o]v]o ˙R}o}P]b
b (}
}vb]}v }( }R uv }}vb } b]b o}vPru vv
b
vR]o]}vLRb]b}X
78. Av˘]˙ Disorders

Av˘]˙ ]b}uu}v˙u}u
b R}b]voo˙R]]
b ]b}b
]vo]vP b] ]oovbb v u}b ˙R}b b bX PR˙b]o ]bb o]l
R˙R˙}]]bu U ] ]bb } R˙vb]}v u˙ ob} bv `]R
v˘]˙ vR(}ub˘oX
TR]}b(}ub}(v˘]˙ ]b}b~XPXPvo]v˘]˙
]b}bUv]]b}bUR}]bU}bb]}uob]]b}U
b ]b}U }b u b ]b}U XZU R }uu}v
}vbvb ]vPvoPvo]v˘]˙]b}bvv]
]b}bX
Iv oo b }( b v˘]˙ ]b}bU ] ]b ]u}v } b
R }b }( R v˘]˙U ]vo]vP R vvbU R]} v
}vbvb }( v˘]˙ (} R v R}PR v ]vR ]v]`X I
]b ob} ]u}v } bl } R bv }( }bb] R}PRb vl
} }uob]}vb b Rb ]vb]vPo˙ }uu}v v v v} }
}}}(ubbuv`R]Ro}uRb}vo]bbX
IvR]b(b }˙R]]b
b X
Iv Pvo] v˘]˙ ]b}bU R ]b ˘bb] v˘]˙ v
`}˙ }vb } ]bU bR b (}uv bR}}o } `}lU
Standard Trtme
}]vP}vu}b˙bU(}obvu}vRbX
A v] ]b} (b } 'v }( v v˘
'lb }( ]vvb ( } ]b}u(} } ]b ]} u} Rv
ub `lX D]vP 'lb } u} }( R ˙u}ub
b o]b o}`
o} o˙ v R l `]R]v u]vbX Pv] ]b}b
}uv] ˙ b]bv }vv } R]vP v}R 'l }
`}˙]vP}]uo]}vb}(R]vPv'lX
Iv R]ov b]oo˙U o }uo˘ b]b u˙ u]u] v]
'lbX M]}vb ] } v] ]b}b }vo˙ ]( R
'lb}(vo˙v}PR}b]bbX
GENERALIZEDANXIETYDISORDERS
sueCa
yy MoovPo](˘]vb
yy Ev]}vuvo(}b
yy Pb}vo]˙]
yy Gv]b}b]}v
Symptoms
yy E˘bb] v˘]˙ v `}˙ }]vP }v u}b ˙bU (} ob v
u}vRb
yy Av˘]˙ }`}˙b}]`]Rob}(R(}oo}`]vPP
yy Mbo vb]}v ~}Lv } b ]v ]v ]}b b o]l
vlUvl}RRbZ
yy ò]vP
C vv]vPbvb}v}vR}˙
yy Rbobbvbb}(o]vP}vP
yy B]vPb]o˙(P
yy D]8o˙}vvvP}u]vP}]vPovl
yy I]]o]˙
yy So ]bv ~]8o˙ (oo]vP bo } (v `lv r
]vPZ
yy Po]}vb
Signs
yy Restlessness
yy S`vP
yy Av˘]}bu}}
yy Tachycardia
yy Tu}b
Invtiga
se tions
yy N}v}}v.uR]Pv}b]bX
yy Tbb } ˘o }o ]+vo ]Pv}bb bR b
R˙R˙}]]bu UR}R}u}˙}u U]R˙Ru]bX
Trtme
ae nt
Tuv}ib
yy T}v˘]˙
yy T}']vo](}(b}u˙u}ub
b
yy Reassurance about the absence of physical disease once they are
ruled out
yy TRo˘}vuR}b
yy Ev}PPoR˙b]o˘]b](}bb]o
yy Ev}PRoR˙b}]o]b
yy C}Pv]BR]}TR˙
AXF}v˘]˙ `]Rb}u}uo]vb
st
L]vTuv
]v
E RvPPB
yy SertralineU}oU
Adults
æuPb]vPo}ov]vP}bV
Then
Ivb˙æuP`l]vobU](vbb˙U}u˘X}(
uP
Children
r˙bV æuP]o˙
vr˙bV æuP]o˙
AMv˙bV v}}uuv
Or
yy Fo}˘v U}oU
Adults
uP]o˙U
Then
Ivb}vuP]o˙](vbb˙
Children
wr˙bV uP]o˙
Then
Ivb}uPLr`lb](vbb˙
Or
yy Au]]˙o]v U}oU
Adults
æræuP]o˙~bb]vPov]vP}bZ
Children
AN˙bV uP]o˙~b b]vPov]vP}bZu˘X
uP
Or
yy Iu]u]v U}oU
Adults
æræuP]o˙~bb]vPov]vP}bZ
Children
N}}uuv(}R]b]v]}v
æ
Standard Trtme
B. For anxiety`]R}u]vvb}u}uo]vb
yy P}v}o}o U}oU
Adults
ruPR}o˙
CXA]}vouv(}v˘]˙ `]Rb]Pv].v]bb
yy D]u U}oU
Adults
ræ uP R}o˙ (} `lb v Poo˙ ]o }+ }R v˘
`lbX
~D}v}P](}u}Rv}vu}vR}vv}bo˙Z
Children
r˙bV XæræuPvR}o˙bv
Refeal
r Criteria
R(} o]v]o ˙R}o}P]b
b (} C}Pv] BR]} TR˙ and
}R v}vrRu}o}P]o uv u}o]bX R( } ˙R]]b b
]vbv}b}vb]}PuvX
PANICDISORDERS
sueCa
yy LPo˙vlv}`v
yy M]b]v}v }( v}uo ]vvo }˙ uo]
b ~XPX ]lv
R]vbR'l}b]}b]oovbbUZX
yy M]b]v}v }( ˘vo uo]
b ~}`bU vo}b b R
bu}]vPR]obUo]LbUXZb]Pvoo]vPvP
yy C}v]vP(}bP
yy Stress
yy Gv]b}b]}v
Symptoms
yy F}(˙]vP}P}]vPR˙ [
yy Po]}vbU}v]vPR}]R
yy Tuo]vP}bRl]vP
yy Svb}v}(bR}vbb}(R
yy Fo]vP}(R}l]vP
yy CRb]v}]b}u(}
yy Fo]vP]˙Uvb˙}(]v
yy Nuvbb}vPo]vPbvb}vb
yy CR]oob}R}GbRb
yy o]bD }v ~(o]vP }( vo]˙Z } b}vo]b}v ~(o]vP
R(}u}vbo(Z
yy Nausea}}u]vo]bb
Signs
yy Tachycardia
yy Tu}b
yy S`vP
v
Invtiga
se tions
yy N}v]Pv}b
Trtme
ae nt
Tuv}ib
yy T} }b R 'lb }( v] } ob R (v˙ v
]vvb]˙}(˙u}ub
b }u]v]uu
yy T}Rov}v}uo]b}(]o˙o]]vP
yy T}vv}(˙u}ub b
yy RR]vP ]v v } }( P o}b }v o]b v v}b
~}]}o˙RvPbU˙oPvo}bZ
yy Eo]u]v +]vr}v]v]vP (}}b XPX }+U U }o v
R}}obU(}uR]]UbR˙v}`}bvv˘]˙
yy Ro˘}v]v]vP
yy C}Pv]BR]}TR˙
AXIv]ouvPuv(}vbvb}vb]}v}vr
pharmacological treatment
st
L]vTuv
]v
E RvPPB
yy Fo}˘v U}oU
Adults
uP]o˙~bb]vPou}v]vP}bZ
Then
Ivb}vuP]o˙](vbb˙
Children
vr˙bV uP]o˙
Then
Ivb}uPLr`lb](vbb˙
Or
SertralineU}oU
Adults
æuP]o˙~bb]vPov]vP}bZ
Then
Ivb}æuPL`l](vbb˙
Then
æuP`lo˙}u˘X}(uP]o˙](vbb˙
Children
N}}uuv
O
yy Iu]u]v U}oU
Adults
æræuP]o˙~bb]vPov]vP}bZu˘XæuP]o˙
Children
w
Standard Trtme
N}}uuv(}R]b]v]}v
BXF}˙(vv]'lb
yy L}u U}oU
Adults
ruP]o˙(}`lb
Children
r˙bV XæuP llP]o˙(}`lb
CXF}v]v˘]˙ 'lb
yy L}u U}oU
Adults
ruPXb
Children
XærXæuPX b
D. F}S˙u}u
A C}v}o
yy L}u U}oU
Adults
ruPrR}o˙]b ~u˘XuP]o˙Z
Children
N}}uuv(}R]b]v]}v
Or
yy Ao}ou U}oU
Adults
XærXæuPvrR}o˙
Ivb](vbb˙˙r˙bUu˘XuP]o˙
Children
AM˙bV v}}uuv
Or
yy D]u U}oU
Adults
ræ uP R}o˙ (} `lb v Poo˙ }+ } R v˘
`lbX
~D}v}P](}u}Rv}vu}vR}vv}bo˙Z
Children
r˙bV XæræuPvR}o˙bv
Note 10-8
}v
D }(uv(}vbR}oob`lb
v vbR}o
}vv(}}u}vRb
v }u}L'lbRu]'}v
o˙obXWv}+bo}ò˙}u}vR}u}X
Refeal
r Criteria
R( R]ov `]R ˙u}ub
b bPPb }( v] ]b} }
]]]vXAob}(vb}˙R}o}P]b
b (}C}Pv]BR]}
Therapyv}˙R]]b b (}]}voPR˙`R]v]X
79. SbvUbD]b}b
Ab }( vbb bR b u]iv U v}]]vbU R}]v U
cocaine X ]b ov ]v uv˙ }uuv]b }v R }v˙X
T˙]oo˙U ]v]]ob `]R bR ]b}b b Ro }vo˙ L R˙
(} } } b} ˙ (u]o˙ uubX TR˙ u˙ ob} P]v } R
`]Rò ˙u}ub b `Rv }v u]bb]}v (} b]}b R˙b]o ]oovbbX
TR]b ]b b R˙ Rv} b } Rvb ]vP bX TR]b
u˙ }uo] uv }( R ]u˙ ]bb (} `R]R R˙ `
u]'X
sueCa
yy Social factors
yy P~ b XPX(u]o˙uubU(]vbZ
yy Ll}(}]vPbl]oob~XPX`]Ro]([b]8obU]b}}]vP]v
ub}(}oZ
yy A ]}v
yy T}ov~]vb]uv}(vb }u]v]vRbu
(o]vPZ
v*Sutasb nceUseDisors*der v
yy W]Rò+b~vobv+bo}v}PbZ
Symptoms
Cannabis withdrawal
yy Ivb}uv]
yy Shakiness
yy I]]o]˙
yy Restlessness
yy Av˘]˙
yy AvP
yy OvbPW]R]vR}b}(Pb
yy }v
D Pr`lb
Benzodiazepine withdrawal
yy Av˘]˙
yy Headache
yy Ivb}uv]
yy MboR]vPv`]R]vP
yy PoRvPb
yy Fo]vPb}(vo]˙
yy b}vo]}v
D
yy S]b
yy OvbPr˙b~v]vP}vRo(ro](}(PZ
yy }v D Prv`lb~u˙o}vPZ
Opioid withdrawal
yy Av˘]˙
ı
Standard Trtme
yy ]vP
C
yy Muscle tension
yy Muscle and bone ache
yy Mboubv]vb }v}vb
yy Sleep disturbance
yy S`vP
yy H}v}oGbRb
yy P]o}}v
yy Y`v]vP
yy L]u}vvR]v}R}
yy A}u]voub
yy NauseaU}u]vP and diarrhoea
yy Po]}vb
yy Elevated pulse and blood pressure
yy D]o]ob
yy OvbPvrR}b~u˙o`]Ro}vPrvP}]}]bZ
yy }v D P lb r ˙bU b ær ˙b ~u} }o}vP (}
o}vPrvP}]}]bZ
Pb˙R}buov`]Rò
yy Crash~(PUG+U]vbboU]vPbZ
yy W]Rò~GvPu}}vvP˙oobU]vPbU]b
boU}}}vv}vZ
yy E˘v}v~b]bv}(`]Rò(bUPoo˙b]]vPZ
yy OvbPvrR}b~}]v ZVrR}b~uRu]vbZ
yy }v D P So `lb (} `]Rò RbU Rv u}vRb (}
˘v}v
Signs
Cannabis withdrawal
yy Su˙u}ub
b
Benzodiazepine withdrawal
yy Su˙u}ub
b
Opioid withdrawal
yy Su˙u}ub
b
Pb˙R}buov`]Rò
yy Su˙u}ub
b
Invtiga
se tions
yy T}˘]}o}P˙vb (}vbb
B}˘rP) Sv]vP}(vb}(
b vb b
PR˙b]ov
yy S`vPUu}UP]}vU}ou`]R}}]v}vUP]XRRb r
vb v b Ru Po ]vob } u}v]} R }Pbb
}( ˙u}ub
b X I( ˙u}ub
b ]vb]vP ]v ]˙
b U v}(˙ bv]} +
b
uuU}](]ooU}}
S]]]blbuv
yy T} u]v R oo }( ]bl P]v u v } }] }]
o]v]ovuvPuvXP}bb]ob]]oR]}]vobR]vl]vP
}b]]URu]vP}vbo(}'uvPb]]X
yy Sv]vP}vb b }(b]]]blP
yy H R]vPb v b} oo˙ R ˙} R R}PR ˙} `}o R
not be here?
yy H˙}Rv˙R}PRb}(Ru]vP˙}bo(M
yy ˙} A R]vl]vP}(b]]M
yy D}˙}Rv˙ovb}}uu]b]]M
yy H˙}]}Ru˙}bo(M
yy H˙}uv˙vovbM
yy D}˙}R}b v˙R]vP`]R`R]R}R˙}bo(M
Mvo˘u]v}v
b
yy T}u]vP
yy TRv(}}R˙R}o}P]o
b R]b
yy C}v}u]v˙R]]
b }v]}vb`R]RoRv}}Rb]bl
yy TR v[b ]˙ (} ]v(}u }vbv v ]}v ]v
uvovv]vP
Abuv}(˙R}bb }]o(}b+vP`]Rò
yy Ablv}P
yy Rb}vb(}bvvP(}`]RòuvPuvR]bu
yy Pb˘]vbUvlv}òPv(b}(`]Rò
yy P]]o]˙}}`]R`]Ròv]buvX
yy Fu]o˙b}bvb}]ov`}lb]oo(}`]RòuvP
yy P}vo]b}(o b `]Rò
yy }(C R]ov~b}bb b]ovPo}R˙b]o}˘o
b }(
b R]o r
v } ˘}b } bR Ru (}u }Rb v ]vv } } b
b}}vb}bb]o}(}}]Pv˙Z
yy DPb}(}R]vb
yy vC oPo]bb
yy F]vv]o}oub
yy W}l}uu]uvb
Trtme
ae nt
Tuv}ib
yy T} }] b} ~]v(}u}vU b }vU
vb Z
yy T} R }]vP bl]oob ~o˘}v Rv]bU ]˙ P]o]vbU
uR}b } ]vP (} R vb U bo ]bv
uvPuvZ
yy T}uvP]8oR]}~v˘]˙ UP]}vUv]vPPbb]}vZ
Standard Trtme
yy T}uvP}v(b]}vU]b}]v}vvRoo]v}vb
yy T} ov v }Pv]b ]bRPU (}oo}` v Lr}v
relapse
yy C}Pv]BR]}TR˙
yy SbbuvPuv}]vP
AXMvPuv}(`]Rò˙u}ub
b rvv]b
yy R]bv}u]o]vv}v
BXMvPuv}(`]Rò˙u}ub
b ruovb
b
yy R]b}b}v}bv}]b].]vv}v
C. Management of withdrawal symptoms - benzodiazapines
yy Sb `]R ]ov }b }( v}]]v (} (` ˙bU
Rv}+}b}r`lb
D. Management of withdrawal symptoms - opiates
yy OoR˙}vG]b}IVG]bu˙]
v*AutisticSpctre umDisorder*v
yy L}vPvPv}]]vbXPX]uU}}v}o]vb}uv]v
uboub~SP}bbv}]b}vbZ
yy Avrub XPX }uR]v XU (} vb v }u]vP (See
P}bbv}]b}vbZ
yy MethadoneU v}R]v and clonidine u˙ bU `R
]oov`]R}vU}R]˙ b }(˙u}ub
b ~S
P}bbv}]b}vbZ
yy NSAIDb XPX]}(v U]o}(v XU(}]vo](~SP}bb
v}]b}vbZ
Refeal
r Criteria
R( (} b]o]b ˙R]]b
b lo]v]o ˙R}o}P]b
b v
uvPuv ]( `]Rò ˙u}ub
b oo˙ ]b(o
b v}
v}b}v}uv}`RvRobbX
R((}C}Pv]BR]}TR˙ }o]v]o˙R}o}P]b
b X
80. Su
Ab D]b}
Abu]bv}o}uvo]b}R]˙o]
]u]uvb}]vP]vR]o(}RP}(u}vRb v U]vRl˙
bV b}]o ]v}v ~}Lv R o]b (b }( Ab Su
D]b} rASD ZU}uuv]}vU]vbbv]bX
TR o]v]o bv}v ]b ] v u˙ v}ubb R]ov
`]R b uv](b}vb }( R } (b } `]R u} ob
R]}o .]bU Rv R b }( R u Ab Su
D]b} XLv]vP]b]o]˙]vR]b}v]}v]b˙}uu}vvR]bl
of epilepsy]bb]Pv].vX
ASD ]b]vb]vPo˙]vP}Pv]]vGRvX
sueCa
yy N}o}o}P˙
yy Gv
Symptoms
yy bv A }( i}]v 'v}v ~]XX (]o} bR}` ]vbU (}oo}` PU
ol }( b}]o bu]o]vP v o]u] b }( Pbb XPX bRl]vP RU
`]vP}o]vPZ
yy C}uuv]}v.]
yy RP (]ob} ]ovPP} o˙b ]v vbv]vP
ovPP
yy E˘bb]Po˙b]vb}(ovPP
yy L]u]vP}(]vbb~o]u]o˙`]R}˙bv}R}ibZ
yy R]b~XPXb]vv]vP}ibZ
yy Go}oo}uvoo˙b~XPXòl]vPUbRXZ
yy Lv]vP]8ob
yy 'v}v A .]
yy So]vP]8ob
yy F]vP]8ob
Signs
yy Ll}(}]vvP}}ib˙u}vRb
yy N}b]vPo`}b˙u}vRb
yy N}`}`}b}vv}bRb˙u}vRb
yy L}bb}(ovPP
yy Avoidance of eye contact
Invtiga
se tions
yy Uboo˙v}v]
yy Eo}vRo}Pu~EGE Z](b]bb
yy ]v B CT}MRI}vo˙]vb]o]ubvbXPXv}uoR˙b]o
features present
Trtme
ae nt
Tuv}ib
yy T}}b}]o}uuv]}v]8obb]vP uo]b]o]v˙
R]}ov}vo}R
yy Ao] BR]} Avo˙b]b ~AAB Z r R]vP b }v R
U
b }ub]bv}R]oUR]ob}vbv(l
AXF}PPbb]}vU]]]o]˙}bo(ruo}v
]v
E RvPPB
yy RisperidoneU}oU
Children
Standard Trtme
ær˙b~}˙`]PRANælPZV Xæ uP ]o˙X M˙ ]vb ˙ Xæ
uP}vov˙b~u˘XuP]o˙Z
ær˙b~}˙`]PRAMælPZV XærXæ uP ]o˙X M˙ ]vb
˙XæuP}vov˙b~u˘XXwæuP]o˙Z
AMæ˙bV v}}uuv
B. For sleep problems
]v
E RvPPB
yy MelatoninU}oU
Children
u}vRr˙bV ruP]o˙~(}uZ
Then
Ivb ]( vbb˙ L r `lb } rv uP ~]o˙ (} r
uZu˘XuP
CXF}b]Pv].vR˙]˙r]vR]ovAH˙b
]v
E RvPPB
yy MethylphenidateU}oU
Children
vr˙bV æuPrR}o˙
Then
Ivb](vbb˙`lo˙]vob˙æruP
~u˘X}(uPR}o˙Z
rv˙bV XæuPR}o˙
Then
Ivb](vbb˙˙XæuP`lo˙]vob~u˘XXrXæuP l
lPR}o˙Z
Note 10-9
D]b}vv](R]bv}b}vbLu}vR
Refeal
r Criteria
Aoo}( b bubR}o(}T˙vX
Chapter
Disorsof
der theSkin
]o
B Sl]vIv(}vb
81. Boils
A boil or furuncle ]b ]o ]v(}v }( R R] (}oo]obX A
u} b.]o ]v(}v ]b u (}oo]o]bX So }]ob P} ]v
v v ]bRP]vP b (}u ob }]vb ]b u voX
Pvb `]R v }]ob } vob bR}o vb (}
]b uoo]b v bl]v ]b}b bR b ]bb U ]o}b]b }
u `R]ovb `]R (}oo]o]b ]v R bR]vPbU XPX
(vu]bbR}o}vbR]vPRv]bX
sueCa
Symptoms
yy S]vPo}uoo]v(oòo]vPb b }vRbl]v`R]Ru˙]bRP
pus
yy F
Signs
yy Sòo]vPb r ovU ùU Gv vl} v ~]v b]vPo }
uoob}(bl]vZ
Invtiga
se tions
yy FBC
yy FbvPo}}Po}b~](]bZb
yy S`b(}ovbvb]]˙]vb]bv}v]v(}v
Trtme
ae nt
Tuv}ib
yy T}]v(}v
yy To relieve pain
yy T}]v(˙vv˙]b}b]vP}v]}v
yy To prevent scars and keloids
æ
Standard Trtme
yy Iv]b]}vv]vPr](}]o}ubGvvoP
yy W}vb]vP
st
L]vTuv
]v
E RvPPB
AXF}}]ob}(vo}b]b ]vvb`]R}v]]oo]vooP˙
yy Foo}˘]oo]v U}oU
Adults
æræuPvR}o˙(}˙bw
Children
ær˙bV æuPvR}o˙(}˙bw
ræ˙bV æuPvR}o˙(}˙bw
AM˙V vXæuPvR}o˙(}˙bw
B. For boils or furunculosis]vvb`]Rv]]oo]vooP˙
yy E˙R}u˙]v U}oU
Adults
æuPvR}o˙(}˙bw
Children
vr˙bV æuPvR}o˙(}˙bw
v*Impetigo*v
Av
yy Pu}o U}oU
Adults
æuPrP}v R}o˙(}ræ˙b
Children
vr˙bV æræuP}v R}o˙(}ræ˙b
ræ˙bV ræuP}v R}o˙(}ræ˙b
u}vRbr˙V vruP}v R}o˙(}ræ˙b
CXF}F}oo]o]b
yy Mupirocin}]vuvU}]oU
Adults and children
R}o˙(}˙bw
Refeal
r Criteria
R( } b]o]b ]( R vo˙]vP }v]}v ]b (R
uvPuvX
82. IuP}
IuP} ]bR]PRo˙}vP]}bb.]o]obl]v]v(}vXI]b
}uu}v]vv}vbvR]ovvu˙b}]`]R}v]}vb
bR b ]bU u U o] ]v(b}v v Rb b]uo˘ ]v(}v b
v
Chatep rP *Disorsof
der theSkin
}v˙b ]v(}vX TR }v]}v }b v} b v˙ ˙u}ub b vo
(} } ˙b L ]v]o ˘}bX I boo˙ ]u}b `]R]v `l
}(uvX
TR `} ˙b }( ]uP}X TR v}vroo}b ˙ ˙]oo˙
+b R bl]v }v R v}b v u}RU b]vP ob]}vb } o}U
R ]lo˙b} o ˙oo}`r}`v X b TR }R ˙U oo}b
]uP}U˙]oo˙+bRvlb]vPG]r.ooo]bb~ooZ}
o}RL b (`˙b}o˙oo}`Xb
B}R˙b}(]uP}u˙oR]vulb`RvRR b
oURbboo˙]u}}R(}oo}`]vP˙b}`lbX
Ib v}v ]v}ob P}} R˙P]vU Po Rvr`bR]vPU
]uu]vP}(.vPv]ob}l]vP}(Rbl]vR}PRR]vP b U
v]b}P]vPRbR]vP}(}òbvo}R]vPX
sueCa
Symptoms
yy Pbr.ooo]bbvb}b}vR}˙}o b
Signs
yy S.]oU(P]oG]r.ooo]bb
v*Impetigo*v
yy IPo]vP b ob`]R˙oo}`b
Invtiga
se tions
yy OLvv}]b
yy M]}b}˙ v o }( R ˘ (}u R o]bb ~˘ ]v
v}bZ
Trtme
ae nt
Tuv}ib
yy T}]]v(}v
yy T}vvbu]bb]}v
yy T} R ]bl }( o}]vP }uo]}vb ~XPX ooo]bU
u]
b Z
yy T}]v(˙vv˙]b}b]vP}v]}v
yy AvbRb(}oob
AXM]ob~(òbb `]R}(}˙bb u]uv](b}vbZ
]v
E RvPPB
yy Mupirocin}]vuvU}]oU
Adults and children
Ao˙R}o˙(}˙bw
w
Standard Trtme
BXM}}}b ˘vb]b]vvb`]R}
penicillin allergy
st
L]vTuv
yy Co}˘]oo]v UIVU
Adults
æuPvR}o˙(}ræ˙b
Children
r˙bV æræuPvR}o˙(}ræ˙b
r˙bV æræuPvR}o˙(}ræ˙b
AM˙bV vXæræuPvR}o˙(}ræ˙b
Then
yy Foo}˘]oo]v U}oU
Adults
æuPvR}o˙(}ær˙bw
Children
r˙bV æræuPvR}o˙(}ær˙bw
r˙bV æræuPvR}o˙(}ær˙bw
AM˙bV vXæræuPvR}o˙(}ær˙bw
Or
Adults
v*Impetigo*v
væuPR}o˙(}æ˙bw
Children
r˙bV væuPR}o˙(}ær˙bw
vr˙bV æwuPR}o˙(}ær˙bw
ræ˙bV uPR}o˙(}ær˙bw
AM˙V uPR}o˙(}ær˙bw
nd
o]vuv
]v
E RvPPB
yy (}˘]u
C IVU
Adults
wæuPR}o˙(}ræ˙b
Children
u}vRr˙bV uP llPR}o˙(}ræ˙b
Then
yy (}˘]u
C U}oU
Adults
æuPR}o˙
Children
r˙bV æuPR}o˙
r˙bV æuP llPR}o˙Uu˘XæuPR}o˙
u}vRbr˙bV uP llPu˘XæuPR}o˙
CXM}}}b ˘vb]b]vvb`]Rv]]oo]v
allergy:
yy A]R}u˙]v U}oU
Chatep rP *Disorsof
der theSkin
Adult
æuP]o˙(}ræ˙b
Children
AMvu}vRbV v} }uuv b }( ]bl }( ˙ r
loric stenosis
Refeal
r Criteria
R((}R}b]ovuv](]vP b ]o˙}ooo]bU
}b}u˙o]b}u] b o}bX
83. Cooo]b and Erysipelas

~Sb}v}vRCooo]b[]vD]b}b}(RMbo}bloo˙bb uZ
X Bo]Uo
TR]b ]b R}v] ]vobb v}b]vP o `]R vu]v PbU
v*CellulitisandysEr ipelas*v
`R]Rvo}]o]vPbl]vvb}L]v(}v b vuvv
]b.PuvXWR]o]]blv}`vRR]bo]bb˙]uU
R u} }( vbu]bb]}v u]vb voX H}Ù uU ]vb ]
v]vRo}vRvbPPbX
WRvo˙URui}]˙v `]R }u]v}v
}( v]}bX TRbU o˙ ]v.}v v }] uvPuv
u}]]˙v]b]o]˙(}uR]b}v]}vX
sueCa
yy Mycobacterium ulcerans
Symptoms
yy P]vobv}b b v}o
yy P]vobòo]vP b }(RoPbUub}(
yy E˘vb]bl]vo}v
Signs
yy N}oP P]vobb .u ob]}v r u ]v ]u b] ]v R
v}b
b bv'R}Rbl]v
yy D]+b]vobòo]vP
b }(RoPbUub}(
yy LP]vob}( b ]v}v
yy E˘vb]bl]vo}v
Invtiga
se tions
yy W}v`b (}AFBbU]oobvbvb]]˙
yy Sl]v]}b˙(}R]b}R}o}P˙
Trtme
ae nt
Tuv}ib
yy T}o]u]R˘v}(}v
b
ı
Standard Trtme
yy To prevent disability
yy T}}R]u˙v}v˙ b ]o]v(}v
yy C}uo ˘]b]}v }( v}obU (o˙ `]R ]u˙ o}b ](
possible
yy Sl]vPL]vP}(ob]((]o]b]oo
st
L]vTuv
]v
E RvPPA
yy R](u]]v U}oUuP llP]o˙(}`lb
Av
yy S}u˙]v UIMUæuP llP]o˙(}`lb
nd
L]vTuv
]v
E RvPPC
yy R](u]]v U}oUuP llP]o˙(}`lb
Av
yy Co]R}u˙]v U}oUwXæuP llPR}o˙(}`lb
Refeal
r Criteria
R(}vb`]R˘b(}uvP]vPo]o X
v*Yas*w v
85. Y`b
Y`b ]b R}v] ]v(}v ˙ ]u R +b u]vo˙ R
bl]vU}vvoPXM}b}o+R]ovvæ˙b
}( P ob v} ˘uX I ]b vbu]' u]vo˙ R}PR bl]v
}v`]Rv]v(b}vXb]vPo A bl]vob]}vo}bR}]v
}( v˙ }( R ]u L `lbX W]R} uvU uoo
ob]}vb oo } R }˙X TR ]bb ]b o˙ (oU R}` ]
v o}R}v] ]b.Puvv ]b]o]˙ ]v } A9}(+
]v]]ob ]( oL vX Tuv `]R v]}b ]b v
ob]bX
O}`]vPU }} b}vo R˙P]v v }} bv]}v
(]o]R}( b R]bbX
sueCa
yy Treponema pertenue
Symptoms
yy Raised skin lesions
yy P]vobbl]vo
yy B}v]v
Signs
yy Pobl]vob]}vb
yy P]vobbl]vo`]Rb
yy (}u]b D }(Rv}bU}vb
æ
Chatep rP *Disorsof
der theSkin
yy Pou}ovbl]vR]lv]vP
Inve ti s gations
yy VDRL
Trtme
ae nt
Treatment }i es
yy T}]R}Pv]buvvb
yy T}v}( b R]v(}v
yy T}vo}vPu}uo]}vb
yy None
]v
E RvPPA
AXS]vPoD}bTuv(}Y`b
yy A]R}u˙]v U}oU
Adults
uP llP}˙`]PR~u˘XPZb]vPo}b
Children
ANæ˙bV P
ræ˙bV XæP
vrı˙bV P
v*Yas*w v
vu}vRbrv˙bV æuP~b˙(oZ
AMvu}vRbV v}}uuv
BXF}N}vrb}vb}N}vr]o]o]˙}(A]R}u˙]v
yy BvR]vPv]]oo]v UIMU
Adults
Xu]oo]}vv]bX
b
Children
AN˙bV XMUX b
AM˙bV vv]bX
b
Refeal
r Criteria
R(]vo}b Ru}o}P]bX
FvPoSl]vIv(}vb
æ
Standard Trtme
86. S.]oFvPoSl]vIv(}vb
TRb(vPo]v(}vbR+R}o˙b}(Rbl]vUR
v]obvR]XWRvG}]U]u˙b}]`]R]uuv}bb]}v
bRb]v]bv}]o]v(}vv}}b}]bX
sueCa
yy Du}R˙b ~vZ ]XX u]}b}u U ]u}R˙}v U
trichophyton
yy Ybb]XX v] U uob]b
Symptoms
yy IR˙o˙ b ]vPbRbR}vRbl]v
yy Scaly bald patches of the scalp
yy D]b}U]b}o}.vP}}v]ob
yy IR˙vb}bl]v(}ob
yy So˙Rb}(bl]v`]Ro]Puv}v
Signs
v*SuperficialFungalSkinInfections*v
yy R}v o˙ b Rb `]R R]lv Pb v o v }v R

skin
yy Scaly bald patches of the scalp
yy D]b}]b}o}v]ob
yy Ao ]Puv}v }( bl]v ~R˙}]Puv } }`v]bR
vZ
yy PbobR]vRG˘b
Invtiga
se tions
yy Sl]v]vPb b (}u]}b}˙vo~u˙}o}P˙Z
yy N]ovl}R]o]]vPb(}u]}b}˙vo
yy FBS v HIV b ~]( ]v(}v ]b G}] vl} }o v]]b]b
bvZ
Trtme
ae nt
TuvluvPuv}ib
yy T}]]v(}v
yy T}vvbu]bb]}v
yy T}]v(˙vv˙]b}b]vP}v]}vb
yy G}}b}voR˙P]v
yy Ub}(o}}bo}R]vP
yy Ov(}}`
AXDu}R˙]v(}v}(ob ~v]b )
]v
E RvPPC
st
L]vTuv
yy GriseofulvinU}oU
æ
Chatep rP *Disorsof
der theSkin
Adults
æuP]o˙~}o]v]v(}v
b Z(}`lb
Children
u}vRr˙bV uP llP ~u˘X æ uPZ }v ]o˙ } ]v
`}]]}bb(}`lb
r˙bV æ uP }v ]o˙ } ]v `} ]] }bb
~u˙}o]v]v(}vb
b Z(}`lb
nd
L]vTuv
yy T]v.v U}oU
Adults
N}}uuv
Children
Children}˙V
B}˙`]PRANlPV æuP}v]o˙(}`lb
B}˙`]PRrlPV æuP}v]o˙(}`lb
B}˙`]PRrlPV vXæuP}v]o˙(}`lb
BXDu}R˙]v(}v}(}˙~v}}]b ZU]vu~v
crurisZURvb~vuvu Zv(~v]b )
]v
E RvPPC
st
L]vTuv
yy Bv}]A]}u}v}]vuv ~WR]]o[b}]vuv ZU}]oU
Adults and children
Ao˙ `] ]o˙ } Rb } }v } `} `lb L R ob
visible rash has cleared
Or
yy Co}]u}o A9U}]oU
Adults and children
Ao˙`]]o˙}Rb}}v}`}`lbLob]b]o
rash has cleared
Or
yy M]}v}o A9U}]oU
Adults and children
rash has cleared
Or
yy C]o}]}˘ }ou]v A9U}]oU
Adults and children
rash has cleared
nd
L]vTuv
yy GriseofulvinU}oU
Adults
æuP]o˙~}o]v]v(}v
b Z(}`lb
Children
r˙bV æ uP }v ]o˙ } ]v `} ]] }bb
æ
Standard Trtme
~u˙}o]v]v(}vb
b Z(}`lb
`}]]}bb(}`lb
Or
yy I}v}o U}oU
Adults
uP}v]o˙}R}o˙(}˙bw
Children
˙br˙bV uP]o˙(}˙bw
u}vRr˙bV ræ uP llP ~u˘X uPZ }v ]o˙ (} æ
˙b}˙b~(}v]b vuvuZ
Or
yy T]v.v U}oU
Adults
æuP]o˙(}rv`lb
Children
Children}˙V
B}˙`]PRANlPV æuP}v]o˙(}`lbU
v`lbru}vRb]vv]o]v(}vb
B}˙`]PRrlPV æuP}v]o˙(}`lb
B}˙`]PRrlPV vXæuP}v]o˙(}`lb
CXDu}R˙]v(}v}(v]ob~}v˙R}u˙}b]b )
]v
E RvPPC
st
L]vTuv
yy I}v}o U}oU
Adults
uP r R}o˙ (} w ˙bU }bb L ˙b ]v r
o~u˘X}(}bb(}.vPv]obv}bb(}}v]obZ
Children
˙br˙bV uP R}o˙ (} w ˙bU
}bb L ˙b ]vo ~.vP v]ob }bbU } v]ob
}bbZ
˙r˙bV æ uP llP ~u˘ uPZ ]o˙ (} w ˙bU r
}bbL˙b]vo~.vPv]ob }bbv}
v]ob}bbZ
Or
yy T]v.v U}oU
Adults
uP]o˙(}v`lbru}vRb
Children
Children}˙V
B}˙`]PR}lPV æuP}v]o˙(}v`lbWu}vRb
B}˙`]PRrlPV æuP}v]o˙(}v`lbWu}vRb
B}˙`]PRrlPV vXæuP}v]o˙(}v`lbWu}vRb
nd
L]vTuv
yy GriseofulvinU}oU
æ
Chatep rP *Disorsof
der theSkin
Adults
æuP]o˙~}o]v]v(}v
b Z(}`lb
Children
r˙bV æ uP }v ]o˙ } ]v `} ]] }bb
~u˙}o]v]v(}vb
b Z(}`lb
`}]]}bb(}`lb
D. For Candida intertrigo
]v
E RvPPC
yy Bv}]A]}u}v}]vuv ~WR]]o[b}]vuv ZU}]oU
Ao˙ `] ]o˙ } Rb } }v } `} `lb L R ob
]b]obRRboX
Or
yy Co}]u}o A9U}]oU
rash has cleared
Or
yy M]}v}o A9U}]oU
v*PityriasisVesic
rash has cleared
Or
yy C]o}]}˘ }ou]v A9U}]oU
r olor*v
bRRboX
E. For Oral candidiasis and Pityriasis versicolor
Pob(}b}v}v}ov]]b]bv]˙]b]bb]}o}
Refeal
r Criteria
R(}u}o}P]b](v(]ob}b}v}uvX
87. Pityriasis Versicolor

P]˙]b]bb]}o} ]b}uu}v˙b]v(}v}(Rbl]vU]v`R]R
Gl˙ ]b}o}Rb }v R Rb v lX I ]b b}uub
oo vb]}o}XI ]bu}}uu}v]vR}o]ubUv}Lv+b
}oRb]R]o˙X I]b]b}}(RRoR˙G}]b
bv]vR]uuv}bbRbR}b`]R]buoo]bU
HIV lAIDS v}]o}] b bX
sueCa
yy Pityrosporum orbiculare
yy Pityrosporum ovale (malassezia furfurZ
Symptoms
yy ˙u}u Ab
yy M]oo˙IR˙
ææ
Standard Trtme
yy Po}lbl]vRb
Signs
yy H˙}]Puvuobvl}Rb
yy WR]o˙ b Rb
Invtiga
se tions
yy Sl]v]vP b (}u]}b}˙
yy FbvPo}}Po}b~(}G}]bZ
yy R}bv~(}G}]bZ
Trtme
ae nt
TuvOib
yy T}]]v(}v
yy T}vvbu]bb]}v
yy T}]bb }b]vP(}b
Non-Pharmacological Treatment
yy G}}b}voR˙P]v
yy }] A bR]vPR}òbUb}vPbvo}R]vP
v*PityriasisVesic
AXF}M]oT]v Versicolor
]v
E RvPPC
yy M]}v}o UA9U}]oU
r olor*v
Adults
R}o˙(}`lb
Children
AN˙bV R}o˙(}`lb
AM˙bV R}o˙(}`lb
Or
yy Co}]u}o UA9U
Adults
R}o˙(}`lb
Children
AN˙bV R}o˙(}`lb
Or
yy WR]]o[b}]vuv U}]oU
Adults
R}o˙(}`lb
Children
N}}uuv
Or
yy Sov]uboR] UbRu}}XæA9U}]oU
Adults
Ov ]o˙ (} ærw ˙b ~`bR }+ L u]vb } v ] r
]}vZ
Children
Ov]o˙(}ær˙bw
æv
Chatep rP *Disorsof
der theSkin
AMæ˙bV v}}uuv
B. For Severe Tinea Versicolor
]v
E RvPPB
yy I}v}o U}oU
Adults
uP]o˙(}˙bw
Children
AN˙bV uP]o˙(}˙bw
u}vRr˙bV ræuPllP]o˙(}˙bw
C}vrX
Ub}(]}v}o]bb}]`]R}voo˙o](rRRv]vPo]r}˘]]˙X
M}v]}o](v}v`R]o}vo}vPuR˙X
Refeal
r Criteria
R(]vo}b u}o}P]bX
V]oSl]vIv(}vb
v*HesSimp
rpe lexInfections*v
88. HbS]uo˘Iv(}vb
TRb bo(ro]u]vP ]o ]v(}vb }( R bl]v v u}b
uuvb bovP ]v o]b]vP }vb boo˙ bv }v R (
(called “cold sores_}Z RPv]o]XRv]b}uu}v}v]}bo˙
+bl]vvb ]b}}o](}v}(]b`]R]vR]u]b
}( R +u}uX E˘vb]ob]}vb u˙ b}]`]R v
]uuv}}u}u]b}b }˙X
sueCa
yy Hbb]uo˘]b ˙
yy Hbb]uo˘]b ˙
Symptoms
yy F
yy T]vPo]vPU]b}u(}U}]v(obvb}v}+bl]v
yy G}buooo]bb
yy Gvouo]b
Signs
yy F
yy TvP}b]ob
yy RP]}voo˙uRv}R˙
yy Genital ulcers
yy Ooob
Invtiga
se tions
yy Uboo˙v}v
æw
Standard Trtme
yy D]Pv}b]b]bu]vo˙o]v]o
yy HSV}o}P˙
b ~](vbb˙Z
Trtme
ae nt
Tuv}ib
yy T}o]]vv]b}u(}
yy T} o]u] ˘v }( ]bb b ]v R ]uuv}}u}u]b v
}]u vb
yy T}v}v˙ b ]v(}v
yy N}b].ubb
AXP]}o}Pv]oob]}vb
]v
E RvPPB
yy AcicloviruæA9U}]oU
Adults
R}o˙~.ub]o˙Z(}ræ˙b
Children
v*HesSimp
rpe lexInfections*v
Note 11-1
S]uu]o˙Ru}v]}˙˙u}ub
b (o}`]R]vR}b}(}v r
X
b
BXF}]u˙
b ]v(}vbU]bbu]vRbb]uo˘U
(vvbv]uuv}bvbb
yy AciclovirU}oU
Adults
uPR}o˙~.ub]o˙Z(}ær˙bw
Children
AN˙bV uP R}o˙ ~. ub ]o˙Z (} ærw
days
u}vRr˙bV uP R}o˙ ~. ub ]o˙Z (} ærw
days
Av
yy Pu}o U}oU
Adults
æuPrPvrR}o˙(}ræ˙b
Children
vr˙bV æræuPvrR}o˙(}ræ˙b
ræ˙bV ræuPvrR}o˙(}ræ˙b
u}vRbr˙V vruPvrR}o˙(}ræ˙b
Refeal
r Criteria
R(}uo]}b u}o}P]bX
æ
Chatep rP *Disorsof
der theSkin
89. Herpes ZosterIv(}vb

TR]b ]b v ]v(o o]b]vP ]o ]v(}v }( R bl]vX I v
} ]v R]oR}} ]b uR u} }uu}v ]v obU b]oo˙ R
oo˙U b]l } ]uuv}bbX TR ]u˙ ]v(}v bvb b
R]lv}˘ (varicellaZU boo˙ ]vP R]oR}}X L]lRb b]uo˘U R
]bb]bboo˙]vRv]}R}voob(}]]bXP}br
R voP] ]b }uu}v }uo]}v v .v b]bv
}v}(]vu}Rvu}vRLR}vb}(bR]vPobX
sueCa
yy V]oo r}b]b
Symptoms
yy F
yy Severe pain over areas involved
yy Headache
yy Bo]bb
Signs
v*HeossZrpe terInfections*v
yy F
yy Tvb]ob`]R]v
b }v}u}u}ubv]ooo˙
yy RP]}voo˙uRv}R˙
Invtiga
se tions
yy Uboo˙v}v
yy HIV vb ~(}vvl}uoru}uobZ
Trtme
ae nt
Tuv}ib
yy To provide adequate pain relief
yy T}v}v˙ b ]o]v(}v
yy T}o]u]˘v}(]b]v b ]uuv}r}u}u]bvb
yy T}v}uo]}vb
yy b B
]v
E RvPPB
AXM]oHb}bZ Iv(}v
yy AcicloviruæA9U}]oU
Adults
Children
Note 11-2
S]uu]o˙Ru}v]}˙˙u}ub
b (o}`]R]vR}b}(}v r
X
b
æı
Standard Trtme
Av
yy D ]o}(v U}oU
Adult
æuPR}o˙(}˙bw
Or
yy I}(v U}oU
Children
æruP llPvR}o˙(}˙bw
Av
yy P}]}v]}]v A9U}]oU
Adults
Ao˙}o]bb]o˙ooob]}vbb}o
Children
B. Severe Herpes ZosterIv(}v
]v
E RvPPB
yy AciclovirU}oU
Adults
v*HeossZrpe terInfections*v
uPR}o˙~.ub]o˙Z(}ær˙bw
Children
AN˙bV uPR}o˙~.ub]o˙Z(}ær˙bw
vr˙bV uPvR}o˙(}ær˙bw
rv˙bV uPvR}o˙(}ær˙bw
AM˙bV uPvR}o˙(}ær˙bw
Av
yy D ]o}(v U}oU
Adults
æuPR}o˙(}˙bw
Or
yy I}(v U}oU
Children
æruP llPvrR}o˙(}˙bw
Av
yy P}]}v]}]v A9U}]oU
Adults
Children
CXP}bHNoP]
yy Au]]˙o]v U}oU
Adults
æræuP]o˙oob}o}v
Children
N}]v](}R]b}v]}v
v
Chatep rP *Disorsof
der theSkin
Or
yy C u]v U}oU
Adults
æræuPR}o˙oob}o}v~u˘]uuvuPR}o˙Z
Children
r˙bV æruPR}o˙
Then
Ivb}vuPR}o˙](vbb˙
u}vRr˙bV XæuP llPR}o˙

Then
Ivbbo}ò˙}æuP llPR}o˙
Or
yy PPo]v U}oU
Adults
wæuPR}o˙oob}o}v
Children
N}}uuv
Refeal
r Criteria
R(}uo]}b b]o]bX
v*Chickenox
90. Chicken pox
p *v
CR]lv }˘ v bR]vPob b ˙ R bu ]b ~V]oo
} Hb }bZ ZX Huvb R }vo˙ b} }( ]v(}v (} R]lv
}˘vbR]vPobXPb}vr}rb}vvbu]bb]}v}b˙]}v
`]Rb]oG](}uvb`]R]R}v]}vXCR]lv}˘u˙
]}voo˙ vbu]' ˙ ]}v b (}u b]}˙
}vb
b XTR]b]bl}(]v(}v}˙bL}vX
CR]lv }˘ ]b R]PRo˙ }vP]}b ]o ]oovbb boo˙ }]vP
]v ]u]bX I ]b Pvoo˙ v]PvU bo(ro]u]vP ]bb ]v ]uuv}r
}uv R]ov vb } u} b ]v }obvb
v ob v ob} ]v ]uuv}bb vb XPX vb }v
}]b
b X C}uo]}vb ]vo ]o r]v(}v b }( bl]v ob]}vbU
vu}v]Uvov}b˙bb u]v}ouv~oo˘] U
vRo]bZU R}u}˙}v] U v }R }uo]}vb bR b
Po}uo}vR]bUR]bUvRbX
E˘}b} R ]b ]vP R}v
b `lb }(Pvv˙v
bo ]v }vPv]o ]oo ˙v}u
b R]b ˙ bl]v ]vP
b U
v}uo]b }( o]ubU ]vU ˙b v o}` ]R `]PRX V]oo
]v(}vv(o(}v]v(v](Ru}Ro}b]oo(}uæ
˙b(}}˙bLo]˙X
SR]vPob bvb `]R bl]v ob]}vb ]v u}uo ]b]}v
v ]v ]uuv}}u}u]b ]v]]obU v ˙ ˘vb]X I u˙
}uo] ˙ ]v b]bvP (} `lb } ˙b L R ]v(}v
v
Standard Trtme
~}bRvoP]ZX
sueCa
yy V]oo rZ}b~}Hb}bZ Z]b
Symptoms
Chicken pox
yy F
yy Malaise
yy Av}˘]
yy Headache
yy IR˙bl]vbR
Shingles
yy P]v(obR
yy F
Signs
Chickenpox
yy Vb]obRvoo˙}u]vPb
yy RbR]v]+vPb b ~obUb]obUobb ]}vbZ
yy A.b}v(Uo b }vlv}b }(
b }˙U
u}}vv}vvl
yy Pb]bb(}ær˙bw
v*Chickenox
yy Pbv }( b ]v ob]}vb bPPbb }v˙ ]o ]v( r

}v
p *v
Shingles
yy Vb]obR
yy Ao}vPu}u
yy Rash eventually crusts
Invtiga
se tions
yy Uboo˙v}v~]Pv}b]b]bu]vo˙o]v]oZ
yy P}o˙ubCR]vR}v~PCRZ }ooo(}ub]oG]U
bU bo]U}b]vo G] } }R b]uvb ~]( ]Pv}b]b ]v
}Z
Trtme
ae nt
Tuv}ib
yy T}o]R]vvb]R]vP}]v
yy T}v}}v˙ b ]v(}v
yy T}vR˙}v in children
yy }] A R]vP
b
yy RPoR]vP`]Rb}v`
yy }] A ]vv}voo˙l]vPb]ob
AXT}o]]vv(
st
L]vTuv
v
Chatep rP *Disorsof
der theSkin
]v
E RvPPC
yy Pu}o U}oU
Adults
æuPrPvrR}o˙(}ræ˙b
Children
vr˙bV æræuPvrR}o˙(}ræ˙b
ræ˙bV ræuPvrR}o˙(}ræ˙b
u}vRbr˙V vruPvrR}o˙(}ræ˙b
B. To soothe the skin and relieve pruritus
yy Cou]vo}}v luU}]oUo˙o]oo˙}Rbl]v
Av
yy ]]v
C }oU
Adults
uP]o˙
Children
r˙bV uP]o˙
vr˙bV æuPR}o˙
rv˙bV XæuPR}o˙
Or
yy P}uR]v R˙}Ro}]U}oU~bvPZ
v*Chickenox
Adults
æuP]o˙}R}o˙]o˙
p *v
Or
yy CRo}Rv]u]v uoU}oU
Adult
uP]o˙}R}o˙]o˙
Children
vr˙bV uPvrR}o˙]o˙~u˘XuP]o˙Z
rv˙bV uPvrR}o˙~u˘vuP]o˙Z
r˙bV uPR}o˙
CXAv]oR˙]v]uuv}}uv]v]]ob(}P}b
exposure prophylaxis
yy AciclovirU}oU
Adults
uPrvR}o˙(}æ˙b
Children
uP llPvR}o˙~u˘uPvR}o˙Z
X
D Av]oR˙]vIuuv}r}u}u]bvb~XPXHIV )
Av
yy AciclovirU}oU
Adults
uPR}o˙~æub]o˙Z(}˙bw }vo˙bLb r
]vP}(ob]}vb
Children
r˙bV uP R}o˙ ~æ ub ]o˙Z ]o˙ (} w
v
Standard Trtme
˙b~}vv(}u}˙bLvP b }(ob]}vb
vr˙bV uP R}o˙ ~æ ub ]o˙Z (} w ˙b
~}vv(}u}˙bLvP
b }(ob]}vb
rv˙bV uP R}o˙ ~æ ub ]o˙Z (} æ ˙b
~}vv(}u}˙bLvPb }(ob]}vbZ
u}vRr˙bV uP R}o˙ ~æ ub ]o˙Z (} æ ˙b
~}vv(}u}˙bLvP b }(ob]}vb
EXS]u}b]obl]v]v(}v]v]v]]obv}ooP]}
penicillins
]v
E RvPPC
yy Foo}˘]oo]v U}oU
Adults
æræuPvR}o˙(}ær˙bw
Children
r˙bV æræuPvR}o˙ær˙bw
r˙bV æræuPvR}o˙ær˙bw
AM˙bV vXæræuPvR}o˙ær˙bw
Or
Adults
væuPR}o˙(}ær˙bw
v*Chickenox
Children
r˙bV væuPR}o˙(}æ˙b
p *v
vr˙bV æwuPR}o˙(}æ˙b
ræ˙bV uPR}o˙(}æ˙b
FXS]u}b]obl]v]v(}v]v]v]]obooP]}
penicillin
yy A]R}u˙]v U}oU
Adult
æuP]o˙(}˙b
Children
of pyloric stenosis
Refeal
r Criteria
R(`Rv b}uo]}vb b ]vX Aob}(vb `R}
]bl}(o}]vP]bbu]vbRXPXvb}v}] b R˙U
}R ]uuv}}u}u]bb v R v`}v `R}b u}R Rb
Rv]v(}vX
N}vrS].Sl]vIv(}vb
v
Chatep rP *Disorsof
der theSkin
91. LPCR}v]Uob
Av o } b} ]b R ]v R }vv]˙ }( R bl]v v R
vo˙]vP bX LP ob v b o} }( u}]]˙ v o }
b]}b }uo]}vbX P]b}b]vP v vo˙]vP ]bb vb }
]vbPX C}uo]}vb ]vo (}u]˙U vl˙o}b]b }( i}]vbU
}b}u˙o]bU ooo]b v uo]Pvv vb(}u}v }( obX SP]o
uvu˙vX
sueCa
yy Iv(}vbv]v(b}vbXPXBo]obU˙`bobUo}b
obUP]v`}uob
yy N}vrb]. ob XPX b ~]bZU uU v}bU
]Ub]loooobU]bRu]
yy Mo]PvvobXPXbu}boo]v}uUuov}uUK}b][b
}u
b
Symptoms
yy P]v
yy L}bb}(bvb}vb]}(o
v*Lager ChronicUlcs*er v
yy D]bRPU`R]Ru˙}+vb]
yy S]b.Puv
yy D]b]o]˙
Signs
yy So}]vPPb~v}vrb].obZ
yy Uvu]vPb~o]vo}bobZ
yy PvR}Pb~˙`bobZ
yy R]bPb~uo]PvvobZ
yy L}bb}(bvb}v]v+~]bUo}b˙U˙`b}˙R]o]b b
obZ
yy (}u]˙ D }(+
yy W}v]bRP~ov}}+vb]Z
yy GvPv}(+~]bU]Robo]bbZ
yy Dlv]vP }( + ~]Ro bo ]bbU v}b
]vb8]v˙Z
yy P]vlPvo}vb`]R}bo}PR~RoR˙`}vZ
Invtiga
se tions
yy FBU C SR
E
yy S]lo]vPb
yy FbvPo}}Po}b
yy W}v`b (}ovbvb]]˙UZ]RoN]obv]v]vP b
yy VDRL lRPRtest
yy Xr˙}(vo˙]vP}v
yy B]}b˙}(o
væ
Standard Trtme
Trtme
ae nt
Tuv}ib
yy T} bo}PR R o v }u} RoR˙ Pvo}v b
(}u}v
yy T}}u}Ro]vP
yy T}]v(˙vuvPv˙vo˙]vPb
yy T}v}uo]}vb
yy CRvPb]vP]o˙
yy Ubb}vb]vP(}`}vbRR}(b]bRP
yy Dbo}PR`}vbRRRvbo}PR
yy Eoo}ò]u}vb]hvP
yy v]}v
A
]v
E RvPPC
AXF}v}vrvb`}vovb]vP
yy N}uobo]v b}o}v~D}v}bE}o Z
v*Lager ChronicUlcs*er v
BXF}vb`}vovb]vP
]v
E RvPPC
yy CRo}R˘]]v b}o}v A9U}]oU
Or
yy ]u]
C æA9U}]oU
Or
yy P}]}v]}]v b}o}vA9U}]oU
CXS˙bu]v]}uv(}}v˙ b ]o]v(}vb
S]. vu]}]o uv ]b P] ˙ o v bvb]]˙
bobX
Eu]]v]}uvu˙ ]v]`R]o`]vPo
vbvb]]˙bobb}v}b o]lo˙}Pv]bubX
Note 11-3
}]
A }]ov]}bbR]b]vb8]v]v(}R]+vbb
Refealr Criteria
R( vb `]R ob (]o]vP } bR}` b]Pvb }( Ro]vP `]R
}uvUvvb`R}`}o]P˙ b ]R(}bl]v
PL]vPU `}v ˘]b]}v } o]u u}v } P]o b b]o]bX Aoo
ob b } uo]Pvv bR}o ob} ( } P]o
b
b]o]bX
v
Chatep rP *Disorsof
der theSkin
92. Pruritus
P]b } ]R]vP ]b v vobv bvb}v }v R bl]v R
}}lbRb]}}R b RXIR]vPv]bb }u(}
v (b}vX Iv b b ] v o } ]b boU v˘]˙
and depressionXC}vbvR]vP b }}]vo](vuPRbl]v
v ]b +vbb ui} } ]X Tuv }(
pruritus ub b R vo˙]vP }v]}vX D]Pv}b]b R(}
vb}u(}+uvX
sueCa
Localised pruritus~}v.v}]v}(R}˙Z
yy S}R}]ub
yy P]b vulvae
yy Av}Pv]o]b
yy Tinea]v(}vb
yy G]}vou
yy L]Rvb]uo˘R}v]b
P]bl]v]b}b~}]u˙bl]v]bbZ
yy }] A u
yy D˙bl]v
v*Pruritus*v
yy AooP]}vub
yy U]
yy Scabies
yy P]P}
yy Miliaria~RbRZ
yy P]o}b]b
yy Ivb]b
yy DubR(}u]b
yy L]Rvovb
yy Boo}buR]P}]
Generalised pruritus (usually due to a systemic disease)
yy Hu}o}P]o XPX ]}v .]v˙ vu]U }o˙˙Ru]
Uo˙uR}ubUolu]b
yy L] ]bb XPX ]vR } ˘R R}obb]bU ]u˙
]o]˙]R}b]bURb
yy Chronic kidney disease
yy Thyroid disease
yy PPvv˙
yy D]buoo]b
yy ]v}ubC
yy DP}v
yy OvR}]b]b
yy Pb˙R}Pv]
Symptoms
yy IR]vP
vw
Standard Trtme
yy SR]vP
Signs
yy E˘}]}v
yy L]Rv].}v
yy Scars
yy Fb}(vo˙]vP}v]}vb
Invtiga
se tions
yy FBU C .ou}uuv
yy BUEUv]v C
yy LFTS
yy FBS
yy TR˙}](v}vb
yy Sl]vbv]vbl]v]vPb b
yy Stool RE
Trtme
ae nt
Tuv}ib
yy T}o]˙u}ub b
yy T}]v(˙vvo˙]vP]b}
v*Pruritus*v
yy }] A }u]v]u]˘}b}v˙]v.obPvbXPX
b}bUPvbUPbUo}Rb}(]U(}}bX
yy G}}b}voR˙P]v
yy C}vboo]vP~(}˙R}Pv] b ]b Z
AXS˙u}uuv
]v
E RvPPC
yy H˙}}b}v A9U}]oUo˙R}o˙(}˙b
Av
yy ]]v
C U}oU
Adults
uP]o˙(}˙bw
Children
wr˙bV uP]o˙(}˙bw
rv˙bV æuP]o˙(}˙bw
AM˙bV (˙
b v}o]b
b R
Or
yy CRo}Rv]u]v U}oU
Children
AM˙bV uPR}o˙(}æ˙b
B. For treatment of Scabies
]v
E RvPPA
yy PuR]v o}}vA9U}]oU
v
Chatep rP *Disorsof
der theSkin
Adult
Ao˙}`R}o}˙v`bR}+LrR}b
RL˙bw
Children
Ao˙}`R}o}˙v`bR}+LrR}b
RL˙bw
AMu}vRbV v}}uuv
N}r
}]
A }v`]RRu}RX
R(v}Ro]v]oRu]b(}}vboo]vP}vR}(
b uR]v
o}}v]vR]ovv(}]vP
b u}RbX
]v
E RvPPC
yy Bv˙ov} æA9o}}vU}]oU
Adults
Ao˙}R`R}o}˙LRv]PR~˘R(v
RZ(}v]PRbv`bR}+Rv˘u}v]vP
Children~AN˙bZ~æA9rRo(vPR
b ]o}vZ
Ao˙}R`R}o}˙LRv]PR~˘R(v
RZ(}v]PRbv`bR}+Rv˘u}v]vP
v*Pruritus*v
Note 11-5
Too}vb]vbuuvvb]uov}bo˙X
C}vbo R o]v]o Ru]b (}}]]o}v v }vboo]vP }v R
b}(v˙ov}]vR]ovX
O
yy MalathionXæA9U}]oU
Adults
Ao˙ } `R}o }˙X L }v (} R}b v `bR }+X R
o]}vL˙bw
Children
Ao˙ } `R}o }˙X L }v (} R}b v `bR }+X R
o]}vL˙bw
AMvu}vRbV v}}uuv
Note 11-6
Co}R]vP v o]vv ub RvPv `bR ]o˙ `]R }vP
b ]b]v r
(vvbR}oòo]v]}v}˙rovX
S˘ovR}bR}o}vbbR}oob}X
C. For treatment of Candidiasis

yy Co}]u}o A9U}]oU
Adults
Ao˙}+R}o˙(}˙b
Children
Ao˙}+R}o˙(}˙b
vı
Standard Trtme
Or
yy M]}v}o A9U}]o
Adults
Ao˙}+R}o˙(}˙b
Children
Ao˙}+R}o˙(}˙b
D. For treatment of Miliaria~P]lo˙HUHRbRZ
yy Cou]vo}}v U}]oU
Adults
Ao˙R}o˙(}˙bw
Children
Ao˙R}o˙(}˙bw
Or
yy Z]v }˘] uU}]oU
Adults
Ao˙R}o˙(}˙bw
Children
Ao˙R}o˙(}˙bw
EXF}uv}(}] A uE
yy A}bu U}]oU
Adults and children
v*Pruritus*v
Ao˙b}Lvb}bb]o
Or
yy Aqueous soapU}]oU
Adults and children
Ubb}(}R]vPR}o˙(}o˙]vPu
Or
yy Salicylic Acid}]vuvU}]oU
Adults and children
Apply as needed
FXF}uv}(}] A uE `]RGrb~bb}v
}vub )
yy T}]o}]b
b u˙ b ]v ]}v } R }(}}]
A E r
u
Av
yy H˙}}b}v uUA9}]oU
Adults and children
Ao˙rub]o˙
GXF}uv}(U]
yy ]]v
C U}oU
Adults
uP]o˙(}˙bw
Children
wr˙bV uP]o˙(}˙bw
w
Chatep rP *Disorsof
der theSkin
AM˙bV v}}uuv
Or
yy C Ro}Rv]u]v U}oU
Children
~Sb}v}vRU] [Z
HXF}uv}(C}vDub
yy H˙}}b}v A9U}]oU
Adults and children
Ao˙R}o˙(}˙b
IXF}IvbB]b~XPXFobUBPbZ
Note 11-7
S}b}(]v(b}vbR}ub
b URUo}R]vP}]vPbR}o}v r
u]v˙R}}PR`bR]vPU]}v]vP}(u]P}vX
yy ]]v
C U}oU
Adults
uP]o˙(}˙bw
Children
wr˙bV uP]o˙(}˙bw
v*Urticaria*v
AM˙bV XæuP]o˙(}˙bw
Or
yy CRo}Rv]u]v U}oU
Children
JXF}uv}(P]o}b]b (lice)
yy MalathionXæA9U}]oU
Adults
Ao˙ } `R}o }˙X L }v (} R}b v `bR }+X R
o]}vL˙bw
Children
Ao˙ } `R}o }˙X L }v (} R}b v `bR }+X R
o]}vL˙bw
AMvu}vRbV v}}uuv
Refeal
r Criteria
R(}u}o}P]bb}}vb}bb]o](]Pv}b]b]bvoX
93. U]
U] }`Ro]bvb]vU]R˙òo]vP
b }(Rbl]v}v˙
b
}Rob}(R]bu]vXR E ]b}}(`Rou˙ob(ù]vb
}ob R}b v u˙ RvP bRX WRob u˙ }vU } (}u
w
Standard Trtme
]vPbU uro]l 'v } P]v RbX TR b( `Rob u˙
}uv] ˙ òo]vP b }( u}b uuv bR b R
˙o]bU o]bU Rvb v }R b }( R }˙X TR òo]vP b ]b
oo vP]}uX
U] ]b obb]. b ] ]( R }v]}v obb obb
Rvb]˘~vZ`lbvR}v]]](]obbu}Rvb]˘~vZ`lbX
Cb }( ]b v b]o˙ ]v. b P]vb R}b (}
R}v]]X
sueCa
yy M]]vb XPX v]]oo]vbU Ro}b}]vbU b]]v U NSAIDSU }˘}]bU
v]uoU b u}R]v U]}}vbu]UCE]vR]]}b
A
yy F}}b XPX .bRU vbU PPbU R}}oU bRoo.bRU }lU b]bU u]olU
RbU(}}˙bU]b
yy Iv(}vbXPXb]bURb~]oZ
yy L˘XPXPo}bUu]o]uv
yy M]o }v]}vb XPX ob ˙Ru}bbU o˙uR}uU
}o˙˙Ru]
yy Povb
yy I]}R]
yy Ev]}vuvovR˙b]o(}b
yy Pb]b P`Rob }vR}(bl]v˘]v r
v*Urticaria*v
]vPv˙(}u}(XP b Xb}ob}((L}o}vPv]vP b
yy S}oU }o v R]P `Rob `Rv˘}b }
Rbv]}vuvb
yy APv]]P˘}b}òb}]R˙`Rob
yy CR}o]vP] ]P ]vvb ] `Rob are seen in rer
b}vb}`vP
b U˘]bUu}}vbUvR}(}}b
yy Du}PR]buPo]v`Rob v}bo}(R]vP
b
or pressure
Symptoms
yy IR]vP
yy WRob
Signs
yy WRob
yy Du}PR]bu
yy AvP]}u
Invtiga
se tions
yy Uboo˙v}v
yy Foo o}} }v ~u˙ bR}` }b]v}R]o] o } ooP˙ }
b] ]v(b}v } o}` `R] o}} }v (}u ˙bb u] ob
˙Ru}bbZ
yy Stool RE
yy TR˙}] v}]b v (v}v ~]v R}v] ] ]( }]uuv
}]P]v]b}vb]o]lo˙Z
w
Chatep rP *Disorsof
der theSkin
yy Sl]v]}b˙~](`Rob }o}vPU}]v(˙bo]bZ
Trtme
ae nt
TuvOib
yy T}}]]uu]o](
yy T}v}uo]}vbbRbvR˙o˘]b UbR}l}bR˙˘]}v
yy T}]v(˙}bb]ovo˙]vPbvb]X
yy }] A }v `]R } (R b }( R b ooPv }
Pv
b
AXC}v}o}(`Rob and itching
]v
E RvPPC
yy ]]vC U}oU
Adults
uP]o˙(}˙bw
v*Rectiv
Children
a ythe
eEr maandBullousRection
wr˙bV uP]o˙(}˙bw
AM˙bV XæuP]o˙(}˙bw
Or
a *v
yy CRo}Rvu]v U}oU
Adults
uPrvR}o˙
Children
vr˙bV uPrvR}o˙
rv˙bV uPrvR}o˙
r˙bV uPR}o˙
Or
yy P}uR]v U}oU
Adults
æræuPrR}o˙
Children
r˙bV XæræuPrR}o˙}æuPv]PR
ær˙bV vXærXæuPR}o˙}ræuPv]PR
ræ˙bV vXæuPR}o˙}æræuPv]PR
AM˙bV v}}uuv
Refeal
r Criteria
R(b}(R}v]]}u}o}P]bX
ıX RE˙Ru vBoo}bR}v
TRb ]uuv}o}P] }vb R] ˙ v]vP `]R
} `]R} o]b]vP }( R bl]v vl} u}bX TR }uu}v ˙b
˙Ru uo(}u U SvbrJ}Rvb}v ˙v}u
b v }˘] ]uo
w
Standard Trtme
v}o˙b]b~TENZ XW]RooRb}v]}vbUR}o}uv˙]vP
˘vb] v}v }( bl]v `]R }vbv G] v o}o˙ o}bb
v]bl}(}v˙
b ]o]v(}vXAooR}v]}vbbR}o
}vb]buPv]b]]vP]vvb]X
E˙Ruuo(}ubvbb]R˙UPro]lUv}vrbo˙ob]}vb
}(RoubUb}obU(}ubvoPbX
SvbrJ}Rvb}v ˙v}ub ]b R] ˙ ˙Ru v
o]b (}u}vU `R]R ]}voo˙ ]v}ob R u}b uuvb
~}vivUu}RUPv]obXZX
T}˘]]uov}o˙b]b~TENZ ]bPvo]ob ˙}(bl]v
}vU }Lv } v ooP] }v } PbX A b]u]o }v
}b]vR]ovuR˙o}}o
b ob bl]v˙v}u
b U`R]R]b
caused by Staphylococcus aureusX
sueCa
yy V]o]v(}vbXPXRbb]uo˘]b U}]b U˙}uPo}]b
v*Rectiv
yy M˙}obuvu}v] ]v(}v
a ythe
yy bA P }v XPX } boR}vu]bU v]]oo]vU NSAIDSU

v}vobvbX
yy Mo]Pvv˙
Symptoms
a *v
yy F
yy Bo]bb
yy IR˙bR
yy Sore throat
yy Gvouo]b
yy D]bRP]vP]v(o˙b
yy ˙u}u Ab
Signs
yy F
yy Fo]oo
yy Gv]ovl}}oo}vb
yy Dv}(bl]v
Invtiga
se tions
yy FBC
yy BUEv]v
yy HIV screen
yy Bo}}v`}vob~](]v]Z
Trtme
ae nt
Tuv}ib
yy T}u]v]vR˙}v
yy T}u]v]vv]}v
yy T}}o}o˙]uov
w
Chatep rP *Disorsof
der theSkin
yy T}u]v]vv}uo}˙u
yy T}v}v˙b ]v(}v
yy T}]v(˙vo]u]vvo˙]vPb
yy T}v(R˘}b}RPvb }P
yy W]Rò}(]v.oPvb }P
yy M]vvv}(]vv}}(G]
yy }o
A G]b
yy Pv }v }( o bl]v `]R }vu]v o]vv b]vP
vb]vPo
yy o˙E }RRou}o}P]o}vbo}v
yy N]}b]
AXF}R˙}v
yy N}uobo]v UIVU
v*Rectiv
B. For Pain and Fever
a ythe
]v
E RvPPA
yy Pu}o U}oU
Adults
æuPrPvrR}o˙
a *v
Children
CXF}C}v}o}(RIuuvP}bb]vvb`R}vòo}`
b
]v
E RvPPC
yy Pv]b}o}v U}oU~}vb}(}v]}vZ
Adults
XæruP llP]o˙v}+}wr˙b
Children
XæuP llP]o˙v}+}wr˙b
X
D F}C}v}o}(RIuuvP}bb]vvb`R}vv}
swallow
yy H˙}}b}v UIVU
Adults
uPvR}o˙voo}òo}`
b
Then
yy Pv]b}o}v U}oUb}
Children
uP llPvR}o˙voo}òo}`
b
Then
yy Pv]b}o}v U}oUb}
wæ
Standard Trtme
EXT}S}v˙]o B Sl]vIv(}v}M˙}obu
Pneumonia
]v
E RvPPB
yy A]R}u˙]v U}oU
Adults
æuP]o˙(}æ˙b
Children
uP llP}v]o˙(}æ˙b
AMvu}vRbV v}}uuv
O
yy E˙R}u˙]v U}oU
Adults
æuPvR}o˙(}˙bw
Children
vr˙bV æuPvR}o˙(}˙bw
FXF}v}v}(bl]v]v(}vb
]v
E RvPPC
yy CRo}R˘]]v b}o}v A9U}]oU
v*AcneVulgaris*v
Or
yy ]u]
C æA9U}]oU
Or
yy P}]}v]}]v b}o}vA9U}]oU
Note 11-8
D}v}b]obo(]]vb]]b bo(P (}bl]vX
G. For oral ulcers

yy P}]}v]}]v A9u}R`bRUR}o˙
Or
yy CRo}R˘]]v XA9u}R`bRUR}o˙
Refeal
r Criteria
R(oovb}}]b]o]bX
95. AvVoP]b
Av oP]b ~]uob or spotsZ ]b }uu}v R}v] ]vGuu}˙
b ]b} ]v}o]vP R R] (}oo]o v b}b Pov `R]R
l]v
bvb u]vo˙ ]v }obvX A ]˙ }( b}b u}bo˙ }v R
( v }R b }( R }˙X S v u˙ ] o}v
} ˘o v vo˙]vP R}u}vo ]b}X TR]b }v]}v u˙ ]v
b}u ˙R}o}P]o
b ]bvbX TR R}] }( uv vb }v
PU ]˙b U v `RR R v ]b }u]vvo˙ ]vGuu}˙ }
wv
Chatep rP *Disorsof
der theSkin
}u}voX
sueCa
yy Ivbbu}v b
yy Av}uolv]b}v}(RR](}oo]ob~R]˙Z
yy Ivbbvb]]˙}(Rb}bPovb}uoR}u}vb
yy Propionibacterium acnes
yy P}o}vPb}(˙bb u]v}]o}]b b XPXAv}o]}]b
b
bRbv}oUv}}o}o
b vvv}o}v
yy Ub}(}ubUb]oo˙}bR}v]vov}o]vU}ouU
Po}]obU˙oU b o˙oo}R}ov}o]]
yy C}vPvbPu}˘˙}Pb}v]vi}vU]uov}
]v]v}Pb}vUv}o}vb
yy PPvv˙
yy P}o˙˙b}]v˙v}u b
yy Adrenal disorders
Symptoms
yy P]uob ~}v R ( v }b]}voo˙ }v R vlU Rb v
bR}obZ
yy Greasy skin
v*AcneVulgaris*v
yy F]o]b.Puv
Signs
yy C}u}vb~olRbv`R]RbZ
yy Pob
yy Cysts
yy Scars
yy Nodules
yy Pbob
yy H]bbu~bPPb˘bbv}PvbZ
Invtiga
se tions
yy Uboo˙v}v
yy Su }bb }v ~]v (uob `]R }uv˙]vP R]bbu v
]]o]b]vP(bZ
yy Po]ob}v~]v(uob}˘o}o˙˙b}]b](R]bbu
bvZ
Trtme
ae nt
Tuv}ib
yy T}]u}}buv
yy T}v}uo]}vboo˙]vP b
yy T}vb
yy T}]v(˙v}]v˙}b }v]vP(}b
yy C}vboo]vP}(vb
w
Standard Trtme
AXF}u]o}u}v
]v
E RvPPA
yy Bv}˙o }˘] æA9 o}}vU }]oU o˙ ]o˙ ~}]]vP u}RU
˙bvRu}buuvbZ
Av
yy C o]vu˙]v UA9o}}v}PoU}]oUo˙]o˙
Or
yy Tv}]v XA9PoU}]oUo˙v}~}]]vPRbvU˙bUv}b r
]obUu}RUu}buuvv}lvbl]vZ
C}vrX
T}]ov}]b~Tv}]v }v]v]
Z ]vPvv˙
Or
yy Adapalene XA9 u } PoU }]oU o˙ R]vo˙ }v ]o˙ ~
v]PR(}boZ
B. For moderate to severe acne (or where topical therapy is
]v+}v}}oZ
]v
E RvPPB
v*AcneVulgaris*v
T}]ouv(}u}~AZ
Av
yy D }˘˙˙o]v U}oU
Adults
uP]o˙(}`lb v ru}vRb
v ~v]vP}vb}vb} r
uvZ
Children
N}}uuv
Or
yy TetracyclineU}oU
Adults
æræuPR}o˙(}`lb v ru}vRb
v ~v]vP}vb}vb
}uvZ
CRvP u]}v } ˙R}u˙]v L u}vRb ]( b}vb ]b
poor
Children
AN˙bV bu}bb(}ob}
AM˙bV v}}uuv
Or
yy E˙R}u˙]v U}oU
Adult
æuPR}o˙(}v`lbrvu}vRb
Children
AN˙bV æuPR}o˙(}v`lbrvu}vRb
r˙bV æ uP R}o˙ Or æ uP }v ]o˙ (}
w
Chatep rP *Disorsof
der theSkin
v`lbrvu}vRb
Refeal
r Criteria
R( vb v} b}v]vP } uv } u}o}P]bX
Sb vo˙]vP v}]v }v]}vb bR}o ( } v
v}]v}o}P]bX
96. Eczema
uE }ub ]bv}R}v]]vGuu}˙}v]v
R bl]v }Lv } v ˘vo ~˘}Pv}bZ } ]vvo ~v}Pv}bZ
(}X E˘}Pv}b u ~}v uZ ]vob ]u˙ ]]v
ub v ooP] }v ub X Ev}Pv}b u ]vob
}] u U b}R}] u U ]b}] u U }b u U
]}bu vv}Pv}bRvvb}obubX
C}vub u˙ v ]]v ~}vv}v vvZ }
ooP] ~o˙ R˙bvb]]˙Z }v } b]. ˘vovb
bR b uobU U Ru]ob X Iv }vb } R v}Pv}b
˙bU R bl]v }v ]b }v.v } R b ]o˙ ]v }v `]R
R}+v]vPvb }ooPvX
}] A u ]b }uu}v R}v] bo(ro]u]vP ] bl]v
v*Eczema*v
]b} u]vo˙ }( R]oR}} b}uub b]bb ]v} o o](X TR
bR boo˙ b `]R]v R .b ˙ }( o](U u}bo˙ `v Pb
v u}vRbX Iv }o R]ov R bR R]boo˙ ]v}ob
R G˘o bX A (u]o]o lP}v }( }˙ ~bRuU R˙ (U
}b]v}R]o]U ooP] R]v]b v b]u]o bl]v }ouZ ]b }Lv vb X
TR}v]}v]bR]b˙obbvu]bb]}vbX
S}R}] u bvb b o˙
b U Gl]vPU ˙ v v
bR }( R ob U ˙}`bU vb}o]o (}obU ]}oU ]}]o v
]]o bl]vbX S}uub ] bvb b R˙}]Puv uobX
I u˙ b}] `]R Pityrosporum ovale ]v(}vX E˘vb] (}ub
b}]`]R]uuv}bb]bUoo˙HIV lAIDS and
]buoo]bX
sueCa
yy Gv
yy I]vb~XPX]bUolo]bUPvbU}ou}bZ
yy AooPvb~XPXv]loUU]bUR}ubUR]˙bU}]o
u]uvbUovbUv]ov]bRU}bubXZ
yy FvPo]v(}vb~XPX Pityrosporum ovaleUu}R˙}b]bZ
yy Vv}bb]b~XPX]}b]vbUR(]oUo˙uR}uZ
Symptoms
yy IR˙bl]v
yy D˙bl]v
yy W]vPUvbR
yy Robbvu]bb]}vb'v
wı
Standard Trtme
Signs
yy D˙bl]v
yy Scaly skin
yy E˙Ru
yy E˘}]}vb
yy L]Rv].}v
yy P}b]vGuu}˙R˙]Puv}v}R˙}]Puv}v
yy Pob
yy Vb]ob
yy F]bb]vP
Invtiga
se tions
yy PRvP b (}}vub
yy Sl]v]vP b (}(vPoouvb
yy HIV vb ~b}R}]u ]vobZ
yy FbvPo}}bP~b}R}]u ]vobZ
Trtme
ae nt
Tuv}ib
yy T}o]}}v}o˙u}ub b
yy T}]v(˙v}]v˙}b ]}b]vP(}b
v*Eczema*v
yy C}vboo]vP}(vb
yy }]v A }(]v.o]]vP(}b
]v
E RvPPC
AXF}}]
A uE
yy Eæu U}]oU
Adults
Ao˙R}o˙
Children
Ao˙R}o˙
Or
yy A}bu U}]oU
Adults
Ao˙R}o˙
Children
Ao˙R}o˙
Or
yy SR' U}]oU
Adults
Ao˙R}o˙
Children
Ao˙R}o˙
Or
yy Salicylic Acid}]vuvA9U}]oU
Chatep rP *Disorsof
der theSkin
Adults
Ao˙R}o˙
Children
Ao˙R}o˙
Av
yy O]oub} ~}RPoZU}]oU
Adults
Ao˙rR}o˙
Children
Ao˙rR}o˙
Av
yy H˙}}b}v ul}]vuvrXæA9U}]oU
Adults
Ao˙rR}o˙
Children~A9uZ
u}vRbr˙bVo˙R]vo˙}R}o˙]v}(bR
Or
yy M}ub}v o}}vl}]vuvXA9
Adults
Apply thinly once daily
Children
v*Eczema*v
Apply thinly once daily
Or
yy uRb
B }v ul}]vuvXærXA9U}]oU
Adults
Ao˙R]vo˙rR}b
Children~XæA9Z
r˙bV o˙R]vo˙}R}b
And
yy C Ro}Rvu]v U}oU
Adults
uPrvR}o˙}uP}vv]PR(}˙bw
Children
vr˙bV uPrvR}o˙}uP}vv]PR(}˙bw
rv˙bV uPrvR}o˙}uP}vv]PR(}˙bw
r˙bV uPR}o˙}uP}vv]PR(}˙bw
B. Seborrhoiec Eczema
]v
E RvPPC
yy M]}v}o UA9obR˙}}b}v A9uU}]oU
Adults
Ao˙R}o˙oobRb}ob
Children
Ao˙R}o˙oobRb}ob
Or
yy Co}]u}o UA9obR˙}}b}v A9uU}]oU
Standard Trtme
Adults
Ao˙R}o˙oobRb}ob
Children
Ao˙R}o˙oobRb}ob
Or
yy K}}v}obRu}} U}]oU
Adults
Ao˙ `] `lo˙ (} `lb `]R ob ˙b `v R
o]}v
Children
r˙b~bRu}}ZVAo˙`]`lo˙(}`lb`]Rob
˙b`vRo]}v
AM˙bV(˙ b v8˙v}o]b
b
O
yy Sov]uboR] bRu}}
Adults
Ao˙`R}o}˙ub`l(}`lb]v]oo˙
Then
Ov˙r`lb}}v}o˙u}ub
b X
Aoo}`}u]v}vRob (}ru]vbRv]vbR}}PRo˙
Children
ær˙bV bubo}b
v*Eczema*v
AMæ˙bV v}}uuv
Or
yy I}v}o U}oU
Adults
uP]o˙(}`lb
Children
AN˙bV uP]o˙(}`lb
u}vRr˙bV ræuPllP]o˙(}`lb
C}vrX
M}v]}o](v}v`R]o}vo}vPruR˙X
CXF}C}vDub
yy uRb
B }v ul}]vuvU}]oU
Adults~XærXA9Z
Ao˙R]vo˙rR}o˙(}˙bw
Children~XæA9Z
r˙bVo˙R]vo˙rR}o˙(}˙bw
Or
Adults
Ao˙R]vo˙}v]o˙(}˙bw
Children
Chatep rP *Disorsof
der theSkin
D. For facial contact Eczema
Adults and children
Ao˙R}o˙
Refeal
r Criteria
R( vb v} b}v]vP } uv v R}b v]vP
(R]vbP}vbbRR b vP
b }u}o}P]bX
97. Intertrigo
Iv]P} ]b R u b } b] bR ]v }˙ (}ob }
}b]vP bl]v b(b bR b ˘]ooU P}]vU buuu˙ P]}vbU
vR v }u]vo }v }( (U .vP } } ` bX A+
bl]v]bvvv}u(}oXIv]P}]boo˙}uu}v]v
R}b`R}}`]PRvvb`]R]buoo]bX
B}˙ (}ob ~G˘bZ }v } ]vGuu}˙ bRb b }(
oo˙R]PRbl]vuvu}]b(}u]vbvb]oò}bbX
S`vP R ]b v} ˙b } } v (]}v (}u u}uv }(
ivbl]vUbob]vRb}bl]vX
sueCa
v*Intetrr igo*v
yy Candida albicans~u}v]o] Z
yy Tinea]v(}v
yy uE ~XPXb}R}]U}]U}vZ
yy Pb}]b]b ~G˘oZ
yy E˙Rbu
Symptoms
yy IR˙Uo˙ b bR
yy D˙bl]v
yy W]vPUvbR
yy D]bRP]vPob]}vb
Signs
yy D˙Uo˙ b bl]v
yy E˙Ru
yy E˘}]}vb
yy Pob
yy Vb]ob
yy u˙ C oo]
b obb RuP]vb}(+
yy Pb]bv}`vRb
yy WooruRb
yy Pob
Invtiga
se tions
yy PRvP b (}}vub
yy Sl]v]vP b (}(vPoouvb
Standard Trtme
yy FbvPo}}Po}b
yy S`(}ovbvb]]˙
Trtme
ae nt
Tuv}ib
yy T}o]˙u}ub b vl}b}]]b}u(}
yy T}]v(˙vv˙]b}b]vP(}b
yy Wo}}b}'}vo}R]vPv}v(}}`(}}v}((}ob
yy W]PRo}bb
yy }] A ]]vP(}b](v˙
AXF}v] intertrigoUb}R}]u }v]v(}v
]v
E RvPPC
yy M]}v}o A9obA9R˙}}b}v uU}]oU
Adults
Ao˙R}o˙(}˙b
Children
Ao˙R}o˙(}˙bw
Then
v*Intetrr igo*v
yy M]}v}o A9uU}]oU
Adults
Ao˙rR}o˙oobRb}ob
Children
Ao˙rR}o˙oobRb}ob
Or
yy Co}]u}o A9uU}]o
Adults
Ao˙rR}o˙oobRb}ob
Children
Ao˙rR}o˙oobRb}ob
Or
yy M]}v}o UA9}Ù}]oU
Adults
Ao˙rR}o˙oobRb}ob
Children
Ao˙rR}o˙oobRb}ob
Or
yy Co}]u}o UA9}Ù}]oU
Adults
Ao˙rR}o˙oobRb}ob
Children
Ao˙rR}o˙oobRb}ob
]v
E RvPPB
yy I}v}o U}oU
Chatep rP *Disorsof
der theSkin
Adults
uP]o˙(}˙bw
Children
AN˙bV uP]o˙(}˙bw
u}vRr˙bV ræuPllP]o˙(}˙bw
C}vrX
M}v]}o](v}v`R]o}vo}vPruR˙X
B. For Erythrasma
yy Fb]]A] UA9uU}]oU
Adults
Ao˙vrR}o˙}+b
Children
Ao˙vrR}o˙}+b
Or
yy Co]R}u˙]v U}oU
Adults
PX b
Children
æræuPX b
v*Intetrr igo*v
Or
yy E˙R}u˙]v U}oU
Adults
æuPR}o˙(}æ˙b
Children
r˙bV æræuPR}o˙(}æ˙b
r˙bV æuP}(˙b R}o˙(}æ˙b
Or
yy M]}v}o A9uU}]oU
Adults
Ao˙rR}o˙oobRb}ob
Children
Ao˙rR}o˙oobRb}ob
Or
yy WR]]o[b}]vuv U}]oU
Adults
Ao˙R}o˙oobRb}ob
Children
Ao˙R}o˙oobRb}ob
CXF}C}vub U}]
A u or Flexural psoriasis
Adults~rXæA9ul}]vuvZ
Ao˙rub]o˙
Children~A9uZ
AN˙bV o˙R]vo˙rR}o˙]v}(bR(}
æ
Standard Trtme
˙bw
Or
Adults
Children
Or
yy uRb B }v ul}]vuvU}]oU
Adults~XærXA9Z
Ao˙R]vo˙rR}o˙(}˙bw
Children~XæA9Z
r˙bV o˙R]vo˙rR}o˙(}˙bw
Refeal
r Criteria
R(vbv}b}v]vP}uv}u}o}P]bX
v*Intetrr igo*v
v
Chapter
EndocrineandMetaolic
b
Disorsder
98. Diabetes Mellitus

D]b uoo]b is characterised by persistently elevated blood
Po}boobXI(oLv}]u}o˙(}o}vP]}bR]b
`]oobo]v`]bo}}bouPv}uo]}vbovP
} R ˙bU l]v˙bU RU ]v v vbX TR ]b v ]vb ]bl
}( o}` o]u u}vbU }} (o]˙ v Pvv˙ }}ub `]R
]u}Po}b}v}oX
AoR}PR R]ov v }obvb }Lv bv `]R
˙u}ub
b U uv˙ ob `]R ]b ˙u}u
b X I ]b R(}
vbb˙ } ˘o ]b ]v oo b}vbU b]oo˙ obU 'v]vP
RoR(]o]b(}}vu]o˘u]v}vbU.b}rv]Ù
vrvo U o v uPv˙ u]bb]}vb } vP}]vP
P]o
b }bX
TR v}vrRu}o}P]o v Ru}o}P]o ]vv}vb ]v
]buvPuvboo˙o](ro}vPX
Iv]]ob (}v } R v}b } ]oo˙ obu Po}b oob
]v R r]b } ]bvPbU b R}`v ]v R o o}Ù `]oo
v(Rbuv}}v.uR]Pv}b]bX
FbvPobu rR}bv]o HA c
Status
Po}b obuPo}b
AMæXvuu}olL AMwXuu}olL AMæXwA9 N}uo

AMæXvuu}olL wXWXuu}olL æXwWvXA9 IGT~Pr]bZ
æXwrvXıuu}olL AMwXuu}olL æXwWvXA9 IFG~Pr]bZ
ANwXuu}olL ANXuu}olL ANvXæA9 D]b
HAWGo˙Hu}Po}]v
IGTWIu]Go}bT}ov
IFGWIu]FbvPGo˙u]
w
Standard Trtme
F}(}ub}(]bv}v]vP
yy T˙]b
yy T˙]b
yy Gb}vo]b ~Sb}v}vRD]b]vPPvv˙ [Z
yy S}v˙ ]b ~o } u]}v bU v}]v }
v]bX
b Z
sueCa
yy }]uuv
A ]b}~T˙]bZ
yy I]}R]~T˙]bZ
yy Gv (}b b]vP (]v R }v }}v
b }( ]vbo]v
~T˙]bZ
yy Ev]}vuvo (}b XPX ˘bb] o}] ]vl v ol }(
R˙b]o]˙~T˙]bZ
yy PPvv˙~Gb}vo]b Z
yy Secondary diabetes:
yy M]}vXPX}}b}]b}b
yy Pv]bb}v}u˙
yy Ev}]v]b}bXPXCbR]vP [b˙v}ub U}uPo˙X
Symptoms
v*DiabetesMellitus*v
yy Uboo˙v}v]vuv˙ob
yy P}o˙]vv}]
yy P}o˙]b]
yy Uv˘o]v`]PRo}bb
yy Bo]b]}v
yy Recurrent boils
yy Recurrent pruritus vulvae
yy oE ˙b(v}v
yy S˙u}ub o } R}v] }uo]}vb ~XPX R]vb v vob[
bvb}v } vuvbb ]v R Rvb } (U (}} PvPv U }}
]b]}vXZ
yy Do]˙}(oP]b~ANlPZ
Signs
yy Uboo˙v}v]vu}bvb
yy Ll}(bvb}v]vR(}Rvb
yy F}}PvPv
yy Po}u
yy Iu]]bo]˙
yy Cataract
yy RvoRvPb}v(v}b}˙
Invtiga
se tions
Nò˙]Pv}bv
yy FbvP}v}uo}}Po}b
yy OoPo}b}ov~]( b ]}}v.u]Pv}b]bZ
yy Bo}}Uo}o˙bvv]v
Chatep rP *EndocrineandMetaolic
b Disorsder
yy FbvPo}}o]]}.o~obZ
yy Go˙Ru}Po}]v~HAZ
yy FBC
yy GCE ~obZ
yy U]vo˙b]b
yy U]vl}vb~`]RR]PR]v]oPo}boobZ
D]vP}v(}oo}`b
yy Bo}}Po}b
yy R} bob }( Po bo(ru}v]}]vP }( (bvP v v r
}uR}u
b ˙Rvb]vPPo}bu
yy P]}](bvP}v}ub]vPo]v]]`b
yy Go˙Ru}Po}]v~HAZ~ob`]˙Z
yy Bo}}o]]b~vvoo˙Uu}(vo˙](oobv}uo}
}vo]]o}`]vPu]}vZ
yy Bo}}Uo}o˙bvv]v~vvoo˙Uu}(vo˙
](oobv}uoZ
yy U]vu]}ou]v~vvoo˙Z
Trtme
ae nt
Tuv}ib
yy T}o]˙u}ub
b
yy T}vR˙Po˙u]}uo]}vb~]XXl}]}b]bv
RR˙}bu}oZ b
yy T}vuvroR˙}Po˙u]
yy T}R]vu]v]v}]Po˙u]Pb
yy FbvP o}} Po}b `v rw uu}olL ~obb ]vvb] Po˙ r
u]Pb]voo˙vbZ
yy rR} }bruo o}} Po}b `v ærı uu}olL ~obb ]v r
vb]Po˙u]Pb]voo˙vbZ
yy Go˙Ru}Po}]vwA9}obb~obb]vvb]Po˙u] r
Pb]voo˙vbZ
yy T}vb`]PR}v]v}`]PRv}b]v]]ob
yy T}vR}v]}uo]}vb}(]b˙u]v]v]vP
yy TRPo˙u]Pbv}}
yy Bo}}obb bRvluuHP
yy LDLrR}ob}oobbRvXæuu}olL
ı
Standard Trtme
B}˘rP) TRo](b˙ou}].}v
D]P
yy C}uo˘}R˙b~XPXlvl˙U˙uUov]vX(Z
yy }]A .v bPb b ]v b}L ]vlbU } ]vP bP}PbX A. r
]o `vb
b v R][ b}L ]vlbU `R]R } v} }v]v Po}bU u˙
R}`b
yy ˙A [b]ubPvoo˙}vb]b}(V
yy C}R˙b ~vA9ZU }]v ~æA9Z v ( ~A9Z u}bo˙ }( ovr}]P]v
vo}`]vv]uo(
yy So~b}]uRo}]ZAMæP l˙
yy F]bvPobAHP l˙
yy S}oo.~XPXb(}v]v}bUvbUobUvbXZ
yy A }o o}] }vv ~}}vbZ }( (}} v v ]vb ]v R
u}v}(.XPXPobU(]bvob
yy O`]vP } R b]o vb }( R]ov (} ] R `]oo vb }uo
P}`RU R] ] ub u]v ˙ ]]v ]v }vbo}v `]R
a paediatrician
Alcohol:
yy Ivl }( o}R}o ]b }R]] (} ]v]]ob obb Rv ˙b }( PX
WR]oo}`}vbu}v]bu]bb]o]vovbUu}}R˙
]vl]vP}(o}R}o]vbbR}oo}]]vlvu˙`}bv} r
`]PRv}b]˙XIu˙ob}]vbR]bl}(R˙}Po˙u]
E˘]bP
yy RPoUb]uo˘]bXPXu]vb]blòl]vPob˙b`l
]vuovvb
yy Aoo]}v˘]bubP]}vb]}v}Rv[bPvR
bv}(}uo]}vbv}Ru]o}v]}vb
AXT˙]bvbvT˙vb}v]vbo]v
monotherapy
Note 12-1
Ivbo]v }b ]uvb ˙ (}u v} v ]b }( P v
}˙`]PRX
TR }o ]o˙ ]vbo]v ]uv (} u}b ob v ro R]ov
]b } XvrX v]bllPU `R]R bR}o P]v ]v ]] }bbX H}Ù ]
]b v } P]v `]R o}` }bb v ]o R]b `]R u } v
R˙}Po˙u]X
Ivbo]v]uvb]vb]vP]v(}vbU˙U]}b}(bU] r
vo}P]o b uUPvv˙X  
TR bo} (} ]vbo]v ]vi}vb (} }v ]buv ]b b r
v}bU u]v]b u]vb (} uo (} Polb}oo ]vbo]vU
u]˘]vbo]vU}NPH]vbo]vv]uu]o˙(}Ruo(}]vP
vo}P]vbo]vb~XPXbUo]b}}]vP Z }R(}oo}`]vPP]uvbP
yy T`] ]o˙ ru]˘ ]vbo]v ~b}oo A= ]vu] vP ]vbo]vZ (}
l(bvb~(Z
O
ı
b Disorsder
yy T`]]o˙]vi}vb}(S}ooPLUSNPHu]vb(}l(bv
S}oo PLUS NPH u]vb (}X
b TR S}oo v NPH ]vbo]vb
ubP]v]v˙]vPb
b X
]v
E RvPPA
yy Ivbo]vPu]˘USCU ~A9b}oo]vbo]vvwA9NPH]vbo]vZU
A0}(}o]o˙]vbo]v]uvu]vb(}l(b
Av
A+}(}o]o˙]vbo]v]uvu]vb(}v]vPuo
~bZ
Or
yy S}oo]vbo]vUSCU
A+ }( }o ]o˙ ]vbo]v ]uv ]v ]] }bb u]vb
before breakfast and supper
vA
yy Ivbo]vNPHUSCU
A0 }( }o ]o˙ ]vbo]v ]uv ~A0 }( `R]R `}o P]v
u]vb(}l(bvA+u]vb(}bZ
BXT˙]bvb}v}ou]}vbV]v]ouvPuv
(Monotherapy)
st
L]vTuv
]v
E RvPPA
yy M}u]v U}oU
Adults
æuPrP]o˙
Then
Ivb˙u}vRb}u˘]uu}(PR}o˙](vbb˙
Children
Refer to specialist
CXT˙]bvb}v}ou]}vbVvbv}
R]]vPPo˙u]Pb`]RM}u]v u}v}R˙L
approximately 3 months (Dual Therapy)
yy M}u]v U}oU
Adults
PR}o˙
Children
Refer to specialist
Av
yy Go]vou] U}oU
Adults
XæruP]o˙
~I(]Uv}u}RvæuP}(Go]vou] }o]}voo˙
P]v]vRv]vPu˘]uu}o}bæuP]o˙Z
Children
N}}uuv
ı
Standard Trtme
Or
yy Go]o] U}oU
Adults
rvuPR}o˙
Children
N}}uuv
Or
yy Go]u]] U}oU
Adults
rvuP]o˙~bb]vPo}b]vRu}v]vPZ
Children
N}}uuv
Or
yy T}ou] U}oU
Adults
æruPrR}o˙
Children
N}}uuv
Note 12-2
T}ou] ]b(]v ]v]]ob `]R ]u]vo (v}v v ]v R

elderly
X
D T˙]bvb}v}ou]}vbVvbv}
R]]vPPo˙u]Pb`]R}u]v}v}(M}u]v and
SoR}v˙oXPXGo]vou]XL}˘]uo˙u}vRb
(Triple Therapy)
st
L]vTuv
]v
E RvPPA
yy M}u]v v Go]vou] ~} ovZU }oU b ]v b}v C
above
Av
yy S˘Po]v U}oU
Adults
XæræuP]o˙
Children
N}}uuv
Or
yy S]Po]v U}oU
Adults
æruP]o˙
Children
N}}uuv
Or
yy V]oPo]v U}oU
Adults
æræuPrR}o˙
ı
b Disorsder
Children
N}}uuv
Or
yy P]}Po]}v U}oU
Adults
æræuP]o˙
Children
N}}uuv
EXT˙]bvb}v}ou]}vbVv}R]]vP
glycaemic targets with Triple Therapy
yy Triple Therapy
Av
yy Ivbo]vNPH USCU
Adults
rv]b(}u
Children
Refer to specialist
v*DiabeticKetoacidosis*v
Note 12-3
R( } ]}o}P]b } R˙b]]v b]o]b (} ]vbo]v v }o u]}v
}u]v}vR˙]v˙]b
Refeal
r Criteria
Aoo ]v]]ob `]R ]b ub ( } ]]v (}
]˙ ]X Aoo R]ov `]R ]b ub bv ˙ b]o]b
~]]]v}v}]v}o}P]bZXAoovb]v`R}uPo˙u]Pb
vv}R]bòobR}b`]R]b}uo]}vbub
(}R}]b]o]bX
Aoo ˙ ]b ]Pv}b]b v ˙ ]b æ ˙b L
]Pv}b]bbR}o(}v˙b]o]b(}v]vP b (}D]
Rv}R˙X
99. D]K}]}b]b
D]l}]}b]b ~DKA ]bZ }v]}vb}]`]RR]PRo}}
Po}b ~boo˙ AN uu}olLZU `R]R v}vRobbU ]b v]oo } R
}˙ b b b} }( vP˙X F ]b R(} }lv }`v b v
ov b} }( vP˙U ob]vP }˘] Ru]ob oo l}vb b
˙r}X A]}voo˙U R ]b b R˙}v and electrolyte
]uov ]v DKAU b]oo˙ o}` }bb]uX I ]b }uu}v b }(
Ru}vP]bvb]vGRvXI}Lv}b]v˙]b
vbu˙ob}}]v˙]bX
Iv}vbU R H˙}bu}o N}vrK}~HONK
b Z ]v ]b
}b]u]o˙]vT˙vbUv]bb]u]o]v]bo]v]obv}v
}]l}]}b]b]vuv˙bXAui}]+vUR}Ù]b
ı
Standard Trtme
Rbv}(b]Pv].vu}v}(l}vb]vR]v~boo˙
} A=Z v R bv }( bR˙}vX TR uvPuv }( R]b
}v]}v]bb]u]o}R}(DKAX
sueCa
yy S.]v˙}(]vbo]v
yy Iv}v }( vrR˙Po˙u] R˙ ~boo˙ (} .vv]o
b}vb}(}ovuvZ
yy Sbb }( ]vv ]oovbb ~XPX ]v(}vU u˙}]o ]v(}vU
strokeUP˙ b U}uo]Pvv˙XZ
Symptoms
yy P}o˙]
yy P}o˙]b]
yy NauseaU}u]vP
yy A}u]vo]v
yy Ao}v]vbvb}]u}}oob
yy S˙u}ub}(]v(}v}}Rvo˙]vP}v]}v
Signs
yy DR˙}v ~˙bl]vUbl]vP}}bvlv˙bZ
yy Dv(bR]vP
yy L}ò}}b
yy Fbv`lob
yy RF]˙ [R~buoo}(}vZ
yy C}v(b]}vU}b }v}vb]}bvbb
yy ]v E }(]v(}vUvP˙
b U}l b X
Invtiga
se tions
yy Rv}uo}}Po}b~boo˙ANuu}olLZ
yy U]vPo}b~boo˙ANA=Z
yy U]vl}vb~boo˙ANA=Z
yy Bo}} v o}o˙b ~boo˙ o}` }bb]uU R}` ]( ]v
vo(]ov}bb]uu˙R]PRZ
yy Bo}}.ou(}uo]b]b
yy Foo o}} }v ~]b `R] oo }v `}o bPPb ]o
]v(}vZ
yy U]vo
yy Bo}}o
yy CRbXr˙~(}vu}v]Z
yy ]o A o}}Pbb
yy Eo}]}Pu~}]v(˙R˙}lou]Uv]vovb}
˘ou˙}]o]v(}v]]vP
b (}Z
Trtme
ae nt
Tuv}ib
yy T}oRG]o}bb
yy T}oRo}o˙o}bbUb]oo˙}bb]u
ı
b Disorsder
yy T}o.]v]vbo]v
yy T}blRvo˙]vPbv}]o˙
AX MvPuv}(D]K}]}b]b~DKAZ
TorP) RP]u(}uvP]vPD]K}]}b]b]vAob
ADULTS Ivv}bFo]b
Bo}}Go}b S}oolRP r P}bb]u
T˙}(Fo] R}(IVFo] oIvbo]v CRo}]~KCoZ
Iv]vP U]v Iv(b]}v Iv(b]}v
MvPuv K}v
AQ Test Results
Monitor blood Bo}}Po}b S}]u o]

b } S}ool SR}b
Po}bR}o˙ ANuu}olL Chloride .bu]vb Po]vbo]vU L]v] r
O XæA9 IV}IMUr ]vP]vbo]v
Monitor urine U]vl}vb vo]} v]bX
b vS}]u
l}vb`] ANA= v˘R} Chloride
daily TRLU Iv(b]}v
o]} u]v]b
v˘R}b S}oolPo Check ader
]vbo]vUIV quate urine
Ro]} Iv(b]}v }~AN
v˘R}b Xv]bllP uolR}Z
hourly
Sbvo˙U O Por
o]˙v ærv]bIM uu}oKCo]v
hours or as R}o˙vo æuoS}] r
required o}}Po}b uRo}]
AMuu}olL XıA9
RvRIV
M]v]v]vP infusion over
MvPuv at least one
AQ hour
Monitor blood Bo}}Po}b Go}bæA9 C}vv S}ool RP}b r
Po}b˙ AMuu}olL Go}bæA9 Po]vbo]v b]uIv(b]}v
Hours TR]bub o]˙ subcutaneously L
is necessary vR}b}} ˙Rbo]]vP R}b](
Monitor urine to prevent u] r ob [ necessary
l}vb`] subsequent uvb
daily R˙}Po˙ r ~b˘uo Check blood
u] }(Rbo]]vPob [ P}bb]u
in the table oo`]
o}`Z D ]o˙
W]RR}oKCo
if blood level
RPo }(}bb]u
MvPuv ANvuu}olL
AQ
Monitor blood Bo}}Po}b PvvPv}uoo˙ CRvP(}u P}bb]u

Po}b`]] r u]v]v ~}uuv]Z Rbo]]vPob [ Ro}]U}oU
o˙~rl(b `v }`]]o˙ if required
vrbZ vruu}olL subcutaneous
]vu] r
U]vl}vb rvP
vP} }u]˘
trace insulin
ıæ
Standard Trtme
TorP) RP]u(}uvP]vPD]K}]}b]b]vCR]ov
CHILDREN Ivv}bFo]b
Bo}}Go}b S}oolRP r P}bb]u
Type of R}(IVFo] oIvbo]v CRo}]~KCoZ
Iv]vP U]v Fo] Iv(b]}v Iv(b]}v
MvPuv K}v
AQ Test Results
Monitor blood Bo}}Po}b S}]u R}

b S}oolP r SR}b
Po}bR}o˙ ANuu}olL Chloride æuollP o]vbo]vUIV} L]v]vP
O XıA9 IMUXæv]l insulin and Sor
Monitor urine U]vl}vb vR} lPb ]uCRo}]
l}vb`] ANA= æuollP Iv(b]}v
daily TRLU
H} u]v]b Check ader
wXæuollP S}oolPo quate urine
]vbo]vUIVIv( r }~AN
RR}v b]}v}IM uolR}Z
vo˙
b U Xv]bllP
ibG] R}o˙vo AKCoX
}u Bo}}Po}b rXuu}ol
]uvb AMuu}olL lP~u˘X
uu}oZ]vIV
G]bXRv
M]v]v]vP infusion over
MvPuv at least one
AQ hour
Monitor blood Bo}}Po}b S}]u SIv(b]}v S}ool RP}b r
Po}b˙ AMuu}olL Chloride in }u Po]vbo]v b]uIv(b]}v
Hours XA9 ]uvb subcutaneously L
Glucose ˙Rbo]]vP R}b](
Monitor urine ob [ necessary
l}vb`] This
daily ub]b ~b˘uo Check blood
necessary }(Rbo]]vPob [ P}bb]u
to prevent in the table oo`]
subsequent o}`Z D ]o˙
R˙}Po˙ r
u] W]RR}oKCo
if blood level
RPo }(}bb]u
MvPuv ANvuu}olL
AQ
Monitor blood Bo}}Po}b PvvPv}uoo˙ CRvP(}u P}bb]u

Po}b`]] r u]v]v ~}uuv]Z Rbo]]vPob [ Ro}]U}oU
o˙~rl(b `v }`]]o˙ if required
vrbZ vruu}olL subcutaneous
]vu]r
U]vl}vb vP}
vP} u]˘
trace insulin
B}˘rP) Sample Sliding Scale Chart

Bo}}Go}bRbo C}b}v]vPD}b}(RPoIvbo]v}u]v]b
~(}oo}`]vPrR}o˙vP
b Z Subcutaneously
uu}olL ADULTS CHILDREN
ıv
b Disorsder
B}˘rP) Sample Sliding Scale Chart

AMvX N}Ivbo]v N}Ivbo]v
vXrıX v]b Xvv]bllP
ıXrX vv]b Xıv]bllP
XræX v]b Xv]bllP
æXrX v]b Xæv]bllP
N}r
TR˘uo}(Rbo]]vPob P]v}]bv}.˘vb XTR] r
uv}(]vbo]v(}Roo}(o}}Po}bub]+b(}uv}
vXTR}b}v]vP]vbo]v}bu˙ b R(}v}ib
}}`v}b]RvX
F}}RobvR]ovU}vvRbo]]vPob Uul]vP}] r
ibuvb } R }bb }( ]vbo]vU vo R v ]b vP v}uoo˙ v R
]v]b(}(l}vb(}RvP]vP}`]r]o˙]vu]}u]˘
]vbo]vXTR]bu˙l}vPWwR}bX
v*DiabetesinPrgna
BX MvPuv}(H˙}bu}oN}vrK}~HONK
b Z
~SRMvPuv}(DKA[}Z
e ncy*v
CX AivTuv(}DKAvHONK
yy }B rbu v]}b (} b ]v(}vb ~S
}]b}vZ
yy Tuo]](}b }v.u~S}]b}vZ
Refeal
r Criteria
I( R ]v b}b (} uvP]vP R vU b
XıA9S}]uCRo}]UIVUvP]]v]o}b}(b}oo}Po]vbo]v
IV}IML}v.u]vPo}}Po}bv]vl}voobv(
}v˙P]}vo}R]vPR}b]oX
I( R v u]vb }u}b } (]ob } b u}vb
}(]vb]uvPuvU(}P]}vo}R]vPR}b]o(}
(RX
100. Diabetes in Pregnancy

~S b}v }v RD]b ]v PPvv˙[ v ROb] v
Ob]D]b}b[Z
ıw
Standard Trtme
101. Treatment-Induced Hypoglycaemia

H˙}Po˙u] (b } o}} Po}b oo o}` Xv uu}olLX
I ]b u} }uu}v ]v oo˙ ]b v R}b `]R l]v˙ (v}v
]u]uv b òo b R}b }v o}vPrvP }o vrR˙Po˙u]
u]}vb } ]vbo]vX S R˙}Po˙u] ~o}} Po}b AM X
uu}olLZ u˙ bo ]v o}v }( }vb]}bvbbU .bU bo(r]vi˙ v
]}bPb}(]b]o]vuPX
F}oo}`]vP(ob uv}(R˙}Po˙u]U]bbub
u]v v ubbU ]vo]vP v }v v ]b]}v }(
vrR˙Po˙u]P}bbUbR}olv}v]bvX
sueCa
yy O}b }( v˙ vrR˙Po˙u] u]}v ]XX ]vbo]v } }o
Pv
yy AvR˙Po˙u] u]}v b ]v vo ]u]uv v R
elderly
v*Trtme
yy Ou]'}]vu}v}((}}
ae ntrInducedHypoglycaemia*v
yy Uvb}uR˙b]o}r]˙
yy E˘bb]o}R}o]vl
Symptoms
yy D]]vbb
yy Bo]b]}v
yy Headaches
yy Po]}v
yy S`vP
yy SRl]vP}(RRvbv}˙
yy Uv}vb]}bvbb
yy Convulsions
yy I]]o]˙vv}uoR]}b]oo˙]vR]ov
Signs
yy S`vP
yy Tu}b
yy Tachycardiav}v]vPob
yy Confusion
yy Uv}vb]}bvbb
yy Convulsions
Invtiga
se tions
yy Rv}uo}}Po}b~Pvo˙}vb]vPPo}buZ
yy Bo}}vo}o˙b
yy L](v}vb
Trtme
ae nt
Tuv}ib
yy T}]o˙}b o}}Po}boob}v}uo
ı
b Disorsder
yy T}u]v]vRoo}(o}}Po}b`]R]vRv}uovPvo
RvvP]vvPv}uoo˙
yy T}]v(˙vbRb
yy M]oR˙}Po˙u]
yy r b}}vb }( Pvo bP } b }( bP } A*
}'o }( b}L ]vl ~bPr}v]v]vPU v} R] [ ]vlbZ } ]v] r
]ob`R}}vb]}bX
yy A Pobb }( u]ol } (] ]vl v ob}}v(o }( R}v˙
(o
b ovb
yy TR}ubbR}o(}oo}`]uu]o˙˙uo
or snack
yy M}R˙}Po˙u]
yy Su(} b u]oR˙}Po˙u]ULu]vbXI(
v}]u}uv]b}bU(} b R˙}Po˙u]
b
AXSR˙}Po˙u]
v*Trtme
st
L]vTuv
ae ntrInducedHypoglycaemia*v
]v
E RvPPA
yy ˘}b
D UIVU
Adults
æA9b}o}v
æræuo}ru]vbR}PRoP]v
Then
ærA9b}o}v
æuoR}o˙voRv]bo}v}uoo˙
Children
A9b}o}v
uollP}˙`]PR}ru]vbR}PRoP]v
Then
æA9b}o}v
}]vP
A } }o ]o˙ G]]uv vo o}} Po}b oob
v}uo]b
nd
L]vTuv
]v
E RvPPA
yy GoP}v UIVUIM}v}b b U
Adults
uPX b
Children
r˙b~}˙`]PRANælPZV uPX
b
r˙b~}˙`]PRAMælPZV æu]}PubX
b
u}vRr˙bV æu]}PubX b
NeonateV u]}PullPX b
ıı
Standard Trtme
Refeal
r Criteria
I( R v }b v} b}v } R } uv
}uuv}vbU(}b]o]bX
102. Dyslipidaemia
TR ]b uo ]v o]vl]vP R]PR o}} R}ob}o oob }
]}b C o D]bb ~CVDZ vbU ]vo]vP u˙}]o ]v(}vU
}lb b Uv]Robo]bbXOvR}RRvUR]bob}
]v (} b]Pv].v }v ]v u}]]˙ v u}o]˙ (}u CVDb
˙]vPo}}R}ob}ooob]vR}b ]bl~]u˙v}vZ
vR}b`R}Rb+CVDv~b}v˙v}vZX
TR}uu}vo˙o}}b o]]ub}oR}ob}oU
HDL R}ob}oU LDL R}ob}o v ]Po˙]bX H}Ù R ]u˙
P (} ]vv}v ]b R LDLrR}ob}o ooX Ab uv u˙
(} o}vP ]}b } o](o}vPU ]}] u}v]}]vP }( o] v ubo
v˙ub ~vbu]vbb v v l]vbZ v o}} Po}b
]bo}(}boou]}vrob]+bX
sueCa
v*Dyslipidaemia*v
yy H]PR]˙]vl}((bb ~v]uo(Z
yy Ll}(R˙b]o]˙
yy M}o] ˙v}u b ~ }u]v}v }( ob }( R (}oo}`]vPV
}b]˙UR˙vb]}vU˙]bU˙bo]]u]UP} XZ
yy Hereditary factors
yy E˘bb]o}R}o]vl
yy H˙}R˙}]]bu
yy NR}˙v}u b
Symptoms
yy Uboo˙v}v
yy A}u]vo]v(}uvbo}R˙]Po˙]u]
Signs
yy Uboo˙v}v
yy Ob]}voo˙
yy WR]bR]vP}vR}v~}vobZ
yy Yoo}`]bRbl]v}vb}vR˙b~˘vRobuZ
yy WR]bRo}}buo~o]u]o}}Z
Invtiga se tions
yy FbvPo}}o]]}.o
yy TR˙}](v}v~]( b o]]oob˙R]PRZ
yy Pobu }]v ~]( o]] oob ˙ R]PRU } ˘o vR}
˙v}u
b Z
yy U]v}]v~](o]]oob˙R]PRU}˘ovR}˙v}u b Z
b Disorsder
Tuv}ib
yy T} R ]bl }( o]v]o R}bo} ]}bo vb
and related deaths in:
yy HoR˙]v]]ob]bl~]u˙v}vZ
yy Iv]]ob `R}Rb+CVDv~b}v˙v r
}vZ
yy T}RLDLrCoo}R(}oo}`]vPPbP
yy Aob æ A9 LDLrC }v (} ]u˙v}v ~]v R
Pvo}o}v]XX]v]]obAH˙b}(P`]Rvv r
LDLrCAHXıuu}olLZ
yy rı A9 LDLrC}v (} ]u˙v}v ~]v ]v]]ob
} wæ ˙b }( P `]R ]b `]R v v LDLrC
XrXıuu}olLZ
yy LDLrC AM X uu}olL (} }v˙ b v}v ~]v ob `R}
R ]}bo˙ b+ R 'lU }l b } ]Ro
bo]bbZ
yy D]˙ ubb r o}` o}]U o}` b ( ~v]uo (ZU
R]PR }o˙vb(~ov (Z ] ]b}uuv v R
b]b]}v}(]]v
yy W]PR}v]vvb`R}}`]PR}}b
v*Dyslipidaemia*v
yy R}v]vo}R}o}vbu}vU`RR]b]b˘bb]
yy RPoR˙b]o]˙}˘]b]o}}R]v]]ov
AXL}`CVD]blr]u˙v}v
st
L]vTuv
]v
E RvPPA
yy S]ubv U}oU
Adults
ruPv]PR
B. Moderate CVD risk - Diabetes and CVD risk equivalents
]v
E RvPPA
yy }bA v U}oU
Adults
ruP]o˙
Or
yy R}bvb U}oU
Adults
æruP]o˙
Or
yy S]ubv U}oU
Adults
ruPv]PR
Standard Trtme
CXH]PRCVD]blWS}v˙v}v
yy }bA v U}oU
Adults
ruP]o˙
Or
yy R}bvb U}oU
Adults
ruP]o˙
Refeal
r Criteria
R( oo vb `R} u]v }b] R P ob b]
]˙U˘]bvu]}vR˙}b]o]bX
103. Goitre
AP}] ]b òo]vP
b }(R(}v}(Rvl }voPuv}(
RR˙}]PovXIu˙+b}vb}(v˙PXN}oovlòo]vPb b
P}]bXG}]bboo˙v]Pvu˙}b]}voo˙uo]PvvX
TR˙ }o b}] `]R v}uoU } ˘bb] (v}v
}( R R˙}] PovX A }v ]v }}v }( R˙}] R}u}vb
bob ]v R˙}R˙}]]bu `R]o v ˘bb ob ]v R˙R˙}]]bu or
R˙}}˘]}b]b X Av}uo]b }( R˙}] R}u}v }}v u˙ ob}
v*Goitre*v
}]vRbv}(P}]X
P}]Pv}b]bvbo}v}(}]P]ob }v}vrbP]o
uv }( v]Pv v uo]Pvv P}]b ]b ˙ (oo o]v]o buv
v ]vbP}vbX Tuv ]b v} vbb]o˙ ˙ ]vb]vP ]}]v
]vl XPX ]v ]} boX E˘bb ]}]v ]vl u˙ oo˙ Ru(o
]vb}ubX
sueCa
yy S]uov}vr}˘]P}] }vu]P}]
yy H˙}R˙}]]bu ~Sb}v}vRH˙}R˙}]]bu[Z
yy H˙R˙}]]bu }TR˙}}˘]}b]b ~Sb}v}vRH˙R˙}]]bu[Z
yy TR˙}]v}oburv]Pv}uo]Pvv
Symptoms
yy Sòo]vP]vRvl
yy R]vP B vòo}`]vP
b ]8o˙U](oP
yy S˙u}ub}(R˙}R˙}]]bu ~Sb}v}vRH˙}R˙}]]bu [Z
yy S˙u}ub}(R˙R˙}]]bu ~Sb}v}vRH˙R˙}]]bu [Z
Signs
yy D]+b~bu}}RZ}v}o~]PoZR˙}]òo]vP b
yy S]Pvb}(R˙}R˙}]]bu ~Sb}v}vRH˙}R˙}]]bu [Z
yy S]Pvb}(R˙R˙}]]bu ~Sb}v}vRH˙R˙}]]bu [Z
Invtiga
se tions
yy TR˙}](v}vbW(TU(TUTSH
b Disorsder
yy Thyroid ultrasound scan
yy TR˙}]}v}]b~](vbb˙Z
yy R]}]b}}v
b }(R˙}]~](vbb˙Z
yy F]vvob]}v˙}o}P˙~](vbb˙Z
yy Xr˙}(Rvl]vo]vPR}]]vo]`(}oPP}]b
Trtme
ae nt
Tuv}ib
yy T}bv}oo}(R˙}]R}u}v}}v
yy T}˙u}ub b b}]`]RR˙}}˘]}b]b
yy T}}v}b˙u}ub b
yy T}]v(˙R˙}]v}obubvuvP}]o˙
yy S}oR˙}]}u˙`R]v]
yy }] A uv }( R˙}R˙}]]bu } R˙R˙}]]bu (See
b}vb}vRH˙}R˙}]]bu [vRH˙R˙}]]bu [Z
Refealr Criteria
R(vb}R˙b]]v}P]o
b b]o]b`R}uo]}vb
v*Hypothyroidism*v
~XPX R˙}R˙}]]bu U R˙R˙}]]bu U R]vP ]8o˙ XZ }
uo]Pvv˙ b} ]( (oo o]v]o buvv ]vbP}vb
v}}bb]oX
X Hypothyroidism
H˙}R˙}]]bu ]b }v]}v b}] `]R }v ]v R˙}]
R}u}v}}vXTR˙}]R}u}v]b](}v}uou}o]bu
vP}`RXIb.]v˙Rbui}}vbvb}v(}oo}uv
b òo b ]vooo v R˙b]o o}uv ]v ]v(vb v R]ov
~b}(v]bu ZX
Iv obU ] u˙ R b }( ob }oub ]vo]vP R
]bbUuvbo]Po]˙v]v(o]˙UuvoRoR}v]}vbv
uvXI}]vouv]bv}Ruv(}R˙}R˙}]]bu X
Sv]vP (} R˙}R˙}]]bu ]v oo v` }vbU v ˙ æ ˙b ]v
ob L P æ ˙bU b]oo˙ (uobU ˙ ub]vP TSH ~R˙}]
uovPb R}u}vZ oob ]v o}} `R R]b ]b }bb]oU bR}o
v}PX
sueCa
yy Av}˙roR˙}]Pov}v b
yy S}oR˙}]}u˙
yy P]]˙P˙ b }ob]}vb
yy C}vPv]o
yy S]}]v.]v˙
yy DP]v~XPX]}]}]vR˙Uu]}}v XZ
Standard Trtme
Symptoms
yy Gvo`lvbbvvbb
yy Iv}ov}}ov]}vuvb
yy C}vb}v
yy W]PRP]v
yy Hair loss
yy D˙bl]v
yy Hoarse voice
yy Mu}˙o}bb
yy Goitreu˙bv
yy Av}uouvbo]}bvbr(o]˙~]vo(uobZ
yy P}}P}`RUo}uvv}}bR}}o(}uv]vR]ov
Signs
Neonate
yy P}o}vPv}voiv]
yy E˘bb]bo
yy F]vP}oub
Children
yy v]b C u ~uvo bv}uo]˙U bR} U b oP }vPU ˙
v*Hypothyroidism*v
bl]vU b R]U }v }uvU u]o]o Rv]U v}uo

(]bZ
obA
yy So}òb~boo˙AMvu]vZ
yy D˙}bbl]v
yy P+˙(
yy Poo}
yy Hoarse voice
yy So}`G˘b
yy Duv
yy Goitreu˙bv
Invtiga
se tions
yy TR˙}](v}vbr(TU(TUTSH
yy FbvPo}}o]]b~(}oR}ob}oooZ
Trtme
ae nt
Tuv}ib
yy T}}o}}oo}(R˙}]R}u}vb
yy T}u]v]vo](o}vPv}uooob}(R˙}]R}u}vb
yy SP]o]vv}v(}]]˙ob]}vb`Rvbb˙
AXIv]}v}(TuvvM]vvv
Note 12-5
Suv `]R o}` }b }( o}R˙}˘]vU b]oo˙ ]v R oo˙ v
b Disorsder
R]ov b òo b ]v]]ob `]R R ]bb ~XPX æræ u]}PuZU v
ib }b b }]˙ vr `lb vo TSH oob `]R]v v}uo
(vvPXTuv]b}Lvo](ro}vPX
]vE RvPPA
yy L}R˙}˘]v U}oU
Adults
æru]}Pu]o˙
Children
AN˙bV æu]}Pu]o˙~u˘Xu]}PubZ
r˙bV æu]}Pu]o˙~u˘Xu]}PubZ
AM˙bV ærwæu]}Pub]o˙
Refeal
r Criteria
R( ]Pv}b } b }( oo PbU b]oo˙ R]ov
`]R ]vooo ]u]uvU v ]v]]ob `]R ]]˙ ]bb }
b]o]bX
105. Hyperthyroidism
E˘bb R˙}] R}u}v ]v R o}} bob ]v R˙R˙}]]bu
v*Hypthyr
~R˙}}˘]}b]b ZX I( oL vU b]Pv].v `]PR o}bbU ˙ v]
er oidism*v
}uo]}vbU u˙ }X A]}v }( ˘ ]}]v } R ] ~XPX b ]v
]}bo]bZ v}R}uuvuvvu˙U]v(U`}bv
R}v]}vX
sueCa
yy G[b]bb
yy T}˘]uorv}oP}]
Symptoms
yy W]PRo}bb]]vb
yy E˘bb]`vP b
yy Heat intolerance
yy Tu}b}(RRvb
yy Nervousness and irritability
yy Mvbo]Po]˙vbr(o]˙
Signs
yy S]vPP}}]vP˙b
yy Tu}b}(RRvb
yy M}]boub
yy R]ob~`R]Ru˙]PoZ
yy W] ob b ~H]PR ˙bb }o] BP `]R o}` ]b}o] BP XPX
wlæuuHPZ
yy Heart failure
yy Goitre~}Lvbvv}o`˙bZ
yy Su}}Rv]+b]vG[b]bb
æ
Standard Trtme
yy IPo]v}˘]uorv}oP}]
Invtiga
se tions
yy TR˙}](v}vbr(TU(TUTSH
yy Thyroid ultrasound scan
Trtme
ae nt
Tuv}ib
yy T}R˙}]R}u}voob]vRo}}}v}uo
yy T}˙u}ubb b}]`]RR˙}}˘]}b]b
yy T}v}}uo]}vbXPXR(]oU}RRou}R˙
yy S}oR˙}]}u˙
AXIv]}v}(TuvvM]vvv
st
L]vTuv
]v
E RvPPA
yy C]u}o U}oU
Adults
ruP]o˙
v*Hypthyr
Children
er oidism*v
r ˙bV Iv]o }b æ uP ]o˙ ~ib }]vP } R˙}]

R}u}vooZ
AM˙bV v}}uuv
Note 12-6
bD }b }( ]u}o `Rv R˙}] R}u}v oob `]R]v R
v}uovPvib}bbvo˙}]vP}`}ru}vRo˙R˙}]
(v}vb
nd
L]vTuv
]v
E RvPPA
yy P}˙oR]}]o U}oU
Adults
uPR}o˙
Children
r˙bV æruPR}o˙
ær˙bV æuPR}o˙
ræ˙bV æuPR}o˙
u}vRr˙V ]v]oo˙æruP llPR}o˙U
Then
XæræuP llPR}o˙b}vR˙}]R}u}voob
AMu}vRV XæræuP llPR}o˙
Note 12-7
P}˙oR]}]o ]b ( ]v Pvv˙ v ]v R}b `R} } v} }o
C ]u}o X bD R }b `Rv R˙}] R}u}v oob `]R]v R
v
b Disorsder
v}uovPvib}bbvo˙}]vP}`}ru}vRo˙R˙}]
(v}vbX
BXAivuv~}˙u}ub b }(R˙}}˘]}b]b )
yy P}v}o}o U}oU
Adults
r uP R}o˙ ~ib }b oo R˙}] (v}v v}uo]bb r
}]]vRubb Z
Children
AN˙V uP llP~u˘XuPZR}o˙
NeonatesV uP llPR}o˙
Refeal
r Criteria
R( oo b v} b}v]vP } }vv}vo uv }
b]o]bb ]v }v˙
b } ˙ R}b]o (} (R ]vbP}vb
vuvPuvX
106. AvoIvb8]v˙
vo
A ]vb8]v˙ ]bb `Rv R vo Pov ]b}˙
b ˙
v*AdrenalInsufficiency*v
]bbU } }R]b (}oo}`]vP ]]˙ (]o } R}v] }}b}]
b } bX Iv Rb b]}vbU R u}v }( }b}o } (}u
RvoPov]b]vb8]v}uR}˙ [bvb]vP]}b
}( R˙b]o v ˙R}o}P]o
b b } b ]oovbbX TR }v]}v ]b
b}] `]R b G] v o}o˙ ]uov v bob ]v
]o}˙}oobX
sueCa
yy Sv}v b }(}o}vP}}b}]b}bX
yy Sb~ b XPX]v(}vUub UP˙ b Uvvo}bZ
]v v `]R v]Pv}b vo ]vb8]v˙ } vb }v
}o}vP}}b}]uvX
yy P]]˙(]o
yy }A r]uuv]bb}(RvoPov~A]b}v[b]bb Z
yy S ]v(}vb +vP R vo Pov ~XPX uv]vP}}bU
o}b]bUHIV Z
yy C}vPv]ovoR˙ob]]vR]ov
Symptoms
yy Nausea
yy V}u]vP
yy Wlvbb
yy Collapse
yy A}u]vo]v
yy D]R}
Signs
yy DR˙}v
yy L}`}v}oo}}b
w
Standard Trtme
yy Dlv]vP }( }o u}bU PubU bl]vU oub v b}ob ]v b}u
individuals
yy ]v
E }( }}b}] b XPX bl]v oR]vPU CbR]vP}]
appearance
yy Au]P}bPv]o]UbR}vb (]o}R]]vR]ov
yy V]ob}(}vb]}bvbb
Invtiga
se tions
yy FBC~u˙bR}`vu]v}b]v}R]o]Z
yy Bo}}vo}o˙b~u˙bR}`R]PR}bb]uZ
yy Bo}}Po}b~u˙o}`Z
yy Pobu}b}o~o}`Z
yy Bo}}.ou(}uo]b]bU](]v]
yy U]vvo}}obU](]v]
Trtme
ae nt
Tuv}ib
yy T}}RG]vo}o˙]uov
yy T}}R˙}Po˙u]
yy T}o}}b}]b
yy T}]v(˙bvv˙]]vP(}
yy None
AXuv
A
st
L]vTuv
]v
E RvPPB
yy Ivv}bG]ouv
Adults
XıA9S}]uCRo}] ]væA9Go}b~D˘}b So]vZUIVU
o]rvR}o˙Uvo}v]}v]bob
Children
XæA9S}]uCRo}] ]væA9Go}bUIVU}]vP}}oG] r
]uv
vA
yy H˙}}b}v UIVU
Adults
uPX b (}oo}`˙uPvR}o˙vo}v]}v]bob
Children
vr˙bV uPvR}o˙
ræ˙bV æuPvR}o˙
AM˙V æuPvR}o˙
Note 12-8
TR IV R˙}}b}v R˙ u˙ ] (} ob ˙bX D} v} bR
} RvP} u]vvv R˙X WRv R v[b }v]}v ]bob ~]XX
b Disorsder
v}uoBPU}v
b }(}u]vP XZP}}v}u]vvvR˙X
BXAivuv]vb
T ]v(}v ~XPX uo]U vu}v]U UTI Z } br]v]vP
}v]}vU](bv}U b `]R}]u]}vX
CXM]vvvr(}vbv}]}bo˙}v}}b]}b
st
L]vTuv
]v
E RvPPA
yy Pv]b}o}v U}oUo](ro}vP
Adults
æuPu}v]vPvXæuPv]vPR˙
Children
wu]}PubllPR}o˙
L]vTuv
nd
]v
E RvPPA
yy H˙}}b}v U}oUo](ro}vP
Adults
ruPu}v]vPværuPv]vPR˙
Children
u]}PubllPR}o˙
X
D M]vvvrF}vb}vo}vPu}}b}]R˙
`R}P}]v}v}}o]b]b~XPXRu b UvR}
syndrome)
Adults and Children
yy RbR]}b }bb }( }o }}b}]b P]v (} R }v r
]}vX
EXM]vvvrF}vb`R}}}b b }]b
Adults
Rb}o}}b}]bU}o}]o}}b}]b`]R
}o}}b}]b
yy Pv]b}o}v U}oUruP]o˙
Goo˙ }+ R }b }ob u}vRb ~XPX ]vP ˙
XæuPu}vRZvvoo˙]b}vvX
C}vrX
yy L}vPru}}b}]R˙]bb]o]bb]b]}vXHoR
}vbbR}o]v(}uvb}(R(}oo}`]vPV
yy Pvb}v}}b}]b bR}o}} R}b]o](R˙}u]oo
v bR}o oo R] }}U vbU vb } Ru]b R R˙
}v}}b}]b
yy Pvb SHOULD NOT }b uv ]( R˙ }u ]ooU R v ]v( r
}v}vP}]vPvo}XRR}o]vP}(RP r
o}bb}(}}b}]b]bv
yy R}R˙}}b}v UIV(}vu]v}P]o
b }b]vo]vP
labour and delivery
yy TR }b }( }}b}]b ub Poo˙ ]( uv Rb
ı
Standard Trtme
v(}o}vPRv`lbv]b}}b
yy D]b}PRb}(}o}}]o}}b}]b
Refeal
r Criteria
Aoo vb b } R vo ]vb8]v˙ bR}o
(U L b]}vU } P]}vo } R]vP R}b]o (}
buvvo}vPruuvPuvX
107. Cushing’s Syndrome

TR]b}v]}vbob(}uR]PRoob}(}b}o]vRo}}v]b
b}] `]R ]}b RvPb ]v R }˙ ]vo]vP R o}uv
}( }b]˙U R˙vb]}vU ]b v }b}}}b]bX TR }o}vP b
} b ~b]oo˙ ˙ `}uv (} }bu b}vbZ }( }o } }]o
}}b}]b bR bv]b}o}vU˘uRb}v U R˙}}b}v or
}b}vU}}vb}v]v]vPv˙}(RbPbU]bob}bX
sueCa
yy P]]˙u}
yy vo A u}
v*Cushing[sSyndome
yy P}o}vP v ˘bb] ]vl ~(} Ru b U vR} ˙v}u

b
XZ}b}(}}b}]b
r *v
Symptoms
yy W]PRP]v
yy E˘bb}˙R]vv~]uob Z
yy ˙bE ]b]vP}(bl]v
yy SRulb~]bR}o]bRZ
yy Mvbo]Po]˙vbr(o]˙
yy Wlvbb}(RR]PRubob
yy L]PRv]vP}(Rbl]v
Signs
yy R}v}Ru}}v[(
yy P}u]vvo]o b (b
yy Truncal obesity
yy E˘bb(]ov}˙R]
yy Acne
yy S]~]bR}o]bRR b ulbZ
yy Thin skin
yy ˙bE ]b]vPvo]vP]v}Rbl]vLvv
yy Hypertension
yy Iv]o]˙}]b(}uRhvP b }b]}v
Invtiga
se tions
yy Pobu }b}o ~}uu}vo˙ o ]v ]]˙ v vo
u}bUo}`]v}}b}]b}bZ
b Disorsder
yy Bo}}o}o˙b~u˙bR}ò}`}bb]uZ
yy Bo}}Po}b~}uu}vo˙oZ
yy A}u]voob}vv b ~u˙bR}`vvou}Z
yy CTv
b ~u˙bR}`]v}(]]˙}vou}Z
Trtme
ae nt
Tuv}ib
yy T}v}uo]bobuoo}(}b}o
yy T}}o}o˙]uov
yy T}}obuPo}b
yy To correct blood pressure
yy T}v}uo]}vb}(˘bbobu}b}o
yy P]]˙}voP˙ b `Ru}b]v RbPovb
Rv]Pv}b
Tuv ]b vv }v R b v ]b b]o]
]vbP}vbX MvP R˙vb]}v v ]b o}vP vb o]vb
v*Ovweight
~S}]b}vbZv(v(}.v]uvX
r
Note 12-9
andObsity
e *v
D}v}`]R`}}b}]bbvo˙]vvb`]RCbR]vP [b˙v}u
b
} }}b}] b } }o}vP bX IvbU R }b ub r
}+bo}ò˙}ob `lbvu}vRb}vvo]vb( r
.]v˙~ Sb}v}vRAvoIvb8]v˙ [ZX
Refeal
r Criteria
R(oo}b vv}]v}o}P]b}b]o]bR˙b]]v
]v P]}vo } R]vP R}b]o (} R }] ]vbP}vb v
uvPuvX
108. Overweight and Obesity

O`]PR v }b]˙ b}] `]R }v]}vb R b
u ]oorRoR v RU bR b ˙ ]bU R]PR o}}
b ~R˙vb]}vZU R ]bb v }l b X OR }v]}vb
bR b P} U }b bo v}U Poob}vbU RvU R]bU
bl]v]v(}vbbòo]}bb vbRvo]vl}˘bb}˙
`]PRX TR˙ ob} ]vb R ]bl }( o}]vP ]v R}u}b]b
v ou}v˙ u}o]bu b òo b o o}} R}ob}oU `R]R
]vbbR]bl(}R'lbv}lb
b X
W]PR}v}Lv}bU}Rob}}v}oURbb}]
}v]}vbX Ob]}voo˙ ] `]PR P]v u˙ b}] `]R v
vo˙]vP v}]v }v]}v bR b R˙}R˙}]]bu v CbR]vP [b
˙v}u
b X
Standard Trtme
sueCa
yy E˘bb]vl}(o}]b
yy Ll}(PoR˙b]o]˙
yy S}v˙bXPXR˙}R˙}]]buUCbR]vP [b˙v}u
b
Symptoms
yy Uboo˙v}v
Signs
yy B}˙MbbIv˘~BMIZ]vb
yy XærXılP lurIo`]PR
yy æXrıXılP lurO`]PR
yy XrXılP lurOb
yy ANæXlP lurSo˙}b
yy M]r}u]vo ~`]bZ P]RU lv }PRo˙ R oo }( R
u]o]bU]vb
Ao(uobP
AMu}]vRb Io}u]voP]R
v*Ovweight
ru}ræ]vRb O`]PR
r andObsity
ANu}æ]vRb Ob
e *v
AouobP
AMıu}w]vRb Io}u]voP]R
ıru}wr]vRb O`]PR
ANu}]vRb Ob
Invtiga
se tions
yy Bo}}Po}b
yy Bo}}o]]}.o
yy Bo}}]]
yy ECG
Trtme
ae nt
Tuv}ib
yy T} vb o}bb }( A9 }( R ]v]o }˙ `]PRU `]R]v v u}vRbU
}(v}u}RvrlPu}vR
yy T}']vR]oBMIvl}}u]voP]R
yy T}]v b R`]PR}vR]
yy W]PR}v]U(o˙vRb]b]}v}(]]v
yy RPo R˙b]o ]˙ }u]b]vP u]vb ]bl òl]vPU }
]ov]˙U(}u]v]uu}(˙b`l](Rv}
b Disorsder
}v]v]}vb
yy }]A uvPuv}(b}]}ru}]]b}b
yy }A vr}b]˙ uvb ]oo bR}o }vo˙
P]vvb]o]bP]v
Refeal
r Criteria
Iv]]ob`]Rvb u}]}b]˙u˙](o}
R˙b]]vb]o]bv}b]}voo˙u˙v˙R}o}P]o
b }vboo]vPX
Iv]]ob`R}P]v`]PR]o˙}bR}]}u˙Rv
vo˙]vP R}u}vo ]b} v `]oo ] (o } R˙b]]v }
v}]v}o}P]bX
v*Ovweight
r andObsity
e *v
Chapter
Obtes tricCarend
Obtes tricDisorsder
109. AvvoC
Antenatal care(b}R}uRvb]P]v}Pvv
`}uv } vb R bR P}b R}PR Pvv˙U o} v R
]u (o˙
b `]RRo]˙}(RoR˙˙X
TR}uuv}R} vvo ]b lv}`v b F}b
Antenatal CareX I Rb R (}oo}`]vP ]v]obP uRb]b o]˙ }(
R Rv v˙ }( ~(} }uRvb] vvo ]b]b
}uuv (} `}uv `]R v}uo Pvv˙ZV ]v]]o]
R ub R `}uv[b }`v u]o v ˙R}b b }]o vbV v
]bb }v ]vb }( ]bl P}]}v b }v R b]uo
]v]oRooPvv`}uv]bl}(}uo]}vbX
PPvv `}uv bR}o (oo˙ b }}l]vP v oo
bv ]b]b } ]v(˙ }oub R o]lo˙ } Rvb
+ }v R Pvv˙X PPvv]b `]R ]bl }v]}vb ~}v } u}
]bl(}bbR}o
Z bvu}(vo˙vob}(}R}b]o
vl}}b]]v(}uvPuvX
Av}R ]u}v }u}vv }( vvo ]b R RoR
}vv}vboo]vPR]bP]v}o]vbXTRb}u}RoR˙
R]}vo](b˙o]vPRPvv˙vob}voR`}uv
} }Pv] vP b]Pvb ]v Pvv˙ v o˙ (}
uPv]bv(b o]˙XF]v]vPbR]b]bR}oo˙
}uvX
AvvoV]b]bSRo(}N}uoHoR˙W}uv
W}uv `R} RoR˙ }}l]vP v `R} u]v RoR˙
bv]b]bv}v}Rv˙]v.}vo]bl}v]}vb
u˙R(}}uRvb]]b]bb(}oo}`bP
TorP) R}uuvbRo(}AvvoV]b]b(}N}uo
Healthy Woman
V]b] R}uuvbRo
B}}l]vP]b] Ab}}vb`}uvbR]bPvvV~(o˙
(}`lbZ
Chatep rP *Obtes tricCarendObtes tricDisorsder
V]b] R}uuvbRo
st
scheduled visit vWA `lb
nd
scheduled visit Ivb]˘Ru}vR~}W`lbZ
rd
scheduled visit Iv]PRRu}vR~W`lbZ
th
scheduled visit Ivv]vRu}vR~}v`lbZ
D]vPRob]b]UR`}uvbR}obl}v
](bR}bv}P]]R`]R]v`lbLR˘
date of birth
M} (v ]b]b } (}oo}` bRob ]uouv }
uRo]v[b]v]]ovbX
Iv GRvU uv˙ o]vb }u (} R] .b ]b] ]vP R] }v
b
]ub}( Pvv˙X Iv R]b bU R ]b] bRo ub u}].
} vb R R o]v ]b oo R bvo }u}vvb }(
(}R]o]RX
Abuv}(Ru}RR}}l]vP]b]
yy Tl ]o R]b}˙ ~bv RoRU b u]o v P]o b
R]b}˙U}bb ]R]b}˙U(u]o˙vb}]oR]b}˙Z
v*AntenatalCare*v
yy C}v.uRobuvbo]}vo]bb RPb}voP
yy E˘u]v(}uR}}voo}˙˙bb ub]vo]vPRl(}
vu]U o}} U b obU Pvo RoR b v uvP
appropriately
yy C}v }b] ˘u]v}v } }v.u Pvv˙U ub
]vb]~SFHZvb(}oòo]vP~FHRZX
yy Rb(}l}vv]vP
b v}vo
b }}}o~So]b
}(]vbP}vbZ
Abuv}(Ru}R(}oo}`r]b]bP
yy Abl}u}R [bRoRb]vob]b]vbl}RoR
concerns
yy Ev]}(}o]˙~Pb}vAN`lbZ
yy Tb]v(}ou]vvbP
yy E˘u]v u}R (} `]PR P]vU vu]U v (} }uo]}vb
bRroub
b ]vuvP}]o˙
yy CRlo}}~R b o]u]}(v}uo]buuHP(}R
˙bb }o]vb ıuuHP(}R]b}o]ZX b
yy Ob]˘u]v}vP
yy MbU]vb]Pub˙uR˙b b ]}r(voR]PR]vv r
ub`vvv`lbPb}vX
yy CRl R o]U bv}v v }b]}v }( R ˙ v R
bv}(RbvvP~]ubZXCRlR(}o
Rb}vbXN}uo]brbu]v
v
æ
Standard Trtme
Invtiga
se tions
yy Fooo}}}v~}}l]vPU vv`lb}u}(vo˙](
]v]Z
yy FbvP o}} Po}b ub }v }v oo Pvv `}uv ~
}}l]vPUv`lbZSv}o}`
yy Hu}Po}]voo~}}l]vPUvv`lb}u}(vo˙
](]v]Z
yy Bo}}.ou(}uo]b]b
yy S]lo]vP~](vbb˙Ho}R}b]bZ
yy GvPD ]˙
yy U]vvo˙b]bR]b]~}]v]UPo}b]Z
yy S}}ovo˙b]b}}l]vP
yy Bo}}P}vv}˙vb
yy VDRL lTPHA lRPRtest
yy HBbAPb
yy HIV v}˙vP b ~}vboo]vP](}vP b Z
yy Uob}vv b
yy o˙ E ob}v vb (} (}o P u}v
b v } ˘o
}]Pvv˙
yy F}ov}uo˙vv]vP b r`lb]bv.]o
v*AntenatalCare*v
yy Lv]vP b `lb
v ~ov}b]}vU(}oòo]vP
XZ
B}˘rP) Screening tests for diabetes in pregnancy
FbvPo}}Po}bubb }v}vooPvv`}uv}}l]vPv
ob}r`lb
Tb(}]vPo}bRvvo]b]
yy U]vPo}b}(A=lA=}v }b]}vb}A=lA=}v}v}b]}v`vb
(oo}oPo}b}ov~OGTT
b Z
TR}b(}v}Rv}uovP]v b o]vPvv˙L
r`lb
TR}b `]R ]u] Po}b }ov } (vlo˙ ] b R}o R
uv
Trtme
ae nt
Tuv}ib
yy T} vb P}} RoR R}PR} Pvv˙U o}lo]˙ v
R]u
yy T} v o˙ v˙ ˘]bvP } }vo RoR
}oub
yy T}vvu]vuo]
yy To ensure delivery of a healthy baby
yy Ev}Pb}(]vb]vb
yy C}vboo]vPv}v}vR(}oo}`]vP}]bP
yy Healthy balanced diet
yy }]A bu}l]vPvo}R}o]vl
v
yy }] A v}vrb]u]}vbvRb
yy PPvv˙]b}u(}bvuvPuv
yy Malariav}v
yy Fu]o˙ovv]vP
yy (]vP
bB vv`}v
yy Iuuv]b}v
yy DvPb]Pvbv˙u}ub
b ]vPvv˙
yy E˘]bP M]o } u} ˘]bU (o˙ v}vr`]PR
]vPU ob ub `l ]b } v}PX }] A
˘]b ]v R b]v }b]}v LR .b]ubX D]b}v r
v ˘]b `Rv R vP b]Pvb bR b v˙ }( R
(}oo}`]vPP o}}˙ P]vo ]bRPU b]bv RRb v
}]bo]bvbU(]vvb}b ]]vbbURb]v and unr
˘o]v}u]vo]v
yy E˘]b]b}v]v]]vP
yy PPvv˙r]vR˙vb]}v
yy Pu}(uuvb
yy Pu o} ]v `}uv `]R ]v}uv ]˘ b r
}vlR]]ubo]vP
yy Uv˘o]vIv]vP}`R}v
yy o} D ]Rvbb v}uo]}v]vbb ov
v*AntenatalCare*v
`]RR`}uv
AXAvu] v}v
L]vTuv
st
]v
E RvPPA
yy F}bboR ~]}vR˙}bZU}oUuP~væuPouv r
o]}vZ]o˙
Or
yy F}b(u U}oUuP~væuPouvo]}vZ]o˙
Or
yy I}v~IIIR˙}˘]
Z P}o˙uo}b}uo˘ U}oUuPouvo]}v
daily
Av
yy F}o]A] U}oUæuP}v]o˙
WR }u]v}v rvo P (}uo}vb }( I}vU (}o v
}R u]}v]vb (U vb R R ]}v }vv
ubRu]v]uu]uv}b}(væuP l˙N
B. Malaria}R˙o˘]b
~Sb}v}vRMo] ]vPPvv˙[Z
yy SoRuR}˘}orP˙]uRu]v ~SPU
Z }oU
æ }bbU }v u}vR vP
b (}u `l v } b ]lv]vP
~}R˙ouvbR}ov}˘`lvZX
w
Standard Trtme
C. Tetanus prophylaxis
yy TetanolUIMUXæuoP
b }b (}u R `l Pb}vV v }b ~}vZ u}vR L
]v]o }bU ]( v Rb v} ]}bo˙ R vrvb Iuuv] r
}v
b
}bA }(vb}˘}]]v}vbbR}oP]v}oo`}uv
}]vP}R(}oo}`]vPbRoP
yy TTrG] R b }b ~Xæ uoU SC } IMZ v˙ }v `]R
Pvv`}uv]vo]vPRvvo b ]b]
yy TTrG]Rv}bob`lbLTT
yy TTrG] R }b ob v u}vRb L TT } ]vP
bvPvv˙
yy TTTTærOv}b]vR}(bvPvv]b}ul
}o}(.}bbXN}(R}b`]oo
b vbb˙]vbv
Pvv]bX
B}˘rP) High-risk pregnancies
H]PRr]blPvv]b]voP
yy Bo]vP v˙u]vRPvv˙(}o}
v*AntenatalCare*v
yy Y}vP~AM˙bZv}o~ANæ˙bZu}Rb]vR].bPvv˙
yy Pbv}(u]o}v]}vbbRbP
yy Svu]
yy S]loroo]bb
yy Hypertension
yy D]buoo]b
yy Heart disease
yy Ru
Ab UR}v]}PRbRbou}v˙o}b]bv
yy TR˙}}˘]}b]b
yy HIV }b]]˙
yy W}uv`]Ru}RvæR]ov~RPvuo}bu}RZ
yy PbR]b}˙}(o]vPLo]˙}]vov
yy Av}uo bv}v v }b]}v }( R ˙ ]v R `}u u
vbbo]}Rbv}v
yy MooPvv]b
yy P}o}vPPvv˙~`RvRPvv˙obbo}vPRv`lbZ
yy C}vo]b~o]b}}buoo(}R˙}o](o˙ b
P]vuZX TR]b u˙ }]}b `Rv R u}R ]b bR} ~AM æ uZ }
Rbbuoo(~bR}b]AMA*UKZ
yy B]P ˙ u `Rv R ˙uR˙b
b ]}r(vo R]PR ]b u} Rv ır
uu}`RvRub (}o`]PR]blP}R]PR
yy Pb R]b}˙ }( oo]Rb
b } ]b `R} ] `]R]v R .b `l }( o](U
b]oo˙](R˙]}(Rbu}ou
yy PbPvv˙R]b}˙}(u]b]Pb}vRbuPb}voP
yy bD ]v P}`R }( R ˙ ~(}o P}`R ]}v

b Z r ]v b]
buooRvRPb}voPX
yy U]vb]uR]PPRvRPb}voP`]R}v(}bbv
yy P]}b]vbuvoo]˙~u˘}v}(}bo]˙Z
yy P]}b}}v}vR`}ubRvbC b}vUu˙}u}u˙
}`RvRb]b]L(}}v]vPDC
yy Puo} ~o}(}}uo
w `lbZ
yy RhesusNPu}Rb`]RRRb}bb ]Rbvbvl}`]R}R
v}]b
yy W}uv`R}]bl(}bvb]}vubP]vAvrDIuuv}Po} r
o]v~æIU`lZ v`]R]vwR}b}(o]˙
Refeal
r Criteria
H]PRr]bl Pvv]b ~S v} }Z bR}o ( }
R}b]o}}b]]v(}uvPuvvo]˙X
v*AntenatalCare*v
ı
v*AntenatalCare*v
TorP) AvvoP}}}o
C CR
VISIT TIMING GOALS HISTORY EXAMINATION LABORATORY HEALTHPROMOTION CTIONS

A
OF VISIT TAKING INVESTIGATIONS
BOOKING Av˙u • Pvb r • Medical • Gvo˘uX • Syphilis test • Educate on ANC visits • G]TT
VISIT (}v uv • SP]o ]vo]vPBP ~RPR Z • Address any observed or • G]]}vl(}o]]
`lb • Pov(}ANC • Ob] • Voo˘uX • VCT }ov}oub • HIV }vboo]vPUvPb v
Standard
Pb}v • o}
D ]R • LMP ~bou
b ]( • Check urine • Iv}oRbv]vANC }brb}vboo]vP
vuPv˙ • C}v.u ]v]Z (}}]vU • o}
D ]RvuPv˙ • I(HIV r}b]UP]v
FIRST vrA plan period of • SFH~b˙uR˙b]}r Po}b plan PMTCT`lb
VISIT `lb • Give health Pb}v (voR]PRZ • Check Hb • TRvPb]Pvb]vP Pb}v
}v • Contrar • A}u]vo˘uX • u]v
D Pvv˙ • Tv˙}oub
Trtme
• Check foetal • V]o}b r o}}P} • D]bbSTI lHIV lAIDS • C}vbo`}uv

P}`Rv ~˙U }vb • Check for sickr • P}]VCTXI(HIVr }b]U • SIPT`]RSPLv
uvo }vZ M}} o]vPUGvPD bl}}ul`lb `lbPb}v
òo]vP • STI ]v
E }( }P]vARV(}PMTCT
• Start prevenr • Social: u • D]bPvv˙
b ]b}u(}bU
]vv r bu}l]vPU ˘o b o}vb
}vb o}R}ol • C}vbo}vv]}vv
Pb bo(r
• Social • C}vbo}vITNb
supports • A]b}v}uu}v]b}u r
(}b}(Pvv˙
ND W • Give TT • Ask for • MbBP • I(BPANlıU • }oub
bA • G]TT
VISIT `lb • E˘o }oub • MbSFH check urine for • U]RvuPv˙ • R.oo]}vl(}o]]
uoo • Ask date • A}u]vo˘uP protein plan • IPTlSP}b
Pvv˙ }(.b o}uoo • Check Hb • R]`vPb]Pvb]v • Mv}o
• CRl(}P r foetal Pvv˙ Pvv˙ • I(HIV r}b]UPMTCT
nancy induced u} r • Check foetal • I(HIVr }b]U}vbo}v • Tv˙}oub
hypertension uvb heartbeat PMTCT • C}vbo`}uv
• Check foetal • Ask if any • C}vbo}vITNb
P}`R P]vo • A]b}v}uu}v]b}u r
• E˘o o]vP (}b}(Pvv˙
vu]
VISIT TIMING GOALS HISTORY EXAMINATION LABORATORY HEALTHPROMOTION CTIONS
A
OF VISIT TAKING INVESTIGATIONS
RD AL • Check foetal • Ask for • MbBP • I(BPANlıU • }oub
bA • R.oo]}vl(}o]]
VISIT `lb P}`R }oub • Check for pallor check urine for • TRvPb]Pvb]vPvv r • IPTlSP}b
• E˘o • Ask if any • MbSFH protein ˙lo} • Tv˙}oub
vu] P]vo • A}u]vo˘u • Check Hb • D]bbo} • I(HIV r}b]UPMTCT
• CRl(}PIH o]vP • Check foetal • U]RvuPv˙ • Ubo}}v(}
• U]R heartbeat plan FPlHIV
Chatep rP
vuPv˙ • D]bb(u]o˙ovv]vP • C}vbo`}uv

plan • I(HIVr }b]U}vbo}v
PMTCT
• C}vbo}vITNb
• TR}}bu
• TR}(Rv`r}v :
o˙ E ˘ob]]vP
b U
RuoU}U
vPb]Pvb
*Obtes tricCarendObtes tricDisorsder
TH ANv`lb • Check foetal • Ask for • MbBP • I(BPANlıU • o˙ E ˘ob]]vP

b U • R.oo]}vl(}o]]
VISIT P}`R }oub • MbSFH check urine for RuoU}U • Tv˙}oub
• CRl(}PIH • Ask if • Count foetal protein vPb]Pvb • I(HIV r}b]UPMTCT
• Check for there is heart rate • Check Hb • }oub
bA • Do}}v(}FPlHIV
oub] P]vo • A}u]vo˘u • D]bbo} v}v
• E˘o o]vP • Check lie • U]RvuPv˙ • C}vbo`}uv
Ro}ro] • Check presenr plan
]b}}}vU }v • TRPMTCT]vo}U]RU
v}uo }bu
bv}vl • C}vbo}vITNb
lie • Rr]bbFPvHIV
• U]R v}v
vuPv˙ • TR}}bu
plan • TR}(Rv`r}v :
vPb]Pvb]vv`r}vUo˙
v˘ob]]vP
b U
RuoU}
v*AntenatalCare*v
Standard Trtme
110. Hyperemesis Gravidarum

TR]b (b } ˘bb] }u]vP boo˙ ]vP R o˙
}( Pvv˙U v ]b boo˙ }uu}vX I ]b ]Pv}b]b }( ˘ob]}v
v R(} ]u}v } o } }R b }( }u]vP bR b
uo]U ]v˙ ]v(}vU Pb]bU o ]bbU Rb
v R˙}Po˙u]X SP]o }v]}vb bR b v]]bU
}ò }b}vU R}o˙bb v `]b }]v ˙bU bR}o ob}
˘oX H˙ub]b P]u u˙ b}] `]R uoo
Pvv˙}u}oPvv˙X
sueCa
yy PPvv˙
Symptoms
yy E˘bb]}u]vP ~b}uub`]R]v]o]˙}lv˙R]vP}`v
R}PR}R˙Z
yy Iv]o]˙}}]vl~}(}(}u]vP Z
yy W]PRo}bb
v*HypermesisGrvid
Signs
yy TRvo}}lbvòo
a arum*v
yy DR˙}v ~˙bl]vU˙}vPUbvlv˙b]v˘ubZ
yy TRob]b]vR˙]v˘ub
yy TRBPu˙o}`
yy Dv(bR]vP]v˘ub
Invtiga
se tions
yy FBC
yy Bo}}.ou(}uo]b]b
yy U]vo˙b]bvo
yy Bo}}vo}o˙b
yy A}u]v}o]ob}v
Trtme
ae nt
Tuv}ib
yy T}}b R}u]vP
yy T}R˙Rv
yy To treat shock if present
yy T}b}]}v]}vbXPXUTI Uuo]X
yy M]ov b RuvR}u`]R(vbuoouob
yy D˙(}}bbRb]b]bu˙˙Ro(o
yy D]vlG]b]vb]b}buoo}oubU](o}
AXM]ob
st
L]vTuv
]v
E RvPPA
yy M}o}u] U}oUuPrR}o˙
L]vTuv
nd
]v
E RvPPA
yy P}uR]v R}oU}oUæuPrR}o˙
Or
yy P}uR]v R˙}Ro}]U}oUæuPrR}o˙
B. Severe Cases
yy N}uobo]v UIVU~ov`]RæA9˘}b
D }u]uvbZ
Or
yy R]vPb o U IVU ~ov `]R æA9 ˘}b
D }u] r
uvbZ
Av
st
L]vTuv
]v
E RvPPA
yy M}o}u] UIM}IVUæruPR}o˙
I(}˙`]PRAMlP
v UP]æuPR}o˙XD}v}˘æu]} r
e ncy*v
PullP]v˙
nd
L]vTuv
]v
E RvPPA
yy Ovvb}v U}oUIMUIVUruPR}o˙bv
L]vTuv
]vE RvPPA
yy P}uR]v R˙}Ro}]UIM}IVUæuPrR}o˙
~u˘X]o˙}bUuPZ
Refeal
r Criteria
R( b b `]R R˙}v vl} bR}l v u}o]
]bvb } R}b]o (} ]vv}b G] ouv v
vuR˙X
111. Hypertension in Pregnancy

Hypertension ]v Pvv˙ denotes a systolic blood pressure of
uuHP } R]PR vl} ]b}o] b }( ı uuHP } R]PR
}v }b]}vb ob æ u]vb b]vP v }]rb] +
b]oo˙ ]v }b vbX I ]b b `Rv ˙bb }o] o}} b
]b v uuHP } R]PR v ]b}o] o}} b ]b uuHP }
R]PRXTR]b]vob`}uv`R}bR˙vb]}v`b]Pv}b]}}
Standard Trtme
Pvv˙bòob]vPPvv˙X
Kv}`v R˙vb]b }v CEA ]vR]]}bU ARBb v oRro}lb
bR}o`]Rb }u]}vb}vb](b ]vPPvv˙X
sueCa
yy PPvv˙r]vR˙vb]}v~v}}]v]Z
yy Proub]~R˙vb]}v`]R}]v]Z
yy oub E ] ~R˙vb]}v`]R}]v]v.bZ
yy CR}v]R˙vb]}v~˘]bvP(}Pvv˙Z
yy CR}v] R˙vb]}v `]R r]u}b b roub] }
oub]
~Sb}vb}vRH˙vb]}v [URProub][vREoub] [Z
Symptoms
~Sb}v}vRH˙vb]}v [Z
Signs
~Sb}v}vRH˙vb]}v [Z
Invtigase tions
yy FBC
yy Co}hvP}.o
yy SuU]A]
yy BUEvv]v C
e ncy*v
yy U]vo˙b]bvo
yy L](v}vb
yy Rv}uo}}Po}b
yy D]o˙buv}(]v}]vb~](v}vu]bb]}vZ
yy Rob}vvb b (}o}b(}oP}`Ru}v]}]vP
Trtmeae nt
Tuv}ib
yy To control blood pressure
yy T} } v˙}uo]}vb Ru˙ ]b b]oo˙ b
]u}broub]
yy T}v(}o}uo]}vb
yy To deliver a healthy baby
~Sb}v}vRAvvoC [v}vRH˙vb]}v [Z
PRu}o}P]ouv
AX H˙vb]}v in Pregnancy not associated with pre-eclampsia or
eclampsia
st
L]vTuv
]v
E RvPPA
yy MethyldopaU}oUæræuPrR}o˙~u˘XP]o˙Z
nd
L]vTuv
]v
E RvPPA
yy Nifedipine]v
b obU}oUruPR}o˙
B. Hypertension in Pregnancy associated with pre-eclampsia and
eclampsia
~Sb}vb}vRH˙vb]}v [URProub][vREoub] [Z
Refeal
r Criteria
R( oo b }( r]u}b
b roub] } }R }b]
}uo]}v }uo˙ } R}b]o } }b]]v L ]v]}v }(
uvX
112. Pre-eclampsia
Proub] ]b ]bb ].oo˙ b}] `]R Pvv˙X I
boo˙ }b ]v R }v
b Ro( }( Pvv˙ v ] ]b R] ˙
R˙vb]}vv}]v]XTRbv}(o}u}˘bb]
`]PRP]vu˙ob}(}(roub]X
Bo}} b u}v]}]vP ˙ R}b }PR `]R ]o˙
`]PR]vP}(Rvbvo]vRuvPuv}(roub]
o}vPb]R}uuv]vbP}vbX
WR]o o}} b }v ]b bvoU o}`]vP R o}}
v*Prree clampsia*v
b o}` lıuuHP u˙ b (}o ]bb v bR}o
}]X
sueCa
TRb]bvlv}`vR]bb]bu}}uu}vo˙b}]
`]RR(}oo}`]vPP
yy P]u]P]
yy MvoP~`}uvAM}ANæ˙bZ
yy MooPvv]b
yy H˙](}uu}o
yy M]o ]b}b XPX }o˙˙b }]bU R}v] R˙vb]}vU
]buoo]bUl]v˙]b}b
yy F]bPvv˙`]Rv`v
yy P]}bR]b}˙}(roub]
yy Fu]o˙R]b}˙}(roub]
Symptoms
yy Pvb`]Rroub]}Lv˙u}u b
yy S`}oov(
Signs
Mild cases
S˙b}o]o}}`v b væıuuHPD]b}o]o}}
`v b ıvıuuHPP}]v]}(A=}A=
yy Po}u
Severe cases
æ
Standard Trtme
yy S˙b}o]o}}vuuHP
b }R]PR
yy D]b}o]o}}uuHP
b }R]PR
yy P}]v]}(A=}A=
yy Po}Pvo]b}u
Invtiga
se tions
yy FBC
yy SuU]A]
yy BUEvv]vC
yy U]vo˙b]bvo
yy L](v}vb
yy Rv}uo}}Po}b
yy D]o˙buv}(]v}]vb
yy Uob}vv b (}o}b(}oP}`Ru}v]}]vP
Trtme
ae nt
v*SeverPrrEe clampsiaandImminentcla
Tuv}ib
yy T}oo}}U b v}obbRvlıuuHP
yy T}}o}vPRPvv˙buRb}bb]o}oo}`R(}b}
P}`vu(}o]˙
yy To prevent foetal distress
E mpsia*v
yy T}v}v˙}uo]}vbRu˙]b
yy T}voub]
yy Au](}]( b }bb]o
yy Ev}Pvb}o]}vR]b]b}}]b]vR˙}vb]}v
AXM]oroub]
TR]b v} v (} Puv }( R R˙vb]}v vobb R
BP ]bb } æ uuHP ˙bb }o] } uuHP ]b}o] } R v
}ub˙u}u
b }(]uu]vvoub]~bo}`ZX
]v
E RvPPB
yy MR˙o}U}oUæræuPrR}o˙~u˘XP l˙Z
Or
yy N](]]vU}oUruPR}o˙
Or
yy N](]]vbo}òbU}oUrvuP]o˙
113. Severe Pre-Eclampsia and Imminent Eclampsia

TR]b ]b v }b] uPv˙ v ub Pvo˙X
Tuv]bRbubR}(oub]~bo}`ZX TRbb
uvP
b ]vR}b]ovRb]b]}v}(v}b]]vX
WR]o o}} b }v ]b bvoU o}`]vP R o}}
v
b o}` lıuuHP u˙ b (}o ]bb v bR}o
}]XBPu}v]}]vPub]}˙æru]vbvoR
BP]bvRv]bob XTRLu}v]}]vPv}v
˙rR}o˙XD]o˙`]PR]vP}(Rv]bbvoX
Symptoms
yy F}voRRb
yy V}u]vP
yy V]bo ]bvb bR b }o ]b]}v ~]o}]ZU o ]b]}vU
GbRb}(o]PR
yy E]Pb]]v
yy b]v D ]v}}v~}o]P]Z
Signs
yy Elevated blood pressure
yy L]vvbb
yy U]v}}v}(AMuolR}}AMuolR}b
v*SeverPrrEe clampsiaandImminentcla
yy Ivbv}vG˘b
yy Pbv}(vloo}vb~}b]}voo˙Z
Invtiga
se tions
yy FBC
E mpsia*v
yy Bo}}o}hvP}.o~b]o}hvPuU}R}u]vuUINRU
APTTZ
yy Su]]
yy BUEvv]v C
yy U]vo˙b]bvo
yy L](v}vb
yy Rv}uo}}Po}b
yy D]o˙buv}(]v}]vb
yy Uob}vv b (}o}b(}oP}`Ru}v]}]vP
Trtme
ae nt
Tuv}ib
yy T}Ro}}U b v}o}`RvlıuuHP
yy T} v R u}R (}u b+]vP (}u }uo]}vb }( R
hypertension such as a stroke
yy T}v.bloub]
yy T}]o]b b Rvvo]R](oub]]b]uu]vv
yy o˙ E o]˙}(u}R](oub]]b]uu]vv
yy I( R v ]b v} ˙u}u b v R Pvv˙ ]b obb Rv
`lb oo}` Pvv˙ } }vv ]( R (}o }v]}v `}o
oo}`
yy I( R Pvv˙ ]b `lb } u} }vb] o]˙ L
]o]b
b }v
w
Standard Trtme
]v
E RvPPC
AXBPuvPuv]vroub
b ]v]uu]vvoub]
yy H˙o]vUIVUæruPbo}ò˙}ru]vb
Or
yy N](]]vUbo]vPoUuPX b
Or
yy Lo}oUIVUuPX b }obu]v
R ru]v ]vob ]( R BP u]vb AN vl uu HP
b (}oo}`bP uPV uPV uP }obb } uo }b }(
uP
WRvRBPAMvluuHP}uuvv]v(b]}v}(uP
R}X
D}oR]v(b]}vru]v]vobvo(}˙
b r
b}vb}}b}(vuPR}]b']vX
Then
yy N](]]vU}oUruP]o˙
Or
yy MR˙o}U}oUæræuPrR}o˙
BXMvPuv}v}v}(b]b]vroub b ]
v*Eclampsia*v
and imminent eclampsia

yy MPvb]uboRUIVUuo}(RA9b}o}v~PZ
Av
yy MPvb]u boRU IMU uo }( R æA9 b}o}vU ~æ PZ ]v} R
'}l~}o}(PZ
Refeal
r Criteria
R( oo b }( b roub] v ]uu]vv oub]
}uo˙}R}b]o}}b]]vL]v]}v}(uvX
WRv R S}b]]v_ }vb]b R R (}b ]b ]uuU R
v bR}o vb( } R}b]o o }( o}}l]vP L R
]uu˙X
X Eclampsia
oub
E ] }b b }uo]}v }( `}bv]vP roub]X
TR o}} b ]b R]PR `]R b}] }]v] v }vob]}v
} ou .U `R]R ]b b]u]o } v ]o . `]R }v] v o}v]
Rbb (}oo}` ˙ }u X TR .b }Lv v }( bR}
}v~vrı}vb b ZX
sueCa
yy Ab(}roub]
Symptoms
yy F]b
yy Uv}vb]}bvbb
Signs
yy Convulsions
yy C}u
yy Elevated blood pressure
yy P}]v]
Invtiga
se tions
yy FBC
yy Bo}}.ou(}uo]b]b
yy U]vo˙b]bvo
yy Bo}}vo}o˙b
yy Uob}v˘u]v}v}(R}b ˘ouooPvv˙
vl}u}oPvv˙
Trtme
ae nt
Tuv}ib
yy T}}Rv(}u]vi˙
yy T}v(R.b
v*Eclampsia*v
yy T}o}`Ro}}b
yy T} u}v]} (} }Pv (]ob ~XPX voZ b òo b }b]
}uo]}vbXPXovo}vv(}o]bb
yy T}vuvou}o]˙
yy T}o]R˙`RvRu}R]bob
yy L˙v]vR}˙}b]}v
yy Pvv(}u(oo]vP
yy }] A ]vPb v } v o]u (b v i}]v
]bo}}vb
yy D}v}v˙R]vP]vv[bu}R}v}vP]vP
yy M]v]v R ]`˙ ˙ ]R R}o]vP R R]v } ]( }bb]oU
]vbvPuRv]o]`˙}R}o}`vR}vP
yy I( }bu v v u]vb v}vb]}b (} o}vP ]}U
}vb]v]vPRu˙R}}vb}b(}uo}]vP
yy A.]ob]}vu˙](}oo}`]vPPvovbRb]
ALR.b
yy O]vIVb
yy R]b C Rv
yy I( v} (R .b v Lv ]b]o]b U o]R (}b ˙
R u}b }] uR} } vb (˙
b }( }R u}R v
baby
yy M}}(o]˙`]oov}vRv[bo]v]o}v]}vUR
status of the foetus and her preference
ı
Standard Trtme
]v
E RvPPA
AXFo]ouv
yy S}]uCRo}] XıA9UIVU
O
yy R]vP [b o U IVU ~M˘]uu L] ]v v R}b } L]b ]v
R}bZ
B. Treatment of convulsions
yy MPvb]uboR UIVUuo}(RA9b}o}v~PZ
Au]v]bbo}ò˙}æ}æu]vb
Then
yy MPvb]u boR U IMU uo }( R æA9 b}o}vU ~æ PZ ]v} R
'}l~}o}(PZ
C. Treatment of recurrent convulsions
I( .b `]R]v u]vbU } v} MPvb]u boR X
~S}Ruv}}vbo}`Z
I(.bLu]vbUMPvb]uSoRUIVU
ANwlPV uo}(RA9b}o}v~PZ
AMwlPV uo}(RA9b}o}v~PZ}v
v*Eclampsia*v
D. Maintenance
yy MPvb]uboR UIMUæP]vovvP'}lb˙R}boo
R}bLobb]}o]˙U`R]R]bo
Note 13-1
T}˘]]˙} MPvb]u SoR bvb b o}`]vP }b}( R R
v R b]}v v o}bb }( R v}vG˘bX (}
B P]]vP }b
vbRR(}oo}`]vPubv}uoP
yy Rb]}˙ANrvu]v
yy U]v}uo}u}}R]}bR}b
yy Pbv}(lvil}}Rv}vG˘b
Ivb}(}˘]]˙}MPvb]uSoR
yy G]b]bb]}v
yy Au]v]buo}(A9Co]u Go}vUIVUbo}ò˙]vuPv
b r
b]uboR}˘]]˙
E. Treatment of convulsions not responding to Magnesium sulphate

Av
]v
E RvPPA
yy D]u U IVU uP bo}ò˙ }r u]vb ~v}˘]vP Xæ uP
˙}vb b U
Then
ANvlPV æruPR}o˙
AMvlPV æuPR}o˙
~D}v}˘æu]}PullP]v˙}uP]vR}bZ
F. Treatment of Hypertension in Eclampsia
yy H˙o]v UIVUæruPX b ~}æru]vbZ
B}obbv˙ru]vbXBPbR}ov}(ooo}`
lıuuHP
Then
yy H˙o]v UIV]v(b]}vU
ruP]væuo}(S}]uCRo}] XıA9
R}(]v(b]}v}P]vbRo}}]vPb
b X
Note 13-2
I(RH˙o]v ]v(b]}vvbv'vU}(}vR˙}vb]}vu˙vbX
H˙o]vU IVU ]b bP]v b uoo }ob }bb r u]v]vob
oo R BP ]b X TR ]b}o] b R}o v} P} o}` ı uuHP b
ovo(b]}vu˙]u]`]Rbov(}o]bbX
Or
yy Lo}o UIVUuPX b }obu]v
Then
R ru]v ]vob ]( R BP u]vb ANvluuHP b
v*MalariainPrgna
(}oo}`bP uPV uPV uP }obb } uo}b }(
uP
WRvRBPAMvluuHPvb ]v(b]}v}(uPR}X
e ncy*v
D}oR]v(b]}vru]v]vobvo(}˙ b r
b}vb}}b}(vuPR}]b']vX
Refeal
r Criteria
Tvb( oo b }( oub] ]uu]o˙ } R}b]o }
}b]]v]v(]o]˙`]R}]˙X
Ab uR b }bb]o b v IV o]v }( S}]u CRo}] XıA9 }
R]vP [bo vu]v]bRIV}b}(MPvb]uSoRbo}ò˙
R RoR (]o]˙X F}oo}` R]b `]R R IM }b v }uv˙ R
v}(o(]o]˙X
I( R IV }b vv} P]vU b]uo˙ P] R IM }b }( æ P ]v}
R'}lvvb(X
115. Malaria in Pregnancy

~Sb}v}vRMo] [Z
116. Avu] in Pregnancy

Avu] ]v Pvv˙ ]b Ru}Po}]v }vv}v }( AM P l
L ~W}o HoR OPv]b}vZX I ]b b] b b ]( R H ]b AM
w P lLX Avu] Rb b +b }v R RoR }( R `}uv v
R }}u }( R Pvv˙X I ]b b}] `]R v ]vb }(
Standard Trtme
u]b]PUu o]˙U (}o P}`R]}v b U (}oR v
]vb ]vo o}bbX I ]b ob} b}]`]R vr v }bru
Ru}RPvv]vbuvou}o]˙X
Ioo˙ v} `}uv bR}o P} ]v} o} `]R vu]X }]
A
ubb ]vo]vP o}} vb(b]}v u˙ ] } } R
vu]b]oo˙](`}uv]bo}b}R˘o]˙X
sueCa
yy PR˙b]}o}P]o~}o}}}ou˘vb]}v]vPvv˙Z
yy P}}]˙]vl}(]}vU(}ov]u]vB
yy Hu}o˙]b}b~XPXb]looo]bbUGvPD (Z
yy Malaria
yy Iv(b}vb`]RR}}l`}uU]bb UbR]b}b}ub
yy CR}v]]v(}vbXPXTBUUTI UHIV
yy Bo]vP }uo]}vb]vPvv˙XPXAPH
Symptoms
yy D]]vbb
yy Sòo]vP}(R(
yy Gvo`lvbb
v*AnaemiainPrgna
yy ˙bE (P]o]˙
Signs
e ncy*v
yy Mucosal pallor
yy Jv] ~u˙}u˙v}bvZ
yy H}rbov}uPo˙~u˙}u˙v}bvZ
yy Heart failure in severe cases
Invtiga
se tions
yy FBC
yy P]Roo}}.ou}uuv
yy Bo}}.ou(}uo]b]b
yy S]lo]vPvHo}R}b]b
yy GvPD ]˙
yy Su]}vU}o]}v]v]vP]˙U(]v
yy S}}ovo˙b]b(}R}}l`}u}
yy U]vo˙b]b(}bR]b}b}u}v}]o]v}Pv
Trtme
ae nt
Tuv}ib
yy T}o]˙u}ub b
yy T} } Ru}Po}]v oo (} v Rb u } P}b
into labour
yy T}]v(˙vvo˙]vPb
yy T} }Pv] v uvP R b}] }uo]}vb ]v u}R
XPX](]oUv˙XPX]v]vP}`R]}v b
yy Ev}P ]vl }( (}}b bR b uU }o˙U .bRU l
o(˙PobUbRoo.bRU](]b`R]R ]R]v]}vU(}oU
V]u]vbBvC
yy }]
A U }+U vU }o v vRoR˙ R]b bR b vP }(
o˙U`R]R]vR]]b]}vb}}v
yy Ev}P ]vl }( (}o v ]u]v ]R (}}b ]vo]vP vbU
}}U]b(]bUb]vRvuvP}b
yy P}]v]R(}}bubob}]vo]vR]
yy Evb Rb vu] vb bv u} (vo˙ ]v R
vvo o]v] v R] b}vb } uv u}v]} `]R
Ru}Po}]vooRlbX
]v
E RvPPA
yy F}bboR U}oUæuPR}o˙
Or
yy F}bPo}v U}oUuPrR}o˙XoE Lr`lb
v
Av
yy F}o]A] U}oUæuP]o˙
v*AnaemiainPrgna
yy Bo}}vb(b]}v
Note 13-3
e ncy*v
Ivvu]
b ~HAMwP lLZUo}}vb(b]}vu˙vbb˙X
Ivo}vu]
b ]b˙b o}}vb(b]}v
WRvR]bR(]o(o˙vb(bloob X
A
yy F}bu] IVUruP](P]]vP`R}oo}}
Refeal
r Criteria
R(vb`]Rvu]}]]v}]vb(}}vboo]vP
v b}X Tuv (} bvu] ~H AM wP lLZ ]b b P]v ]v
RoR(]o]b`]Ro}}vb(b]}v]o]˙X
Aoo `}uv `R} } v} b}v (}]o˙ b } }o uv
bR}o((}(Ro}vX
TR}b `]R b}]}v]}vb o]lHIV v Hu}P}]v}R]b
bR}o uvP ]v R R}b]oX HIV vb }v v}]o
u]}vu˙vu}].}v}(R]P}u]v}vb}˘o
R}bRPPvu]XPX]}]vX
Flowchatr
Standard Trtme
v*SickleCellDissein
a Prgna
e ncy*v
F]PrP) Flowchart: management of anaemia in pregnancy
117. Sickle Cell Disease in Pregnancy

PPvv˙ ]v R S]lo Coo D]bb ~SCD Z v ]b b}]
`]R }} }b] }}ub (} }R R u}R v R ˙X D
(}u(o vb ]v GRv bR}` Rb]lo oo}uo]}vb ]vP
Pvv˙ob}R]PRuvov]vou}o]˙X
C}uu}v Pvv˙ }uo]}vb }( R u}R `]R SCD include
u]b]PbU (v b}r}ob] ]bbU b vu]U v
]v˙ ]v(}vbU Rb ˙v}u b U u o} v
ou}v˙ u}o]buX Iv R (}bU }uo]}vb ]vo ]v]v
P}`R]}v
b Uu]˙v]v]v(}oRX
C ˙ uo]b]o]v˙ u }vb]bvP }( R Ob]]vU
PR˙b]]v b]o]bU Hu}o}P]bU Co]v]o PRu]bU AvbRbU
NbvM]`](vbbP}}RoR}}ub(}RbvbX
sueCa
~Sb}v}vRS]loCooD]bb [Z
Symptoms
yy RvJv]
yy B}vvi}]v]v~v]b}bZ
yy Do˙˙
yy Sr(o]˙
yy Avu]}uo]}vb~b˙(P]o]˙Uo]}vbZ
Signs
Invtiga
se tions
v*SickleCellDissein
yy S]lo]vPvb Hu}Po}]vo}R}b]b
yy Fooo}}}v]vo]vPo}˙}v
yy RDT }o}}.ou(}uo]b]b
yy M]bu]v(}Covbvb]]˙}}l]vPv`Rv
a Prgna
indicated
e ncy*v
yy Rvo(v}v~B b UNUv]vC Uo}o˙bZ
yy L](v}vb
yy Su]}vUTIBC vF]v ~](}bb]oZ
yy Aoo}Rvvov]vP b b
Trtme
ae nt
Tuv}ib
yy T}]v(˙vb`]R}v]}vo˙]vPPvv˙(}o}b
u}v]}]vP
yy T}}vu]
yy T}vlv}`v]bb]PPb
yy T} v uvP }uo˙ oo b}] }uo]}vb v
crises
yy To deliver client safely as soon as baby is viable
Pre-pregnancy Care
yy P}]Pv}vboo]vP
yy Ab]bv}ovPvv˙]vb}(}uuRoR
yy }vE }vo]blvRoR}oub}(SCD ]vPPvv˙
æ
Standard Trtme
Care during Pregnancy
}}l]vP
A
yy Ab v (oo˙ (} ]bl }( (v ]bbU v ]}b
}b]}uo]}vb
yy E˘u]v (} v]}vo bU vu]U iv]U v
R}bov}uPoo˙
yy P(}uob}v}Pvv˙v˘o(}ov}uo]˙
vP}`R}v
yy P(}u R } o]b ]vbP}vb } vb (} v
}uo]}vb
yy MvP]v.}oub}}l]vP~XPX]v˙]v(}vU
uo]X}]o˙ Z v}uo˙
F}oo}`]b]b
yy I(o}`]blUbRo(}oo}`]b]bu}vRo˙vov]ubURv
`lo˙voR`lvRL`lo˙
yy I(R]PRr]blUbRo]b]b`lo˙voR]]ubURv`lo˙
vou
v*SickleCellDissein
yy A ]` ]b]bU v] } uvo òor]vPU ˙u}ub

b }(
]bbU]v(}vv(}o]˙XE˘u]v(}oo}Uiv]U(
v}]v]XCRl(}(}oP}`Rv}u}Pb}vo
P
a Prgna
Labour and delivery

e ncy*v
yy Sbvb ]v}(o}vo]˙v]PP]b]bXR]blb}(]b]b
]b ]vb ]( R˙}v U (U ]v(}vU R˙}Ru] o}
]vP o}X C ]vP o}lo]˙ ]b P vvP
Rb]PPb
yy Aoo `}uv `]R S]lo oo D]bb ub o] ]v R}b]oU v R
u}b ˘]v u]`]( v }b]]v bR}o ]v}o ]v
their care
yy Ivv}uo]Pvv]bUb}vv}bP]voo]˙ub
]uvo`lb~uZXIv}vubvlv}vo˙](
R`}uvRbv}o]LR]buX
yy F}RR]PR]bl`}uv`]Rv}uo]}vbo]b}}v
as baby is viable
yy u]b
A b]}v]vo}V
yy L}bR}ou}v]}o}bo˙`]R}PR
yy CRl(}Ru}Po}]voo
yy G}v}bbruRv]}(o}}}vv˙ b
yy M]v]vP}}R˙}v`]RIVG]b
yy P}] ]v o]( ~S b}v }v RAvoPb] ]v L r
bour [Z
yy P}]}R˙ov]}b~Sb}v}vRAv]}} r
R˙o˘]b ]vo}v]u [o}`Z
yy VP]voo]˙bR}oR]uvobR b }b]b}vb
(}vb b}v
v
yy P}o}vP}v
b P
b o}bR}o}]˙}+]vPb]b
o]˙~uZ
yy A MvPuv }( TR] SP }( L} ~AMTSLZ ]b
}uuv}vPPH
Postpartum care
yy Aoo S]lo Coo D]bb vb ub R}b]o] v u}v]}
o}bo˙(}obwR}b}bu
yy CRl (} oo}U o b]bU Rb ˙v}u b U b}r
}ob]]bbv]v˙]v(}v
yy C}vv `]R }R˙o v]}b (} ob w R}b
}bu
yy C}vbo `}uv v R] b} b}vb } }] ]bb ]PPb
bRbU]vUol}(boU(PX
yy Ev}Po˙uo}v~b]oo˙L}o]˙Z
yy R]` o]v w ˙b }bu v RL `lo˙ vo v
`lb
yy R(v}R˙b]]v(}}vv]vP
v*SickleCellDissein
yy C}vbo}v(u]o˙ovv]vPv}+}v}v
Baby
yy The baby should be screened for sickle cell disease
yy Co}bo˙u}v]}R]b`]Rb}]}uo]}vbXPXIUGRU
a Prgna
u]˙X
e ncy*v
Sickling crises in pregnancy
yy Au] oo b]lo oo vb `]R b]lo]vP vl} }b]
}uo]}vb]vPPvv˙}R}b]o
yy }]A NSAIDb XPXD]o}(v ]vR]ub
yy O]}bo]lR]]vvu}R]v (}]vuvPuvbR}o
`]R
b ]vPo}}b]}vb]}v +b}v
˙~Sb}v}vAvoPb]]vL} Z
yy Iv(˙ v vo˙]vP ]PPb XP UTI U uo]U R˙}v
X~S}]b}vbZ
yy Bo}}vb(b]}v ]b}uuv](Ru}Po}o]voo]bobbRv
wP lo v `lb vl} ]vP ]bb ~S b}v }v RS]lo Coo
D]bb [Z
yy I(]vb}r}ob]]bu]v]v b R˙}v`]RIVG]b~˙boo}]bZ
r o]b ]v R}bU v }] voPb] ~S b}v }v RS]lo
CooD]bb [Z
yy A Rb ˙v}u b ~ACSZr (}o u}v]}]vP ]b bvo ]vP
R]b]b]b~Sb}v}vRACRbS˙v}u[Z
AXAvvouvb
~Sb}v}vPRu}o}P]ouvbvRAvvoC [Z
w
Standard Trtme
Av
yy Mo]u]v U}oU}v]o˙
BXAv]}}R˙o˘]b in labour and puerperium
yy L]˘}v
C UIVlIMUP]o˙(}wR}b
Or
yy Au}˘]]oo]vA=Coov]A] UIVUXPXb
Then
yy Au}˘]]oo]vA=Coov]A] U}oUvæuPR}o˙(}wR}b
Refeal
r Criteria
Aoo vb `]R b]lo oo ]bb `]R }b] }uo]}vb
bR}o(}b]o]b(}}vv]vPX
118. Diabetes Mellitus in Pregnancy

D]b Moo]b ]v Pvv˙ ]vob ]v]]ob lv}`v }
] ]} } Pvv˙ v R}b `R} o} ]u] Po}b
v*DiabetesMellitusinPrgna
}ov ]vP Pvv˙X Gb}vo ]b (b } ]u]

Po}b}ov}(v˙PRo}b}]b.b}Pv]]vP
R v Pvv˙U ]b }( `RR ] b}ob L o]˙
} v}X D]b ]b b}] `]R }} RoR }}ub (} u}R
v R ˙ ]( v} }o˙ uvPX Mv˙ vb `]R Pb}vo
e ncy*v
]b ˙u}u
b ul]vP v]vP
b (} oo Pvv `}uv
uv}˙} ]v(˙ R}b ]blX A (bvP o}} Po}bbub
}v }v oo Pvv `}uv }}l]vP v ob} r `lb ~S
b}v}vRAvvoC [ZX
TR uvPuv }( ]b uoo]b ]v Pvv˙ v R
]u ]v}obo}bu}v]}]vP}(R`}uv˙uo]b]o]v˙
}R}u]b]vPu}(}b]]vbUu]`]bUvbbU]]vbU
R˙b]]vbUvbRbbv]]]vbX
L} ~]v } b}vv}bZ v vCb b}v b
b]b]vR}b]ovb]o]bX
Avr] uv ]uvb uoo˙ L
o]˙ RvU }b o]˙ uv }bb ub ]o} } R
]v]]ov[bvbX
TR v`}v ˙ }( ] u}R vb b]o v
]b b uvP ˙ ]]]vl v}v}o}P]bX H˙}Po˙u]
]v R ˙ ]v R .b (` R}b }( ]R ]b ui} }ouX I v
v ˙ ]v]vP o˙ ~`]R]v R}Z ]vP b X TR˙ u˙
ob} ] uvPuv (} b]}˙ ]bb ˙v}u
b U o}o˙
]uovb~XPXR˙ou] UR˙}lou]UR˙}uPvbu]Zv
R˙]o]]vu] X
Aoo]u}Rbub}vboo}v(u]o˙ovv]vPX
sueCa
yy Pr˘]bvPT˙]buoo]b
yy Pr˘]bvPT˙]buoo]b
yy Gb}vo]b uoo]b
Symptoms
yy Uboo˙˙u}u
b
yy P]}bR]b}˙}(oP]b~ANlPZ
yy P]}b}}}b]R]b}˙~(}oRbUu]b]PbXZ
yy OR(b}(]b~Sb}v}vRD]bMoo]b [Z
S]Pvb
yy F}b oPRv Pb}vo P~b b ˙ b]o˙uR˙b
b ]}r
(voR]PR}˙ob}vv b Z
yy F}bbuooRvPb}voP~IUGRZ
yy Pbv}(}o˙R˙uv]}b
yy OR b]Pvb }( ] }uo]}vb ~S b}v }v RD]b
Mellitus[Z
Invtiga
se tions
yy All basic Antenatal CareIvbP}vb
yy Uob}vv b
yy F}ov}uo˙v b vr`lb
yy S]ovb b (}P}`Rbuv]vR]]ub
e ncy*v
yy U]vovbvb]]˙~u}vRo˙Z
yy H]PRP]vo`b (}v]]b]b
yy Bo}}Uo}o˙bvv]v
yy Bo}} Po}b }.o ~FbvP o}} Po}b v rR} }br
v]o o}} Po}b u}vRo˙ ]v R oV u} (vo˙ ˙ bo(r
u}v]}]vPZ
yy Go˙Ru}Po}]v~HA˙CZ vr`lb
N}r
TR]bv}o(}]vPo}bu}v
b ]vRuvPuv}(]b]v
Pvv˙˘(}v]vP
b X
So(ru}v]}]vP}(o}}bPbR}o v}P(}R}b`R}v+}
Po}buX
Trtme
ae nt
Tuv}ib
yy T} R] v}uo o}} Po}b v Po˙ Ru}Po}]v oob
R}PR}Pvv˙Uo}Uo]˙v]u
yy T}vuvov(}o}uo]}vb
yy T}vv}vou}]]˙vu}o]˙
yy T} v uvP }R b}] }uo]}vb XPX r
oub]
ı
Standard Trtme
yy Gvoub~]˙
b u}].}vU˘]bUv}vboo]vP
v }vU o}} Po}b u}v]}]vP ub ]bb `]R
]]vU}b]]v}u]`](Uo˙ b Z
yy FvANC]b]b]
yy Do]˙
yy ˙`lbPb}vP]vòo}v}oovb`]Rv}}u r
o]}vb
yy ˙ `lb Pb}vV ]v Ivbo]v vb v R}b
`]R}uo]}vb
yy vCb b}vV(}vb`]R]R}(R(}oo}`]vPV
yy roub
b ]U]}bvb b}vU
yy vuvoPUuobv}v}(}o
yy u}b}u]
yy I(ouo]˙]bvbb˙UuR(}oovPb
`]R}}b}]bvb]o]b
yy P]u
yy Co}b o}} Po}b u}v]}]vP ]v R .b R}b L r
livery
B}˘rP) Notes on glycaemic control of diabetes in pregnancy
(}
B ovvPvv˙
Ou]bPo˙u]}v}o]vlv}`v]b(}Pvv˙X
e ncy*v
D]vPPvv˙
I( ] o}v vv} }v}o R o}} Po}b oo }vb] R˙}Po˙u]
PvbPu}u]vUPo]vou]v]vbo]v
yy D] vb }v }o u]}v `R} }u Pvv v u]v r
]v }v R] }o u]}v ]( bP}v}o ]b (}˙
b ~(bvP Po r
}boob`vrvuu}olLvrR}}bv]oPo}b`v
rwuu}olLVPo˙HHAobbRvvXæA9Z
Iv]}vb(}}ov]PvbbP
yy Gb}voD]b`R}(]o}R](}˙b }v}o`]R]v
˘]bo}v~FBSANvXuuu}oloZ
yy P}}}uo]v}]vbo]vXPX}}u]v]b}vbl]oob
yy P}}Po˙u]bo(u}v]}]vP
yy Ivbo]vR˙}bb.vv]ov}]bv}]o˙]oo
b}oA Iv]}vb(}Ivbo]vb
yy S]Pv].v]ou}]]˙˘]bXP b XvR}R˙Uv]v}R˙U
neuropathy
yy Pb]bvo˙R]PRHu}Po}]vA
yy Pb]bvl}v]
yy S]Pv].v }b] u}]]b XPX (}o u}b}u]U }o˙R˙u]v]}bU
IUGR
yy D]vPvvo}}b}]R˙`]R˘]}}v}(Po˙ r
u]}v}o
yy P}}Po˙u]}v}o`]R}ov]Pvb
]v
E RvPPB
yy M}u]vU}oUæuPrR}o˙X~u˘X}bP˙Z
AvlO
yy Go]vou]U}oUXæræuPrR}o˙XIvb}b˙æuP](
vbb˙vou˘X}b}(æuP l˙
Note 13-5
M}u]v v P]v b u}v}R˙ } ]v }u]v}v `]R ]vbo]v vl
or Sulphonylurea
TR}(b boR}v˙ob~XPXPo]vou]]v Z Pvv˙bR}oPvoo˙
}]}(
b R]bl}(v}voR˙}Po˙u]XH}ÙPo]vou]
vb]vR nd
v]ub]v`}uv`]RPb}vo]bX
AvlO
yy Ivbo]v
]v
E RvPPA
~Sb}v}vIvbo]vTR˙]vRD]bMoo]b[Z
yy S `]R buoo }bb ~XPX }o ]o˙ }b }( vr v]bZ }( NPH
]vbo]v } u]˘ ]vbo]v ~`R]R Rb A9 }( Po v wA9 }(
NPH]vbo]vZUv}b b o˙X
yy G]}˘]uo˙`}rR]b}(R}o]o˙}b(}l(b
v}vrR](}]vvX
v*CardiacDissein
yy Aib R ]vbo]v }bb (} l(b vl} ]vv ˙ ob }
u]vbv]b}]vP}bob}(o}}Po}bbX
a Prgna
yy M}v]} ]vbo]v R˙ `]R r `lo˙ FBS ~v rR} }br
e ncy*v
v]oo}}Po}b`R}bb]oZ } `lbRv`lo˙
ooo]˙X
yy K (bvP Po}b oob `v rv uu}olL v rR}
}bv]oPo}b`vrwuu}olLX
yy TR]b ]b }Lv R]o }v v }rv b]bX H}Ù b}u
vb `}o v } u]'} R}b]o (} bR} ]}b }
vbP}}Po˙u]}v}oX
yy Ivbo]v ]uvb ]vP o} bR}o P]v }]vP }
bo]]vPo b ~Sb}v}vRD]l}]}b]b[vSo]]vPob Z
yy Ivbo]v ]uvb ]vP vb b}v v }R }
}b ~b]vP bo]]vP o b } Go}brP}bb]urIvbo]v
]v(b]}v}GKIZbR}o]bb`]RRvbRb
Refeal
r Criteria
R(} R}b]o (} b]o]bX F} R}vv]v }(vb
bR`vb]o]bvu]o}8u˙}]X
119. Cardiac Disease in Pregnancy

]C ]bb b}] `]R R]PR uvo v (}o
u}o]˙ v u}]]˙X TR˙ u˙ bv (} R Pvv˙
} o} ]vP R Pvv˙ } ]u ~XPX ]u
]}u˙}R˙ZX PPvv˙ ob ]}vo v }v R R v
ulbr˘]bvP]]bb`}bX
Standard Trtme
S}u }( R b]Pvb }( Pvv˙ u˙ u]u] ] ]bbX (o
C
buv}(oovbub vlv}u]v](R˙R
]]bb}v}X
MvPuv ]b uor]b]o]v˙ u ]vo]vP R
}b]]vU v}v}o}P]bU vbRb v R˙b]]v b]o]b }
]}o}P]bX
Pvb `]R lv}`v ] ]bb ub ov R] Pvv]b
(oo˙]v(oo}vbo}v`]RR]]}o}P]bv}b]]vXTR˙
ub }}l o˙ b }}v b R˙ }u Pvv (} vvo ]v
R}b]oX
Aoo vb v]vP Ru}o}P]o uv ub uvP
˙R˙b]]vb]o]b}]}o}P]bv}b]]vX
sueCa
yy RRuR]bbXPXu]o]v}uvvv}b b ]b
yy Hypertension
yy ]}u˙}R˙
C
yy Avu]
yy C}vPv]oR]bb
v*CardiacDissein
yy TR˙}}˘]}b]b
a Prgna
Symptoms
e ncy*v
yy ˙u}u Ab
yy Po]}vb
yy ˙bE (P]o]˙
yy Chest pain
yy D˙bv}r}R}v}U}˘˙buov}vo˙bv}
yy C}PR
yy LPòo]vP b
Signs
yy ]C uub
yy OR b]Pvb }(] ]bb v]vP }v R ˙ }( ob]}v ~S
b}v}vRD]b}b}(R]}bo˙bb u[Z
yy Pbv}(R(]o~Sb}v}vRH(]o[Z
Invtiga
se tions
yy FBC
yy Bo}}vo}o˙b
yy TR˙}](v}vU b ](]v]
yy Eo}]}Pu
yy R}]}Pu E
yy CRbXr˙~`]R}}v}((}bZ
yy Aoo}Rvvo]vbP}vb
Trtme
ae nt
Tuv}ib
yy T}u]v]vP}}](v}vR}PR}RPvv˙Uo}U
o]˙v]u
yy T}vuvov(}o}uo]}vb
yy T}vuvoR
~S}]]]bbZ
~S}]]]bbZ
Refeal
r Criteria
Aoo vb `]R ] ]bb ub ( } b]o]b
R˙b]]v}]}o}P]bvv}b]]vX
120. Jv]]vPPvv˙
Jv] }]vP ]v Pvv˙ u˙ ˙u}u
b } b]Pv }(
]bb bvbR}ov}vbuX
sueCa
Obstetric
v*JaundiceinPrgna
yy S roub]loub]lHELLP S˙v}u ~Hu}o˙b]bU
EoL]v˙ubUL}`Poob˙v}ub Z
yy SR˙ub]bP]u
e ncy*v
yy CR}obiv]}(Pvv˙
yy F'˙ A L]}(Pvv˙
Non-obstetric
yy V]oRb
yy Hu}o˙P uo]U b]lo oo ]bbU GvPD (U u] b U
PbvRou]}vb
yy SP]oPR}o˙bbUR}oo]R]b]bU}biv]
Symptoms
yy Yoo}`]bR]b}o}}v}(˙b
yy D˙oo}`}l]v
yy Gvo]]R]vP
yy OR˙u}ub b ovP}R~b XPXPvouo]bU]]vbbU
(XZ
Signs
yy Yoo}`]b}o}}v}(u}buuvbvbl]v
yy Do]]uv}u~](Zb
yy L]voPuv~I(b}]`]Ro]]bbZ
yy ORb]PvbovP}R~ b XPX(Uoo}}Zb
Invtiga
se tions
yy FBU C o}}.ou(}uo]b]bURDT
yy S]lo]vPb
yy GvPDb
Standard Trtme
yy Bo}}P}v}bbuR]vP
yy Bo}}Uo}o˙bUvv]v
yy L](v}vb
yy HbBb(vPv
yy A}u]vo ob}v v
b `]R uRb]b }v R R}r]o]˙
˙bb uvvb
Trtme
ae nt
Tuv}ib
yy T}]v(˙vb
yy T}vouvov(}o}uo]}vb
Refealr Criteria
Sb }( iv] v R}b b}] `]R }u]vo ]v
ub((}b]o]bX
v*PostrPatur mHaemorrhage*v
121. Post-Partum Haemorrhage

P}bru Ru}RP u˙ ]u˙ } }v˙ b X P]u˙
}buRu}RP(b}o]vP}(u}Rvæuo(}uR
Pv]o `]R]vR.b`v˙r(}R}b}(o]˙}v˙u}v
}( o}} o}bb Rbo ]v Ru}˙vu] }u}u]b }( R vX I
boo˙}b]vP}]uu]o˙LRR]P b }(o}X
S}v˙}bruRu}RP]b.v˘bb b]P]vo
o]vP}]vP(}u`v˙r(}R}b}b]˘`lbLo]˙X
TR o]vP u˙ } `]R R ov ]v } L ]b
˘ob]}v (}u R bX P}bu Ru}RP }ub o](
Rv]vP ]( R u}R ]b o˙ vu]X Bo}} o}bb }( u} Rv
æuou˙o}bR}lX
sueCa
yy U]v}v˙~wrıA9}(bZ
yy Rv}v}(oo}}(ovob`]R]vR]v]˙
yy Iv(}v`]R]vR]v]˙~v}ru˙}u]bZ
yy Gv]ou
yy Co}hvP]b}b
Symptoms
yy E˘bb]}}o}vPP]voo]vPLo]˙
yy L}`}u]vo]vb
Signs
yy o]vP
A (}uRPv]o
yy C}vivooo}
yy Rapid pulse
yy Bo}}u˙b o}`}v}uo
yy ]}}v
D }(uvooob}(}vb]}bvbb
yy Fo˙}}o˙}vb
yy O]}bb]v]Rvovl}]vu
yy O]}b]vov
yy Suprapubic tenderness
Invtiga
se tions
yy FBU C b]lo]vPb
yy Bb]o}hvPb
yy Bo}}P}]vPv}bbruR]vP
yy Uob}v v b ~]( v ]b ob } Rl (} ]v ov
bZ
Trtme
ae nt
Tuv}ib
yy T}]v(˙Rbv}b o]vPb]lo˙b}bb]o
yy To correct hypotension
yy T}}bovPvu]
}D ]v}v˙~wrıA9}(bZU`]Rv}ovov}v
yy MbbP(vb}(}b uo
b }v}v
yy Ev}P `}uv } u˙ o } b Ro R }
u˙Rovu}v]}]v}
yy B]uvo }ubb]}v }( R b v oo}}v u}v ](
b(]ob}}v`]RubbP
Due to retained placenta
yy 'uA u}o}(Rov˙}v}oo}}vb}}v
b }v}v ]b (oX I( v} (o
b `] R v˘ }v}v
and repeat the procedure
yy I( R ov vv} ˘oo ]v R]b (bR]}vU uvo u}o
under anaesthesia is indicated
yy I(RovRbvo]v]b]v}uoU˘o}}vR
bvuvou}ovvbRb]]b]v]
yy I(R(]o]b(}uvou}o}(ovvvbRb]
v}]uu]o˙]oo(}R}b]o
Bleeding with uterus well contracted and placenta completely
delivered
yy E˘u]v R v ]v R o]R}}u˙ }b]}v `]R
voPb] vl} vbRb]U P}} o]PRvP } ]v(˙ v b
]voUP]vov]ob
yy I(R~b˘vb
Z ]v}R]v}˙U+b]vPvv}
æ
Standard Trtme
(}uv]`]oo]v}oo}}u˙
yy F}bU]}R˙b}u˙]b]
Bleeding associated with coagulopathy
yy Bb]o}hvPrb æuo}(o}}o]vuo}v}'}u
PobbR}oo}]vvu]vb
AXI(Rb]b}}o˙}v~A}v˙Z
st
L]vTuv
]v
E RvPPA
yy O˘˙}]vUIMUv]bX b
Then
yy O˘˙}]vU IVU]v(b]}vU rv]b ]v æuo˘}b
D bo]v } XıA9
}N}uobo]v
Note 13-6
D}bv}}˘v]b
I( ]vv}b }˘˙}]v ]b v]ooU } ]( R o]vP }b v} b}v }
}˘˙}]vUR(}oo}`]vP}v b o]vPb}uuvX
nd
L]vTuv
]v
E RvPPB
yy M]b}}b}oU bo]vPoU v u]}Pu ~(} PPH }R˙o˘]b `]R]v
u]v}(o]˙Z
yy M]b}}b}oU bo]vPoU u]}Pu b ]( v ]b }vb]}b
~(}PPHuvZ
Or
L]vTuv
]v
E RvPPB
yy P}u]v
E UIVUæu]}PuX
b
Or
]vE RvPPB
yy O˘˙}]vrP}u]vU IMU ~O˘˙}]v v]b v P}u]v
E æ
u]}PuX Zb
Or
]v E RvPPB
yy O˘˙}]vru]b}}b}oU~O˘˙}]vUIVUv]bvM]b}}b}oUoU
vu]}PubX Zb
Note 13-7
H]PRb}(+b
b ~vbU}u]vPUvR]PRo}}Z}b
]v`}uv`]RP}u]vX
TR˙ bR}o v} P]v } `}uv `]R R˙vb]}v ]v Pvv˙ } R
]bbX
v
B. Protracted bleeding uncontrolled by Oxytocin and other
U}}v]b}](o]vP]bo˙}u
]v
E RvPPB
yy Tv˘u]A]Ubo}ÌV~v}}˘uPu]vZU
PXb
Then
PR}o˙~M˘]uuP]vR}bZ
C. Hypovolaemia
yy S}]uCRo}]XıA9}R]vPboUIVUvo}}vb(b]}vb
clinically indicated
~Sb}v}vRSR}l[Z
X
D AvbRb](}uvou}o}(ov
yy M}R]vUIVUXæræuPX b b]~](v}vbRb]b]o r
oZ
Or
yy PR]]vUIVbo}ò˙}IMUuP llPrv R}o˙]b ~u˘X
uP}bZ
And
yy D]uUbo}ÌVUæruPR}o˙]b ~NOTu}RvXæ
uPu]vZ
Note 13-8
D} v} u]˘ R]]v v ]u ]v R bu ˙]vP
b X M}v]} b]}˙
}(vo}bo˙XS}Pb](b]}˙]bobbRvu]vX
Or
yy Ku]vUIMUæruP llPX
b
Or
yy Ku]vUIVUXæruP llPXb
Note 13-9
Ku]vubb}vo˙˙]vM]oO8lvbRb
P}]v]}b}R˙o˘]bLuvou}o}(ov}˘o}}v
}(b}]}(]RvobX
E. Secondary Postpartum Haemorrhage

yy O˘˙}]vUIV]v(b]}vUv]b]vL}(N}uoSo]v
Or
yy P}u]v
E U}oUæu]}PuR}o˙(}˙b
FXAv]}}R˙o˘]b
yy Au}˘˙]oo]vU}oUæuPR}o˙(}˙bw
Av
yy M}v]}oU}oUuPR}o˙(}˙bw
w
Standard Trtme
Refeal
r Criteria
R( vb `R} } v} b}v } R uvb }
} b]o]bX Aob} ( }uo˙ } R}b]o `]R R v
o}} vb(b]}v (]o]b (} ˘u]v}v v vbRb] vl}
o}}u˙](Rbv}]uu]o˙]ooX
F]PræP)Flowchart: Post partum haemorrhage

122. Post-Partum Pyrexia

P}bru˙˘](b}}˙u}(£C}u}}v
}u}}b]}vb]vPR.b˙b}(R]u˘o]vP
R.b˙XR]blF}b]vo}o}vPo}U}o}vPu
}( uuvbU]v ovo bU ]vbuvo o]]b
v]Rvo]vi]bX
sueCa
yy Malaria
yy U]v]v(}v~v}ru˙}u]bZ
yy P]voIv(}vb~XPX]v(]b]}}u˙Z
yy }oub
bB ~vP}PuvUubbUb(}u}vZ
yy U]v˙]v(}v
yy Rb]}˙]v(}v
Symptoms
yy F
yy OR˙u}ub b ob }b
Signs
v*PostrPatur mPyrxia
yy F
yy ORb]Pvbob }b
Invtiga
se tions
e *v
yy FBC
yy RDT
yy Bo}}.ou(}uo]b]b
yy Bo}}(}ovbvb]]˙
yy U]v(}ovbvb]]˙
yy H]PRP]vo`b
yy FbvP}Rv}uBo}}Go}b
yy Po] v b } ˘o ]v }b }( }v}v } o]
abscess
Trtme
ae nt
Tuv}ib
yy T}]v(˙vRvo˙]vPb
yy E˘u]v}v v vbRb] `]R }bb]o ]v 'P (}
]v}b}(}v}v
yy Ev}P (v u˙]vP }( b ]( b ]b }
vP}Puv
yy Iv]b]}vv]vP(}vb ]vob
ı
Standard Trtme
AX}oub
bB rvP}Puv
]v
E RvPPB
yy Pu}oU}oUPvrR}o˙]b
BX}oub
bB rubblbb
]v
E RvPPA
yy Foo}˘]oo]vU}oUæuPvR}o˙(}ær˙bw
CXEv}ru˙}u]bv]vo]v(}vb
]v
E RvPPB
yy Au}˘]]oo]vA=Coov]A]UIVUvuPrXPR}o˙(}wR}b
Av
yy M}v]}oUIVUæuPR}o˙(}wR}b
Then
yy A u}˘]]oo]v A=Coov]A]U}oUvæuPrPR}o˙(}˙bw
vA
Refeal
r Criteria
R(oob}(b]b}R}b]o(}uvPuvX
e *v
æ
Flowchatr
e *v
F]PrvP) Flowchart: Management of Postpartum pyrexia
æ
Standard Trtme
123. AvoPb]]vL}
TR ]v RbR}o u˙ o}` ]vP o} }v }v }( (U
v˘]˙vv]v˙X]v A o](]vPo}bob]vobb
v˘]˙vP}}}PbbX
Iv R .b P
b }( o} ]v o]( u˙ ] (} ]v(o
]v }v}vbU `Rb ]v R }v
b Pb }( o}U voPb] ]b
](}]vbuvoo]˙v`Rvv]b]}}u˙]bP]vX
AX D]vPR.bP
b }(o}rvo
]v
E RvPPC
yy M}R]vUIVUXæræuPR}o˙]b
vA
yy M}o}u]UIVUæruPR}o˙]b (}}u]vP
Or
yy PR]]v R˙}Ro}]U IMU ær uP X
b b]
rR}bo~M˘]uuuP]vR}bZ
vA
v*AnalgesiainLaoub r*v
yy P}uR]vUIVlIMUæuPb]~M˘]uuæuPvR}o˙Z
]b }RRvb}(}u]vPv}}vR
voPb]+}(PR]]v
B}˘rwP)
yy G]v IMU R u˘]uu voPb] + }( PR]]v ]b }]v L æ
u]vbvob(}
b rR}bXI]bR(}v} b }P]]`Rvo] r
˙]bv]`]R]vR}b]XX}vrwu]o}v
yy I( R ˙ ]b }v `]R]v v R}b }( PR]]v u]v]b}v ] u˙ R
b]}˙ b]}v ]]vP v} vP}v]bb R b No}˘}v IMU
u]}PullPX b ~I(v}b}vbUP]bv}b}(u]} r
PuLru]vbZXC}vvb]}v`]R}˘˙Pv] (ubl
}R}PRvv}Ro vbo(]vGvP~AuZPvoR r
b]}v]bbX
yy H}Ù PR]]v bR}o v} `]RRo (}u vb `R} v vo r
Pb] `Rv R ]˘ ]b o˙ vrw u ]o ]v `R]R b ærwæ uP IM
PR]]v`]RXæræuPXP}uR]vu˙P]v]vv}bo˙X
BX D]vPR.bP
b }(o}W]vRo}vo
yy N]}b}˘]vO˘˙Pvu]˘UæPæ
Note 13-10
T}b]vRo.bP
b `Rvo]˙]b˘`]R]vR}X
æ
CX D]vPR.bP
b }(o}r]o
Note 13-11
TR]b}]b]b }˙vvbRbX
D. During the second stage of labour

yy L}oAvbRb(}]b]}}u˙vvoo}lvbRb]}
(]o]]vbuvoo]˙X
yy L]}]v R˙}Ro}] ~X˙o}]vlL]Pv}]vZ A9U `]R } `]R}
vo]vU ]v.o ]v R ]vu (} v ]b]}}u˙X I( v}
P]v (} o]˙ ] v P]v (} R ] }( R ]b] r
}}u˙
EXAvbRb](}bR}}b]}bXPXuvou}o}(
ovU]}(oPP]vov]ob
yy PR]]vUIM}IVU uP llPbo}ò˙~u˘X uPZ](v}vbRb
is available
Av
yy P}uR]vR˙}Ro}]UIMUæuPX b ~](}u]vP}bZ
v*AnalgesiainLaoub r*v
Or
yy M}o}u]UIVUæruPR}o˙]b
vA
yy D]u Ubo}ÌVUæruP~}(XæuPu]vZ
Note 13-12
M}v]} b]}˙ o}bo˙X S} D]u if respiratory rate is less than
lu]vZX
D}v}u]˘R`}Pb]vRbu˙]vP
b X
nd
L]vTuv
yy Ku]v UIMUæruP llPX b
Or
yy Ku]v UIVbo}ò˙UruP llP
Or
yy Ku]v U IV ]v(b]}vU ~F} o}vP }bZ uP uo }( l r
u]v]v˘}bæA9}v}uobo]v~u]vvv}bræu] r
}PulPu]vib}]vP}b}vbX
Av
yy D ]u Ubo}ÌVUæruPUu]v]b}ru]vb~}˘ r
]uo˙XæuPu]v}Z vHoo]v}vb
FXPu]}v(}Ku]v u]v]b}v
yy AtropineUIMUvu]}PuX b
Av
yy O˘˙Pv U˙(ublUvrLlu]v
æ
Standard Trtme
Note 13-13
Ku]v ]b}v]v]]vvb`]RR]PRo}}~H˙vb
b ]}v Z
vR]bbX
X Preterm Labour in Premature Delivery

Puo} (b}o}}]vPL `lb (}
w }uo `lb bovP ]v u o]˙X TR u
v`}v ]b ]bl }( R b oo ]b }˙ ˙bb ub bR b ovPbU
]vU ]Pb v ]uuv ˙bb ub v} (oo˙ o}X TR ]b
]vb ]o]˙
b } ]v(}v v ]u] o}hvP uRv]bubX
TR ˙ ]b ob} ]bl }( ]R ]vi]b bR b o Ru}RP
b R (P]o v]o }vb } v} }] b8]v }}v
(} R ]vX S}u ]bl (}b (} u o} ]vo ˙}vP P }(
u}RbU}}b}]}r}v}u]obbvbu}l]vPX
v*PretermLaoub rinPrematureDlivyer *v
sueCa
yy Mvo]v(}vbXPX˙o}vR]b Uuo]
yy Iv}uv]˘
yy Pu}(uuvb
yy MooPvv]b
yy }A ov
yy D]buoo]b
yy Proub]loub]
Symptoms
yy RPov]v(o]v}v}vb}}u]vo]vb
yy TRu˙bR}`
Signs
yy Suoou]˙
yy PooPo]v}v}vb
yy P}Pbb]+uvv]o}v}(R]˘
yy Ruuvb
Invtiga
se tions
yy FBC
yy FbvP}Rv}uBo}}Go}b
yy Uob}vv b ~(}R}bv}]vo]b b Ro}Z(}
yy Gb}voP
yy F}oo]
yy Pbv}v
yy Auv]}G]}ou
yy Povob]
yy u}v Eb }(R(}o`]PR
æ
Trtme
ae nt
Tuv}ib
yy T}}b ]v}v}vb](o}]bv}(oo˙o]b b R
yy T}oo}`(}oP}`Rvu}v]v}]((b]o
yy T}}u}(}oovPu]˙~Pb}vbr`lbZ
yy T}oo}ò}}}Pbb](]]bo˙òoo]b b R
yy T}v˙vo˙]vPb~XPXuo]U˙o}vR]b Z
yy }] A ˘ob ]v}b
yy }] A v}b
b R˙b]o]˙
yy b B
yy C]o oP b (} b ]Pv}b b } ]o
]v}uv
AXT}}o˙b]b
v*PretermLaoub rinPrematureDlivyer *v
]v
E RvPPB
yy Sou}o UIV]v(b]}vUXæuP]væuo}(˘}b
D æA9V
S]v(b]}vu]}Pubu]v~]XXuou]vvZ
]vbPoo˙}]vP}b}vbu]v]vobv r
o }v}vb ]u]bRU Rv ]vb bo}ò˙ vo }v}vb
b~M˘]uuæu]}Pubu]vZV
M]v]v (} }v R} L}v}v Rb}b U Rv P r
oo˙˙æA9˙vR}bV~M˘]uu}vR}bXZ
Or
]vE RvPPA
yy NifedipineU}oUuP]v]oo˙U
Then
uPLıu]vb
I( }v}vb b]b R˙ v }vv `]R uP ˙
r R}b (} rw R}b b }o˙ v ~u˘X v uP
˙Z
N}r
Monitor blood pressure
yy MPvb]uboR UIVUP
v ]vv}bo}]v]o}u]vb
Then
P]v(b]}vR}
AL
Iv(b]}v]bb}vb}vb
BX F}oovPM}v`]RAvvo}}b}]bGb}vb
`vr`lb
]v
E RvPPA
yy uRb
B }v U}oUXvrwuP˙R}b~}bbZ
Or
ææ
Standard Trtme
yy ˘uRb
D }v UvuPR}o˙(}~}bbZ
Note 13-15
Tuv ]b u}b + ]( o]˙ }b ob R}b L R .b
}b}(Ru]]vRbvP]vvobbRv˙bw LRob}b}(
Ru]]vX
C}vrX
VOID
A ˘uRbD }v lBRuRb}v b`Rv]v(}v]bbvX
DvPb }( }]
b b ]vo ]o]˙
b } ]v(}vU G] v}v v
ou}v˙}uvuvo}bu}oobX
Refeal
r Criteria
Tuv]bb}v]v R}b]o`RR(]o]bvb}
R}(Ruv}v XTR(}U(Ru}R](
Ro]v]vv}o˙(}R]uuv}vXI]b'}
v*PrematureRutup reoftheMembaner s*v
vb(R(}b]vr}}R(ovX
125. PuR}(RMuvb
TR]b]bR}(Ruuvb(}R}vb}(o}XTR
`} ˙b u ~(} w }uo `lbZ v u ~L w
`lbUAHR}(}}vb}(o}ZX
sueCa
yy C]oIv}uv
yy Gv]o]v(}v
yy Tu
Symptoms
yy GbR}olP}(}]}bG](}uRP]v
Signs
yy Sou˘u]v}voboG](}uR]o}b}}}o
}(G]]vR}b]}P]vo(}v]˘
yy Suoo]vb](}RPb}voP
yy I(}uo]˙]v(}v~R}]}uv]}v]bZ
yy F
yy PovP]vo]bRP
yy F}oR˙]}˙]
yy Maternal tachycardia
yy U]vvvbb
Invtiga
se tions
yy FBC
yy S]obou˘u]v}v]vo]vP`b (}o
yy Uob}v v b ~]( ]ooZ (} R Pb}vo PU (}o o] v
æv
bv}vU uv]} G] }ou ~v}uo } ZU v R
ovob]XuEb R(}o`]PRX
yy U]vo˙b]bvo
Trtme
ae nt
Tuv}ib
yy T}vvl}]v(}v
yy T}vo}](uv˙]b˙]uu
yy T}]u}(}ob]oR}PR]u}(}oovPu]˙
yy b B
AX Iv(}vPv}v
st
L]vTuv
]v
E RvPPB
yy Au}˘]]oo]v~Au}˘˙]oo]vZ U}oUæuPR}o˙(}˙bw
v*PrematureRutup reoftheMembaner s*v

vA
yy M}v]}o U}oUuPR}o˙(}˙bw
L]vTuv
nd
]v
E RvPPC
yy Au}˘]]oo]v + Clavulanic AcidU}oUvæuPrPR}o˙(}˙bw
BX Iv(}vPv}vWvb`]Rv]]oo]vooP˙
yy E˙R}u˙]v U}oUæuPvR}o˙(}˙bw
vA
yy M}v]}o U}oUuPR}o˙(}˙bw
CXF}oovPu}vW(}]br`lb
]v
E RvPPA
yy uRb
B }v U}oUXvrwuP˙R}b~}bbZ
Or
yy ˘uRb
D }v U}oUvuPR}o˙(}~}bbZ
Note 13-16
Tuv ]b u}b + ]( o]˙ }b ob R}b L R .b
}b}(Ru]]vRbvP]vvobbRv˙bw LRob}b}(
Ru]]vXTR˙ob}v.Ruv`}v ˙o}`]vPR]bl}(
]vv]oRu}RPvRX
Refeal
r Criteria
I( br]b] oo ( vb } R}b]o } b]o]b (}
(RuvPuv](b]Pvb}(uvo]v(}vUPvv˙]bobRv b
w`lbv}uo}}bX
æw
Chapter
Gynaologic
ce alDisorsder
126. Dysmenorrhoea
D˙buv}R (b } ˙o]o o}` }u]vo ]v b}]
`]Ruvb}vXTR]v]bR}PR}bo(}u]v}v}vbX
Iu˙]u˙`RvR]bv}]v.ob}}v˙
b `Rv
b}]`]Rvvo˙]vPbX
sueCa
yy OLvv}vo˙]vPb~]u˙Z
yy U]v.}]b
yy CR}v]o]]v(}vbXPXCRou˙]o]v(}vb
yy Ev}u]}b]b
Symptoms
yy L}`}u]vo ]v R]bu]vP }}o]l˙ ]v v u˙
be dull and constant
yy P]vu˙]}Ro}`l}oPb
yy NauseaU }u]vP U RRb v ]]vbb u˙ b}uub
b}]`]RR]v
Signs
yy N}˙]oR˙b]ob]Pvb
Invtiga
se tions
yy FBC
yy S]lo]vP
yy Po]ob}vv b }o}o]ob]}vbbRb.}]b
Trtme
ae nt
Tuv}ib
yy To relieve pain
yy T}vo˙]vPb
yy b B
yy Wubo]}Ro}`}uv
æ
Chatep rP *Gynaologic
ce alDisorsder
AXM]oCb
st
L]vTuv
]v
E RvPPA
yy Pu}o U}oUPvrR}o˙
B. Severe cases
yy I}(v U}oUruPR}o˙
Or
yy M(vu]A] U}oUæuPR}o˙
Refeal
r Criteria
R( } P˙v}o}P]b ]( ]v ]v(b `]R v}uo ]˙
b]oo˙](uv]b]v+}vvo˙]vPb]b]v.X
127. A}}v
A}}v (b } R ˘ob]}v }( R (}b v }R }b
}( }v}v (} R R `l }( Pvv˙X I u˙ }
b}vv}bo˙ ~RvU ]v]oU ]v}uoU }uo } u]bbZ
} ]v ~RU ]u]voZX B}R b}vv}b v ]v
v*Aorb tion*v
}}v u˙ }u }uo] ˙ ]v(}v ~bb]bZ vl} }(b
o]vPX
AL }] uv v ]bRP (}u R}b]oU ] ]b
}uuv R vb } l } R}b]o ]( R ]b o}`
}u]vo ]vU (U P]vo o]vP v uo}}}b ]bRPX A
(}oo}`]`bR}oob}}v]v`}`lbX
sueCa
yy S}vv}bA}}vb
yy Iv(}vbXPXuo]UUTI U]oP]v}b]b X
yy F}ov}uo]b
yy Iv}uv]˘
yy CR}v] ]oovbb XPX ]bU R˙}] ]b}bU b]lo oo ]b r
X
b
yy Tu
yy Uvb(A}}vb
yy Iv(v}(RPvv˙`]Ru]}vb~}oUv r
o}}RbZ}]vbuv}v
THRETEA NEDABORTION
Symptoms
yy Sv˙}u}]vobP]vo b o]vP
yy M]oo]]b}u(}
Signs
yy TR]vb]]b}uo`]RRPb}voP
æı
Standard Trtme
yy TR]bv}]o+uv}]o}v
Invtiga
se tions
yy FBCvb]lo]vP
yy Uob}vv b ~}}v.u]o(}b]v}`]Ro}b]˘Z
yy OR]vbP}vb(}}vovo˙]vPbXPXuo]
Trtme
ae nt
Tuv}ib
yy T}u]v]v]oPvv˙}u](}bb]o
yy R}u bB }R}b]o
yy T}]v b (}u˘o
b ]v}b
yy T}}l](o]vP}]v]vbb
yy N}b].uv]
yy Tv˙vo˙]vP]oovbbXPXuo]
INEVITABLEABORTION
Symptoms
yy L}`}u]vo]v
yy H˙P]voo]vP
v*Aorb tion*v
yy N}(}b}}b}(}v}vP]v b
yy P]vobbo}bb}(o]}P]vu
Signs
yy TR]˘]b]o`]RRuuvboP]vP
yy TRu˙o}bb}(o]}
yy TR]vb]]b}uo`]RRPb}voP
yy TR u˙ b]Pvb }( bR}l oo}U }oob ]Ro bobU
]b]vPob`]R]vP}ouU(oo]vPBPv}oouu˙bl]v
Invtiga
se tions
yy FBCvb]lo]vP
yy Bo}}P}]vPv}bbuR]vP
yy Uob}vv b ~bR}`bR(}b}o]Z
yy C]˘u˙]o`]RuuvboP]vPR}PR]
yy Iv ]vbvb b}] `]R o}bb }( o]} R u˙
}o]P}R˙u]v]}b
yy Uob}v]bvbb˙}vo˙](R]Pv}b]b]b]v}
Trtme
ae nt
Tuv}ib
yy T}b]vvl}vbR}l
yy To relieve pain
yy T}oo}`Rv}}~bb]b]v}v}vb](`lZ
yy T}R]v}b}(}v}v(}uRb
v
ce alDisorsder
yy T}u]vb}(}}v](v
yy T}v]v(}v`]Rv]}}R˙o˘]b
yy To prevent risk of Rhesus]v}u]o]˙]v(Pvv]b
yy }v
E }(R]bb }v˙]R}(R(}oo}`]vPRv]b
LR˘ob]}v}(R(}b}(}R˘ob]}v}(R(}b
](]]bobbRvr`lbb]
yy MvoVuAb]}v~MVAZ`]R}`]R}]o
block anaesthesia
Or
yy U]v 'P v ]o o}l } Pvo vb r
Rb]~Gb}vb`lb}obb
yy U]v }v v vbRb] b]oo˙ `Rv R
]vb]]boPRv`lbb]
AXI(v]b]vbR}l}o]vP]bb
yy IVG]bvo}}vb(b]}vbvbb˙
B. To relieve severe pain
]v
E RvPPC
yy MorphineUIVUXæræuPR}o˙]b
v*Aorb tion*v
Av
yy M}o}u] UIVUæruPR}o˙]b (}}u]vP
Or
yy PR]]v UIMUwæruPX b
Then
æruPvrR}o˙](]
vA
yy P}uR]v U IVlIMU æ uP b ] ~u˘X æ uP v R}o˙Z b
] } R Rvb }( }u]vP v } }v R
voPb]+}(PR]]v
C. Evacuate uterus
I(]vb]ANr`lb
]v
E RvPPA
yy O˘˙}]v UIVUrv]bo]}(N}uobo]v
Or
U]vb]AM`lb
]v
E RvPPC
yy MisoprostolU}olSLUvu]}PuXb
X
D T}PvIv(}v
yy Au}˘]]oo]v U}oUæuPR}o˙(}ær˙bw
Av
yy M}v]}o U}oUuPR}o˙(}ær˙bw
v
Standard Trtme
EX T}vRRbb Ib}uuv]}v]vRRbbvP`}uv
]v
E RvPPA
yy Av D RR Iuuv Go}o]v U IMU u]}Pu ~Uæ Uv]bZU X
b
`]R]vwR}b}(}}v
INCOMPLETEABORTION
Symptoms
yy PbbP }( oP o}} o}b vl} R (}b v b}u }b
P]vu
yy So}`}u]vo]v
Signs
yy I( o]vP ]b P b Poo} vl} SR}l ~}oob ]Ro
bobU(bobU(oo]vPBPv}oouu˙bl]vZ
yy U]vb]]bbuooRvRb
yy C]˘]b]o`]RR(}bo˙}
yy WR}o ov } b R}( u˙ bv `]R]v R ]v
cavity
Invtiga
se tions
yy FBCvb]lo]vP
yy Uob}v v b ~} b ]( } ˘]bb ]v R ]Pv}b]b
v*Aorb tion*v
b]oo˙]vo˙Pvv]bZ
Trtme
ae nt
Tuv}ib
yy T}b]v
yy T}R]v}b}(}v}v(}uRb
yy T}v]v(}v`]Rv]}}R˙o˘]b
yy T}u]vb}(}}vU](v
yy D]P]o 'P ]vP P]vo ˘u]v}v } u} b uR }(
R]vb}bb]o
yy SP]o }v }( ]v }b }( }v}v XPX uvo
ub]}v~MVAZ`]R}`]R}vbRb]
yy P}b}}vv}v b (}u˘o b ]v}b(}ob`lb
yy P}b }}v }vboo]vP v ˙R}o}P]o b b} ~]vo]vP
Fu]o˙Povv]vPZ
AX I(]vbR}lvl}o]vP
b
BX A}}v `]R]vb]AM`lb
]v
E RvPPA
yy P}u]v
E UIMlIVUæu]}PuX
b
v
ce alDisorsder
Or
yy M]b}}b}oU}oUvu]}PuX
b
Or
yy M]b}}b}oUbo]vPoUu]}PuX
b
CX A}}v `]R]vb]AN`lbvAG`lb
]v
E RvPPA
yy MisoprostolU}oUvu]}PubX b
Or
yy MisoprostolUbo]vPoUu]}PubX b
X
D A}}v `]R]vb]AN`lb
]v
E RvPPB
yy O˘˙}]v UIVU v]b]v} L}(S}]uCRo}] XıA9v]v(b
r}bv u]v
Or
yy MisoprostolU}oUvu]}PubXb
Or
yy MisoprostolUbo]vPoUu]}PubXb
EX T}v]v(}v
yy Au}˘]]oo]v U}oUæuPR}o˙(}ær˙bw
vA
v*Aorb tion*v
FX T}v]v(}vW]vvb`]Rv]oo]vooP˙
yy E˙R}u˙]v U}oUæuPR}o˙(}ær˙bw
Av
GXT}vRRbb Ib}uuv]}v
]v
E RvPPA
~Sb}vvRIv]oA}}v [}Z
OMPLE
C TEABORTION
Symptoms
yy }v Cb }}v }(P]vo o]vP (}oo}`]vP R˙ o]vP
`]RbP}(o}bvl}R(}bvovX
yy Rb}o}v}uv}(]v
Signs
yy TRb]bbuooRvRPb}voP
yy TR]˘]bo}bv.u
yy No pelvic tenderness
Invtiga
se tions
yy FBC
yy Uob}vv b P}}v.uu˙]v]˙
v
Standard Trtme
Trtme
ae nt
Tuv}ib
yy T}}v.u}}v]b}uo
yy T}b(}vuvPvu]](bv
yy T}b(}vuvPo]]v(}v](bv
yy C}vboo]vPv˙R}o}P]o
b b}~]vo]vP(u]o˙Povv]vPZ
yy Tvu]](bv~Sb}v}vRAvu] ]vPPvv˙ [Z
yy P}] v]}b ]( v ~S b}v }v uv }(
RIv}uoA}}v [Z
yy P}]AvIuuv D Po}o]v](Iv]~Sb}vvRIv r
]oA}}v [}Z
SEPTICABORTION
TR]b ]b o]( Rv]vP }uo]}v }( }}vX M}b }Lv
R ]b R]b}˙ }( ]u]vo ]v(v `]R R Pvv˙X I u˙
o } }uo]}vb bR b bR}lU ]v uPU ]}v]bU
Ru}RPU ]bbu]v ]vbo }Po}v ~DIC ZU vo
v*Aorb tion*v
(]oUob]}˙]b˙v}u
b Uvb}PbPvPv X
sueCa
yy Iv(]v}b}(}v}v
Symptoms
yy So}`}u]vo]v
yy F
yy V}u]vP
yy Headache
yy O+vb]Uo}}˙P]vo]bRP
Signs
yy F ~uu˙v}uoZ
yy Tachycardia
yy I(]vbR}lPo}ò}}b
yy P]}v]bu
yy Bol˙vb
yy C]˘u˙}v}o}b
yy R]v}+vb]}b}(}v}v
Invtiga
se tions
yy FBCvb]lo]vPb
yy Co}hvPvb
yy Bo}}ovbvb]]˙
yy U]vovbvb]]˙
v
ce alDisorsder
yy Ev}r]o`b (}ovbvb]]˙
yy Bo}}vo}o˙b
yy CRb v }u]vo Xr˙ ~} ˘o (}]Pv }˙U Pb v R
]RPubPPbvP]v(}}vZ
yy A}u]v}ro] ob}v}PR˙ ~(} ]vr}u]vo v o]
bUbv}(}b]vbUG]bvPb]vRo]bZ
Trtme
ae nt
Tuv}ib
yy T}b]v
yy T}]v(}v
yy To evacuate uterus
yy T}}]}br}}v}vboo]vP
yy R E ]v}b}(}v}v~(o}v}(
Rbub}vb]bl}(]v(}}v]bR]PRZ
yy Gvo ]P]o 'P (}oo}` ˙ R ]vbuvo 'P
v Pvo vbRb] `]R]v v R}b }( ]v]}v }( v]}
therapy
yy E˘u]v } }v.u ]( b ]b (}v u]v ]( P˙b
is required
v*Aorb tion*v
yy Pb˙R}o}P]ob}v(u]o˙ovv]vP}vboo]vP
AX Rbb]}v(}bR}l
]v
E RvPPA
BXTuv}(Sb]b
yy Au}˘]]oo]v + Clavulanic AcidUIVUXPR}o˙(}rwR}b
Av
yy Gvu]]v UIVUuPR}o˙(}æ˙b
Av
yy M}v]}o UIVUæuPR}o˙(}rwR}b
N}r
Covbvb]]˙bob`]oo](Rv]}R˙X
IVv]}R˙bR}o}vvvoRv]b(]o(}ob
R}bXOoR˙bR}o}vv(}obvb ˙bXI(Gvu] r
cin]b}}vvP]uPIM}IVR}o˙(}obæ˙bX
C. Evacuate uterus
N}r
T} } (}b ]( oo
b ]v } vl} ]( P]o
b }v }( }b ]b v}
]uu]o˙}bb]oX
væ
Standard Trtme
yy O˘˙}]v UIV]v(b]}v
~Sb}v}vRIv]oA}}v [Z
Or
yy MisoprostolUbo]vPo}o}P]voUvu]}PuX
b
~Sb}v}vRIv}uoA}}v [}Z
D. Severe Pain management
]v
E RvPPC
yy MorphineUIVUXæræuPR}o˙]b
vA
yy M}o}u] UIVUæruPR}o˙]b (}}u]vP
Or
yy PR]]v UIMUæruPrvR}o˙~M˘]uuuP]vR}bZ
vA
yy P}uR]v U IVlIMU æ uP r R}o˙ b ] ~u˘X æ uP
v R}o˙Z } R Rvb }( }u]vP v } }v R
voPb]+}(PR]]v
EXTvb P}R˙o˘]b
yy TetanolUIMUXæuoX b
vA
yy HuvIuuvTvb GlobulinUIMUæræv]bX b
v*Aorb tion*v
MISSEDABORTION
TR]b(b}(}oR]vr}(}`lbPb}vX
Symptoms
yy TR]bbo}(R˙u}ub b }(Pvv˙
yy TRu˙vo}}˙P]vo]bRP
yy bv A uvo}v }( (}o u}uvb ~]( ]lv]vP Rb
o˙}Z
Signs
yy Ub]bbuooRvPb}voPlb
yy F}oR}vbv}R]R`]RRP]vbR}b b }
}`]R(}oD}o]bRbS}v]]
Invtiga
se tions
yy FBCvb]lo]vPb
yy Bo}}.ou(}uo]b]b](vbb˙
yy Bo}}o}hvP}.o(}RoPPvv]b
yy PPvv˙b
yy Uob}vv b
yy FbvPo}}bP
v
ce alDisorsder
Trtme
ae nt
Tuv}ib
yy T}ulv.(}]v}v
yy T}vb(b ]v}v
yy To establish cause of foetal death if possible
yy }v E }( R b ˙ b}v 'P ~uvo } `]R
uR]vZVAM`lbPb}v
yy SP]o }v }( b ~DEZ L ]o ]v]vP `]R
u]}vV}v
b ]ub
AXR]v]vP}(]˘}(]o]P]o
b }v
]v
E RvPPA
yy MisoprostolU }o } P]voU u]}Pub X
b ob R}b
]}}P]o
b }v
BX Eu˙]vPb`]RM]}v]vM]bbA}}v
~S b}v }v M]b}}b}o uv v RIv A}}v [
o}`Z
O
v*Aorb tion*v
]v
E RvPPB
yy O˘˙}]v ]u˙b(}]v}v`R}R]o]v r
]vPuR}b~XPXF}o˙bRoo}}vbXZ
N}r
O˘˙}]v bR}ov}}vvo˙ b }PR`]RM]b}}b}o for uterine
b]bPRv `lbXA }vR}u]voub P]v`v
b }( R `} PbX I( }R ub b R]b ub }v `]R ˘u
}vb]bl(}]v]bPX
INDUCED~SAFEZABORTION
TR]b (b } R o]u]v}v }( Pvv˙X Tu]v}v
}( Pvv˙ ]b b (} v }v (} b}vb u]bb]o ˙ o`
]RR}PRP]o b }}˙Ru}o}P]ouvbXUv
Rv}]b]}vb(}GRvUv]v}}vu˙]}
oPoo˙}vo˙vR(}oo}`]vP}v]}vbP]vb}(U.ouv}
]vbV R} R R˙b]o v uvo RoR }( R u}RVbv
}((}ov}uo]˙vuvo}v}(Ru}RX
PvbP]vRu}o}P]o}}v(}}}v`]oov}
u}v]}o}bo˙(}}uovbb}(R}}v}bbXTR˙bR}o
]v(}u } } l ]uu]o˙ ]v b }( }(b } R˙
P]voo]vPU(}}+vb]P]vo]bRPX
Invtiga
se tions
yy FBC
yy Bo}}P}vRRbb factor
vw
Standard Trtme
yy S]o IvbP}vb (} u]}roPo ]v]}vb XPX ~DNAU
HIV X
b Z
Trtme
ae nt
Tuv}ib
yy T}vbRoPo]uvb(}u]v}vu
yy T}vb(b }}v
yy T}}](u]o˙ovv]vP}vboo]vPvb]bbv
yy MvoVuAb]}v~r`lPb}vZ
yy D]o}vv'P~r`lPb}vZ
yy C]o]v]vP(}oo}`˙D]o}vv}v
E ~DEZ
yy ~AN`lbPb}vZ
AXM]}vA}}v
]v
E RvPPA
yy Mifepristone
Then
yy Misoprostol
v*Aorb tion*v
~SToo}`(}}bPP]ub(}R]}bPb}voPbXZ
TorP) Dosage regimes for Mifepristone and Misoprostol for various
Pb}voPb
Gestational Mifepristone and Misoprostol MisoprostolOvo˙
Pb ~E]vRvPAZ ~E]vRvPAZ
r`lb MifepristoneuPX b PLUS Misoprostol}vo˙P
(}oo}`rR}bo˙ u]}PuXb P]voo˙
MisoprostolUu]}Pub~}oU (}oo}`˙}bb}(
P]voo˙(}oo}`
Zb ](v˙ u]}PuP]voo˙}
}bb}(u]}Pub bo]vPoo˙](v˙
P]voo˙}bo]vPoo˙˙r rR}o˙~u˘X}bbZ
R}o˙~u˘X}bbZ
ır`lb M](]b}vuP}oo˙UPLUSv Misoprostolu]}Pu
rR}boP P]voo˙Xb U
F}oo}`˙}bb
Misoprostolu]}PuP]voo˙U }(u]}Pu˙r
(}oo}``]R}]}vo}bb R}b](v~u˘X}bbZ
}(M]b}}b}ou]}Pu
bo]vPoo˙}P]voo˙rR}
]vob~u˘X}bbZ
v
ce alDisorsder
Gestational Mifepristone and Misoprostol MisoprostolOvo˙

Pb ~E]vRvPAZ ~E]vRvPAZ
r`lb M](]b}vuP}oo˙UPLUS Misoprostolu]}Pu
vrR}bo P]voo˙(}oo}`˙
u]}PuP]voo˙~}
Misoprostolu]}Pu bo]vPoo˙](R]b
P]voo˙UF}oo}`˙}b b]Pv].vo]vPrZ v
}(M]b}}b}ou]}Pu˙ R}o˙]vobX
rR}o˙P]voo˙~}bo]vPoo˙
](R]bb]Pv].vo]vP(}u R}b]vPvo˘ob]}v
o]P]vou]b}}b}ou]v]b r ~u˘Xæ}bbZ
}vZvo˘ob]}vX
~u˘Xæ}bbZ
r M](]b}vuP}oo˙UPLUS Misoprostolr
`lb vrR}bo u]}PuP]voo˙}}oo˙
Misoprostolru]}Pu ˙R}b
P]voo˙}}oo˙˙R}b
R}b]vPvo˘ob]}v~u˘Xæ R}b]vPvo˘ob]}v
}bbXb}bD }(u]b}}b}o ~u˘Xæ}bbX
`]R]vb]vPPb}voPX }bbD }(u]b}}b}o
`]R]vb]vPPb}vo
PX
v*Aorb tion*v
N}r
yy U]vbvb]]˙}M]b}}b}o ]vb`]R
b Pb}voPXL}`}b r
b}(u]b}}b}oR(}b(}}oPb}vb
yy M]}vA}}vb]v}v b ]ubbR}o}vo˙}v˙}}b
Refeal
r Criteria
F}oo˙b}(}}vU(o˙(}b]o]b](R]bb
b } (}v } (}} ]( }uo]}vb XPX ]v(}v }
}(bo]vPX b
TorP) M]b}}b}oUbbvD}bP]vMvPuv}(PPvv˙
C}uo]}vb
Iv]}v D}bP Notes
Iv}}v Misoprostolu]}Pu Ioo˙brR}bL
~r`lbZ P]voo˙}}oo˙} M](]b}vU}oUuPX
bo]vPoo˙rR}o˙
~u˘X}bb
Iv}}v Misoprostolu]}Pu Ioo˙brR}bL
~ır`lbZ P]voo˙(}oo}`˙ M](]b}vU}oUuP
M]b}}b}ou]}Pu
P]voo˙}bo]vPoo˙
˙R}bR}o˙~u˘X
}bb
vı
Standard Trtme
M]bb}}v Misoprostolu]}Pu G]}bbvo}`}l

~r`lbZ P]voo˙](v (}r˙b~vobbR˙
}b]v}wR}b o]vP}]v(}vZ
OR
Misoprostolvu]}Pu
bo]vPoo˙(}oo}`˙`}
]}vo}bb](v
R}o˙
Iv}uo}}v vu]}Pu}oo˙b L}`}l(}˙b~vobb
~r`lbZ R˙o]vP}]v(}vZX
Iv}}v u]}PuP]voo˙r Ioo˙bR}bL

~r`lbZ R}o˙~u˘Xæ}bbZ M](]b}vU}oUuPX
Ao}`M]b}}b}o dose of
AMu]}Puu˙b
`]R}v]v`}uv`]R
caesarean scar only under
specialist supervision
Iv]v(}o rw`lbPM]b}}b}o Misoprostol should be used
R~AM`lbZ u]}PuvR}o˙ `]R}v]v`}uv`]R
r`lbPM]b}}b}o caesarean scar and only under
v*Aorb tion*v
u]}PuvR}o˙ specialist supervision
Iv]v(}o r`lbPM]b}}b}o D}v}u]v]b}`}uv

R~AN`lbZ æræu]}PuR}o˙ `]R]}bvb b}v
or other uterine scar
Iv}v}(o} æu]}PuP]voo˙ D}v}b](]}b
~o](bAN R}o˙O vb b}vX
`lbZ æu]}Pu}oo˙R}o˙
O
u]}Pu}ob}o}v
R}o˙
PPHuv vu]}Pu}oo˙} Ub}v
b o]vP](
bo]vPoo˙X
b }˘˙}]v]bv}]oo}]b
]v+X
Cervical u]}PuP]voo˙ Ub(}]vb}v}(]v]v
]v]vP]}} hours before procedure ]UP]o
b u]v}v
]vbuv}v }(Pvv˙U]o}vv
'PUR˙b}b}˙
AA
b b]vPo}blv]uu]o˙UPPH AA}buRu}RP
Note: Misoprostol]bb}]`]Rv]vb]vbR]]vPU]R}UvuR]PR r
Rv£CX
w
ce alDisorsder
128. Av}uoVP]voBo]vP
TR]b (b } o]vP `R]R ]b (}u R v}uo uvbo
'v~]vub}(Ru}vU}v}]voZXAv}uouvbo
'vb v o]vP }uu}v ]v ˙}vP }obvb v `}uv
`]R]vRPb}(æræ˙bXN}u˙ b (}v}v]vbP}v]v
RbPP}b]b ]bu}bo˙}]uu]˙}P]vP}(R}]b
v]b]]˙}v}obX
Bo]vP u˙u]o}vb o](Rv]vPX
Iv }R PP}bU Rb uoo v u˙ b}]
`]RR]v.o]b}bXP}buv}boo]vP]bb]}}
`Rv `}uv `R} Rb }b R]vP uvb}v (} vr } u}
u}vRbP]vb}oP]vXOb]}voo˙o]vP(}uRu
vRu˙}v(b`]RPv]oo]vPX
Tuv]b]Rb(}vX
sueCa
Pre-pubertal girls
v*AbnormalVaginalBleeding*v
yy URou}bo}ob
yy C}]oo}vb}v.ouv
yy Tu
Y}vPA}obvb
yy D˙b(v}vo]vo]vP
yy C}uo]}vb}(Pvv˙
yy C}]oo}vb}v.ouv
yy A]vouob]}vb}(ovP]v
W}uv}(CR]oB]vPAP
yy C}uo]}vb }( Pvv˙U ]vo]vP }] Pvv˙U }}v
vR}]}]v}u
yy C}]oo}vb
yy Ub }( R}u}vo uR}b }( }v}v } ]v]v
}v]~IUCD Z
yy Cervical cancer
yy F]}]b
yy D˙b(v}voo]vP
Peri-menopausal Women
yy D˙b(v}vo]vo]vP
yy Aoo}Rbo]b(}`}uv}(R]o]vPPob}o˙
Post-menopausal Women
yy Po]vbbRb]ovUv}u]ovUP]vo}
ovv}]vu}b
yy W]Rò(}u}b}PvR˙
yy }R] A P]v]b
yy Ev}u]b
yy Coital tears
yy URovo
w
Standard Trtme
Symptoms
yy VP]voo]vP`R]R]b(}uv}uouvbo'v
yy M˙b}]o}`}u]vo]v}˙buv}R}
yy S˙u}ub}(vu]~]]vbbUo]}vbU˙b (PXZ
Signs
yy S]Pvb}(vu]~](R˙o]vPZ
yy ORb]Pvbo}b
Invtiga
se tions
yy FBC
yy S]lo]vPb
yy Bo}}o}hvPvb XPXP}R}u]vu UINR
yy Po]ob}vv b ~}o}o]ob]}vbZ
yy U]vo˙b]b
yy D]Pv}b D]o}v v 'PC ~DD CZ (} `}uv }( R]o
]vPPv}buv}bo`}uv
Trtme
ae nt
v*AbnormalVaginalBleeding*v
Tuv}ib
yy T}b]v`Rvbb˙
yy T}.vRb}(o]vP
yy T}v}b Ro]vP
yy VP]vo}]orb]vP]vR
yy Iv]o}]v}uo}}vr]v}v
yy SP˙~u˙}u}u˙UR˙b}u˙U}}R}}u˙XZ
yy R]}vR˙(}vb
AX D˙b(v}vo]vo]vPWu]oo]vP
st
L]vTuv
]v
E RvPPB
yy Norethisterone acetateU }oU æ uP R}o˙ (} r ˙b ~} }b
o]vPZ
Then
æuPR}o˙~˙bı}v}(˙o}vo]vPZ
nd
L]vTuv
]v
E RvPPB
yy M(vu]A] U}oUæuPR}o˙}v˙b}æ}(˙o
~Eb]oo˙](b}]`]R˙buv}R}Z
B. Life threatening bleeding
st
L]vTuv
]v
E RvPPA
yy IVG]bvo}}vb(b]}v]b
w
ce alDisorsder
Av
]v
E RvPPA
yy Tv˘u]A] U}o}IVUPvrR}o˙(}r˙bw
nd
L]vTuv
]v
E RvPPB
yy M(vu] A] U bo}` IV ]vi}vU æ uP R}o˙ ~˙b } æ }(
˙oZ
C. For recurrent or protracted abnormal bleeding
st
L]vTuv
]v
E RvPA
L}`}b}o}v]oo]o˙(}rv˙ob}o}vP
yy R]v˙ob
E ]}oA=o}v}Pbo
Or
yy Ethinylestradiol + norethisterone
nd
L]vTuv
]v
E RvPPC
yy C}viP}b}Pv U}oUXærXæuP]o˙(}r˙b
v*AbnormalVaginalDischager *v
Av
]v
E RvPPA
yy NorethisteroneU}oUæruPR}o˙(}˙b~˙bæræZ
Or
]vE RvPPB
yy M}˘˙}Pb}v U }oU ær uP ]o˙ (} ær ˙b
~˙bı}v}(˙oZ
Refeal
r Criteria
R( oo `}uv `]R R˙ uvbo o]vP vl} v}uo
P]vo o]vP v} b}v]vP } R˙ } P˙v}o}P]b (}
}uRvb]buvvuvPuvX
129. Av}uoVP]voD]bRP
WR]o P]vo ]bRP ]b v}o o]v]o ( }( S˘oo˙
Tvbu]'Iv(}v~STI Z Uv}oo(}ub}(P]vo]bRPv}uo
} ]v]}( v STIX VP]vo ]bRP u˙ b}] `]R v}uo
R˙b]}o}P]oRvPbbRR b uvbo˙o}Pvv˙XIvb
]bRPu˙ ob} } `]R Rbv } b }( (}]Pvvbb
bRbRIvU]vC}v]D ~IUCD ZX
(o
C R]b}˙ l]vP bR}o o `RR P]vo ]bRP
]b v}uo v ]( ] ]b b}] `]R b }( Ru]o vbb XPX
}]o bo(ru]}vU }R]vP `]R b] vbb }
]v } STI X CRvPb ]v R R]bb }( `}uv[b P]vo
]bRP ]R ]v }o}U }}U u}v v bv }( ]}vo
w
Standard Trtme
˙u}ub
b v b]Pvb bR b b}vbb v ]R]vbb ]v] v (}
u]o'v}vX
Av}uoP]vo ]bRP } STIb u˙bo ]v b]}b o]
]vGuu}v `]R bo bR b }] Pvv˙ v ]v(o]˙X
(o C ]blbuv]bR(}]~bv}o}`Z}(`}uv
bvvP`]RP]vo]bRP]v}}]v(˙R}bb]ob
v }] }] uv P]uvb b }v R u}b o]lo˙
}o}P˙ }( R P]vo ]bRPX F}b R ub ob} }vb]
`Rv bovP uv (} vb ]vo Pvv˙ b v
v]b}u(}X
A]}voo˙U R ˙v}u] b }R ub b } b R
vU]v(˙]bl(}bvRo]lo˙b}(]v(}vX
sueCa
yy STIro
yy Trichomonas vaginalis~Pv}˙oo}Ùbuoo˙Uo˙}(}R˙
]bRPb}]`]R]R]vPZ
yy Hbb]uo˘]b ~(}oo}`]vP˘vb].b]b}}(]v( r
}vZ
yy N}vSTI ro
yy Candidiasis ~`R]U ou˙ } R]l ]bRP b}] `]R
]R]vPZ
yy ]o B P]v}b]b ~P˙ } `R]U .bR˙ buoo]vP ]bRPU b r
]oo˙L˘o b ]v}bZ
yy Gardnerella vaginalis
yy F}]Pv}]b
yy Ho}vb
Symptoms
yy Av}uo P]vo ]bRP r RvP ]v }o}U }}U }vb]bv˙
}u}v
yy Voo]R]vP
yy Vooòo]vP b
yy P]v}v]v}v
yy L}`}u]vo}l]v
Signs
yy Av}uoP]vo]bRP
yy Vooòo]vP b
yy Voo˙Ru
yy L}`}u]vovvbb
yy C]o˘]}vvvbb
yy C]ou}b}}b]}vb~}vbou˘u]v}vZ
Invtiga
se tions
yy H]PRP]vo`b (}u]}b}˙Uovbvb]]˙~](]ooZ
w
ce alDisorsder
Trtme
ae nt
Tuv}ib
yy T}]v(˙vv}vrSTI P]v]b
yy T}bSTI ]blvSTIro]v(}vb}]o˙
yy T}v}uo]}vbvbo
yy T}}Rvbb]uov}bo˙buRb}bb]o
yy P}u}P}}]rvovPv]oR˙P]v
yy Ev}Pb}(o}}b}'}vv`
yy D˙v`}]vRbv
yy Kv`˙
yy }] A }R]vP`]RRo}Ru]o}vb
yy }] A b}(u]b}b
B}˘rP) R]blbuv
Pubb]vR]blbuv(}]]bP
]XPv[bv]b˙u}u
b ~]XXvRbRo]bRPZ
]]XPv]bobbRv˙b}o
]]]XPv]bb]vPo
]XPvRbu}Rv}v˘o b v
XPvRbRv`˘o b v]vRobu}vRb
TR]blbuv]bb]} }b]vuv(}]]b]b}u r
uv](
TRvb`}~]Z]b˙b}
TRvb`}v˙}(]ub~]]Zr~Z]b˙bX
I(`}uvRbP]vo]bRP`]Rv}}b]]bl(}U(}P]v]b
o}vX
I( bR Rb P]vo ]bRPU v }b]]bl (}U (} }RP]v]b
v]]bX
AX Tuv(}VP]v]b due to trichomoniasis and bacterial

vaginosis
]v
E RvPPB
yy M}v]}o U }oU uP R}o˙ (} æ ˙b ~}v]v]
]vPR]ub
b }(Pvv˙Z
Or
yy M}v]}o U}oUPX b ~}v]v]]vPR]ub b r
}(Pvv˙Z
Or
yy Sv]}o U }oU PX
b ~}v]v]]vP R b ]ub
}(Pvv˙Z
BX Tuv(}VP]v]b due to trichomoniasis and bacterial
vaginosis for pregnant women in the 1st trimester
yy Co]vu˙]v uU A9U P]voU Ov o]} (oo u (}
˙bw
wæ
Standard Trtme
CX Tuv(}VP]v]b due to Candidiasis
yy Fo}v}o U}oU
Uv}uo]PæuPX b b]vPo}b
C}uo]PæuPwR}o˙(}}bb
RvP æ uP ]o˙ (} } ˙b (}oo}`˙ æ uP }v
`lo˙(}vu}vRb
Or
yy Co}]u}o U P]vo obU uP ]vb ]v} P]v v]PR
(}˙b
Or
yy M]}v}o P]vo obU uP ]vb ]v}P]v v]PR (}
˙b
Av
yy C o}]u}o uU P]voU A9 } A9U Ao˙ `] ]o˙ (} } w
˙b~(}oo]]}vZ
X
D Tuv(}C]]b due to gonorrhoea
st
L]vTuv
]v
E RvPPB
yy .˘]u
C U}oUuPX
b
Av
yy A]R}u˙]v U}oUPX
b
nd
L]vTuv
]v
E RvPPB
yy L]˘}v
C UIMUæuPXb
Av
yy A]R}u˙]v U}oUPX
b
EXTuv(}C]]b due to Chlamydia
st
L]vTuv
]vE RvPPA
yy D}˘˙˙o]v U}oUuPR}o˙(}˙bw ~}]]vPvvv
vb]vPu}RbZ
Or
yy E˙R}u˙]v U}oUæuPvR}o˙(}˙bw
Or
yy A]R}u˙]v U}oUPX b ~}uuv]vPvv˙Z
Refeal
r Criteria
R( oo b }( v P]vo ]bRP vl} uv
(]ob } RoR (]o]˙ `R bou ˘u]v}v v ]
} v u]}]}o}P]o ov vu]}]o bvb]]˙bv
}v}vRP]vo]bRPX
wv
ce alDisorsder
Flowchatr
F]PrP) Fo}`RPAv}uoVP]voD]bRP~W]R}SouZ
w
Standard Trtme
Flowchatr
F]PrP) Fo}`RPVP]voD]bRP`]RSouAvB]uvo
E˘u]v}v
w
ce alDisorsder
130. AL}À}u]voP]v
A o}` }u]vo ]v ]v `}uv u˙ Rob bX
TRb ]vo Po] IvGuu}˙ D]bb ~PID Z U }]
Pvv˙ v b }}vX TR o' `} P]o b uPv]bU
`R]R ] ˘u Pv˙ ]v R] uvPuv ~S b}vb }v
RE}]PPvv˙[vRA}}vb[ZX
PID ]b b ˙ }Pv]bub `R]R u˙ S˘oo˙ Tvbu]'
Iv(}v ~STI Z ro } }R ] R bv (}u R o}`
Pv]ov}]vGuu}v}(RbU(oo}]vbv
}R]v b Ro]bXH}ÙL˘o]vP}]Pvv˙U
STIro}Pv]bubRu}bo]lo˙}( b o}`}u]vo]v]v
˘oo˙
b `}uv`R}Rbv}vo˙o]˙U}Rbv}
}b vR]b}˙}(]v]vbuv}vX
TR bv }( ]v]v }v ]b ~IUCD Z (}b
Ro}uv}(PID oo˙]vRu}vR(}oo}`]vP]vb}vX
sueCa
v*AcuteLowerAbdominalPain*v
yy }] E Pvv˙
yy Av]]b
yy O]v}b]}v
yy STIro
yy N}vSTI ro~XP]v˙]v(}vZ
yy S}}v
yy P}bub]b
yy F}]Pv}˙]vo]vPIUCD
Symptoms
yy F
yy L}`}u]vo]v
yy P]v`]R˘o b ]v}b~˙bv]Z
yy O+vb]P]vo]bRP
yy D˙b]}Ro]b}u(}
Signs
yy Av}uoP]vo]bRP
yy Tvvbb }v u}]vP R ]˘ ~]o ˘]}vZ }v ]uvo
P]vo˘u]v}v
yy L}`}u]vovvbb
yy Av˘ovvbb
yy Av˘oubb
Invtiga
se tions
yy Po]ob}v
yy PPvv˙~]( b ˘oo˙
b vuv}R}bvZ
yy H]PRP]vo`b ovbvb]]˙
wı
Standard Trtme
Trtme
ae nt
Tuv}ib
yy T}]v(˙vuvP}voo](Rv]vPbXPX}]
yy T}v˙vo˙]vP]o]v(}v
yy T}o]]vv]vGuu}v
yy SP˙`R]v]
yy Ru}IUDU](bvU˙bL]v]}v}(PR˙
AXF}Po]]vGuu}˙D]bb (mild cases)
st
L]vTuv
]v
E RvPPB
yy C]}G}˘]v U}oUæuPR}o˙(}˙b
Av
yy D}˘˙˙o]v U}oUuPR}o˙(}˙b
Av
yy M}v]}o U}oUuPR}o˙(}˙b
B}˘rP)
C}vb]R}b]o]}v}(o]vR(}oo}`]vPbP
yy WRP]o
b uPv]bXPX}]Uv]]bvv}˘oX
yy TR v ]b Pvv ~PID ]b v}uu}v ]v Pvv˙U b]oo˙ L
R.b]ubZX
yy TRv}bv}b}vo]v]oo˙}}ovu]}]oR˙X
yy TRv]bvo}(}oo}`}}ov}v}oP]uvX
yy TRvRb]oovb
b bUb}]`]Rvbv}u]vP U}R]PR
X(
yy TRvRb}r}]vbX
yy HIV ]v(}v
yy Y}Rl}obvb~oo˙](}uo]v]bv]bbZ
BXF}Po]]vGuu}˙D]bb (severe cases)

yy L]˘}v
C UIMUæuP]o˙(}˙b
Av
yy D}˘˙˙o]v U}oUuPR}o˙(}˙b
Av
yy M}v]}o UIVUæuPR}o˙(}˙b
Then
yy D }˘˙˙o]v U}oUuPR}o˙(}˙b
vA
yy M}v]}o U}oUuPR}o˙(}˙b
N}ræ
TRb}(]}G}˘]vv}˘˙˙o]v]b}v]v]]vPvvvo r
vP`}uvX
ce alDisorsder
C. Pain relief
yy D]o}(v UoU }oU IMU ær uP } R}o˙ ~u˘X uP
`]]o˙Z
Or
yy M(vu]A] U}oUæuPR}o˙
Refeal
r Criteria
R(}P˙v}o}P]b}PvoP}v
b ](R]bv}]u}uv
}](o]b]bXb
Flowchatr
F]PræP)Fo}`RPL}`
A A}u]voP]v
Standard Trtme
131. FuoIv(o]˙
P]u˙]v(o]˙ ]bb]}}`Rv}oRbvR]
Pvv˙ b] ob }v ˙ }( v]v v
v} ˘ob ]v}bX S}v˙ ]v(o]˙ ]uo]b R R
Rb v ]}b Pvv˙X I ]b }Lv vbb˙ } o }R
vb b]uov}bo˙ v } o]] ˘o
b U uvbo v }b]
R]b}˙U b R]b}˙ }( Po] IvGuu}˙ D]bb ~PID Z v S˘oo˙
Tvbu]'Iv(}vb~STIbZU}v}vvb }Rb]Pv].vb
u]oR]b}˙X
sueCa
Female factors
yy Oo}v(]o
yy P}o˙˙b}]v˙v}u b ~PCOSZ
yy H˙}ovu]
yy Po](}b
yy C}vPv]ouo(}u}vb}(X b
yy Tubal disease
yy Po]Rb]}vb
v*FemaleInfetility*
yy U]v.}]b
yy Ev}u]}b]b
yy Cervical factors
r
Male factors
yy Oo]P}bu]
v
yy }}bA u]
yy Pv]ovob v}uo]b
yy oE ˙b(v}v
Symptoms
yy Iv]o]˙ } R] Pvv˙ b] Po v} ˘b
obrub`lo˙
yy Auv}R} ~(uobZ
yy Iu}v ~uobZ
Signs
Female
yy bv A }(}v˙
b ˘ob R]bb
yy V]]o]b}v RvPb ~R]bbuU o]}}uPo˙U v]vP }( }]
XZ
yy Galactorrhoea
yy A}u]voub}b ]v}}]vvoPuv
yy Av}uoP]vo]bRP]v]}(]v(}v
Male
yy Av}uov]o]bRP]v]}(]v(}v
yy bv A }(}v˙
b ˘ob R]bb
yy Tbov}uo]bXPX]}}obUbuoo}bvb
ce alDisorsder
Invtiga
se tions
yy FBU C S]lo]vP
yy H]PRP]vo`b
yy Bo}}Po}b
yy H˙b}rSo]vP}Pu~b}vvG}}b}]P]vZX
yy Suvvo˙b]b
yy Su}Pb}voo]vu]rooRb~˙r}(uvbo
˙o}Z Rl(}}o}v
yy TR˙}](v}vb
yy FR R}u}vo ]bb XPX Su LHU FSHU Su Tb}b}vU
P}ov}}v˙b]o]b
Trtme
ae nt
Tuv}ib
yy T}Rvo˙]vPb}(R]v(o]˙](}bb]o
yy T}R]Pvv˙`]R]vRbR}b}bb]ou
yy C}vboo]vP
yy U]vUTovTboP˙ b `Rv
v*FemaleInfetility*
yy Ab]b R}}v TRv}o}P]b XPX A.]o ]vbu]v}vU Ivr
]}r(o]}v`]Ru˙}vb(`R]v]
r
A. F]o}(}o}v
v
st
L]vTuv
]v
E RvPPA
yy Co}u](v ] U }oU æ uP ]o˙ (} æ˙bUvP
b `v R
vvæR˙}(Ruvbo˙oX
B. H˙}ovu]
st
L]vTuv
]v
E RvPPA
yy }u}]v
B U}oUXæuPv}(}˙bw ~`]RRv]vPuo
}uZXIvb`lo˙}u˘X}(XæuPR}o˙
Refeal
r Criteria
o˙E (o}(oovb`]R]v(o]˙}b]o]b]b(U
oo˙ `}uv `]R ]vU }]v } o ]bb ]]vP
P˙
b } `R} ] }o}v ]v}v v} b}vb] } o}u](v
]XAob}(uovb(}]`˙}o}P]bX
Standard Trtme
132. Menopause
Menopause (b } R }]v ]v u `Rv uvv }v b
}( uvb}v }b } o}bb }( }]v (v}vX TR }v b
}( uvbb ]b ˙ ]ruv}bo Rb ]vP `R]R R
u˙ uvbo ]Po]˙X TR P }vb ]b boo˙ `v æ
v ææ ˙bX A `}uv ]b }vb]} uv}bo ]( R Rb v}
v uvb}v (} ]} }( ob u}vRb ]v R bv
}( Pvv˙X Mv}b u˙ b}] `]R R˙b]oU u}}voU
v ˙R}o}P]o
b Ro }( ˙]vP ]vvb]˙ ]v b}u `}uvX S]˘˙
v }( uv}bo `}uv R}` R u]o ˙u}ub b }
˙u}ub X TR ]bl }( }b}}}b]b v ]}bo ]bb
]vbLRuv}bX
sueCa
yy Avoo](v}RP]vP}(R]v]]o
yy SP]ou}o}(R}]b~]oo}}R}}u˙Z
yy Po]]]}v
yy Pu}]v(]o
yy P]]˙uP(}u]u˙}bruRu}RP~SRRv[b
˙v}u
b Z
v*Menopuse*a v
yy C˙}}˘]~vvZR˙
Symptoms
yy H}GbRb~R}v]vP]vR(UvlvRb`]Rbov
`vP
b Z
yy TRGbRbu˙b}]`]R
yy Po]}vb
yy F]vvbb
yy D]]vbb
yy FP
yy Wlvbb
yy Eu}}vov˙R}o}P]o b }oub]voP
yy M}}RvPb
yy b]}v
D
yy Av˘]˙
yy Nervousness
yy I]]o]˙
yy L}bb}(o]]}
yy VP]vo˙vbbv˙bv]
yy S˙u}ub}}R]RvPb]vRPv]oP
yy Ivb(v˙}(u]]}vv˙b]X
yy Sbb ]v}vvv ~]v˙ ]v}vvv `]R }PR]vP }
]v]vP
b Z
Signs
yy Uboo˙v}v
ce alDisorsder
Invtiga
se tions
yy SuLHUFSHUOb]}o
yy R}v]vbP}vbXPXFBU
C o}}Po}bUo]]}.o
yy U]v}o}}Pvv˙b~}˘oPvv˙Z
Trtme
ae nt
Tuv}ib
yy T} }v}o }Rb}u ˙u}ub
b XPX b R} GbRbU }R]
P]v]bvv˙bb
yy T}v]}bou}]]˙
yy T} v }b}}}b]b b]oo˙ ]v ]v]]ob `]R u
uv}b
yy C}vboo]vPvvb
yy Ev}Po](b˙obURoR˙]U˘]bvPoR˙b]o
Rlb(}}uu}vu]o}oub
AXH}u}vRouvTR˙~HRT ) for women with intact
uterus
st
L]vTuv
v*Menopuse*a v
]v
E RvPPA
yy C}u]v}viP}b}Pvbv}Pb}PvU }oU
~ ob R }v]v]vP }viP}b}Pvbrvæ u]}Pub
]vo]vPob}v]v]vPv}Pboræu]}PubZ
Ovo]o˙
Or
yy C}viP}b}Pv vv}PbooU}oU
~væu]}Puvæu]}PuZ
o]o˙}v˙bwr}(Rr˙uv˙oV
BXH}u}vRouvTR˙~HRT ) for women with previous
hysterectomy
]v
E RvPPA
yy C}viP}b}Pvb U}oUvæu]}Pu]o˙
C. For relief of vaginal symptoms only
]v
E RvPPA
yy Ob}Pvu UP]voUo˙}]oo˙}v]o˙
N}rv
W}uv`]R]vbR}ovP]v}b}Pvbo}vX
vC ]v bPPbb R R}u}v ouv R˙ ]v R uv} r
b}bv}v}}v˙R]bb}}lb b X
HRT ]vbb R ]bl }( v}b R}u}ru}o] Rv}uvU b v
v v}u]ovL}o}vPb v bR}o R(} P]v (}
RbR}b}bb]ou`Rv]v]
æ
Standard Trtme
Refeal
r Criteria
R( b `]R }b}}}b]b } b vu]hvP ˙u}ub
b }
Rb]o]bX
133. Carcinoma of the Cervix

]v}u
C }( R ]˘ ]b R }uu}vb (}u }( (uo Pv]o
v bv ]v GRvX WR]o R ]bb ]b voU ]v GRvU R
bv }( v + v]vP b ˙bb u Rb bo ]v u}b b
bvvP o `]R v ]bbX Iv o} }v]bU R
]v]v }( ]o v Rb (oov }vb]o˙ } Po
v]vP
b }b ~XPX P bu U ]bo ]vb}v `]R ]U
HuvP]oo}uV]b HPV ZX b
V]v}vP]vbvrb]vPHPV ]v(}v]bR]ouR}
(} ]u˙ v}v }( ]o vX Tuv }( ]o v
]b R b]b }( P˙v}o}P]o }v}o}P]b v ]}R]bX
Tuv ]vob P˙ b vl} ]}v vl} Ru}R˙X
v*Ccinoma
SP˙]v}obu}o}(Rvou}bòobRo˙uRb
ar
]v]vP R ~WR]u[b R˙b}u˙ ZX TR]b ˘vb] P˙

b
ofthevix
bR}o ] } }vo˙ ˙ ]v b]o]bbX R]}v uv

Cer *v
}Lv]v}obo}o]o]]]}vX
sueCa
yy Huv]oo}u]b ~}vb(}A9}(bZ
yy Associated risk factors include:
yy S˘o}u]b]˙
yy MooR]o]Rb
yy Iv(}vb`]RHbS]uo˘H}u]v]b˙IIUHIV
yy Su}l]vP
yy L}`b}]}r}v}u]b
yy Fu]o˙R]b}˙
Symptoms
yy ˙u}u Ab ~]Pv}b}v}v]ov]vP b Z
yy S˙u}u~v]bbZ
yy Av}uoP]voo]vP
yy Iv`vPouvbo]}b
yy AL˘o b ]v}b
yy P}buv}boo]vP
yy Av}uoP]vo]bRP
yy L}`}u]vo]v
yy P]v]vP˘o b ]v}b
yy W]PRo}bb
yy U]v˙˙u}ub b XPX˙b]U(v˙U]v}vvv
yy Rectal pain
v
ce alDisorsder
Signs
yy o˙ E ]bbP}bE ]}v}(]˘}RvPb}(R}v]]]b
yy Llv ]bbP Uo } (vPvP ]o ob]}v }v
bou˘u]v}v
Invtiga
se tions
yy Cervical biopsy
yy FBCvb]lo]vPb
yy Bo}}vo}o˙b
yy Suv]v C
yy Su]]
yy CRbXr˙
yy Uob}v}(K]v˙b
yy CTSvv}MPvRb}vvIuP]vP~}}v}b
vub}b RovPbvo]Z
yy Po]˘u]v}vvvbRb]
yy C˙b}b}˙ v }}b}˙ `]R } `]R} ]}b˙ } oo}`
]bo]b}v}(b]o}ou}b
Trtme
ae nt
v*Ccinoma
ar
Tuv}ib
ofthevix
yy T}vou}
Cer *v
yy T} b }( u} b `]R R ]u }( ]vP R
disease
yy SP˙
yy Radiotherapy
yy }u]v}v A }(P˙b Uv]}R˙
]v
E RvPPA
yy AivRu}R˙ ~Sb}v}v(oo}`Z
Refeal r Criteria
Aoovb ub (} b]o]b(}o}v} ]
}vP b }(]bbvu} b }(uvXTuv}(]v}u
}(R]˘]b}v b ]vR}b]ovb]o]buX
w
Chapter
Disorsof
der theKidneyand
Genitourinayr System
X Go}uo}vR]b
A
TR]b]b]bR]b
b ˙uP}RPo}uo.o}v
bU `R]R b }]v v o}} } ol ]v} R ]vX
MRv]bub (} R Po}uo uPu˙ ]uuvru]X TR]b
}v]}vu˙b}]`]RR˙vb]}vvG]v}vX
sueCa
yy P}b}}o b ]v(}vb~R˙vPo}bl]v]v(}vbZ
yy Iv(]bb
yy OR]oIv(}vbXPXbou}voo
yy Hb B]bUHbC]bUHIV
yy Pb]XPXSR]b}b}uUMo]
yy S˙bu]ob˙Ru}bb v}Rbo]b
Symptoms
yy AR]b}˙}(]vP]v(}v
yy Gvo]}uu}bul}vR˙b
yy Rob B bvbb
yy Av}˘] ~b}uubb}]`]R}u]vP v}u]vo]vZ
yy F
yy S]b
yy Scanty urine
yy Hu]
Signs
yy Ou
yy Oo]P]~]v}oubAMuol˙Z
yy Hypertension
yy Hu]
yy Dl}o}]v
yy Acute heart failure
yy C}u
Invtiga
se tions
yy U]vo˙b]b
Chatep rP *Disorsof
der theKidneyandGenitourinayr System
yy S]uv bR}`b ˙R}˙bU ol}˙b v ]˙ }( b
]vo]vP˙R}˙b
yy P}]v]boo˙obRv b P lR}bu˙]vRvR}
vP
yy FBC
yy BUEvv]v
C
yy TR}ob~]vR]ovu˙(o b Z
yy CRbXr˙~u˙bR}òu}v˙}uZ
yy ECG
yy Iuuv}o}P˙~XPXANA UAvDbDNAZ
yy ASO~vb}o˙b]vObZ
yy Uob}v}(l]v˙b
Trtme
ae nt
Tuv}ib
yy T}]v(˙v}b Rb}(vo]vi˙
yy T}vv}v}o}uo]}vb
v*AcuteGlomerulonephritis*v
yy b B
yy So]}v b ]v]
yy C}v}oG]ovP
Adults
C}v}oG]v}v˙]vP
b ]o˙G]]vl} uoob
]}b˙[b]v}X
Children
Rb]G]b}uolu}(}˙b(v]}b˙[b
]v}X
AX F}G]v}v]vP}br]v(}bGo}uo}vR]b
]v
E RvPPB
yy F}bu] U}o}IVU
Adult
uP]o˙U]vb]vP}uP]o˙
Children
u}vRr ˙bV r uP llP l˙ ]v]oo˙X Ivb ˙ r uP llP
R}o˙}u˘X}(vuP llP˙Uv}}˘uP˙X
Neonates
XæruP llP}R}o˙Vu˘XuP llPX
BX F}R˙vb]}v]vP}br]v(}bGo}uo}vR]b
yy To}}~S b b}v}vRH˙vb]}v [Z
Refeal
r Criteria
R( oo vb `]R }uo]}vb }( vo (]oU b]
failure and hypertensive encephalopathy R ]b (}oo}`]vP }b
]v(}bPo}uo}vR]b}R˙b]]vb]o]b}vR}o}P]bX
ı
Standard Trtme
Pvb `]R }R b bR b ob vR]b } ˙bb u]
bo]bUbR}oob}(}R˙b]]vb]o]b}vR}o}P]bX
135. NR}S˙v}u
TR]b}v]}v]bb}]`]R}]v]]v˘b}(
b rXæP lXw
u ]o˙ }uv] ˙ R˙}ou]vu] U }uU R˙o]]u]
vR˙}PooXb D]bbR}o`]R
b }vvv}
P]v}v
b ]vR]ov`]RvR}˙v}u b X
sueCa
yy P]u˙Go}uoD]bb
yy M]v]uoRvP]bb r}uu}v]vR]ov
yy F}ovbPuvoPo}uo}bo}b]b
yy Muv}bvR}R˙
yy Muv}b}o](Po}uo}vR]b
yy Iv(}vb
yy ]o B ~P}b}}o
b ]v(}vZ
yy V]orHb BvU
C HIV
yy Pb] ~ Plasmodium malariaeUSchistosoma mansoniU F]o] r
v*NephroticSyndome
sisZ
yy S˙bu]D]bb
yy D]buoo]b
r *v
yy S˙bu]LbE˙Ru}bb
yy Au˙o}]}b]b
yy DPro
yy N}v}]o b vr]vGuu}˙Pb
Symptoms
yy o˙ E u}v]vP(]o8vbb
yy Gvo]}˙òo]vPb
yy F}u˙v}(]v
yy W]PRP]v~v]vv}voZ
yy P}}
Signs
yy P]}]oU]RoUPv]o}u
yy Ascites
yy Poo+b]}v
yy P}]v uov]}v oo˙ ]v R]ov `]R o}vP v]vP
b
disease
Invtiga
se tions
yy U]vo˙b]b
yy BUEvv]v
yy Suou]v
yy Suo]]b
yy FbvPo}}Po}b
ı
Chatep rP *Disorsof
yy S}o}P˙rHb U
B U
C HIV
yy Hb electrophoresis
yy Avvov}˙~ANA Z
yy Uob}v}(l]v˙b
Trtme
ae nt
Tuv}ib
yy T}o]˙u}ub b
yy T}vo˙]vP}v]}v
yy T}vvuvP}uo]}vb
yy T}o˙}Pbb]l]v˙uP
yy Restrict salt intake
yy }]v A ]VXvrXP llP}˙`]PR}(bobb}]v
~PPbU uU .bRU ]˙}bZ ˙ (} o v r P llP
day for children
AXF}}v}o}(}u
L]vTuv
v*NephroticSyndome
st
]v
E RvPPC
yy F}bu] UIVU
Adult
r *v
ruPrR}o˙~u˘XvuP]o˙Z
Children
R(}b]o]bX
N}r
IvR]ovU(}bu]]b]v
b }viv}v`]Rou]v]v(b]}v}vo˙]vb r
}uX
Or
yy F}bu] U}oU
Adult
uP]o˙U]vb]vP}uP]o˙Vu˘XuP]o˙
Children
R(}b]o]bX
B. For control of resistant oedema
yy F}bu] UIV}}oX~b}(}obvR]ovZ
Av
yy M}o}v U}oU
Adults
XæruP}v]o˙
Children
R(}b]o]bX
ı
Standard Trtme
N}r
D]b bR}o b `]R }v v v} P]v b }v ]v vR}
˙v}u
b ]vR]ovX
C. For control of proteinuria

yy L]b]v}]o U}oU
Adult
æruP]o˙
Av
yy Pv]b}o}vU}oU
Adults
uP llP]o˙
Children
v uP lu } uP llP ]o˙ ~u˘X uPZX F} o}vPru uvP r
uvU(}]]]vX
N}r
C}}b}]b bR}o P]v } R]ov v bo ob `]R u]v]uo
RvPvR}˙v}u b ˙b]o]bb}vo˙X
v*AcuteKidneyInjuy*
Refeal
r Criteria
R( oo vb } R˙b]]v b]o]bU ]]]v }
vR}o}P]b]uu]o˙L]Pv}b]bv]o]b
b }vX
r v
136. AK]v˙Ivi˙
A K]v˙ Ivi˙ ~AKI Z ]b u R Rb v}` o R u
Rvo
A F]o~ARFZXIb]bbv]v b vo(v}v
}]vP } ]} }( R}b } ˙b bovP ]v uo}v }(
v]}Pv}b `b}b v ]b}v }( o}} }ouU o}o˙
v]rbovX
TR ]+vo ]Pv}b]b }( AKI ]vob vo }u]U vo
~]v]vb]Z v }b vo ~}b vR}R˙Z (}ub }( AKIX TR
u}b ]u}v ]bl (} (} R o}uv }( AKI ]b R bv
}( r˘]bvP R}v] l]v˙ ]bbX OR Rv P}} u]o
`]R }]v }( }ou }v}vU v}v }( R˙}vb]}v
v }]v }( vR}}˘] PvbU v} b]. ]vv}vb R
v o]o˙ u}vb } v R o}uv }( AKIX D]vP
uvPuvU]b G]]vv}RbR}ou]v]vX
AKI Rb v P b ˙ R K]v˙ D]bbP Iu}]vP Go}o
O}ub ~KDIGO ZU AKI `}l]vP P} (} ]˙ b }]vP } R
]]o}`P
KDIGO AKI DEFINITION
Ivi˙Ub}vRAKINC]]
ı
Chatep rP *Disorsof
SP Suv]v]] U]v}]]
XærXıubbo]v}]vb}(AN AMXæuollP lR}(}vrR}b
vXu]}u}o
XrXıubbo]v AMXæuollP lR}(}
ANR}b
Xubbo]v}]vb]vub AMXuollP lR}(}ANR}b
v]v}ANæXvu]}u}olLO Ov](}ANR}b
]v]}v}(]o˙b]b
sueCa
Obstetric
yy S}}v
yy P}brbvb}v
yy Sroub]lEoub]
yy P}buHu}RP~PPH Z
yy HELLP~Hu}o˙b]b EoL]Ev˙ubL}`PooZS˙v}u
Gynaecological
yy B]ooo]P}v}(b(}oo}`]vP}u]voR˙b}u˙
Medical
v*AcuteKidneyInjuy*
yy Go}uo}vR]b
A
yy Hu}o˙b]b due to:
yy Malaria
r v
yy Iv(}v
yy Hou]]vb
yy Typhoid fever
yy GvPD .]v˙
yy D]R} U}u]vP vR˙}v
Surgical
yy Hu}RP
yy P]}v]b
yy Pvb A
yy Ob}R˙
yy Bvb
Symptoms
yy Nauseav}u]vP
yy Oo]P]
yy Anuria
yy Ou
yy b D
yy Moo]]v b u}R
yy Hiccups
yy CRvP]vu}}
yy Fovl]v
yy FP
ı
Standard Trtme
yy D]R}
Signs
yy Uboo˙v}b].b]Pvb
Invtiga
se tions
yy U]vo˙b]b
yy FBC
yy BUEvv]v
yy Su]]
yy Bo}}o
yy U]vo
yy A}u]v}ro]ob}vv b
yy Po]vXr˙}(}uv
Trtme
ae nt
Tuv}ib
yy T}}Pv]bv}b]ob
yy T}v(Rvo]vi˙
yy T}u]v]vv}uoo}o˙vG]}ouu]o]
yy T}u}}˘]`b(}uR}˙~]o˙b]bZ
v*AcuteKidneyInjuy*
yy N]}vPG]}]v}(R]PR]}o}P]ooP}]vl˙]v
obXIvR]ovXrP llP}(obb }]v
b l˙
r v
yy D]o˙`]PR]vP
yy M]v]vG]ov
yy `B }( R˙lou] r }] }bb]u }v]v]vP (}}b XPX
vvbU}}v
st
L]vTuv
]v
E RvPPC
AXTuv}(R˙}}ou]
yy S}]uCRo}] UXıA9UIVU
Or
yy R]vPb o ~]( R ]b v} R˙lou]Z ]v b }( ]R}
v}u]vP
Or
yy Bo}}vb(b]}v ~]vo]vP
b Z
Or
yy Pobuouv ~]vb}(vbb ZX
N}r
IvR]ovUP]ruollPG]}obbX
BXT}rbo]bR]b]bLG]ouv
yy F}bu] UIVU
ı
Chatep rP *Disorsof
Adult
ruPX
b
Children
ruP llPX
b D}v}X
C. Control of hyperkalaemia
Adult
yy Co]u Po}v A9UIVUruoUbo}ÌVU}ræu]vb
vA
yy S}ooIvbo]v UIVUv]b]væruo˘}b
D æA9
vA
yy S}]u]}v UIVUXA9~æuE]væuorZ uollP}æu]v r
utes
N}ræ
D}v}u]˘o]uPo}vv]}v]vRbuo]˙˙bb uX
Children
yy Sou}oUvo]bU~(Z
ANælPV æuP
AMælPV XæuP
v*AcuteKidneyInjuy*
Or
yy Co]u Po}v A9UIVUXæruollPUbo}ÌVU}æru]vb
r v
Av
yy S}oo Ivbo]v UIVUXv]b ]væuo˘}b
D A9UP]XæræuollP l
R}XKo}}Po}bræuu}olLX
Av
utes
N}rv
D. Tuv}(R˙vb]}v]bblvRo}R˙
~Sb}v}vRH˙vb]}v [Z
N}rw
Iv]}vb(}]o˙b]b
yy }vPb
C R(]o
yy Pou}v˙Ou
yy Eo}o˙ v}uo]b b]oo˙ R˙lou] v} }v}oo ˙ }v r
uvbb
yy Metabolic acidosis
yy Uu]˙u}ub
b ~b]bU]]bZ
yy H˙vb]C]bblEvRo}R˙
ıæ
Standard Trtme
Refeal
r Criteria
Aoo vb `]R o]v]o ]v]}vb (} ]o˙b]b ub (
}uo˙}v`]R(]o]b(}]o˙b]bX
137. CR}v]K]v˙D]bb
CR}v] K]v˙ D]bb ~CKD Z (b } l]v˙ uP }( u}
Rv u}vRb}vX TR o˙ P b }( CKD ]b boo˙ ˙u}u
b
v R}PR o}}˙ b }( bu v]v v
u}v
b }( Go}uo F]o}v R ~GFRZ U ubuv }( ]v
ou]v v]v } v v]vPb }( ]v]]ob ]vb ]bl
bR b R}b `]R R˙vb]}vU ]b uoo]b } b R]b}˙ }(
Po}uo}vR]bX
CKD u˙ uv](b ]R b ]v v}uo]b ~XPX b]bv
u]}ou]v]U }]v]U Ru]ZU o}} v}uo]b ~XPX
ovv]vvub GFRAMıuolu]vlXuw Z
vob l]v˙RvPb}vob}v}PR˙X
F} oo Pbb }( CKD U vb bR}o v}P } b
v*ChronicKidneyDisse*a v
bu}l]vPU`]PR](}bURlo]]bvUv}]NSAIDb
v}RvR}}˘]PbX
TorP) SPb}(CR}v]K]v˙D]bb
SP Db]}v GFR
~uolu]vlXwuZ
K]v˙uP`]Rv}uo}]vbGFR ANı
K]v˙uP`]Ru]o}v]vGFR vrı
M}}v]vGFR ræı
S}v]vGFR ærı
æ K]v˙(]o AMæ
sueCa
yy Chronic hypertension
yy CR}v]Po}uo}vR]b
yy D]buoo]b
yy Ob}R˙
yy Renal calculi
yy P}o˙˙bl]v˙]bb
yy T}˘]vb~PbURbUR˙uobUXZ
yy C}vvb]bb
Symptoms
yy N}v]vRo˙Pb
b
yy R'v}vv}vv}v
yy Av}˘] UvbU}u]vP
ıv
Chatep rP *Disorsof
yy Gb}]vbvoo]vP
yy Hiccups
yy Rob
B bvbb}v˘}v
yy Thirst
yy N}]U}o˙]
yy MboubC
yy PbRb]
yy P]b
yy Ivb}uv]
Signs
yy LRP˙
yy Bo]vP tendency
yy Poo}
yy Hypertension
yy P]]b
yy P]Rov}R˙
yy P]Ro}u
yy ]˘]b Ab ~G]vPu}Z
yy Ivbbl]v]Puv}vvl}˘}]}v
Invtiga
se tions
yy FBU C S]lo]vPUBo}}.ou}uuv
yy U]vo˙b]b
yy Bo}}UUEo}o˙bUSuv]v C
yy Co]u UPR}bR
yy FbvPo}}Po}b
yy L]]b
yy CRbXr˙
yy Uob}v}(l]v˙b
Trtme
ae nt
Tuv}ib
yy T}R}v]l]v˙]bbo˙]vo b ]v]]ob
yy To control hypertension
yy T}}v}oo}}Po}b
yy T}uvPvo˙]vPb
yy T}v}uo]}vbv(R`}bv]vP}(l]v˙(v}v
yy }] A vR}}˘]vbXPXNSAIDb URou]}v
yy D]o˙ ]vl }( G] }( v uo } ]}b ˙ [b ]v } (}
ob~uolu}˙b(]vR]ovZ
yy Restrict salt intake
yy Rb]]˙}]v}PullP l˙
yy }] A }bb]u}v]v]vP(}}bXPXvvb
yy D]o˙b]b~(}vR}o}P]bZ
ıw
Standard Trtme
AXT}}v}oG]}o}
st
L]vTuv
]v
E RvPPC
yy F}bu] U}o}IVUruP]o˙
B. Treatment of hypertension
~Sb}v}vRH˙vb]}v [Z
C. Treatment of renal anaemia
~Sb}v}vRAvu] ]vCR}v]K]v˙D]bb [Z
D. Control of hyperkalaemia
Adult
yy Co]u Po}v A9UIVUruoUbo}ÌVU}ræu]vb
vA
yy S}ooIvbo]v UIVUv]b]væruo˘}b
D æA9
vA
utes
N}r
Children
yy Sou}oUvo]bU~(Z
ANælPV æuP
AMælPV XæuP
Or
yy Co]u Po}v A9UIVUXæruollPUbo}ÌVU}æru]vb
Av
yy S}oo Ivbo]v UIVUXv]b ]væuo˘}b
D A9UP]XæræuollP l
R}XKo}}Po}bræuu}olLX
Av
yy S}]u ]}v U IVU XA9 ~æ uEZ } æ u]vbU r uu}ol
lP~ruollPZ
N}rı
Refeal
r Criteria
R( oo vb `]R ]b}b]vP (}b v }uo]}vb }
R˙b]]v b]o]b } vR}o}P]b (} (R .v] uvPuv
}( R}v] l]v˙ ]bbX R( oo vb ]]vP ]o˙b]b }
vR}o}P]bX
ı
Chatep rP *Disorsof
TorP) Suu˙}(uvPuv}(]}bPb
b }(CKD
CKD STAGE SCDE RIPTION CTION
A
K]v˙uP`]R D]Pv}b]bvuvPSo}`}Pbb]}v
v}uo}GFR ˙uo}bBP}v}oUAvvo(}oo}`
UGFRUU]vo˙b]bvU]vP}]v
v]v}ubuvb
K]v˙uP`]R uEb }Pbb]}vvuvPb
u]oo˙bGFR Pb
Moderately decreased uEb v}uo]}vbPI(HAM
GFR P lLRlF]v UB v(}oXAvvo
Rl}(buo]uUR}bRv
PTHXR(](GFRAGuolu]vlXw u
So˙bGFR P(}l]v˙ouvR˙P
Refer
æ K]v˙F]o K]v˙ouvR˙PD]o˙b]b}
vbov}vPR(
v*AnaemiainChronicKidneyDisse*a v
138. Avu] ]vCR}v]K]v˙D]bb
Avu] o}b o˙ ]v R }b }( CR}v] K]v˙ D]bb
~CKD Z v ]b vo˙ v]bo ]v vb `]R CKD P
b æ ~EvrbP
l]v˙]bbZXTRov}(vu]R]PRoob}(Po}uo
.o}v~GFRZ ~]XXCKDP b r]bZ oo˙o}`]v]v]]ob(}u
RPvo}o}vXAvu]}(CKD]b]u]o˙b˙.]v˙
}( ˙R}}]vX TR l]v˙b R ui} b} }( ˙R}}]v
vU b vo (v}v o]vbU }}v }( ˙R}}]v o]vb
}}}vo˙X
TR}PR ˙R}}]v .]v˙ ]b }uu}v u}vP vb `]R
vu]]vCKDU}R}vovb }v]vP]b}bbR}o
]v.}˘o](]v]oo}v˙]ob]v(}]b}b
}R Rv ]}v .]v˙ } ˙R}}]v .]v˙X C}}v }(
vu]]vCKDvb]u}bb]ovo]˙}(o](X
sueCa
yy .]v˙ D }(˙R}}]v
yy R oo }v b (}u u]}bo ]bb (}u ]b }
hypertension
yy IvbPb}]vbvoo]vP
yy Ivb}˘]bo]vP}bR}voob]o
Symptoms
~Sb}v}vRAvu] [Z
ıı
Standard Trtme
Signs
~Sb}v}vRAvu] [Z
Invtiga
se tions
yy FBC
yy Ro}˙}v
yy Tvb(]v}v b
yy Su(]v
yy Stool occult blood
Trtme
ae nt
Tuv}ib
yy T}R]vu]v]vPrvPHoo}(rP lL
~Sb}v}vRAvu] [Z
AX CKD Stages 1-2
v*AnaemiainChronicKidneyDisse*a v
L]vTuv
st
]v
E RvPPA
yy F}bboR U}oUæuPR}o˙(}`lb
BXCKD SPbr
I}vouvPTPHbR}orP lL
yy F}bboR U}oUæuPR}o˙
Or
yy F}bPo}v U}oUuPrR}o˙XoE Lr`lb
v
Or
yy I}v}bb UIVU}vbob]o]b
Or
yy F]b}]uPo}v}uo˘ U}vbob]o]b
Av
yy E }]v USCU}vbob]o]b
Or
yy MR}˘˙ }o˙R˙ov Po˙}o }]v ~P˙o(}u }( E}ZU
SCU}vbob]o]b
Or
yy D}]vo( USCU}vbob]o]b
Refeal
r Criteria
R( oo ~ob v R]ovZ vb `]R CKD v vu] }
b]o]b}vR}o}P]bX
Chatep rP *Disorsof
139. U]v˙TIv(}v
U]v˙]v(}v ~UTI ]bZ Rbv}(u]}r}Pv]bub]vR
]v } b }( R v}uoo˙]o b Pv]}]v˙X Iv(}v u˙
o}o]}Roo}v}Rl]v˙b}U]vuvR}bX
A v}uo] UTI }b ]v `}uv `]R v}uo
Pv]}]v˙ v boo˙ uv](bb b ˙bb (bladder
]v(}v } o}` ]v(}vZX C}uo] UTI }b ]v ]v]]ob
`]R ob } (v}vo v}uo]b }( R Pv]}]v˙ U
]vo]vPR}b`]R]vòo]vP]bbRRo b RbX
C}vPv]o v}uo]b }( R Pv]}r]v˙ ]b}b
R]ov } UTI X P}v UTI ]v R]o } v UTI ]b (R
}Pv]oo}vX
.v]
D uv }( UTI vb }v o v bvb]]˙
}bX H}Ù u]]o uv u˙ ]v] `R]o `]vP
R}X
sueCa
yy u] B }u]b
v*Urinayr Trcta Infection*v

yy U]v˙ }b}v XPX voP }b ]v o uobU
}b]}Roob]v]v(vblR]ov
Symptoms
yy Fv]v(o]v}v
yy Hu]
yy Co}˙l(}obuoo]vP]v
yy V}u]vP
yy Suprapubic pain
yy F ru˙b]bvvv˘o]v~]vR]ovZ
yy TR u˙ (]vP }oubU ]R}U v (]o } R] b
òo~]vR]ovZ
N}r
UTI˙u}ub
b vv}vrb].]v˙}vPR]ovX
Signs
yy F
yy L}]vvvbb
yy F}obuoo]vP]v
Invtiga
se tions
yy FBC
yy M]rbub]uv}(]v(}u]}b}˙Uovbvb]]˙
~ro]vLuvZ
yy A}u]voob}vv b ]vR]ov](]v]
Standard Trtme
Trtme
ae nt
Tuv}ib
yy T} o] ˙u}ub
b bR b (v ]v ~S b}v }v RF[
vRP]vMvPuv[Z
yy T}]Pv b
yy T}v}uo]}vb
yy T}]v(˙vb`]Rv}uo]b}(RPv]}r]v˙
yy L]o}oG]b}v}PP}}]v˙}
yy Pb}voR˙P]vv}ov]vPL(}v
AX Tuv}(Uv}uo]UTI
st
L]vTuv
]v
E RvPPC
yy C]}G}˘]v U}oU
Adults
æuPR}o˙(}˙bw ~(uoZVr˙b~uoZ
Children
v*Urinayr Trcta Infection*v
æruP llPR}o˙V~u˘X}(wæuP]o˙]v`}]]}bbZ
Or
yy (}˘]u
C U}oU
Adults
æræuPR}o˙(}ær˙bw ~(uoZVr˙b~uoZ
Children
r˙bVæuPR}o˙(}ær˙bw
r˙bVæuP llPR}o˙~u˘XæuPZ(}ær˙bw
u}vRbr˙bVuP llPR}o˙~u˘XæuPZ(}ær˙bw
BXTuv}(C}uo]UTI ~]vo]vPRroU}vb
b U
}bvoPuvU}o}P]v}uo]bvPvv˙Z
st
L]vTuv
]v
E RvPPC
yy C]}G}˘]v UIVU
Adults
uPrR}o˙(}˙bw ~}u]v]b}vu]vbZ
Or
yy Gvu]]v UIVU~](l]v˙(v}v]bv}uoZ
Adults
ruPR}o˙(}˙bw
Children
r˙bV uP llPR}o˙(}˙bw
u}vRr˙bV XæuP llPR}o˙(}˙bw
Or
yy L]˘}v
C UIVU
Adults
rP]o˙(}˙bw
Chatep rP *Disorsof
Children
Or
Children
u}vRr˙bV ruP llPR}o˙~u˘XæuP(}
Z ærw
days
Neonates~}b}o]v]v(}v
b Z
wr˙bV uP llPR}o˙(}ær˙bw
AM˙bw V uP llPR}o˙(}ær˙bw
Av
yy Gvu]]v UIVU~bo}`]vv}b]vi}v}obu]vbZ
Children
r˙bV uP llPR}o˙
Or
yy (}˘]uC UIVU
Children
u}vRr˙bV uP llP R}o˙ u˘X wæ uPU ~]vb
v*MedicinesandtheKidney*v
}ræuP llPu˘XXæPvrR}o˙]v]v(}vb
b Z
Neonates~}oR}b]v]v(}vb
b UIV}}vo˙Z
r˙bV æuP llPvR}o˙
wr˙bV æuP llPR}o˙
AM˙bw V æuP llPR}o˙
Refeal
r Criteria
R( vb `R} ˙ ]ooU `]R v UTI U b]bv
Ru]v}vPv]ov}uo]b}R}]b]o]bX
X M]]vbvRK]v˙
M]]vb v o } vo uP ]v vu }( ]+v `˙b
v ˘uob P]v o}`X Iv R `}vP ]ubvb o](rb]vP
u]]vbv}u}RuRvP}}XD}}bURu]bvb vbb
vRoR]vb˙Rl]vPR]uvRb]vR}b]o}
R}vbuvXTRu]]vbo]bo}ù˙vo b
]u]uvvubR(}}b }v}b]]vvb
`]R ]}vP vo (v}vX Aoo u]]vb ]v R]b o bR}o
}bb}vl]v˙(v}v~buGFRZX}] A }v}u]vb
}( vR}}˘] u]}vb v ]bX M}v]} vo (v}v (}
v ]vPuvX Pvro]bl (}b (} oo Rb u]]vb
]vo PU r˘]bvP R}v] l]v˙ ]bbU }ou o}vU v
}vvb}(vR}}˘]u]]vbX
Standard Trtme
M]}v R]blF} PR}R˙b]}o}P˙ Pv}v

Aciclovir H]PR}bUIV D}b]}v}(A]o}] }]
A }ob}bU
bolus dose crystal P]}R˙}v
r]vo}b}v ~u]v]v]v
v(}]}(]vbo }ANwæuolR}
]vGuu}v So}`P]v(b]}v
W˙bovR}R˙ }rR}b
}˘]uoo}R˙
u]v}Po˙}b
A ]b D}bU}v Iv}˘]uoo M]v]vR
~XPX and frequency of u]v}Po˙}b]}v vPXG]}v
Pvu]]vZ u]v]b}vX }v]}v]R}bR}o]]U daily dose if
Concurrent renal o]}uPo]vU necessary
]bRu]} v}˙l]v}
u]v]b}v RooXW]R]vooU
}(vR}}˘]vbX uobW]
L]]bb }˘]]˙rAKI
obu
}vv}v
ANuP lol
AvP]}vb]v Vb}}vb]}v Avoid in bilateral renal

C }vvP WrvoARF artery stenosis
E v˙u
]vR]]}bl
AvP]}rvb]v
Receptor
blockers
~XPXL]b]v}]o l
L}bv Z
Non Steroidal V}ou Hu}˙vu]oo˙ }]
A }b]}v
Avr]vGu r vb}]u ]vAKI due to }(]b
u}˙Pb o}vX b}}vb]}v] }]
A oP}b
~NSAIDb XP
Z X D]bX }bPov]v
I}(v LP}bv }}v
o}vPR˙X Acute and chronic
Severe liver o}]vo
disease vR]bU`]R}
`]R}vR}
˙v}u
b X
D]}˘]]˙rR}v]
]vbovR]bv
papillary necrosis
Radiocontrast D}bv H]PR}bu}o]˙U H˙}v(}v
frequency uoo˙b}}vb] r Lu]v]b}v
Obu}o]˙}( }vUvb} Acetylcysteine
}vbu] ]vR]lv]vP
b o}} unproven
}(HvoW]vb
}˘˙Pvuv
Chatep rP *Disorsof

MR}˘ Acidic urine P]]b]vR]v P]}R˙}v
H]PR}b and induces tubular Alkaline urine to
]vi˙ HANwX~L}(æA9
˘}b
D ]v`
A=rvuu}o}(
NHCO˙
C]bov L}`Ro}]U CRo}]]v]br}b]}v Mesna
R]PR}b o˙HO
rR]PRo˙R˙}˘˙o
]o]CYPæ
WDNA]vi˙ooo
death
NR}Pv]]b
]vb]]bUH˙}uP r
vbu]~u˙
b]bvZ
Cyclosporinl D}b PG
bD Uv Maintain in
T}o]ub PA ]vbrHETE] RvP
P}b} }}v }]
A PbR
AKI Wb}}vb]}v ]b~CYPA
D]b Pv}v}(HO ]vR]]}bZ
Hypertension bovP]vo Co]u channel
PoR]}v blockers
WbGFRU
]bRu]}oob
}]vP
b }(R
Po}uo]U}o]}v
}(RobUv(}o
areas of tubular atrophy
v]vbo.}b]b
Iv(}v PrvoAKI
To}]vbo
vR]b
TR}u}
u]}vP]}R˙
Muv}}o](
Po}uo}vR]b
Tenofovir D}bU}v
D Tubular cell
l˙}uPo˙U
Pv}vv
necrosis
W]vbovR]bU
AKI UFv}v]˙v}u
b
æ
Standard Trtme

L]R]u Renal Iu]uv}(}oovP TRvP
]u]uv }vvvP ~XvrXuu}olLZ
D R˙}v ability PvR˙}v
H˙}vu] W]b]vb]]b }]
A o}`rb}]u
D]b CR}v]o}]vb r diet
especially ovR}R˙ }]
A R]]
R]]
AKI WK]v˙
A Ivi˙
CEWA AvP]}vb]v}vvPv˙u
HETEWH˙}˘˙]b}bv}]]
PGWP}bPov]v
X C˙bA b
A ˙bb ]b v ]vGuu}v }( R oX W}uv
+ ub u} Rv uv } R bR}vbb }( R] R
}u} R }( uvX A9ræA9 }( oo `}uv `]oo o} ˙bb in
R]o](uX
TRbv]vP(or]vorRo}]bR]u˙u}}(
v*AcuteCystitis*v
]v(}vX Ob]}voo˙ ˘oo˙

b vbu]' }Pv]bub ]v}oX R]bl
(}b]voRoR]}vv]bX
sueCa
yy E. coli~}A9Z
yy Staphylococcus saprophyticus
yy Kob]oo
yy Proteus mirabilis
yy Gonococcus
yy Enterococci
Symptoms
yy L}`P(
yy Fv˙
yy Nocturia
yy UPv˙
yy D˙b]
yy Hu]
yy Co}˙v(}obuoo]vP]v
yy L}`lv]b ]v
Signs
yy L}`P(
yy Hu]
Invtiga
se tions
yy U]vo˙b]b
v
Chatep rP *Disorsof
yy M]rbu]v(}ovbvb]]˙
yy FBC
yy FBS
yy IuP]vP }( ]v˙ ]v v } b]bv b } ˘o
v}u]ov}uo]bUo}`]v˙}b}vX
yy UR}˙b}b}˙]vbob
Tuv}ib
yy T}]]v(}v
yy T}vvv}uo]}vb
yy To relieve pain
yy L]o}oG]b}v}PP}}]v˙}
yy Pr}]ov}br}]ou˙]vP}(Ro
yy Pb}voR˙P]vv}ov]vPL(}vb]oo˙]v
(uob
AXv}uo]
A ˙bb ~bv}((vGvl]vZ
st
L]vTuv
]v
E RvPPA
v*AcuteCystitis*v
yy NitrofurantoinU}oU
Adults
uPvR}o˙(}ær˙bw
Children
r˙bV æuPvR}o˙(}˙bw
u}vRbr˙bV wæu]}PubllPvR}o˙(}˙bw
nd
L]vTuv
]v
E RvPPA
yy C]}G}˘]v U}oU
Adults
æuPR}o˙(}ær˙bw
Children
r˙bV ærwæuPR}o˙
u}vRr˙bV wXæ uP llP R}o˙ ~}b }o ]v b r
bZ
Neonates
wXæuP llPR}o˙
Or
yy (}˘]u
C U}oU
Adults
æuPR}o˙(}ær˙bw
Children
r˙bV æuP R}o˙~}b}æuP
R}o˙]vo}`]v˙]v(}vbZ
r˙bV æ uP llP R}o˙ ~u˘X æ uP R} r
w
Standard Trtme
o˙Z
u}vRbr˙bV uP llP R}o˙ ~u˘X æ uP R} r
o˙Z
Av
]v
E RvPPC
yy M]bP}bb]u] U}oU
uoR}o˙](]v]b]]~H}(}v o}`ZXT}o
]vv˙b]X
N}r
M}v]} }bb]u oob v }] ]v R˙lou]X D} v} P] `]R ]} r
G}˘]vX
Or
yy Pu}o U}oUæuPrPvrR}o˙`Rv]
BXF}˙u}u
b ˙bb vUTI in pregnancy
yy (}˘]u
C U}oU
Adults
æuPR}o˙(}ær˙bw
v*BenignProstaticHyperplasia*v
Av
]v
E RvPPC
yy M]bP}bb]u] U}oU
uoR}o˙](]v]b]]~H}(}v o}`ZXT}o
]vv˙b]X
N}r
M}v]} }bb]u oob v }] ]v R˙lou]X D} v} P] `]R ]} r
G}˘]vX
Refeal
r Criteria
R( oo bU `R]R ] ˙b}b}˙ v oo b }( b]bv
Ru]Uv˙bb }]ob]bv}Rb]o]bX
X Bv]PvP}bH˙ob]
Bv]Pv P}b H˙ob] ~BPH Z (b } v}vrv}b
voPuv }( R }b Pov `R]R bob ]v }b}v }( ]v
G}` (}u R oX BPH ]b R }uu}vb b }( uo ]v˙
˙u}ub
b ]v GRvX TR P P `R]R o}` ]v˙
˙u}ub
b ~LUTS Z o}BPH}b]b}æ˙bXMvu˙bl
uv(}LUTS]RR b ˙u}ub
b }Rb}u}R˙
(o R ] u˙ o } ]v˙v}v } } }( (R ] u˙
v]v]}v}(}bvX
I ]b ]u}v } o]b
b R `R R v `vb (}u R
}vbo}vX Iv b}u vbU }v b R R o]lo]R}} }(
]v˙v}vv}bv]bo}ÙR˙u˙v}`]bRuv
Chatep rP *Disorsof
(}R˙u}ub b X
vo˙
C ]oo u]]vb v ]R o˘ }b bu}}R
ubob } b }v ]v R }b b] v R(} b R
˙u}ub
b }( BPH X A }u]v}v }( ]oo u]}vbU b]oo˙ ]v
vb `]R }bb]u}Rv uoU} 'b}vbb
Rvu}v}R˙X
BPH u˙ o } }uo]}vb bR b v ]v˙
]v(}vU ]v v}v `]R ]v(o ]bvb]}v }( R oU
R}v] ]v v}v `]R ]vobb P}bb ]bvb]}v }( R oU
Ru]Uvvo(]oX
sueCa
yy Ivb ]v vu }( }b oob } uo}v b ˙
testosterone
Symptoms
yy L}Ù]v˙TS˙u}ub ~]}bo˙(}}bb bu Z
yy Hb]v˙ro˙]v]v]vP]v}v
yy P}}}`l]v˙ub
v*BenignProstaticHyperplasia*v
yy S]v]vP
yy Tu]vo]o]vP
yy Svb}v}(]v}uoou˙]vP
yy U]v˙]v}vvv~}G}`Z}`hvP
yy FvbP}(]vb]oo˙v]PR~N}]Z
yy UPv˙vP]v}vvv
Signs
yy EvoP}bPov}vo˘u]v}v
yy Tvooo~]v˙v}vZ
yy N}vrvooo~R}v]v}vZ
yy Uu]b]Pvb~XPX}`b]vbbU}v(b]}vXZ
yy Pool]v˙b]vR˙}vR}b]b
Invtiga
se tions
yy Suv]v
yy P}bb].vPv~PSA Z r}˘o}bv
yy U]v(}ovbvb]]˙
yy A}u]vo v o] ob}v W } ˘o R˙}vR}b]b ](
buv]v]bo
Trtme
ae nt
Tuv}ib
yy T}˘o}bvvvbb }]vPo˙
yy T}o]˙u}ub b vvo}uv}(}uo]}vb
yy T}]v(˙vv˙b}]}uo]}vb
yy P}Puu }( u}v]}]vP v `R(o `]vP R}PR Po
Rlrb(}u]o˙u}ub
b
ı
Standard Trtme
yy URo R]}v (} v}v }( ]v } ]b
˙b}b}u˙](RoR]}v(]ob
yy S] vo v v b]}vl]vP }( ]v }
oo˙}ubbRovo]]vU`Rv]b
˙b}b}u˙]bo˙X
AX Pvb`]R}Rb}u˙u}ub
b v}bb]obbRv
uo~buoo}bZ
st
L]vTuv
]v
E RvPPA
yy T}b]v U }oU r uP v]PRU ~b `]R uP v]PRV }o
}b`lo˙]vobZu˘XuPX
Or
yy Tubo}b]v U}oUu]}Pu}v]o˙
Or
yy Ao(}b]v U}oUuP]o˙
BXPvb`]R}Rb}u˙u}ub
b v}bb]u}Rv
uo~]P}bZ
v*Bctea rialProstatitis*v
]v
E RvPPA
yy F]vb] UæuP]o˙
Av
yy T}b]v U }oU r uP v]PRU ~b `]R uP v]PRV }o
}b`lo˙]vobZu˘XuPX
Or
yy Tubo}b]v U}oUu]}Pu]o˙
Or
yy Ao(}b]v U}oUuP]o˙
Refeal
r Criteria
R( vb `R} }v[ b}v } Ru}o}P]o uvU
} R }uo]}vb ~]v v}vU Ru]U vo (]o v
v]v˙]v(}v}Z U}o}P]b}SP]ob]o]bX
X ]o
B P}bb
P}bb ]b ]vGuu}v }( R }b PovU `R]R u˙
]o } ]oX ]o B }bb ]b u} }uu}v Rv
]o }bbX I u˙ vb b v }v]}v `R]R u˙
]R ˘oo˙
b vbu]' } bo (}u Ro G˘ }( ]v(
]v ]v} R }b bX OR }vo b}b u˙ ]
(}u
b u}o}}buX
I( ]vo˙ R]b u˙ }Pbb } R}v] }bbX I ]b
u}}uu}v]vuvo}ò}`æ˙bX
Chatep rP *Disorsof
sueCa
yy GurvP ]o ]v(}vb XPX (}u E. coliU Pb}u}vbU
Streptococcus faecalisU P}bU Kob]ooU S v
Ev}]X
yy S˘oo˙vbu]']v(}vbXPX(}uG}v}}bvCRou˙]X
Symptoms
A
yy F
yy CR]oobvuo]b
yy L}`lv`]b]v
yy M˙oP]vRoP]
yy Rol]vo]v
yy U]v˙Pv˙v(v˙
yy Nocturia
yy D˙b]
yy D]8o˙]v]v}vlv}v}(]v
yy Hu]
yy Hu}bu]vo}bb}(o]]}
Chronic
yy Ivb]}b}vb
yy Rob]vPUTI
yy Pb]bv}(]]vbu]voG]b]v]}uv
yy L}`lv`]b]v
yy U]v˙Pv˙v(v˙
yy Nocturia
yy D]8o˙]v]v}v
yy Hu]
yy Hu}bu]
Signs
A
yy S`}oov v v }b }v D]P]o Ro E˘u]v}v ~DREZX
~A}]}bubbPbR]b}oo}u]
b ZX
yy TRu(obSR} _(}uR]vGuu}vX
Chronic
yy F]v]vPb }v DRE u˙ v}uo } v }b }b]}voo˙
(} o}vPbv]vP ]bb ] u˙ (o ˙ .u } R b ]v }b
vX
Invtiga
se tions
yy U]vo˙b]bvo
yy FBU C SR
E
yy PSA
yy Bo}}o
yy E˘bb }b }vb
b (} o v bvb]]˙ R}PR
DREXV}]b]uv(}vL}bubbP}u
Standard Trtme
~]vR}v]}bb}vo˙ZX
Trtme
ae nt
Tuv}ib
yy To relieve pain and fever
yy T}}v}o]v(}v
yy T}o]o}`]v˙}b}v
yy T}vR}v]}bb
yy b B
yy H˙}v
yy H}b]o]b}vu˙]]v}b b `RvR}v]}v
]b}uo]˙]v˙v}vvb]Pv].vRu]X
yy S] ˙b}b}u˙ (} ]v˙ v}vX ~URo
R]}vbR}o}]XZ
AX M]o}M}]v(}vb
st
L]vTuv
]v
E RvPPB
yy C]}G}˘]vU}oUæuPR}o˙(}rv`lb
vA
yy D}˘˙˙o]vU}oUuPR}o˙(}rv`lb
ndL]vTuv
yy L}G}˘]vU}oUæuP]o˙(}rv`lb
Av
yy D}˘˙˙o]vU}oUuPR}o˙(}rv`lb
BX S]v(}vb
yy C]}G}˘]vU IVU uP r R}o˙ ~} u]v]b } v
u]vbZ
Or
yy L}G}˘]vUIVUæuPR}o˙
Or
yy L]˘}v
C UIVUrPD]o˙
Av
yy Gvu]]vUIVUuPH}o˙
N}r
Iv]oR˙`]Rvov]}b]b]v]]vbXF}oo}`
bR}o(}obu}vRb
CX F}]u}uv}(]v˙G}`
yy Tubo}b]vUu]}Pub]o˙~v]PRZ
Or
yy Ao(}b]vUuP]o˙
Or
Chatep rP *Disorsof
yy T}b]vUræuP]o˙~v]PRZ
X
D Aivuv]vbv}vb
]v
E RvPPC
yy S}]uRo}]XıA9UIVU]b ]v˙bb u]]v(}vbX
vA
yy I}(vU}oUuPR}o˙`Rv]
Or
yy D]o}(vU}oUwæuPR}o˙`Rv]
Av
yy Lo}bU}oUræuoR}o˙vib}b}]vPo˙
Refeal
r Criteria
R(oo}( b ]v(}vb
b }R}v]}b(}
b b]o]b
X
X Scrotal Masses
TRbòo]vPb
b (}v]vR}u
b X
sueCa
v*Scota
Painless Swellings
r lMas*e v
yy Tbou}
yy IvP]v}b}oRv]
yy Hydrocoele
yy H˙}}o}(bu}
yy Su}}ol]]˙uo˙bb
yy V]}}o
yy E]]˙uou}b
yy CR}v]]]˙u}r}R]b
Painful Swellings
yy Tbo}b]}v
yy ]]˙u]b
A ~STI}v}vrSTIoZ
yy ]]˙u}A r}R]b
yy SvPo]vP]v}b}oRv]
yy Tbo u} ~boo˙ ]vobb ˘ ]o˙ P}`]vP ˙ }
u}v}b]bZ
yy V]}}ob}b]}voo˙}uv]˙]vl]b}u(}
Symptoms
yy Sòo]vPvl}]v}(}u b }]b}vvb
yy Sv}vbXPX}b]}v}(b
yy Go}vbXPXbu}}oUR˙}}ob
yy Go}vb}u]vPbvo˙]v(oXPX}bRv]
yy FUu˙bv]v]v(}vbXPX]]˙u]b A v
]]˙u}r}R]b
Standard Trtme
Signs
yy Tv } v}vrv òo]vP b ]b } R }u
b ~˘
Rv]`R]Ru˙˘v]v}R]vP]voZ
yy Fu˙bv]v]v(}vb
yy Tvb]oou]v}v (} ˙b òo]vPb b XPX R˙}}ob v
bu}ob
yy Hòo]vPb XPXTu}
Invtiga
se tions
yy Uob}vv b `]R}`]R}}o}}o
yy L}}˙ ]vbP}vb ]o} }`b b v b].
uv
Trtme
ae nt
Tuv}ib
yy T}ulv]Pv}b]b}vb}]uv
yy To relieve pain
yy T}v}uo]}vb
yy T}˘]uPv˙]vv}vPTboT}b]}v
v*TheEmptyScotu
yy SP˙Po}uPv˙
yy EuPv˙P˙ b `]R]vR}b
v ]b](}ob }b]}v}
boPRb
r m*v
AX F}˘oo˙
b vbu]']v(}v
]v
E RvPPB
yy C]}G}˘]vU}oUæuPb]vPo}b
vA
yy D}˘˙˙o]vU}oUuPR}o˙(}˙b
Or
yy L]˘}v
C UIMUæuPb]vPo}b
Av
Refeal
r Criteria
R( oo uPv˙ b v R}b b } u}b }
}o}P]b}P]o b b]o]bX
æX The Empty Scrotum

TR]b(b}Rbv}(b~bZ]vR}u
b lRu]b}uX
Tvv}(]oob XSv˙r.v}((oou]v(vb
`]R vbv b v ıA9 }( u ]v(vb `}o R
b}vv}bbv}((}u
b R]vr}u]vob]˙RP}(
}v˙XPb]bvvbv}(R]bb b}]`]Rv]vb
Chatep rP *Disorsof
]bl}(uo]Pvv˙U(o]˙b U}R˙}(Rvb }b]}vXAooRoR
`}lb`R}v}vb
b vR]ovbR}o}}v˘u]v}v}(
R}ub v}b vobv}vbv}uo]}vbX
sueCa
yy Uvbvb
yy Uvlv}`vl]]}R]Vu}b}vPv]o
b
yy Pu]R
yy Gvoo˙]vR]]bb
yy Ab}] `]R v}uo]b o]l Pv Boo˙ ˙v}u
b v
hypospadias
yy }]E b
yy Rob
yy Severe atrophy
yy OR]}u˙
yy APvb]b}(Rb~o˙Z
Symptoms
yy Absence of one or both testes
yy IvR]ovUvb}RRoR`}lu˙v}R]b]R
v*TheEmptyScotu
Signs
yy bv A b]v}Rb]vv]PR}b]}vb
r m*v
Invtiga
se tions
yy Uob}vv b }(}uvUo]bv]vP]vovo
Trtme
ae nt
Tuv}ib
yy T}b}vo(}v
yy T}]u}(o]˙
yy To repair hernia
yy To decrease risk of torsion
yy T}}]b}]ov˙R}o}P]o b }uo]}vb
yy SP]o ]vv}v (} `} ˙b }( PX ~Aoo }] b
bR}o}bR˙`]oov}bvZ
None
Refealr Criteria
R( vb P } }v ˙ `]R v} ]v }( ob
bv}}o}P]b}P]o b b]o]bX
æ
Standard Trtme
vX Priapism
TR]b (b } b}vv}bU }o}vPU b]bvU boo˙ ]v(o
}vU `R]R ]b v`v v v} b}] `]R ˘o b b] v
v} o] ˙ }]bX P]]bu ]b obb]. ]v} R ˙b vuo˙P
L}`rG}` } ]bRu] ~}uu}vbZU H]PRrG}` ~v}vr]bRu]Z v
S']vP P]]buX I ]b }uu}vo˙ bv b }o}vP}v }( N}vo
Pv]oTubv~NPTZ}o˙u}v]vP}vXTR]b]b òorlv}`v
}uo]}v}(b]looo]bbX
Pvb boo˙ bR˙ v ov } }u } R R}b]o
} Pub b }vX L bv}v ]b R(} }uu}v v Ro
u]]v o]}vb v b]]o u]b u˙ R v ] }
o] ˙u}ub b ]} } ]vP bv ]v R}b]oX o˙
E bo `]R]v
r R}b u˙ R R]PR ]u}v }uo]}v }( æA9X
AoR}PR R }v ]b boo˙ ]v obU ] u˙ ]}]oo˙ } ]v
}oR]ovX
sueCa
yy I]}R]}vlv}`v]vvA9}(b
yy DPbXPXu]ivvRo}v}}vb
yy ORbP
v*Priapism*v
yy Llu]
yy S]looo]bbvRobbu]
yy Pv]ou
yy S]vo}]vi˙
yy Po]]v(}vb
yy Po]u}
yy I}Pv]XPXIvv}bo}bPov]vE(}]u}vU
b]ov.o]U˙R}}]b
b XPXRo}}u]v
Symptoms
yy P]v(ob]bv}v
Signs
yy U E vv]b
yy Co]v]ob]Pvb}(b]looo]bb
Invtiga
se tions
yy FBU C o}}.ou}uuv
yy S]lo]vPbrHo}R}b]b
yy U]vo˙b]b
Trtme
ae nt
Tuv}ib
yy To relieve pain
yy T}vbo˙o](}(v]o}vPb}v
yy T}v}uo]}vb
v
Chatep rP *Disorsof
]v
E RvPPA
yy M]v]vR˙}v
yy W]v[bP}
yy C}}I]P}v
yy SP˙PSRvb
AX C}vbuvPuv
]v
E RvPPC
yy S}]uCRo}]XıA9UIVU
Adults
LvR}o˙vo]o}oG]b
Children
æuovR}o˙vo]o}oG]b
vA
yy PR]]vUIMU
Adults
uPR}o˙](]
v*PosteriorUrethralValvs*e v
Children
uP llP~u˘XæuPZR}o˙](]
vA
yy D]uUIVU
Adult
uP Xb ~P]v bo}ò˙ } r u]vbU }˘]uo˙ Xæ uP
˙}vb
b ZRv(
Children
XuP llPXb ~P]vbo}ò˙}ru]vbZRv(
B. Specialist management
yy Ivv}bo]vi}vb~b(o]]Z
Refeal
r Criteria
Pvb v} b}v]vP } }vb uvPuv bR}o
}uo˙(}}o}P]b}P]ob b]o]bX
wX P}b]}URoVob
TRbob}(}ob}(}vPv]o
b }bvPuuvb
`]R]v R ouv }( R RX I +b `v ]v æU W U
uobXI]bR}uu}vb}( b }vPv]oo}o}b}vX
TR˙ }b]v˙ }o}` (}u R o u]˙b Ro
R]b}vX bB R }b}v b ]vr}U }v˙ b
RvPb]vRov]v˙v]RX
S}uvbu˙}v`]Rvob ]u]uv}R]bu˙
o} b}}v L ]R ]( }Pv]}v ]b o˙X M}b vb bv
b v}vb } ]v(vbX Ob]}voo˙bv}v ]b o]v R]oR}}X Aoo
w
Standard Trtme
uo v`}v ]b bR}o o}bo˙ `R } vb P}} ub
}(]vXPvo]Pv}b]b]b}bb]ob]vPob}vX
sueCa
yy C}vPv]oob}(}ob`]R]vRouv}(R}b]}R
Symptoms
yy P}}]v˙ub
yy C˙]vP`R]o}]]vP
yy S]v]vP}}]`]R]o]vP}(]v
yy Ivu]'vub
yy F]o}R]
yy F
yy P}}(]vP
yy A}u]vo]bvb]}v
Signs
yy V}]]vP˙b(v}v
yy Pooovl]v˙b
yy Respiratory distress
v*PosteriorUrethralValvs*e v
yy S]Pvb}(b]bXPXF
yy }u] A lu]
yy P}}R˙b]oP}`RlP}`R}v
Invtiga
se tions
yy FBC
yy Bo}}Uo}o˙bvv]v
yy U]vo˙b]b
yy U]vo
yy A}u]voob}v
yy M]vP˙b}rR}Pu
Trtme
ae nt
Tuv}ib
yy To prevent and treat renal failure
yy T}u}}bvPob
yy P}u o }ubb]}v v }vv}b]vP}}
R(}uluP
b XTR]b]b(o˙}v˙
b]}b}u˙]vu}b]v(vbXIvòo]vPRbbR}o}]
]vu}b}b }uo]}vbvR(}uu]b
yy SP]ou}o}}v b }(Ro
]v
E RvPPA
yy Tuv}(]v˙]v(}vb~S}]b}vZ
Refealr Criteria
R( ]uu]o˙ L ]Pv}b]b (} b]o]b o}v v
Chatep rP *Disorsof
uvX
X U]v˙TCoo]
TRb ˙boro]l }ibU `R]R (}u ]v ]}b b }( R
]v˙ X TR˙ }vb]b u]vo˙ }( u]vo bob ]XX ˙bor(}u]vP
]}vbX S}u }( R }uu}v }v b r˙b ]vo o]u }˘oU o]u
R}bRU uPvb]u uu}v]u R}bR v ] ]X S}u
]bl (}b ]v o}]vP }vb
b ]vo ˙boo]U OvU ]U
}}vU o]u ~R˙}vZU (u]o˙ R]b}˙ v u]}vbX
Mi}]˙}(}vb b obbRvæuu]v]u`]oob}vv}bo˙X
sueCa
yy H˙ou]
yy H˙]u]
yy H˙}˘o]
yy U]v˙b]bv}b}v
yy U]v˙]v(}vP]b ~]v(}v}vbZb
yy F}]Pv}˙]vo]vP]v˙Rvu]o b
v*Urinayr Trcta Calculi*v

yy I]}R]R˙o]]
yy D R˙}v
yy Iuu}]o]b}vb]oo˙]vRoo˙
yy Iv}v}b}(u}o]buXPXC˙bv]
Symptomsandsigns
LOCTION
A OF SYMPTOMS SIGNS
CALCULI
K]v˙lU • L}]vP]v • S]Pvbu˙(`
• U]}o]Pbv tenderness in the loin and
P}v]]vP}˘˙buo]vU }uv`}o(o
`R]RP]vb]vRo}]vU ]vP]v(o'l
then radiates around the • S}uubRu˙
Gvl}`bRo b}]}u]vo
v}u
b lbb]vR distension and fever if there
uovo]uuib ]brb ]v(}v
]vR(uoXM˙ • AR˙}vR}l]v˙
b}]`]RvbU u˙oo
}u]vPv`vP b
• Hu]
ı
Standard Trtme
LOCTION
A OF SYMPTOMS SIGNS
CALCULI
BolUR • Suprapubic pain • Suprapubic tenderness
• Fv˙ • Pooo~(}u
• UPv˙ v}v}oP}vb Z
• Hu] • HRoou
• SvP˙Pvv}v}ooo ~]u}v
b Z
v}Lv]v(ob]} • Hu]
b]vU`R]Rbob]v
o]'o]v~u˙o}}r
]v
b Z}v}]v]vP
voided
• Rv}v}(]v
Invtiga
se tions
yy U]vo˙b]b
yy U]vo
yy Bo}}Uo}o˙bvv]v
yy Su]]Uo]uUR}bRUuPvb]u
yy Po]vXr˙}(}uv
yy Uob}vv b }(}uv
v*Urinayr Trcta Calculi*v
yy Ivv}b}Pu
yy R}P}˙o}Pu
yy CT scan
yy Stone analysis
Trtme
ae nt
Tuv}ib
yy T}}v}o]v]vP'l
yy T}]bP}(Roob}vb}uou}o}(oob
yy T}u}oP}vb b
yy T}vv](Rb]blv}`v
yy T}b}]]v(}vb
yy Ev}P }o G] ]vl ~r L ]o˙ ]v v oZ v }]
R˙}v
yy }] A o}ò]u]~]v}Pb]vb}˘o˘}vZ
yy D]rR˙
yy MvP]v˙v}v}o}Ro}vb b ˙
RoR]b}v}]b ˙b}b}u˙o˙
b
]v
E RvPPB
yy PR]]vUIMUuPR}o˙]b
Or
yy D]o}(vUIMUwæuPR}o˙
Or
yy D]o}(vUoUuPR}o˙
Chatep rP *Disorsof
Av
yy H˙}b]v˙o}u]UIVUuPR}o˙
Or
yy M]vU}oUæuPR}o˙u˙(o b
C}vrX
}]
A u}R]v]b u˙(R
b ]buv`}bv]vP}(˙u
b r
}ub
yy G] v]}b ]( ]v˙ ]v(}v ]b bvX ~S b}v }v
RU]v˙TIv(}v[Z
Refeal
r Criteria
R(}}o}P]b}P]o
b b]o]b(}.v]uvL
]v]ouvPuvX
ıX URoS]
TR]b (b } v}`]vP } }uo }b}v }( R Ro
ouv } .}b]b ~b]vPZX I ]b R }v
b }uu}vb b }(
v}v}(]v]vGRvvRu}b}uu}v]v˙}vPuobboo˙
v*UrethralStricture*v
bovP (}u ]}b ]vo˙ STIX TR }uu}vb b] ]b
R v]} R ]XX o v v]o R ]v uobX I u˙
}uo] ˙ ]Ro bU b.]o ˘b}v }( ]v
v R}v}b .boU v}v }( ]v v }brvo vo
(]oX
sueCa
yy G}v}}o}v}vrP}v}}oR]b
yy E˘vo u XPX } 8 ]vi]bU (oobU ob } ]b
]vi˙vo](b
yy I}Pv]PURo]vbuv}vXPXR]b}vUv}b}˙
yy P}b}XPX}b}u˙
yy C}vPv]o]bb ~Z
Symptoms
yy L}Ù]v˙TS˙u}ub~LUTSZXPX}}]v˙ub Ubo]
}bo˙ub Uo]}(ub ]u}˙]v]vP
b U
(v˙ v ˙b]U }br}] ]o]vPU ]v}uo u˙]vP }(
bladder
yy U]v˙~}G}`Z]v}vvv
yy U]v˙v}v~}R}v]Z
Signs
yy TRu˙v}v]vv}uo]b
yy Poo]v}v}(R
yy P]Rob
yy E˘b}v}(]v]v}}u b vb.]ob
yy UR}v}b.bobl`]vPrv}u b
Standard Trtme
yy Bou˙oo](R]bv}v
yy K]v˙u˙oo]vR˙}vR}bb
yy L}o]]v}vu˙(oo}vPRR
yy F]o}(R]b}vrR]bR]PRvbRb]]}v}(]b
Invtiga
se tions
yy U]vo˙b]b
yy U]vovbvb]]˙
yy Bo}}Uo}o˙bvv]v
yy Uob}v Sv }( l]v˙bU oU }b}] b]o ]v v
b}vP]}.}b]b
yy R}PR}Pu
yy AvP R}PulM]vP C˙b}r}Pu ~MCUGZ
provided a suprapubic catheter is in place
yy U}G}ù˙
yy UR}˙b}b}˙
Trtme
ae nt
Tuv}ib
v*Vactomy
yy T}o]˙u}ub b vv}uo]}v
se ~MaleSterilistion
yy T}vo˙]vPb
yy T˙ R]b}v r Pvo 'u ]b u } b Ro
RU`R]R`]ooRoURb]}(]b ]vvb`R}
a Z*v
bv`]Rv}v}(]vXC}v.u}v}(b]}(}b}v]b
oo
b v˙R}PR˙}R}b}˙X
yy I(R]}v(]obvv]b]vv}v
yy S]˙b}b}u˙}]b vovvb]}v
~˙R]b}]((]o]b(}]b ˙b}b}u˙ol]vPZX
Ab] b uR ]v b }bb]o } }ubb R o v
relieve pain before referral
yy .v] D uv]bP]ob X Iv u}bb(o} b]o]b
v`]oovbb˙
yy N}v˘(}U]v˙TIv(}v~S}]b}vZ
Refealr Criteria
R( } b]o]b (} (R ]vbP}vb ]} } .v]
uvX
150. Vb}u˙~MoS]o]b}vZ
Vb}u˙ ]b uvv uo }v uR}U `R]R ]b
b U bR} v (b P]o
]uo b }X I ]b ] } ˙ ]v
P}vb
b boo˙ v o}o vbRb] L (o }vboo]vP v
]v(}u}vbvX
Chatep rP *Disorsof
Vb}u˙ ]b R u}b + uo (u]o˙ ovv]vP uR}X
Iv}o]vP uob ]v ]bb }( } RoR v (u]o˙ ovv]vP Rb
ob v.b`]R}b]]u}vb}]˙X
Vb}u˙ bR}o v}P (} }] o]vbX I ]b obb
]vb]v b]uo Rv (uo]o]b
b }vX Rbo }(}u˙ b ]b
]8o P˙
b b]vP o}blu]}b} `]R b }( vrA9 ](
}v]vobbRv˙bL}u˙ b X
B}˘rP)
M]b}v}vb
yy Vb}u˙]bo]P}v}(R(vb b vNOTCASTRATION
yy Vb}u˙}bv}+}v
yy Vb}u˙ }b v}+io}v v }PbuX TR`}o v}uo
io}vRbuv}bv}}v]vbu}}
yy Vb}u˙}bv}`}l]uu]o˙XAlruR}}(}v}v
]bvbb˙(}}io}vbUu}vRbLR}}vo
˘u]v}v}(buvbR}`bv}bu
yy AL}u˙
b uob`]oooo b ]Rb}(}v}ub}v˘b r
oo˙vbu]']v(}vb]vo]vPHIVrAIDS
v*AcuteEpididymororchitis*v
B}˘rP)
+vb
E b}(]}buo}vuR}bP
]vE RvPPB
yy Vb}u˙rııXæA9
yy Mo}v}urvA9
yy W]RòuR}rA9
P}]uvb
yy ]o
D }vboo]vP ~]oo˙ }R vb ub bvZ v ]v(}u
consent
yy C}vboo]vPbR}ouv}v]b]]o]˙}(}U}bb]ovo] r
}vv]bl}(R}v]}ob ]v}b}X
yy Medical history
yy PR˙b]o˘u]v}v
yy L}}˙]vbP}vbXPXHUb]lo]vPU]vo˙b]b
yy H]b}R}o}P˙ }v.u}v }( R u} bPuv }( b (vb u˙
vbb˙(}u]}oPob}vbX
Refeal
r Criteria
Co]vb bR}o (} Fu]o˙ Povv]vP Uv] } U}o}P]b(}
R}X
151. AE]]˙u}r}R]b
TR]b]bv]vGuu}v}(R]]˙u]bvboo˙
}]o]v(}vXIu˙(}oo}`bv]vP]v(}v(}uRR
~]vo]vPSTIbZU]vbuv}vlR]}vUvo}`]v˙
Standard Trtme
}b}vvPv]}r]v˙P˙ b XI]blv}`v}uo]}v}(
uubX P}}o˙ uvP ]]˙u}r}R]b u˙ }uo]
˙u] b U(}u}v
b UR}v]]]˙u}r}R]bU}v˙
b
R˙}}oU]v(o]˙vF}v] [bPvPvX
(}
B uvP]vP b ]˙u}}R]b ul b ob
}b]}vRbv}vob]o˙˘oX
sueCa
yy Mub]b~}R]bZ
yy Escherichia coli
yy CRou˙]
yy Gonococcus
yy Staphylococcus
yy Streptococcus
yy Pb}u}vb
yy Mycobacterium tuberculosis
Symptoms
yy F
yy S}olbo]v
v*AcuteEpididymororchitis*v
yy S}oòo]vP b
yy URo]bRP
yy D˙b]
yy Malaise
Signs
yy F
yy Tvv`}oov b Ru]b}u
yy IvGu]]˙u]bvb
yy Secondary hydrocoele
yy P}b] PRv[b b]Pv ~o]L]vP }( }u b }`b ] ˙uR˙b
b ]b ]v
Rouo]b]vZ
Invtiga
se tions
yy U]vo˙b]b
yy U]v o v bvb]]˙ r .b R }( ]v ( }
u]bu]v
yy FBCvSR E
yy Bo}}ovbvb]]˙
yy S}oob}vlMRI
Trtme
ae nt
Tuv}ib
yy T}o]˙u}ub b
yy T}]R]v(}v
yy T}v}uo]}vbXPXbv]o]˙ b
yy b B
Chatep rP *Disorsof
yy Scrotal support
yy SP]o]vP}(b
yy }]
A v} ˘b vo uv Rb v }uo
(oo˙
b v(}oo}`}vbo]vPX
yy Tv˘o b }vb
st
L]vTuv
yy C]}G}˘]vU}oU
Adult
æuPR}o˙(}˙b
Children
æræuP llPR}o˙(}˙b
Av
yy D}˘˙˙o]vU }oU uP R}o˙ (} `lb ]v b }(˘oo˙
b
vbu]']v(}vb
v*Tetic
Or
s ularTorsion~TorsionofSpermaticorC dZ*v
yy A ]R}u˙]v U}oU
Adult
æuP]o˙(}˙b
Children
uP llP]o˙(}˙b
nd
L]vuv
yy N}G}˘]vU}oUuPR}o˙(}˙b
Av
D}˘˙˙o]v}A]R}u˙]v~b}]v L]vTuvZX
st
Or
yy L}G}˘]vUæuP]o˙(}˙b
vA
D}˘˙˙o]v}A]R}u˙]v~b}]v L]vTuvZ
st
Av
yy D ]o}(v b}]uU}oUæuPR}o˙
Or
yy I}(vU}oUuPR}o˙
Refeal
r Criteria
R( oo b }( b]bv ( v }uo]}vb } R P]o
b
b]o]b}}o}P]bX
152. TboT}b]}v~T}b]}v}(SuC}Z
TR]b ]b }v
b }( o}} bo˙ } Rb } `]bvP }( R
ub }XTR]b]b u]ouPv˙Rvb}}Pv]
(} R ]vo b]Pvb v ˙u}ub
b (oo˙ uv](b b }u
æ
Standard Trtme
P˙ b bRbX
Do˙]vuv}obo]vob }R˙Uv}uobu
}vo]vP}]v(o]˙lb]o]˙X
I v obb]. ]v} ]vP]vo }b]}vU `R]R }vb u}
Rv ıæA9 v ˘rP]vo }b]}vU `R]R ]b boo˙ (}v ]v ]v(vbX
A} æA9 }( }b]}v }b ]vP bo v o˙ ]v R u}v]vPX I ]b
]v}oR]ovvob}uu}v]vR]ovvæ˙bX
sueCa
yy Uvbvb
yy Boorouo(}u}v
yy H}]}voo]}(bl]vb]}v}(b
yy L}vPub}R]u
yy Tu
yy Sbu}(ububob
v*Tetic
Symptoms
s ularTorsion~TorsionofSpermaticorC dZ*v
yy Sv }vb }( b]v ]v }v ob } v ]v
`R]Rb}obb}vv}bo˙~v}b]}vv}b]}vZ
yy P]vu˙}˙]oo˙o˙]vRu}v]vP
yy L}`}u]vo]v}v+b]
yy Nbv}u]vP
yy N}]v˙˙u}ub b
yy No fever
Signs
yy S`}oovUvvv}uo}b]}v}(bv]]˙u]bX
yy SR}v`]b}X
yy Oulv]vP}(}o b òo
yy R]PRbr`]bo}l`]b
yy LLbr`]bvo}l`]b
yy PRv[bb]Pv]bbv~o}v}(}u b ]vRou}`bR
P]˙uR˙b
b ]b}bv}o]]vZ
TorP) D]bvP]bR]vP`vT}b]}vvE]]˙u}r}R]b
Pu Torsion E]]˙u}r}R]b
AP AMæ˙b ANæ˙blb˘oo˙
Ovb}(]v Svlo˙u}v]vP Gradual
History of coitus Uboo˙bv Uboo˙bv
F Absent Pbv
U]v˙˙u}ub
b Absent Pbv
URo]bRP Absent Pbv]vSTIb
P}b]}v}(b CRvP UvRvP
v
Chatep rP *Disorsof
Pu Torsion E]]˙u}r}R]b
Sòo]vP Tbb E]]˙u]bvb
PRv[bb]Pv bvA lvP Pbvl}b]
Bo}}bo˙P}o Reduced N}uo}]vb
test
Tuv SP]o N}vP]o
b
Invtiga
se tions
yy U]vo˙b]b
yy FBC
yy D}oR}b b }
yy C}o}D}oUob}vSv
yy ııuTrRvb]voo}vv b ~ırA9Z
Trtme
ae nt
Tuv}ib
yy T}RP]o b ]vv}v`]R]vvR}b}(}vb
yy T}P]oo˙ b ˘o}oo}ob
v*Fournier[sGangrene*v
yy T}vob o}bb
yy EuPv˙P˙ b ]bRvb uv
yy I( P˙ b ]b o˙ Rv uvo }b]}v bR}o ] }
(oo˙}vo}bb}(bX
yy Mvo }b]}v }rv o}o vbRb] ~b o}`Z
v v]vP
b R (}} }( v`]bP R]PR b vo}l`]bU
LLbro}l`]b
yy EuPv˙P˙ b bR}o(}oo}`R]b}b}}vb}bb]o
]vE RvPPC
yy L]Pv}]vA9U]v}Rbu}}v}Rb]br(}}o}l
vbRb]ruo
Refeal r Criteria
R(b}}v}bb b]o~](P]o b ]vv}v]bv}]oo}Z
P}v
b }}o}P]bX`B ob }b]}vRb}vou]}roPo
]uo]}vbX
153. Fournier’s Gangrene

I]bv(ou]vv}o˙u]}]ov}b]vP(b]b}PvPv
+vP R }u
b v b}uub ˘v]vP } R ]vuU v]b
vo}`}uvXI]bob}oo]]}R]PvPv}(R}u b X
TR˙vP]b
b ]v(}vb}(v}]v}]]}o
`]R}o]]bbob]vR˘vb]PvPvXTR]bl(}b
w
Standard Trtme
]vo ]b uoo]bU HIVlIuuv}bb]}vU ]vo bl
]v(}v }( }u b v }vvbU uU ˘b}v }( ]vU
]Ro b v Ro ]b loo]X TR }uo]}vb }(
F}v] [bPvPv]vou] b U˘b}v}(]vU˘}b
}(bv.bo(}u}vX
sueCa
yy Staphylococcus spp
yy Microaerophilic Streptococcus
yy E. coli
yy Fb]]
yy Clostridium welchii
yy }]b
B
Symptoms
yy A}vb}(]v(ov]}}ob òo]vP
b ]v]}bo˙RoR˙
b
yy F
yy P]v]v+}u b
yy Gvouo]b
v*Fournier[sGangrene*v
Signs
yy F
yy P}b}v
yy R]o˙}Pbb]vPPvPv
yy F}}}
yy SRu}v`vR[bvRoR˙b
yy ]bC }vo}v}(+b
yy Tbb]bboo˙b
yy U]v˙˘b}v
yy Pbv}(]bl}]b}b]vP(}b
Invtiga
se tions
yy W}vovbvb]]˙
yy Suovbvb]]˙
yy U]vo˙b]b
yy FBCvSR E
yy G}]vPv}bbruR]vP
yy FbvPo}}Po}b
yy HIVv]vPb
yy Po]vXr˙}(o]b`]oooPb]v+b
Trtme
ae nt
Tuv}ib
yy T}b]v
yy T}R]v(}v
yy T}uvP}v}u]v]bl(}b
yy T}boPRb
Chatep rP *Disorsof
yy T}vl}uo]}vb
yy SP]o]vv}v
yy R]o]uv
yy R}vbP˙b P
yy Tbb]]vR]PRu}]o˙}vb]}v
yy Sl]vPL]vPv}vb}v}(}u b ~b}}ob˙Z
yy M˙}v}bGb
yy N]}vbouv
yy W}v
yy MvPuv}(]buoo]b](bv
yy MvPuv}(HIVlAIDS](bv
]v
E RvPPC
AX IVG]bURu}vb(b]}vvR˙]}˘˙Pv
]Ab (}vbo]v]ob
BX Av]}b
yy Gvu]]vUIVUuPR}o˙
v*BladerCancer*v
vA
yy Au]]oo]vUIVUæuPvR}o˙
vA
yy M}v]}oUIVUæuPR}o˙
Or
yy A u}˘]]oo]v A=Coov]A]UIVUPR}o˙
vA
Or
yy (}˘]u
C UIVUwæuPR}o˙
Av
Refeal
r Criteria
R(oo`]R
b bR}lLb]}vvooR}b`R}
]}vbP˙b }}o}P]b}P]o b b]o]bX
æX Bladder Cancer
Bo v ]b R }v
b }uu}vb }o}P]o v L
}bvX I ]b R }uu}vb }( oo R vbU `R]R + R
]v˙ o]v]vP ~}Ro]uZX Mob u} + Rv (uob
]v } }( } PX I ]b u} }uu}v ]v R `R] }u
} R ol ]v } }( PX M}Rv A9 }( o]vb `]R o
v } æ ˙bX TR }uu}vb R}o}P]o ˙b
ı
Standard Trtme
vb]}vooo]v}uTCC~ıA9ZUSu}boo]v}u~A9Zv
v}]v}uv]v}u]vrb]~A9ZX
sueCa
yy CR}v] Iv(}vb }( R o o]l Schistosoma haematobium
~B]oR]ZvR}v]]o]v(}vb
yy Su}l]vP }( ]P'bP v boo˙ o}b r ˙b L
bu}l]vP v lbb ˙l l ]b R]PR ]bl }( v
o}uvXPbb]bu}l]vPu˙ob}˙R]bl}(v
yy O}vo ]blbV v]}vuvo ˘}b } vrb]vP
Ru]ob b ]v ]vb]b XPX ˙U˘oUU oU ]vvP
X
yy Gvv(u]o]o(}b
Symptoms
yy M˙˙u}u b ]vo˙]bb~æA9Z
yy Hu] ~boo˙ ]vobbZX P]v(o }vo˙ ]v v ]bb v
]v(}vlUTI
yy I]˙u}ubb P(v˙UPv˙U˙b]
yy Fovl]v~R˙}vR}b]bZ
yy Po]]v(}uv]vb]}v
v*BladerCancer*v
yy Ou}(o}ò]ub(}uv]bb
Signs
yy Poo}
yy WbvP
yy Poooubb
yy Pool]v˙(}u]}b}vvR˙}vR}b]b
yy L˙uR}u}(o}ò]ulo]ub
yy S}v˙UTI]vA9}(b
Invtiga
se tions
yy FBCvSR E
yy U]vvo˙b]bvo
yy U]v˙}o}P˙
yy UUv]vUo}o˙b
yy Uob}vv b PA}u]v}o]
yy CTSvlMRI(}P]vP b ~B˙b]o]bZ
yy S]oIvbP}vbPA}u]v}o]IVU
yy UR}˙b}b}˙v]}b]b~B˙b]o]bZ
yy E˘u]v}v v vbRb] ~B]uvo o}v }( o
R}PRDREvPo]˘u]v}vbZX
Trtme
ae nt
Tuv}ib
yy SP]o(}o˙]bb
yy Pv}v}(vU}Pbb]}vvubb
yy MvPuv}(}uo]}vb
Chatep rP *Disorsof
yy A]}vo uv `]R v Pb v ]}R˙ `R
vbb˙~N}ivvivR˙Z
yy C˙b}u˙PPo}]o`]R}`]R}oouvX
yy Radiotherapy
]v
E RvPPC
AX o˙ E SP
yy GBC } TR]} o ]vboo}v (} b.]o u}b L
TvbrURoRb}v}(BoTu}~TURBTZ
BX vA D]bb
yy CRu}RPvb}uuv(}vP b ]vo
MR}˘UV]vobvUA]u˙]vvC]bovX
Refeal
r Criteria
R( oo b }( o v (} b]o]b o}v v
uvX Aoo b }( R}v] ˙bb R}o (} b]o]b}
˘oovX
v*Ccinoma
ar ofProstate*v
155. Carcinoma of Prostate
N]v˙r. v }( Rb u}b v}]v}ubX
TR ui}]˙ }( uv + P `v væ v æ ˙bX TR
]v]v]vb`]R b PXI]b}uuvR˙uoU˙b
v }U bR}o R vvo v]vP b ˙ P}b S]. AvPv
~PSAZ b v D]P]o Ro E˘u]v}v ~DREZ b]v o˙ }v ]b
b}] `]R ' }Pv}b]bX TR v. } }R`]b }( v]vP
b
bR}o]bb`]RvbX
Pvb`]R(u]o˙R]b}˙}(}bvvbR}o}vb]
vvov]vP
b (}u ˙b v }`]R PSA v DREX I ]b `}R
v}vP R v} ˙ R }b }v DRE ]b uo]PvvX L]l`]b
v}uor(o]vP}b}bv}˘ouo]Pvv˙X}bA ]}b˙
]bR(}vbb˙}o]b
b R]Pv}b]bX
sueCa
yy AP]vP
yy Fv}vob
yy Fu]o˙R]b}˙}(}bvUvb U}]vv
yy R~u}}uu}v]volbZ
yy H]PR]˙(]vl
Symptoms
yy ˙u}u
Ab P }b v u˙ bv `]R} ˙u}ub
b
]vRo˙P
b
yy L}Ù]v˙TS˙u}ub~LUTSZvIPSS
Standard Trtme
yy Rv}v}(]v
yy Hu]
yy Gvo]o]˙v}˘]U`]PRo}bbUo]bobbvbb
yy B}v]v~}uu}vo˙]vR`]b}o]ubZ
yy Po˙b]b]vRo}ò]ub}]v]o]˙}òl
yy PR}o}P]oF
yy Iu}v
yy Hu}bu]
yy Tvbub
Signs
OvDREo]v]ob]Pvb]voV
yy H}bPov`]Rv]Pob(vPb
yy Oo]u]vbob
yy ARvou}b
vA }ub]bbP
yy Avu]
yy Uu]
yy WbvP
yy B}vvvbb
v*Ccinoma
yy PoP]
ar
yy PR}o}P]o(
ofProstate*v
Invtiga
se tions
yy FBC
yy Bo}}Uo}o˙bvv]v
yy P}bS].AvPv~PSAZ
yy L](v}vb
yy A}u]vovo]ob}v
yy TvboUob}v~TRUSZ}(R}bU](]oo
yy Transrectal needle biopsy of the prostate
yy TRUSrP]}.vPrP]
Trtme
ae nt
Tuv}ib
yy T}o]˙u}ub b
yy T}}v}o}uo]}vb
yy To achieve cure for early disease
yy T}vo}o}Pbb]}vvubb
yy URoR]b}v}o]]v˙v}v`Rv
yy R]o }b}u˙ } ]}R˙U v b]o]b U (}
early disease
yy SP]o}v b ~]oo}R]}u˙Z(}v]bb
]v
E RvPPA
yy PRu}o}P]o uv }( ]v}u }( R }bU `R]R
Chatep rP *Disorsof
]v}obR}u}vouv]o}vU`R]R]vR]]bP}`R}(Ru}
˙]]vP]}(v}PvbU]b]b }vb]o]bX
yy TR}uu}vPbb]vv}bvR˙P
AX Avv}Pvb
yy B]ou]U}oUæuP]o˙~(}b]o]bZ
Or
yy Fou]U}oUæuPR}o˙~(}b]o]bZ
B. Oestrogen
yy So}b}oU }oU ræ uP ]o˙ ~A}] ]v o]vb `]R ]}bo
]bbZU~(}b]o]bZ
CX LHRHAvo}Pb
yy G}bo]vUSCU(o˙]vR}u]voòo~(}b]o]bZ
Or
yy L}o]UIMU~(}b]o]bZ
Av
yy B]R}bR}vbvFvv˙oRb~(}b]o]bZ
v*Ectile
Refeal
r Criteria
re
R(oo}b b]o]bv(}o}vvuvPuvX
Dysfunction*v
156. EoD˙b(v}v
I uvb R b]bv ]v]o]˙ }( uv } R] v }vU
`R]R ]b ]v ub }( Rvbb v }v (} (}˙
b
˘o b ]v}bXS}o}vPbuvvR]Rv}PR}v
} u] P]vo v}vU `]R o}vP v}PR Sb˙]vP }` _
} (}u R ˘o b oo io}v ]b ']vU R ]b iP }
}vXTRvu}(S}vb_b]}v]b]ovX
TR }v]}v u˙ obb]. b }Pv]U˙R}Pv]
b } u]˘]v
ub }( }o}P˙V ]u˙ ~v v o } ']v vl} u]v]v
v }v (} (}˙
b ˘o b ]v}bZ } }v˙
b U `R
]u}v }b ]v uv `R} R ]}bo˙ R (}˙
b ˘o b
(}uvX
sueCa
Psychogenic
yy Av˘]˙
yy b]}v
D
yy Stress
yy M]o}vG]
Organic
yy Vbo}Pv]P]o]vb8]v˙l}ob]}vVv}b]v}uv
yy N}Pv]P]Rov}R˙Vb]vo}ob]}vb
yy TuP v}u˙V o] ( ~`]R Ro ZV
Standard Trtme
]vou
yy Ev}]vP ]b uoo]bU R˙}P}v]buV R˙}ovu]V
]]˙UvovR˙}]]b}b
yy DPbPXPXvR˙vb]bUvbbvb
yy P}br}P C˙b}u˙U R]o P}b}u˙V
A}u]v}]vob}v
yy IvGuu}vVR]bV}bb
yy MRv]oP}vPv]ov]ov}uo]bVP˙}v]b]bb
yy EvvoPRlvolo](]oVou}v˙]vb8]v˙
yy P}br]]bu
Symptoms
yy Iv]o]˙}R]}v
yy Iv]o]˙}]v b }v
yy R˘o b b]
Signs
yy Fbo}vo˙]vPb
yy H˙}P}vo (b XPX P˙v}ubU ol }( uo ˘o
b
R]bb
v*Ectile
yy Pv]oobv~P˙}v]b]bbZ
re
Invtiga
se tions
Dysfunction*v
yy FBCvb]lo]vPb
yy L]]}.o
yy U]vo˙b]b
yy FbvPo}}Po}b
yy Su}ov
yy SuLHUFSHv}bb }v
Trtme
ae nt
Tuv}ib
yy T}u]v(}b b v}]o˙
yy T}}b ˘o b }v˙
N}r
oE ˙b(v}v u˙ R .b`v]vP b]Pv }( vo˙]vP]}bo
]bbo]lM˙}]oIv(}v
yy Pvb bR}o }] ˘bb] o}R}o }vbu}vU ]P'
bu}l]vPU}voPbv˘bb]`]PRP]v
yy Pb˙R}b˘o}vbo]vP
B}˘rP)
yy TuvbR}o ] vo˙]vPb XPX RvP} ]b}vv r
u]}vU ]( (}v } R bU ]v }vbo}v `]R R v[b
physician
Chatep rP *Disorsof
yy DPb(}o˙b(v}vXPXb]ov.oUo.o}v.o~PDEæ]v r
R]]}bvZ b].bb o]vuvL(o]}bo
o}vX TR˙ }v]v] ]v ]bRu] R ]bb v R}b
on nitrates
yy S]ov.o]Uæ}uPu]vb}R}(}}]b
Or
yy To.oUuPrvu]vb(}}]b
Or
yy Vv.oU}uPrvu]vb(}}]b
N}ræ
TRbu]}vb]˘o
b uo}v
b (}}uobob
yy P}bPov]vEub}vo˙bvb]o]bX
Refeal
r Criteria
R(o} b]o]bv]bvbb˙(}}o}vv
uvPuv]vu}bbX
v*MaleInfetility
157. MoIv(o]˙
Iv(o]˙ ]b R (]o }( }o } R] }v}v `]R]v
r
u}vRb }( v} }]bX A} }v R] }( b }(
]v(o]˙bo (}uR}o}P] (}b ]v uvU}v R](}u (}b ]v
*v
}Ruvv`}uvv}vR](}u(}b]v(uobXMob
R(}}v(}æA9}(]v(o]˙XA}æA9}(oou]}ob
˘]v } ]8obX C}u}vvb }( ]v(o]˙ R]b}˙
]vo u]oU P]o
b U (o]˙U ˘o b U (u]o˙U u]}vU b}]o v
}}voR]b}˙X
sueCa
F}o}bbRu]vvb ]]]v}RP
yy Treatable causes
yy P}voo˙ob
yy Uvob
TR b v ob} obb]. v R P}]bP Pr
ob UTbovP}brboX
TorP) Cb}(MoIv(o]˙
Treatable causes P}voo˙o Uvob
causes
V]}}o I]}R] C}vPv]ov}uo]b
XPXvb }(}R
bvR}u}b}uo
v}uo]b
æ
Standard Trtme
Treatable causes P}voo˙o Uvob

causes
Iv(}vb}(bU Uvbv B]ooob }R˙
]]˙u]bURU Tbb
prostate
Eio}˙˙b(v}v G}v}}˘]vb~PbU
]}vZ
oE ˙b(v}v Bo}lP}((vb
b
H˙}ovu]
H˙}P}v}}]
R˙}P}v]bu
Symptoms
yy Pvb boo˙ }uo]v }( R] `]b[ ]v]o]˙ } P] Ru
R]oX SR vb ] }Lv ˙ Rvb]U (b
vov}vP}]vbP}vb
yy S˙u}ubbPPb}(R]b}˙}(STIUUTIUuubUPv]oUo]}
]vP]v}b}oP˙b v]vi]b
v*MaleInfetility
Signs
yy bv A }(uo}v˙
b ˘o
b R]bb
r
yy G˙v}ub
yy E˘u]v˘voPv]o]}bP
*v
yy TbbPbv}bvUb]v}vb]bv˙
yy E]]˙u]bPR]lv]vP
yy Vb(vbPbvUR]lv]vP
yy V]}}ob
yy IvP]v}b}oP]}vP(}u b ]}bRv]}RR˙
yy Pv]bPb]UUR˙}b]bU]b]b
yy URP]bRPUuov}b b ]bU]b
Invtiga
se tions
yy FBCvb]lo]vP
yy Suvvo˙b]b
yy U]vo˙b]b
yy FbvPo}}Po}b
yy S]. ]vbP}vb ovP } ]}b b XPX }o b
ultrasound
yy S]o]b]vbP}vbXPXR}u}vo}.o}v˙b]o]bb
yy o}v E }((uov˙P˙v}o}P]b
Trtme
ae nt
Tuv}ib
yy T}]u}(o]˙}vo
yy T}R]Pvv˙`]Rv
v
Chatep rP *Disorsof
yy S˘o}vboo]vP
yy Su}l]vP}v b
yy R}v]vo}R}o]vl
yy }] A o}o~b}o˘}b Z }˘bb]RU}ovRu]ob
yy }] A PR v`X Ub }( }˘ bR}b v }'}v ](b ~v}
b]ollv˙o}vZ]b}uuvX~TR]bbR}vR}b
}u}bu}Pvb]bZ
yy TR]b]b}] b vb]o]bX
Refeal
r Criteria
R(oobR]b]o]vbP}vURu}o}P]o}
P]o
b uv}b]o]bX
158. Haematuria
TR]b ]b R bP }( o}} ]v R ]vX I u˙ u]}b}] }
u}b}]U]vu]'v}}vv}bXTR'v}(o}}]vR]v
u˙]v]oUu]vo}(vll}oXBo}}]v]v]bb]}b˙u}u b
v*Haematuria*v
v ub o`˙b (oo˙ ]vbP b]oo˙ } ˘o vX
]v C Pb v (}} }b u˙ }o} ]v bovP ]v (ob
Ru] v Rb bR}o ]+v (}u Ru]U
`R]R ]b ˙ u]}b}] ˘u]v}v }( R ]vX E˘uob
}( bR vbb ](u]]v v R}u]v B (}} }o}]vP b
]v lbU }}l]b v b}L ]vlbX Ob]}voo˙ P]vo o]vP u˙
u]blv(}Ru]X
.v]
D uvvb}vRbX
sueCa
Glomerular
yy Go}uo}vR]bboo˙bvb`]R˙bu}R]o}}oob
]vR]v}o}}oobb`]R}]v]
Non-Glomerular
yy URPTuUIv(}v
yy BoP Iv(}vU }v b U o vU ]bU BPHU }b
vP}v~˙o}R}bRu]]}v Z ˙bbUb]
]v(b}v~ S. haematobiumZ
yy UPIv(}vU}v b Uu}
yy K]v˙P Iv(}v ~˙o}vR]bZU }v b U v}u] v}uo]b
~P}o˙˙b K]v˙ D]bbU rV A F]boZ vo ]v } ˙
R}u}b]bU
yy N}obubPRvooo]v}u~W]oubTu}Z
yy Tu
yy Sickle cell disease
yy Bv]PvP}bH˙ob]~BPHZ
w
Standard Trtme
yy ]v}u
C }(}bUovl]v˙
yy U]v˙]v(}v
yy U]v˙oo]
yy M]oXP
b Xb]looo]bbUPo}uo}vR]bv
v}PovR˙
Symptoms
yy FbPPbb]v(}vXPX˙o}vR]bU˙bbv}bb
yy C}o]l˙Gvl]vbPPbb]v˙}vb b
yy Ab}]o}`]v˙˙u}ub
b bPPbo}}b
cause
yy Bo}}]vR]v~}v]v]}vUu]˘`]RR]vU} Rv
}(b]vP]vZ
yy P]vl]b}u(} }v b]vP ]v boo˙ b}] `]R ]v(}vU
oo]}u
yy P]vob]vu]'vb Ru]b}]`]RvbPo
and kidney cancers
yy L}Ù]v˙TS˙u}ub~LUTSZ
yy L}]v]v
Signs
yy Poo}
v*Haematuria*v
yy A}u]voubbXPXl]v˙Uo
yy L}`}]b vvb(}u b ]v˙]v(}v}oob
Invtiga
se tions
yy FBCvb]lo]vPb~Ho}R}b]b](b]lo]vP]bb }b]Z
yy Bo}}Uo}o˙vv]v
yy U]vo˙b]b
yy U]vovbvb]]˙
yy A}u]vovo]ob}v
Trtme
ae nt
Tuv}ib
yy T}vo˙]vPb
yy T}o]vP b
yy H]PR G] ]vl]b ]b ]v }}vo} (}u}v ]v R
urinary bladder
yy I(vbvb`]Ro}v}vURvR]bv(
AXF}U]v˙SR]b}b}u]b]b
]v
E RvPPA
yy P]voU}oU
~Sb}v}vRU]v˙SR]b}b}u]b]b[Z
Chatep rP *Disorsof
BXF}U]v˙TIv(}v
yy G]}]v]}b~Sb}v}vRU]v˙TIv(}v[Z
Refeal
r Criteria
R(oo}Rb òobR}b`]Rb]bvRu](}
}]]vbP}vbvuvX
159. U]v˙SR]b}b}u]b]b
TR]b ]b `r}v ]bb b ˙ v}v }( R bl]v
} u}b uuvb ˙ R o˙ Pb b }( R b }Pv]bu
(Schistosoma haematobiumZU`R]R]vRo(}u'ob b ]vRo}}
bob }( R ]v˙ o bovP ]v R }uu}v bv}v }(
Ru]X
TR]b ]bb ]b }uu}v ]v GRv `]Rob vu] b o}vP
R olbU bo}`rG}`]vP ]b v ]]P}v ˙bb ubX TR }uu}vb
}˙b]b+RoUbvo]}PvbXPv}v
v]ob}]]vP}v`]R]v(b`X
CR}v] ]v(b}v u˙ o } b vu]U ] ]b
v*Urinayr Schistosomiasis*v
vR˙}vR}b]bbòo]v}u b }(RoX
useCa
yy Schistosoma haematobium
Symptoms
Iv]o
yy IR]vPvvbb}(bl]vb]}(v}v}(b]
yy FPU o}` P (U uo]bU obb]U ˘bb] `vP b U
headache and backache
Later
yy Tu]voRu]
yy P]v(o]v}v~˙b]Z
yy L}`}u]vo]v~o]vZ
Signs
yy Poo}
yy Pool]v˙(}uR˙}vR}b]b}]]b
yy Poo o (}u o v } v}v }( ]v }
clots or bladder neck stenosis
yy DRE u˙ o .}b }bU voP bu]vo b]o }
thickened bladder base
Invtiga
se tions
yy FBC
yy U]v (} o}} oobU b oobU v bR]b}b}u } ~u]r˙
]vb]uv(o˙lvLR˙b]o˘]b]b]oZ
yy M]bu]v(}o]vb}]]v˙]v(}vb
yy IuP]vPP Uob}v v b V Ivv}b U}Pu ~IVUZ u˙ bR}`
ı
Standard Trtme
o].}v}(oUbUR˙}vR}b]bvR˙}b
Trtme
ae nt
Tuv}ib
yy T}o]u]vR}Pv]b b u
yy T}uvPR}uo]}vb
yy }] A ˘}b}]v(b`}]b](}bb]o
]v
E RvPPA
yy P]voU}oU
Adults and Children
uP llPb]vPo}b
yy Tvu]](bv~Sb}v}vRAvu][Z
Refeal
r Criteria
v*Pesis
R( v L uv ](P Ru] vl
r tentorRecurentUrethralDischager *v
} ˙u}ub
b }( ]v˙ ]v(}v b]b } ]( }uo]}vb o]l
R˙}vR}b]bU o ubbU v}v }( ]vU b `bvP v
vu]
b bvX
160. Pb]bv}RvURoD]bRP
~S }v
b }v RSTIro b]bv } v Ro
]bRP[ZX
161. Rv}v}(U]v
Rv}v }( ]v ]b ]v]o]˙ } u˙ (oo oX I ]b R
}uu}vb }o}P]o uPv˙ ]v GRv v `}o`]X Ao uob
u} }uu}vo˙ +X I ]b ]v R]ov v ]v (uobX TR
b ]+ ]v ]+v P P}b b òo b ]v uob v (uobX A
(u]o˙R]b}˙}(v}v}(]v]vBv]PvP}bH˙ob]~BPHZU
}bvUvb v}]vv]bl(}bX
Rv}v}(]vvobb].]v}RP
Xv}v
A }(U]v]b}(bv}vb`]Roov
oX
XCR}v]Rv}v}(U]v]b}(]vb]]}b}vbvbvb`]R
oov}vrvov}G}`]v}vvvbovP]vu}
uP} R oUb v l]v˙bX P}brvovo (]ou˙
}uo]R]b˙}(v}v`]RR˙}vR}bbvR˙}bX
Xr}v
A rR}v]v}v}(]v]b`RvR}v]v}v}(
]v]bbvo˙}uo]˙v}v}(]vX
Chatep rP *Disorsof
sueCa
yy Aouobr~}æ˙bZPBPHURo]bb Uovl
stenosis
yy Ao uob r ~o}` æ ˙bl˙}vP uobZP Ro ]bb U
Ro ]vi]bU o vl v}b b ]bU v}Pv] olb]vo
]vi˙UR]u}b]bURoo]U}bb
yy Mo R]ov r }b]}RoobU uov}b b ]bU R]u}b]bU
Rooo]U}vPv]o]bb
yy Ao (uob r}P] bU ]v .}]blu˙}ubU
]u }]v ˙bbU v}Pv] ~}b} v o]
]vGuu}˙ ]bbZU]v}u }( ]˘ `]R ]v.o}v ]v} R
urethra
Symptoms
yy Rv}v }( ]v ]v BPH ]] ˙ }b}vuv }(
u]]}vUo}R}obv]v(}v
yy Sv ]v]o]˙ } b ]v `]R ]v(o oP ]v o}` }uv
(}v}v}(]v
yy Go }vb }( ]v]o]˙ } b ]v `]R ]vobb oP ]v o}`
}uv(}R}v]v}v}(]v
v*RetentionofUrine*v
yy H]b}˙ }( R]bU Ro ]vbuv}v ~XPX R]b}vZ
}]vo]vi˙Uo](}P˙ b ]vRo]bb
yy Ivv}voP}bS˙u}uS}~IPSSZ
Signs
yy Poovo]vv}v}(]v
yy Poov}vrvo(}R}v]v}v}(]v
yy Uu]lA}u]]vvo(]o
yy F]v]v(}vbPUTIv}bb
yy Pool]v˙b]vR˙}vR}b]b
yy Hu]]vBPHU}bvvRo]bb
Refeal
r Criteria
Pvb `]R R˙}vR}bb }v ob}v vb v vo (]o
bR}o(}b]o]bX
Chapter
SexuallyTransmitted
Infections
v
162. S˘oo˙Tvbu]'Iv(}vb]vAob
S˘oo˙ Tvbu]' Iv(}vb ~STIbZ bo ]v ob o]v]o
˙v}ub
b b ˙ }Pv]bub R v ] v vbu]'
R}PR˘o b ]˙X
TR˙ b u}]]˙ ]v ob v u˙ bo ]v o}vPru
}uo]}vb bR b Ro ]b U ]v(o]˙U }] Pvv˙U
vo .boU ]o vU (}o `bPU u]˙U o}` ]R
`]PRU }RRou] v}v}u v }vPv]o ˙R]o]b b X TR] }v}o ]b
R }vb}v ]v ]u}]vP } RoR v ]vP Huv
Iuuv}.]v˙V]b~HIVZ]v(}vbX
C}uRvb] uvPuv }( STI ]b ]u}v v }u]bb
}u v + b }v v uvX H}Ù }`]vP }
Rol}(o}}˙]uvvuv}`]v]u˙(]o]b
`R u}b vb .b bvU v ]Pv}b]b ]b }Lv v}
}bb]oX Aob} `]R u}b STIbU }v vv} boo˙ oo `R]R }Pv]bu ]b
b]vP R ]v(}v (}u R R]b}˙ v R˙b]o ˘u]v}v o}vX
Moo]v(}vbob}}U`]RRv]vP}XF]o}
}v ]v(}vo˙ u˙ bo ]v R o}uv }( b]}b
}uo]}vbX
I]bR(}u}o]vuvP]vPSTIb}uv b }v
Rb˙v}u]]Pv}b]b[U`R]R]v.booSTIbR}oob
˙u}u
b }b]Pvv}]uv(}R}(Rub]uov}bo˙X
TR}uu}vo]v]o˙v}ubb b}]`]RSTIb]voRo
]bRP ]v uobU b]bvlv Ro ]bRPU P]vo
]bRPU o}` }u]vo ]vU Pv]o oU }o b òo]vPb
b U
]vP]vo o˙uRv}R˙ ~}bZU v}ro ˙v}ub b ~v}ro
]bRPUobvb]obZUvPv]o`bXS]bv]o}b]b
]bu˙ob}vbu]'˙˘o b }vX
Iv o]vP `]R vb `]R STIU ]˙ v }v.vo]˙U
b]oo˙`]RRR]b}˙l]vPv˘u]v}vUu}vX
}vE v }vboo]vP }( STI vb v }vv
uvPuv}(R]vb}]]}vo}}v]b}
R]bl}(STI]vR}uuv]˙X
Chatep rvP *SexuallyTransmittedInfections
~S b}v }v RS˘oo˙ Tvbu]' D]bb ]v CR]ov[ (} STIb

]vR]ovZ
163. STIroURoD]bRP]vMob
Ca s e u
yy Neisseria gonorrhoea~G}v}}oR]bZ
yy Chlamydia trachomatis~N}vrP}v}}oR]bZ
vX Mycoplasma genitalum
Sympt oms
yy URo]bRP
yy D˙b]}]b}u(}}v]v}v
Signs
v*STIrrelatedUrethralDischager inMales*v
yy URo]bRP
Note 16-1
Gvou]ol]vP}(RRu˙oR]bRP](]]bv}]v]oo˙]b]oX
Iv v]u]b uobU Rl R R ]bRP ]b }u]vP (}u R Ro
}v]vPvv}(}uRPovbv]bX
Inve ti
s gations
yy URo`b ovbvb]]˙~](]ooZ
Tre a tment
Treatment }i es
yy T}P}v}R}vRou˙]R]bb]uov}bo˙
yy T}v(Rvbu]bb]}v}˘o
b vbX
yy T}vo}uv}(}uo]}vbvbo
yy T}]bl}(HIV]v(}v
yy None
]v
E RvPPC
AXF}G}v}R}
yy L]˘}v
C UIMUæuPb
Or
yy .˘]u
C U}oUuPb
Or
yy C]}G}˘]vU}oUæuPb
Av
Standard Trtme
B. For Chlamydia and Mycoplasma:
yy D}˘˙˙o]vU}oUuPR}o˙(}˙bw
Or
Or
Or
yy A]R}u˙]vU}oUPX
b
165. STIroPb]bv}RvURoD]bRP
TR]b u˙ } } P b]bvU }} uv }uo]v

} r]v(}v (}oo}`]vPuv (} v STIX Iv b}u b ]bv
v*STIrrelatedPesis
}(Ro]bRPu˙}]v(}v`]R Trichomonas vaginalisX

Ca s e u
yy Neisseria gonorrhoeaeU Chlamydia trachomatis or Mycoplasma
r tentorRecurentUrethralDischager *v
genitalum(}oo}`]vPPb]bvU}}}uo]v}r]v(}v
Luv
yy Trichomonas vaginalis
Tre a tment
Treatment }i es
yy T} r(} P}v}}o } v}vrP}v}}o R]b ]( b
}}]}b}}uv}uo]v}r]v(}v
yy T}]v(}v`]R Trichomonas vaginalis
yy T}vvbu]bb]}v}˘o b vb
yy T}vo}uv}(}uo]}vbvbo
yy T}]bl}(HIV]v(}v
yy None
]v
E RvPPC
AXF}G}v}R}UCRou˙]UM˙}obu
Ruv(}Ro]bRP
B. For Trichomonas vaginalis
Or
yy M}v]}oU}oUPX b
Or
yy T]v]}oU}oUPX b
Or
yy Sv]}oU}oUPX b
Refeal
r Criteria
R( oo b }( uv (]o } RoR (]o]˙ `R
u]}]}o}P]oovvu]}]obvb]]˙bv}v}v
RRo]bRPX
166. STI-related Vaginal Discharge

WR]oP]vo]bRP]bv}oo]v]o(}(vSTIUv}oo
(}ub}(P]vo]bRPv}uo}]v]}(vSTIXAP]vo
]bRP u˙ b}] `]R R˙b]}o}P]o b R b uvbb
} Pvv˙U } `]R R bv } b }( (}]Pv vbb v
Ru]ob]vRP]vX
A (o ]bl buv ~S v} o}`Z }( `}uv `]R
P]vo ]bRP u˙ Ro ]v(˙ STIb v v}vrSTIb v bo}v }(
}]uvP]uvb}v b Ru}bo]lo˙}o}P˙}(R
P]vo ]bRPX OR }vb]}vb (} bovP uv ]vo
Pvv˙bvv]b}u(}X
v*STIrrelatedVaginalDischager *v
sueCa
yy Trichomonas vaginalis ~Pv } ˙oo}Ù buoo˙U o˙ } (}R˙
]bRPb}]`]R]R]vPZ
yy Hbb]uo˘]b~(}oo}`]vP.b]b}}(]v(}vZ
Sympt oms
yy VP]vo]bRPrRvP]v}o}U}}U}vb]bv˙}u}v
yy Vooòo]vP b
yy P]v}v]v}v
yy L}`}u]vo}l]v
Signs
yy VP]vo]bRP
yy Vooòo]vP b
yy Voo˙Ru
yy L}`}u]vovvbb
yy C]o˘]}vvvbb
yy C]ou}b}}b]}vb~}vbou˘u]v}vZ
Inve ti s gations
yy H]PRP]vo`b (}u]}b}˙Uovbvb]]˙~](]ooZ
Tre a tment
Treatment }i es
yy T}]v(˙vv}vrSTIP]v]b~b]oo˙v]]b]bU`R]R]b
(vo˙]Pv}b]v`}uv]vPo(}STIbZ
yy T}bSTI]blvSTIro]v(}vb}]o˙
yy T}v}uo]}vbvbo
æ
Standard Trtme
yy N}v(}STIro]bRP
]v
E RvPPC
Note 16-2
R]blAbuv
Pubb]vR]blbuv(}]]bP
]XPv[bv]b˙u}u b ~]XXvRbRo]bRPZ
]]XPv]bobbRv˙b}o
]]]XPv]bb]vPo
]XPvRbu}Rv}v˘o b v
XPvRbRv`˘o b v]vRobu}vRb
TR ]bl buv ]b b] } }b] v uv (} ]]b ]b
}uuv](
rTRvb`}~]Z]b˙b}
rTRvb`}v˙}(]ub~]]Zr~Z]b˙bX
I(`}uvRbP]vo]bRP`]Rv}}b]]bl(}U(}P]v]b
v*STIrrelatedVaginalDischager *v
o}vX I( bR Rb P]vo ]bRPU v }b] ]bl (}U (} }R

P]v]bv]]b
AXTuv(}]R}u}v]b]bv]oP]v}b]b
yy M}v]}oU}oUPX b ~}v]v]]vPR]ub
b r
}(Pvv˙Z
Or
yy M}v]}oU }oU uP R}o˙ (} æ ˙b ~}v]v]
]vPR]ub
b }(Pvv˙Z
Or
yy Sv]}oU }oU PX b ~}v]v]]vP R b ]ub
}(Pvv˙Z
Or
yy T]v]}oU}oUPX b ~}v]v]]vPR]ub
b }(
Pvv˙Z
Or
yy Co]vu˙]vu~A9ZU}]o~(]vPvv˙Z
Av
B. Treatment for candidiasis
yy M]}v}oP]vo obU uP ]vb ]v}P]v v]PR (}
˙b
yy O
yy Co}]u}oU P]vo obU uP ]vb ]v} P]v v]PR
(}˙b
yy And
yy Co}]u}ouUo˙R}o˙~(}oo]]}vZ
C. Treatment for gonorrhoea
yy L]˘}v
C UIMUæuPX b
v
Or
yy .˘]u
C U}oUuPb
Or
yy C]}G}˘]vU }oU æ uP X
b ~}] ]v Pvv v ovP
u}RbZ
Av
D. Treatment for chlamydia
yy D}˘˙˙o]vU}oUuPR}o˙(}˙bw ~}]]vPvvv
ovPu}RbZ
Or
yy T˙o]vU}oUæuPvR}o˙(}˙bw ~}]]vPvvv
ovPu}RbZ
Or
Or
v*STIrrelatedLowerAbdominalPaininWomen*v
Refeal
r Criteria
R( oo b }( v P]vo ]bRP vl} uv
(]ob } RoR (]o]˙ `R bou ˘u]v}v v ]
} v u]}]}o}P]o ov vu]}]o bvb]]˙bv
}v}vRP]vo]bRPX
167. STIroL}À}u]voP]v]vW}uv
Ca s e u
yy Av}]]~}LvovP}v]v(}vbZ
Sympt oms
yy L}`}u]vo]v
yy P]v`]R˘o b ]v}b~˙bv]Z
yy VP]vo]bRP
yy D˙b]}Ro]b}u(}
yy F
Signs
yy L}`}u]vovvbb
yy VP]vo]bRP
yy Tvvbb }v u}]vP R ]˘ ~]o ˘]}vZ }v ]uvo
P]vo˘u]v}v
yy Av˘ovvbb
yy Av˘oubb
Inve tis gations
yy H]PRP]vo`b ovbvb]]˙
w
Standard Trtme
yy Po]ob}v
Tre a tment
Treatment }i es
yy T}(}P}v}R}URou˙]vv}]]o]v(}v
yy T}o]]vv]vGuu}v
yy Ru}IUDU](bvU˙bL]v]}v}(PR˙
]v
E RvPPC
AX O t-Pvb
yy .˘]u
C U}oUuPX b
Or
yy C]}G}˘]vU}oUæuPR}o˙(}˙b
Av
yy D }˘˙˙o]v U}oUuPR}o˙(}˙b
vA
yy M}v]}oU}oUuPR}o˙(}˙b
v*STIrrelatedGenitalUlcer*v
B. In-Pvb
yy L]˘}v
C UIMUæuP]o˙(}˙b
Av
Av
168. STIroGv]oUo
Ca s e u
yy Hbb]uo˘
yy Treponema pallidum~b˙R]o]bZ
yy Haemophilus ducreyi~Rv}]Z
yy Calymmatobacterium granulomatis~Pvo}u]vP]voZ
Sympt oms
yy Gv]oo~]v(o}]vobbZ
yy URo]bRP
yy IvP]voòo]vP
b ~o˙uRv}R˙Z
Signs
yy IvP]voo˙uRv}R˙
yy Hbb]uo˘
yy MooUvb]oob]}vb~Hbb]uo˘Z
yy S˙R]o]ob
yy OLv b]vPoU ]vobb v ]v ob]}vb `]R o b
vòor.vPb
yy Ob]}voo˙ uooU ]v(oU v}vr]v } R r
lent base
yy D]bU.uU]vobbU]vP]voo˙uRv}R˙`lL
R]u˙ob]}v
yy P]u˙ o boo˙ Rob `]R]v b]˘ `lbU boo˙ `]R}
o]vPX b
yy Chancroid
yy P]v(o`]Rvu]vPPPb
yy TR b ]b }`]R ov˘v b]o˙ ob
to touch
yy Soobu˙}ob}(}ub]P]v}bob]}vb
yy L˙uRv}R˙ ]b boo˙ v]oo v u˙ }u G r
tuant
yy Gvo}u]vP]vo
yy BP]vb `]R buoo o R }Pbb ]v} v voP]vP
Pvo}u}bo`]Ru
yy PbE òo.v
yy Ho]vP ]b v} b}vv}b v ]b }uv] ˙ ˘vb]
]vP
b
v*STIrrelatedGenitalUlcer*v
Inve ti
s gations
yy VDRL~](]ooZ
yy TPHA~](]ooZ
Tre a tment
Treatment }i es
yy T} buoo ob v b]obU b]oo˙ ]( v (} Hb
b]uo˘
yy T} ]]v]o uvPuv}( oo ob Rb b]uo˘U˙R]o]b
b
and chancroid concurrently
Non-pharmacological Treatment
yy Kob]}vb˙vov
]v
E RvPPC
X
A For Herpes simplex
yy A]o}]U}oUuPrvR}o˙(}wr˙b~æ}bb]o˙Z
Or
yy A]o}]U}oUuPR}o˙(}wr˙b
F}]v]]ob`]RRbvHIV}r]v(}v
Or
Episodic therapy for recurrent episodes
yy A]o}]U}oUuPR}o˙(}æ˙b
Or
yy A]o}]U}oUuPR}o˙(}æ˙b
Or
ı
Standard Trtme
yy A]o}]U}oUuPR}o˙(}˙b
Sbb]R˙]vHIV]v(]v]]ob
yy A]o}]U}oUruPrR}o˙(}rv˙b
B. For Syphilis
yy BvR]v Pv]]oo]v GU IMU X MU ]v R '}l ~}o }b X
MUX Zb
Or
yy P}]vPv]]oo]vA}bUIM~˙]vi}vZUXMU]o˙(}
˙b
F}b}vbooP]}v]]oo]v
Or
yy T˙o]vU}oUæuPvR}o˙(}˙b
F}Pvv`}uvooP]}v]]oo]v
yy E˙R}u˙]vU}oUæuPvR}o˙(}˙b
Or
yy A]R}u˙]vU}oUæuP]o˙(}˙b
v*STIrrelatedScota
C. For Chancroid
yy L]˘}v
C UIMUæuPX b
Or
r lSwelling*v
Or
Or
169. STI-related Scrotal Swelling
Ca s e u
yy Treponema pallidum~˙o˙Z
Sympt oms
yy S}oòo]vP
b
yy Scrotal pain
yy URo]bRP
yy D˙b]
yy Fv˙}(u]]}v
yy F
Signs
yy S}oòo]vP
b U}uvl}˙Ru
yy Scrotal tenderness
yy URo]bRP
æ
yy F
Inve ti
s gations
yy URo`b (}o
yy U]vovbvb]]˙
v*STIrrelatedInguinaloBub
yy Uob}vv b }(R}u
b
Tre a tment
Treatment }i es
yy To provide pain relief
yy T}]v(˙vSTIvv}vrSTIo}]o˙
b
yy T}(}P}v}RvRou˙]b]uov}bo˙
yy b B
yy S}ob}vo]vGuu}vv(b]
]v
E RvPPC
AX F}G}v}R}
yy L]˘}v
C UIMUæuPX
b
Or
yy .˘]u
C U}oUuPX b
Or
yy C]}G}˘]vU}oUæuPX
b
Av
B. For Chlamydia
Or
*v
Or
Or
170. STI-related Inguinal Bubo
Ca s e u
yy Chlamydia trachomatis~L˙uR}Pvo}uvuZ
yy Haemophilus ducreyi~CRv}]Z
Sympt oms
yy P]v(o}]vobb]vP]vobòo]vP~bZ
Signs
yy IvP]voòo]vPb
b P
yy unilateral or bilateral
yy v}v}vrv
æ
Standard Trtme
yy Gv
yy vPb
yy Genital ulcer
Inve ti
s gations
yy N}]vbP}vb]U]v]`}(R˙v}u] b }R
yy R}uuv]vuvP]vPSTIb
Tre a tment
Treatment }i es
yy To relieve pain
yy T}o]Ròo]vP b
yy T}R]v(}v}(o˙uR}Pvo}uvuvRv}]
concurrently
yy Ab]}v }( Gv }b b]vP `] } vo R}PR
iv RoR˙ bl]v ˙ }v
b } R] ˙X Av ]v]b]}v v
]vP bR}o v} 'uX I( }b b]bU R v
bR}o(X
v*STIrrelatedGenitalWatsr *v
yy SobR]bb vl}.bou˙]P˙b X
X
A F}L˙uR}Pvo}uVuv~LGV
RCv}]Z
]v
E RvPPC
Or
Or
171. STI-related Genital Warts
Ca s e u
yy Huv]oo}u]b
Symptoms
yy Uboo˙v}˙u}ub b
yy Suoo]vobòo]vPb b ]vRv}rPv]oP]}v
yy IR]vP}]b}u(}]vRPv]o
yy M˙b]vbP]vo]bRP
yy Avo}P]voo]vP]vP}L˘b
Signs
yy SuooU GU oU voU GbRr}o} òo]vPb b }v R
bl]v v u}b uuvb }( R Pv]ob ~v]bU oU P]vU
]˘URU]voP]}vZ
æ
Inve ti
s gations
yy ]A b}o}v~]vPbZ
Tre a tment
Treatment }i es
yy T}o]u]vR`b
yy P} v}uo bl]v `]R bo]v ~8vZ `R]o o˙]vP
P}}R˙oo]v
yy E˘vo Pv]o v ]vo `b bR}o `bR R}}PRo˙
r R}b L o]}v }( P}}R˙oo]v v vr R}b L
o]}v}(Iu]]u}X
yy C˙}R˙ `]R o]] v]}PvU b}o] }v ]}˘]U }
˙}}XRo]}vb˙r`lb
yy Eo}bP˙
yy SP]ou}o
v*STIrrelatedAnorrctae lRelatedSyndome
]v
E RvPPC
yy P}}R˙oo]vræA9v}(v}]vU}]oUo˙]o˙}R
`b}]]vPv}uobl]vbX
yy P}v}uobl]v`]Rbo]v~8vZX
Ruv`lo˙]vobvo}uob}o}vX
r s*v
Or
yy T]Ro}}A]~TCAZ~rıA9ZU}]oU
o˙ (oo˙ } R `b }]]vP v}uo bU (}oo}` ˙
}`]vP}(R`]Rou}`}u}v
]X
Ruv`lo˙]vobvo}uob}o}vX
Or
yy P}}R˙oo}}˘]vU XæA9U }]oU o˙ R}o˙ R ub `l
(}`lb
Or
yy Iu]]u}U æA9 uU }]oU o˙ R ub `l (} v
`lbXSR}o`bRvrR}bLo]}vX
Note 16-3
D}v}bTCA]vPPvv˙vo}vX
D}v}bP}}R˙oo]v}TCA}v]o`bX
172. STIroAv}roRoS˙v}ub
sueCa
yy C. Trachomatis
yy HbS]uo˘V]br~HSVrZ
yy NXG}v}R}
æ
Standard Trtme
yy Treponema pallidum
Symptoms
yy Avo]bRP
yy RoBo]vP
yy P]b
yy Ro]vU
yy Tvbub
yy C}vb}v
Signs
yy Anal ulcers or blisters
yy AvoP}`R
yy Tvvbb}vo˘u]v}v
yy Avo]bRP}o]vP
Trtme
ae nt
v*STIrrelatedAnorrctae lRelatedSyndome
Tuv}ib
yy To relive pain
yy T}(}Rui}b]uov}bo˙
yy Kob]}vb˙vov
r s*v
AX F}v}o]bRPU(}P}v}RvRou˙]
~Sb}vb}Z
B. For anorectal ulcers or vesicles
F}]bb }}(b]oob]}vb(}Rbb]uo˘]b
yy A]o}]UuPUrvR}o˙(}˙bw ~æ}b˙b Z
Or
yy A]o}]UuPUR}o˙(}˙bw
E]b}]uv(}vHSVb]oob]}vb}b
}v.b˙}(v}(ob]}vb
yy A]o}]UuPUR}o˙(}æ˙b
Or
yy A]o}]UuPUR}o˙(}æ˙b
Or
yy A]o}]UuPUR}o˙(}˙b
Av
C. For Syphilis
yy vR]v
B Pv]]oo]v GU IMU X MU ]v R '}l ~}o }b X
MUXZb
Or
yy P}]vPv]]oo]vA}bUIM~˙]vi}vZUXMU]o˙(}
˙b
Or
æ
D. For persons allergic to penicillins
Or
Or
vA
E. For Chlamydia
Or
Or
vA
F. For Chanchroid
v*SexuallyTransmittedInfectionsinChildren*v
yy L]˘}v
C UIMUæuPX b
Or
Or
Or
Refeal
r Criteria
I( R ˙u}ub
b } ob]}vb } v} ]u} Luv (}
RoR(]o]˙`]Ru]}]}o}P˙b}(}}]uvv
˘ob]}v}(}R}b ˘o}RbX
173. S˘oo˙Tvbu]'Iv(}vb]vCR]ov
N}vbU ro v o R]ov ob} ]bl }(
}vvP STIbX TR u}b }(vbu]bb]}v ]v Rb R]ov u}bo˙
R}PR uvo ]v(}vbU ˘o b b } ˘o}]}v v }ov˙
˘o
b ]˙ ]v }o R]ovX TR STob ]v R]b P P} ]vo
v}vo }viv]b ~}RRou] v}v}uZU v }R STIro
˙v}ub
b b]u]o}R]vobX
S}u }( Rb STob ~XPXU P}v}RU ˙R]o]b
b U v Rou˙]ZU ](
] L R v}vo ]}U ]v] }( ˘ob }vX F}
}RSTobU~XPXHPV]v(}vbvP]v]bZURb}]}v`]R˘o b
}v]bv}oX
wX STIroN}voC}viv]b~ORou]N}v}uZ
~Sb}v}vRN}voC}viv]b[vN}voD]b}bZ
ææ
Standard Trtme
MvPuv}(b].STIvSTI˙v}ub
b ]vR]ov
175. STIroURoD]bRPS˙v}u]vCR]ov
AXF}G}v}R
ChildrenAM˙b~}R]oAMælPZ
yy L]˘}v
C UIMUæuPX b
ChildrenAN˙b~}R]oANælPZ
yy .˘]u
C U}oUuPX b
Or
yy L]˘}v
C UIMUæuPX b
Av
v*STIrrelatedUrethralDischager Syndome
B. For Chlamydia
ChildrenAM˙b
ChildrenAN˙b
Or
r inChildren*v
Or
176. STI-related Vaginal Discharge Syndromes in Children
N}vr
E˘u]v}vbR}o ]}`]R} bouXIvP]vouv
]b v}}uuv (} ˙}vPP]obX Oouvu˙ u}}] r
X
yy EvbP}}Pv]oR˙P]v
yy Ev}Pb}(o}}bv`
yy D˙v`]vRbv}]}v`]RR}o
yy EvbP}}]rvoR˙P]v
yy }]
A }R]vP`]RRo}Ru]o}vb
yy }]A u]b}b
A X F} VP]v] b ~ T ] R } u } v ] b ] b v B ] o P ] v } b ] b Z
ChildrenAM˙b~}AMælPZ
yy M}v]}oU}oUwXæuP llPR}o˙(}˙bw
ChildrenAN˙b~}ANælPZ
æv
Or
yy M}v]}oU}oUPX
b
vA
B. For Candidiasis
yy Co}]u}o A9 uU }]o ~P]voZU o˙ r R}o˙ (} w
days
Or
yy Fo}v}oU}oUrvuP llPX b
v*STIrrelatedLowerAbdominalPainorPelvicInflammatoryDisseSynd
Note 16-5
IvP]vo uv ]b v} }uuv (} ˙}vP P]obX Oo uv
u˙u}}]X
Av
C. For ]]b C
F}G}v}R
yy L]˘}v
C UIMUæuPX b
yy .˘]u
C U}oUuPX b
Or
a ome
yy L]˘}v
C UIMUæuPX b
r inChildren*v
Av
F}CRou˙]
ChildrenAM˙b
ChildrenAN˙b
Or
Or
177. STIroL}À}u]voP]v}Po]IvGuu}˙D]bb
Syndrome in Children
CR]ovAM˙b~}AMælPZ
yy L]˘}v
C UIMUæuPX
b
Av
Av
yy M}v]}oU}oUwXæuP llPR}o˙(}˙b
CR]ovAN˙b
yy L]˘}v C UIMUæuPX b
Av
æw
Standard Trtme
vA
yy M}v]}oU}oUuPR}o˙(}˙b
178. STIroGv]oUoS˙v}u]vCR]ov
AXF}S˙R]o]b
yy Bv˙ov]]oo]vUIVU
Children
AN˙bV æUv]bllPrvR}o˙(}˙b
AM˙bV æUv]bllPrvR}o˙(}˙b
Or
yy P}]vv]]oo]vUIM~ZU
Children
v*STIrrelatedGenitalUlcerSyndome
AN˙bV XMU]o˙(}˙b
AM˙bV æU IUllP ]o˙ (} ˙b ~u˘X ]o˙ }b
wæUv]bZ
Or
yy BvR]vPv]]oo]vUIMU
AN˙bV XMU]v}R'}l]vP}vo]v]]b]~}o
XMUZ
r inChildren*v
F}b}vbooP]}v]]oo]vP
Or
Av
B. For Chancroid
ChildrenAN˙b
yy .˘]u
C U}oUuPX b
Or
Or
Or
yy L]˘}v
C UIMUæuPX b
Or
yy E˙R}u˙]vU}oUXæuP llPvR}o˙(}˙bw
Av
C. For Genital Herpes Simplex
yy A]o}]U}oU
Children
æ
AN˙bV uPrvR}o˙(}æ˙b
u}vRr˙bV uPrvR}o˙(}æ˙b
F}Iv(vb`]RKv}`v}SbN}voHb
yy A]o}]UIVU
ChildrenAMu}vR
uP llP˙ R}b (} ˙b ~ (} ]bb o]u]} R bl]v
vu}buuvbZ
Or
uP llP ˙ R}b (} ˙b ~(} ]bbu]v v CNS ]b r
bZ
179. STIroAv}rRoRoS˙v}ub]vCR]ov
v*STIrrelatedAnorRectalRelatedSyndome
Anorrctae lDischager
AXF}G}v}R
yy .˘]u
C U}oUuPX b
Or
yy L]˘}v
C UIMUæuPX b
r sinChildren*v
yy L]˘}v
C UIMUæuPX b
Av
B. For Chlamydia
ChildrenAN˙b
Or
Or
yy E˙R}u˙]vU}oUæuPvR}o˙(}˙w
ChildrenAM˙b
Anorctae lulcsler sic
ve les
AXF}S˙R]o]b
~S b}vb } v RGv]o Uo S˙v}u ]v CR]ov[ (}
uv}(S˙R]o]b[Z
B. For Chancroid
uv}(CRv}][Z
C. For Genital Herpes
æı
Standard Trtme
uv}(Gv]oHb[Z
GenitalWatsr inChildren
~Sb}v}vuv}(RGv]oWb[]vobXP}}R˙oo}}˘]v
vIu]]u}v}b]vR]ovZ
Scabies
~Sb}v}vRP]b[Z
PubicLice
yy MoR]}vo]]XæA9]v}bb
Ao˙}`R}o}˙voo}`}˙voo˙XWbR}+L
R}b}}v]PRXRL`l
Refeal r Criteria
I( R ˙u}ub
b } ob]}vb } v} ]u} Luv (}
v*STIrrelatedAnorRectalRelatedSyndome
RoR(]o]˙`]Ru]}]}o}P˙b}(}}]uvv
˘ob]}v}(}R}b ˘o}RbX
r sinChildren*v
v
Chapter
HIVInfectionsandAIDS
w
180. HIVIv(}vvAIDS
A] Iuuv .]v˙
D S˙v}u ~AIDS Z ]b o P
b }(
]v(}v `]R R Huv Iuuv .]v˙ D V]b ~HIV ZX I v +
}R ob v R]ov }Lv ]b}b]vP Ru } }}v]b
]v(}vb v ]v uo]Pvv]bX C}r]v(}v `]R o}b]b ~TBZ
v Hb B oo˙ (v ]v HIV ]v( ]v]]ob v
ubvb (}]voobX
TRu]v]bl(}b(}HIV lAIDS u]vvbu]bb]}v˙˘RvP
}( }˙ G]b v o}} }b R}PR ˘o b }vU vb(b]}vU
vorbl ]vi˙U v}vrb]o P]o b b v u}R } R]o
vb(X
HIV ]v(}v ]b vo˙ v} oX H}Ù (} b}vb o]]vP
`]R HIV ]v(}v ~PLHIVZ U + vr}]o R˙ ~ARTZ ]b
]oo }v˙r`] ] vb R P]}vo v ]b]
oo]v}Ro]v]RoR(]o]b}`R]Roo]Pv}b
vbub(X
Pv}v}(]v(}vu]vbRl˙}]vP]bX b
sueCa
yy HuvIuuv}.]v˙V]b
Symptoms
yy Pb]bv}PR
yy Pb]bv}v]R}
yy W]PRo}bb
yy Skin rashes
yy Pb]bv}v(
yy Mouth ulcers
Signs
yy W]PRo}bb
yy Chronic diarrhoea
yy P}o}vP(
yy Gvo]bo˙uRv}R˙
v
Standard Trtme
yy O}R˙vPov]]b]b
yy Pb]bv}PR
yy Gvo]bub
yy RvRb}b~obZ
yy CR}v] }Pbb] v ]bbu]v Rb b]uo˘ ]v(}vb
~obZ
yy F]vPv]oRvPbXPXo]b}o}}v}(Rv]ob~obZ
yy F]o}R]}bo}`P}`R~]v(vbvR]ovZ
yy Rv }uu}v ]v(}vb XPX }b u] U R˙vP]b ~]v(vb
vR]ovZ
Invtiga
se tions
yy C}v.u}˙HIV ~HIV
b UHIVUHIVvZ
yy HIV V]oo}
yy }v CD
yy OR b OR b OR b ] ~S To wr
}vPZ~STowr}vPZ~STowr}vPvZ
TowrP) Other baseline tests for HIV
Hu}o}P]ob Fooo}}}v
v*HIVInfectionandAIDS*v
B]}Ru]ob Bo}}U
Eo}o˙bvv]v
C
L]Fv}vb
FbvPBo}}SP
CR}ob}ovo]]}.o
R}v˘u]v}vb U]vo˙b]b~U]vRlEZ
S}}oRlE
Rb]}˙˘u]v}vb TBv]vP
b
CRbXr˙
S}o}P]oTb S}o}P]oTbHb BS(vPv
Souv˙b H]b}o}P˙}vbl]vvo˙uRv}]}b˙
TRb(}u
b K]v˙]}b˙
v]vP}vb]Pvbv Sv]vP(}STIb
˙u}ub
b PPvv˙b
Pbu UHPVDNA
Trtme
ae nt
Tuv}ib
yy T} b HIV o]}v } b o}` b }bb]o v (} b o}vP b
possible
yy T}v b vRvR]uuv(v}v~C}}v
bD Z
yy T}]u}o]˙}(o](
yy T}u}]]˙vu}o]˙o}HIV
yy T}}u}P}`Rvv}o}P]oo}uv]vR]ov
v
Chatep rwP *HIVInfectionsandAIDS
AXSvTuv
st
L]vTuv
TowrP) Standard Treatment (1stL]vTuvZ(}HIVrAIDS
Medicines C}v C}uuv
P(RP]uv
Tenofovir~TDFZA= C}v`]R M}v]}vo(v}v]vo]vP
Lu]]v ~TCZ Tenofovir in renal urinalysis
~}Eu]]]v ZA= ˙b(v}v
(]v
E ~EFVZ
AovRP]uv
TenofovirA=Lu]]v C}v`]R M}v]}vo(v}v]vo]vP
~}Eu]]]v ~FTCZ Tenofovir in renal urinalysis
+ Nevirapine~NVPZ ˙b(v}v S}NVP](o]vo}biv]
Nevirapine is or severe rashes and refer to ART
v*HIVInfectionandAIDS*v
contraindicated in v(}(RuvPuvX
o]˙b(v}vv
NVPR˙bvb]]˙
Z]}]v ~AZTZA= Z]}]v is TDF}b`RH]bAMP l
Lu]]v ~TCZA= contraindicated in L}}bANæA9(}uRbo]v
Nevirapine~NVPZ vu]
b o]vo]v}vAZTX
Nevirapine is S}NVP](o]vo}biv]
contraindicated in or severe rashes and refer to ART
o]˙b(v}vv v(}(RuvPuv
NVPR˙bvb]]˙
Z]}]v ~AZTZA= Z]}]v is TDF}b`RH]bAMP l
Lu]]v ~TCZA= contraindicated in L}}bANæA9(}uRbo]v
(]v
E ~EFVZ vu]
b o]vo]v}vAZTX
nd
L]vTuv
TowrP) SvTuv~vL]vTuvZ(}HIVrAIDS
Medicines C}uuvb
F]bAov Z]}]v + I(TDF.bb o]vX
Lu]]v (or I(LPVl`bb(}HIV]v.b
E u]]]v ZA= o]vUTV bA l
L}]v] l~}
v] A lZ
S}vAov Tenofovir + I(VZD b.bo]vX
Lu]]v (or C}vb]]A ](v
E u]]]v ZA= has used both Tenofovir and
L}]v] l~} Z ]}]v
v]A lZ
v
Standard Trtme
BXS]o}v]}vb
TowrP) SvTuv]vb]o}v]}vb(}HIVrAIDS
C}v]}v R}uuv}v C}uuvb
HIV }r]v(}v`]R TR}uuvP]uv Lu]]v and Tenofovir
Hb BX~Sb}v bRooPLu]]v + P]vb}RHBV
}vRHbB[Z TenofovirA=(]v
E vHIV
DoHIV rvHIVr} }D R]v+vbb
HIVr]v(}vb }(v}vrvo}b]Pb
(Nevirapinev(]v
E Z]v
HIV r]v(}v}u]v}v
v*HIVPostxpE osureProphylaxis~PEPZforxpe osedhealthcone
of nucleosides and protease

]vR]]}bbRbLPV}
TVA lbR}oXb
Refeal
r criteria
R( oo HIV }b] vb } v ] uv v ]v
GRvX
181. HIV Post Exposure Prophylaxis (PEP) for exposed healthcare

sarep l*v
personel
P}br˘}b }R˙o˘]b ~PEPZ ]b bR}ru v}]o
uv } R o]lo]R}} }( HIV ]v(}v L }vo
˘}b˙vvPRo]b b Ruv}(]v(}v}vvPv`
]v(}vX PEP b + ˘}b } HIV ]v(}vb `}l v ob}
ob }bb]o HIV ]v(}v (}u ]v( v] oobX W}lo
]vb } ]vi˙˘}b RoR `}lb} }˙ G]b }(vbX R]bl
}( ˘}b } o}} v o}} }v R}Pvb ]b bo]PRo˙ R]PR (}
RoR b}vvoX TR ]bl }( ]v(}v (} HIV (}u v}b
]vi˙ ]b }˘]uo˙ rA9 v R }( u}b uuvb } v}vr
]v bl]v uR o}`X PEP ]b oo˙ + `]R]v r R}b
vv}u}RvwR}bL˘}bX
sueCa
yy Av ˘}b }vb] b }bb]o ]bl ]b .v b Sv ˘}b
(}u}bb]o˙]v(o}}Ub}}R}˙G]bR}PRP
yy A v}b ]vi˙ ~XPX vo lb } `]R bR
}iZ}
yy Au}v}buuv}v}vr]v~RU
bl]v}v
Z
yy TR]bl}(]v(}v}b R]PRLP
yy E˘}b}oPv˙}(o}}}}}R]v(}bG r
ids
yy E˘}b} R o}} }( v]v vv HIV ]bb
v
P
b
yy A v}b ]vi˙ } v ]vi˙ `]R R}oo}` }U
o}}.oovoX
Signs
yy None
Symptoms
yy None
B}˘wrP) Sb}v}}vovbu]bb]}v}(HIV
IvRv}(}bb]o˘}b}HIVR(}oo}`]vP}vbbR}olvP
yy TR`}vb]bR}oov`]Rb}v`

yy F}u}buuvbUR˘}bbR}oGbR`]Rov˙}(
`~XPX˙b`]R`}bo]vZ
yy Ab R oo }( ]blP R ]bl }( }bb]o ]v(}v (}u R ˘}b
bR}obvobb].b}vRP}]bo}`P
yy V˙L}È˘}bP
yy E˘}b}(}voo˙]v(}bu]o}]vbl]vZ
yy L}`R]blE˘}bP
yy E˘}b } buoo }ou }( o}} } }˙ G]b }vu]v `]R
o}}(}u˙u}ub HIVr}b]v
yy Ivi˙`]Rb}o]vo}v˙b.]o]vi˙}u}v}b˘ r
posure
sarep l*v
yy H]PRR]blE˘}bP
yy E˘}b}oP}ou}(o}}}}voo˙]v(}bG]b
yy E˘}b } o}} } }˙ G]b }vu]v `]R o}} (}u v HIV
}b]v`]RR]PR]oo}
yy Ivi˙ `]R R}oo}` }vol v˘vb]]vi˙ (}u }v r
u]vbR]vbuv
yy E˘}b}o}}(}uvHIVPb]bvv
Invtiga
se tions
yy Fooo}}}v
yy L]vvo(v}vb
yy HbBS(AvPv
yy HIV}o}P˙ b }PCR](]oo
Trtme
ae nt
TuvOib
yy T}vo]b b Ruv}(HIV]v(}v
yy C}vboo]vPvTbvPP
yy E˘}b RoR `}lb ub ] }vboo]vP v vP b
]uu]o˙ (}u ]v }vboo}X TR b]}v ]b } }vv
R}PR}RPEP]}vRL](vbb˙XR(bo}(HIV
˙b v˙˘}b`}lbR}o}uv
yy C}vboo}ubuRb](b ˘b ]vo]vP}v}ubX
yy Aoo lv}`v b}rvb bRoo ob} }vboo v b
væ
Standard Trtme
(}HIV]v(}v](R]b]bv}lv}`vX
Note 17-1
T]u]vPPI(PEP]bvbb˙U]bR}o]v]}uo˙U(o˙`]R]vr
R}b}bW˘}bvv}u}RvwR}bL˘}bX
]v
E RvPPA
AX V˙L}`R]bl
yy WbR˘}b]uu]o˙`]Rb}v`
BX L}`R]bl
yy Tv}(}]uP]o˙(}˙b
vA
yy Eu]]]v uP]o˙(}˙b
Or
yy Z ]}]v uPR}o˙(}˙b
vA
yy Lu]]v æuPR}o˙(}˙b
sarep l*v
CX H]PRR]bl
yy TenofoviruP]o˙(}˙b
vA
yy Eu]]]v uP]o˙(}˙b
vA
yy L}]v] luP luPR}o˙(}˙b
Or
yy Z ]}]v uPR}o˙(}˙b
vA
yy Lu]]v æuPR}o˙(}˙b
vA
yy L}]v] luP luPR}o˙(}˙b
Note 17-2
I(Rb}v]bHIVlHBV}r]v(RvTv}(}] }v]v]vPP]uv
bR}obX
Follow up
D]vP R ]} }( }R˙o˘]b vu }( bo]v v (}oo}`r
]vbP}vb v } }v } u]v HIV }b rbbU v }
u}v]}Roo}(P}˘]]˙X
v
TowræP) R}uuvM}v]}]vP}(DPT}˘]]˙HIVS}o}P˙}(
Exposed Health Care Personnel
o]v
Bb bP Fooo}}}v
L]vvo(v}vbUHbBS(AvPv
HIV}o}P˙
b }PCR](]oo
T`}`lbP Fooo}}}v
L]vvo(v}vb
S]˘`lbP HIV}o}P˙
b
TRu}vRbP HIV}o}P˙
b
S]˘u}vRbP HIV}o}P˙
b

Iv]]ob `R} }b r}v bR}o R b } }uRvb]
vARTb]bX
B}˘wrP) R}vPvD}uv}v
Aoo }}vo ˘}bb R}o } ]uu]o˙ } R b]b}V
]ubvb}(R˘}bvPEPuvPuvbR}o}X
]ob
D bR}o]voP
yy vD u}(˘}b
yy WRvR}`R˘}b}U˘}bb]}vR}˙v˙
}( bR ]X T˙ v ub u}v }( ˘}b G]U ]˙
b
sarep l*v
~Rl˘vZ}(R˘}b
yy S} }( ˘}b v `RR R b} u]o }v]v HIV }
o}}X
yy Co]v]ob}(b}vX
yy Rov ]v(}u}v } ˘}b RoR `}l ~u]o }v] r
}vbU ]v}v ]vo]vP Hb U B v u]}vbU Pvv˙ }
r(]vP
b Z
yy D}uv}vboo]vPU}b˘}buvPuvv(}oo}`b
vw
Chapter
InfectiousDissande
Infetas tions
182. Fever
F ]b}uu}v}uo]vU`R]R]bboo˙o}v]v(}v
}( ]oU ]o } b] }]P]vX I u˙ oo P] } R
]Pv}b]bv]˙ b }(]v(}vbX
F ]b.vbv˘]oo˙u}wXæ£C~L
l]vP R Ru}u ]v o (} u]vbZX F } £C ]v
R]ovvob}LvvbPv'v}vUb]oo˙](Rv
]b obb b } o]]}bX N} ˙ ( ]b } uo] } ˙R}]X
˙E (bR}o ]vbPv}]o˙XAR}}PR
R]b}˙UR˙b]o˘u]v}vv}]]vbP}v`}oboo˙
oRb}(R(X
Ivv}vbvRoo˙U]v(}vb
b u˙v}}uv]
˙ (X Iv ]v(vb v ˙}vP R]ovU ( u˙ b}] `]R
}vob]}vbU }oob } }u X ~S o o}` (} }bb]o ]+vo
]Pv}bbv}]}vZ
sueCa
yy V]o]v(}v
yy ]o B ]v(}v
yy FvPo]v(}vb
yy Pb]]v(b}vb
yy Hu}o}P]ouo]Pvv]bXPXo˙uR}uUolu]
yy C}vvb]bb
yy M]]vro
Symptoms
yy CR]oobU]P}b
yy B}˙Rb
Signs
yy TuANwXæ}C
yy ]v E }(R˙}v XPXbvlv˙b
yy ]v E }(vo˙]vP}v]}vb~(P]o]vbo}`Z
yy Tachypnoea
yy Tachycardia
v
Chatep rP *InfectiousDissande Infetas tions
Invtiga
se tions
yy FBC
yy Bo}}.ou(}uo]b]b
yy R]]Pv}b(} b uo]
yy Cob}(]vUo}}UbuU]bRPUR}`b U`}v
`b U}b]voG]v]vP}vbv}v
Trtme
ae nt
Tuv}ib
yy T}}˙u}v}uo
yy T}o]˙u}ub b
yy T}]v(˙vRvo˙]vP}( b R(~bP]o]vb
o}`Z
yy K R v òo R˙ `]R G]b XPX Ù (] i]bU
o]PR}]PUS]r`_}}}vu]ol
yy M]v]vv]}vU}vvr(]vP b ]v]b
yy T]b}vPRR]oX~W}ò`]Rolù`vo˙
} R }˙ vP b (}u R ˘u]b v Poo˙ `}l ˙}
`˙ `b } R RX L .ou }( `}v R }˙ } ˙
}vRbl]vXRR}bb}LvbvZ
v*Fever*v
]v
E RvPPA
yy Pu}o U}oU
Adults
PvrR}o˙
Children
ræuP llP l}bXM˙}bvrR}o˙bvbb˙
Or
yy Pu}o Uob}b]}˙U
Adults
PvrR}o˙
Children
æræuPvrR}o˙
Or
yy I}(v U}oU
Adults
ruPvrR}o˙
Children
wr˙bV uPvrR}o˙
rw˙bV uPR}o˙
vu}vRbr˙bV æuPR}o˙
rvu}vRbV æuP llPvrR}o˙
TRb}(R(}]o˙~S}]b}vZ
vı
Standard Trtme
Note 18-1
DONOTP]Ab]]v }R]ovvRP}(v˙bXC}v}o}vob]}vb
`]R]u~ Sb}v}vRS]D]b}b[Z
Refeal
r Criteria
F b]bvP (} u} Rv ˙b ]v b] }(uv bR}o
}vb]˙˘]
b }(vlv}`v}]P]v~PUOvZ bR}o(
(}(R]vbP}vX
TorP) G]o]vb(}Ruv}(Rv`]R(
(See appropriate ~S}]b}vZ
b}vZ
R]P}bU(~}b]}voo˙ Malaria Tlo}}.ou}(}u
]}]ZU`vP
b UPvo ]]Pv}b(}b
uo]bUi}]v]vb uo]b]bv
appropriately
R]P}bU(U`vP
b UPvo Cerebral Malaria Tlo}}.ou}(}u
uo]bUobvb}]u ]]Pv}b(}b
uo]b]bv
appropriately
v*Fever*v
HeadacheU}u]vP U Mv]vP]b D}v}o˙uv`R]o

}`b]vbbU+b vlUb]b `]vPbob}(ou
puncture
C}PR U}`vbuU] Pvu}v] G]}]v]}

R]vPU]v}v
R]vP
Ivb(v˙}( U]v˙ D}]v˘u]v}vob

]v}vvl}]v(o ]v(}v ovbvb]]˙VG]
u]]}vUo}]v]v }]v]}
F U}vb}v} Typhoid S}]uv

]R}~u˙`]Ro}}ZU
RRU}u]vo]vU
Pvouo]b
WuU`}oov
b U]v(oU Cooo]b UE˙b]ob G]}]v]}
]bRo}}l]vPo]u }]uP}
F ]vR]o`]R}PRU Obu] G]}]v]}

b}R}vub
w

F ]vPPvv˙`]R P˙o}vR]b Tlbuo(}]vo
loin pain vvbb ]]˙vP]
}]v]}
P]v]v}v~boo˙o]u Ob}u˙o]b Xr˙R+Vb
}vZU]v(o}}R (}}b}u˙o]b
Jv] ˙(o]vP V]oRb D}o](v}vbUHb

vòoUv}˘]Uo}`P Bb(vPvV
F }vbo˙Ub
HeadacheU}˙RUvv˙ C}uu}v}o} G]Pu}o if required

v}bUbv]vP ]vGv
L}vPv]vP
b (U`]PR Acquired MvP}]
b
o}bbUR}v]]R}U ]uuv}.]v˙
o˙uRv}R˙ ˙v}u
b
Sore throat or pain on T}vb]oo]b and MvP}]

b
òo}`]vP
b R˙vP]b
v*Tuculos
ber is*v
(A UR]oobv V]oRu}RP] MvP}]vP}vb
uo]bV`lvbbUubo (XPXE}o protocol
]vUbRU]R}Uo]vP virus disease
183. Tuberculosis
Tuberculosis~TBu˙ Z +v˙}(R}˙UR}uu}vb
b] ]b R ovP ~Pou}v˙ TBZX OR b]b + ]vo R b]vU
}v v i}]vbU ]vU ]v˙ U }uv v o˙uR v}b X
Pou}v˙ TB vb `R} R ]r(b ]oo] ~AFBZ ]v R] bu
~]}o}P]oo˙}b]TBZu}b]v(}bvbR]bb
R}PR ]}v }ob `Rv R˙ }PRU b] } bvX D]vl]vP
vb] u]ol u˙ b }]v TBU `R]R uv](bb }u]vo
TBX Pb}vb `]R o}` b]bv } ]v(}vU bR b HIV lAIDS and
]bU b]oo˙ ]bl }( o}]vP TBX SR ]v]]ob v
v}}RR˙]o˙u}ub b vb]Pvb}(TBXTR˙u˙R(b
bR b (U `]PR o}bb v ]R}U `R]R }o ob} ']
}R}v]}vX
Iv R]ov `]R b uov]}v `R} bR}` }} b}vb }
]˙uvUTBub}vb]v˘oX
w
Standard Trtme
sueCa
yy Mycobacterium bovis~}]vTBZ
yy Mycobacterium africanumIvII
yy M. microtiUM. kansasii and M. malmoensi~bZ
Symptoms
Aob
yy C}PR }Lv(}`lb}u}
yy Chest pain
yy L}bb}(`]PR
yy L}bb}(
yy Bo}}]v b bu
yy F
yy vR]vPD v]PR`bb
Children
yy Aooo˙u}ub b vR(}oo}`]vP
yy Mov}]bRvR}v]oo˙]ooo}}l]vP~R˘]Z
yy Pb]bvo}`P(~obvPAHr`lbZ
yy F]o}R]
yy FPUuo]bU}}
v*Tuculos
yy Bl]v vl}o}ò]u`lvbb
ber is*v
yy I]]o]˙
yy V}u]vP v]u]}vb]}bvbb~}TBuv]vP]b Z
Signs
yy S]Pvb}(uov]}v
yy CR˘]
yy Poo}
yy S]Pvb}(vu}v]}oo+b]}v
yy L˙uRv}R˙
yy Nl+vb b bUooo}(}vb]}bvbb]vTBuv]vP]b
yy S]vovvbbUP]bUoP]lb]b]vP}' [b]bb
yy S]Pvb}(˘ou}v˙]bb
Invtiga
se tions
yy Subuu]}b}˙
yy CRbXr˙
yy Mv}˘ test
yy GvX~XMTBlR](Z
yy L]vP}˙Ab
yy Mycobacterial culture
yy Fooo}}}v
yy ESR
yy L](v}v~(} b u}v]}]vPu]}vb]+bZ
yy HIV v]vP b
w
Trtme
ae nt
Tuv}ib
yy To cure the disease
yy T}v(Rvbu]bb]}v
yy T}vRo}uv}(Pb]bv
yy T}uvPPb]+b
yy T}}+˙R}b b }]ob}
yy T}]vbPo}b}vbXWRR]o]b+Uo`˙bRl
o}vb`]R}}PR
yy C}vboo]vP
yy Ev}P P}} v]}v ~b}u (}} bouv}v ]b }]
˙N}voTBP}PuuZ
yy Ev}Pb
yy Au]o˙ b ]oovb
yy Ab]Pvuvb}
Note 18-2
F}R}bb}(TBuvPuvU}vb]R(}oo}`]vP.v]}vbP
v*Tuculos
yy AobWAoob}vbPæ˙bv}
ber is*v
yy CR]ovWAoob}vbPo}`æ˙b
yy N`PvbWAoob}vb`R}RvRTBuv}Rlv
TBuv(}obbRv}vu}vRX
yy P]}bo˙ TPvb W Aoo vb `R} R]}bo˙ ] TB
uv(}}vu}vR}u}X
R( } R TB Co]v C ~TB Z (} P]v }v (}uo}vb v }b]vP
by weight.
AXSvuv
L]vTuv
st
TB
Tuv TBPvT˙ TuvRP]uv C}uuvb
P}˙
C
C}vv}v
Adults Iv]oPRb PRb
AooN`bC u}vRb u}vRb Tuv]b}v
~]vo]vPZPN` }(HRZE = }(HRAA daily
bur}b] æv}bb}( doses of HR
PTBV HRZE IvHIV ]bbU
N` N`bu uvv
Pvb vPPTBV ˘v}
IC A=III C}v}u]vHIV u}vRb
]bV
b
E˘rou}v˙
TB
w
Standard Trtme
TB
Tuv TBPvT˙ TuvRP]uv C}uuvb
P}˙
C
P]}bo˙ u}vRb}( æu}vRb}( RbDP
bu SA=u}vRb HRE ]o]˙
b
P]}bo˙ bur}b] }(HRZE AA}bb vP
b ~DSTZ
Treated PTBP AAæv}bb of HRE before start of
Pvb rRob }(Sv uv
IIC rTuvL doses of
]v}v HRZE Tuv]b}v
rTuv(]o daily
TB All cases u}vRb u}vRb Tuv]b}v
Mv]vP]b }(HRZE = of HR daily
Ob}r r æv}bb}( AA}bb
oTB HRZE of HR
C}vv}v
Children Iv]oPRb C}uuvb
PRb
AooN`bC u}vRb u}vRb Tuv]b}v
~]vo]vPZPN` }(HRZE = of HR daily
v*Tuculos
bur}b] æv}bb}( AA}bb

PTBV HRZE of HR IvHIV ]bbU
ber is*v
N` N`bu uvv
Pvb vPPTBV ˘v}
C}v}u]vHIV u}vRb
]bV
b
E˘rou}v˙
TB
P]}bo˙ u}vRb}( æu}vRb}( RbDST
bu SA=u}vRb HRE before start of
P]}bo˙ bur}b] }(HRZE AA}bb uv
Treated PTBP AAæv}bb of HRE
Pvb rRob }(Sv Tuv]b}v
rTuvL doses of daily
]v}v HRZE
rTuv(]o
TB All cases ~HRZE ZAA ~HRZAA Tuv]b]o˙

Mv]vP]b æv}bb}( doses of HR
Ob}r r HRZE
oTB
Ib}v]] ~HZUR](u]]v ~RZUP˙]vu] ~ZZURu}o
E ~EZUS}u˙]v ~SZ
Note 18-3
Tuvu}vR]b˙bX
Aoovbl]vPIb}v]] ~HbR}o
Z læuP}(P˙]}˘]v ~V]u]vBv }Z
v]Rov}R˙X
D}b}(P˙]}˘]v bR}o}o]vHIV vb
w
Iv]}vb (} }]
b b ]v R]oR}} TB ]vo Ev}}vR]o TB U LP
Poo+b E ]}vbUP]]o+b E ]}vvTBMv]vP]b XTR}v}(}]
b
bR}ov}˘}vu}vRX
Aoo R]ov v æ ˙b v oo HIV }b] R]ov `R} }vb }(
TB v bR}o P]v }R˙o Ib}v]] }b }( uP llP }˙
`]PR(}obvu}vRbX
TorP) Dosing for TB Medicines

AvrTB DP ~A r R}uuvD]o˙D}bP~M˘]uuD}bZ
]}vZ AoD}b]vP CR]ovD}b]vP
Ib}v]] ~HZ rvuP llP~wæuPZ WæuP llP~uPZ
R](u]]v ~RZ ruP llP~wæuPZ WuP llP~vuPZ
P˙]vu] ~ZZ ruP llP~uPZ WuP llP~uPZ
Ru}o
E ~EZ æruP llP~wæuPZ æWæuP llP~uPZ
S}u˙]v ~SZ ruP llP~uPZ WuP llP~uPZ
BXAivuv
yy P˙]}˘]v ~V]u]vBv ZU}oU
v*Tuculos
Adults
ber is*v
æruP]o˙(}ru}vRb
Children
æræuP]o˙(}u}vRb
Av
yy Pv]b}o}v U}oU~]vb}(TBuv]vP]b vTB]]bZ
Adults
rv uP ]o˙U r `lb Rv }+ }v ]u}uv } r
`lbv]b}vv
Children
ruP llP]o˙Ur`lbRv }+}v]u}uv}r
`lbv]b}vv
CXTuv]vS]oS]}vb
Chronic kidney disease
N`b~AobvR]ovZ
O`]vP}R]PR]bl}(]bUP]R(}oo}`]vP
yy Ivvb]Rb rHRZ(}u}vRb
yy C}vv}vRb rHR(}u}vRb
PPvv˙v]vP b
yy G]vb uvX
yy D}v}}u˙]v
b ~}}}˘]}(}bZ
N}r
Pv}v}(Pb]bv
yy T} v R o}uv }( P b]bv } R](u]]v ] ]b }u r
wæ
Standard Trtme
uvRIb}v]] A=R](u]]v}u]v}vo]bb]vbXP r
b]]vPR](u]]vo}v]bv}}vub]b}P
yy D]vPuvRv ubòo}` b oo R }o Pb(o˙ }v
vu˙}uR
b v]}b}v
yy TR v vb } v o}b b]b]}v ˙ RoR `}l }
b}vb]ob}v}uu}(R}uuv]˙`]Rb}(}uRoR
+ b ]vPR(oo}v}(uv
Monitoring
D]vPR}b}(uvUoobu}b]ou}v˙TBvbbR}o
R bu bub ˘u]v L ~} u}vRb ](uvZU
æ u}vRb v R v }( uvX I( bo ]b bu }b]U b (}
u˙}]oovPbvb]]˙vP b X
X DPb]bvo}b]b~DRrTB )
DP b]bv o}b]b ~DRrTBZ ub bu ~bZb
]v b}vb `R} u]v ]}o}P]oo˙ }b] ~]R bu }b]U
o}b]}GvX}b]ZL]vvb]Rb}(vb
v*Drugsis
.bro]vTBuv`]R}`]R}o]v]o]u}uvXPb}vb`R}
re tanttuculos
b ](u]]v b]bv }b] ]v]o ]Pv}b]b `]R Gv X

ber is~DRrTBZ*v
ub ob} b }( DRrTBX TRb b}vb ub (R

ob]vPTBovDPSb]o]˙TbvP~DSTZ}v`
u}oo]Pv}bbRbL]vP}˙bAb ~LPAZX
Pb}vbR]PR]bl}(Pb]bvTBvb(]o]vPP}˙ C
IA=III } P}˙ C II uvU }vb }( }v.u DRrTB vb v
TBlHIV}r]v(vbv}]u}]vP}vuvX
Pb}vb u]u ]bl }( P b]bv ob TB vbU
v L o}br}r(}oo}` v RoR `}lb vò˙ ]Pv}b
`]R TBX Pvb obb]. }]vP } R 'v }( }uv
Pb]bv}.oX
TR P P]uv (} uv ]b bo b }v R (}oo}`]vP
principles:
yy H]b}˙ }( Pb b} TBvbU}.o }( Pb]bv
]vGRvvl}DST}.o}(Rv
yy u]v]uu A }((}v`}u]]vbRlv}`v}+
yy Kvu˙]vlC}u˙]v v ]vio u]]vU ]b R l}v }(
R(}}u]]vbvbR}ob]vR]vvb]Rb
yy Av + G}}]v}o}v bR}o b } R ˘vb]
b}(o]Pv}vG}}]v}o}vb
yy M˙]vo.bo]vP}`R]RR]v b ]bo
b X
yy }bC brb]bv u˙ } `v Pb }( R bu P} v
R]b]blv]v}}vb]}vX
yy DPb u]v]b ]o˙ v ]b DOT R}PR} R
]viov}vv}vRbbX
Tuv }( Mo DP Rb]bvrTB ~MDRrTBZ v R](u]]v
Rb]bvrTB ~RRrTBZ vb ]b ]}]bX Tuv }v ]b r
wv
u}vRbv]bu]v˙bubuvo~]}o}P]oZ
}vb]}v ~Tuv obb vr u}vRb L ]}o}P]o
}vb]}vZX P}Pbb]}v (}u ]v]o } }vv}v Rb ]b vv
}vob(}~}vb Z u}vRb}(vPbuobX
C}uuv]˙rb]b}u}]vGRv}(]o]˙rb
˘]vb]}vb]]vPu]bb]}v(}uvPuv}(}uo]}vbX
TR}(]v(}vv}vv}v}obR}o u]v]v
ooub]vPuv}(RbvbX
Tuv Rv ]b ]o ]v R uv }( DRrTB }
o]u]vu}(]ooU+u]]vbXTuv]bRoovP]vP
}o}vP}vUP}˘]]bvb]+bXCo]v]oubub
b vrv }R v b} vb R}PR}
uv vo X Pb˙R}b}]o v }v}u] b} ]b ]
(}uuvb}bUv(u]o]bvo]v]oubR}PR}
uvXo˙ E }v v}u uvPuv}( P b]+b
vb(ob }}ubX
v*Drugsis
Trtme
ae nt
re tanttuculos
ber is~DRrTBZ*v
Note 18-5
Tuv }( Mo DP Rb]bvrTB ~MDRrTB Z v R](u]]v Rb]bvrTB
~RRrTBZ vb ]b ]}]bX Tuv }v ]b r u}vRb v ]b r
u]v˙bubuvo~]}o}P]o}vb Z ]}v~Tuv
obbvru}vRbL]}o}P]o}vb]}vZXP}Pbb]}v(}u]v]o}
}vv}vRb]bvv}vob(}~}vb Z u}vRb}(vP r
buobX
nd
L]vTuv
BXMoDPRb]bvrTB~MDRrTB )
TBTuv TBPv TuvRP]uv C}uuvb

P}˙
C Type
Adults and Children Iv]o C}vv}v
PRb PRb
MoDP AooNò˙ u}vRb u}vRb Tuv]b
Resistant D ]Pv}b }(rCZ ur rL(˘
Z rP}rCb• ]o˙~Tuv
Tuberculosis MDRrTB`]R} L(˘rP}r ~PASZ u}vR]b
~MDRrTBZ `]R}HIV Cb•~PASZ ˙bZX
S˙u}u Modify
contacts of uv
C }v.u }]vP}
MDRrTB`]R} obobX
`]R}HIV
•F}˙æuP}(C˙o}b]vP]æuP}(P˙]}˘]v~V]u]v}BvZ vP]Ro
N}R˙XD}b}(P˙]}˘]vbR}o}o]vHIVvbX
PAS]bvov}Cb
w
Standard Trtme
CXTuvP}}}o(}ORRb]bvT˙b
TorP) TuvP}}}o(}ORRb]bvT˙b
Rb]bv P r TB Pv TuvRP]uv C}uuvb
tern Type
Adults and Children Iv]oPRb C}vv}v
PRb
S}u˙]v M}v}rRb]b r u}vRb}( u}vRb}(HR
b]bv~SZ tant HRZE
Ru}o
E M}v}rRb]b r u}vRb}( u}vRb
v }(HR
b]bv~EZ tant HRZ
Ib}v]]b]b r M}v}rRb]b r ıu}vRb}(HRZE ˘A }b}(
v~HZ tant Ib}v]]}
u˘]uu}(
uP]o˙(} r
uv}v
v*Drugsis
S}u˙]v P}o˙rRb]bv ıu}vRb}(HRZE ˘A }b}(

re tanttuculos
vIb}v]] TB Ib}v]]}
ber is~DRrTBZ*v
b]bv~SrHZ u˘]uu}(
uP]o˙(} r
uv}v
Ib}v]]vRE r P}o˙rRb]bv ıu}vRb}(RrZrL(˘ E˘vuv
u}ob]bv TB }u}vRb](
~HrEZ ˘vb]ovP
}v
b (}u
˘r˙]uP
HUEUvS~AFZ P}o˙rRb]bv u}vRb}( æu}vRb}( M}].MDR
TB KurP}rL(˘rRrZ P}rL(˘rRrZ P]uvobR
Ru}v}r}}o˙r R](u]]vrR r u}vRb}( u}vRb}( FooMDRP]uv
resistance b]bvTB HrZrCurL(˘rP}r HrZrL(˘rP}rCb plus H
Cb~PASZ ~PASZ
PAS]bov}Cb
Note 18-6
.v]}vb
D
Mono-resistant TB:
TB]oo]Rb]bv}}vo˙}v(}uR.bo]vvro}b]bu] r
]vbP}u˙]v
b U]b}v]]U](u]]vU˙]vu]}Ru}oX
P}o˙rRb]bvP
TB ]oo] R b]bv } ob `} u]]vb v} } }R ]b}v]]
v](u]]vX
R](u]]vrRb]bv~RRrTBZP
TB]oo]Rb]bv}](u]]vU`]R}`]R}b]bv}}R.b
o]v vro}b]b u]]vbX TR]b u˙ u}v}U }o˙U uo } ˘vb]o˙
Pb]bvTBX
w
MorDPRb]bv~MDRrTBZP
TB]oo]Rb]bv}ob}R](u]]vv]b}v]]X
E˘vb]o˙ DP Rb]bv ~XDRrTBZP TB ]oo] R b]bv } }v }( R
G}}]v}o}vbvob}v}(RR]vio}v b ro]vPb~l r
vu˙]vU}u˙]v}u]l]vZU]v]}v}MDR TBX
TorP) Dosing of Second-Line Medicines

AvrTBDP R}uuvD]o˙D}bP~M˘]uuD}bZ
~A]}vZ
AoD}b]vP CR]ovD}b]vP
P˙]vu]~ZZ ruP llP}v]o˙~uPZ ruP llP}v]o˙~
uPZ
Kvu˙]v~KuZ æruP llP}v]o˙~uPZ æruP llP}v]o˙~
uPZ
}u˙]v
C ~CuZ æruP llP}v]o˙~uPZ æruP llP}v]o˙~
uPZ
L}G}˘]v~L(˘Z wæruP}v]o˙~ æruP llP l˙]v]]
uPZ }bb~uPZ
R]}vu]
E ~E}Z ærwæuP]o˙]v]] æruP llP l˙]v]]
v*TyphoidFever*v
}bb~uPZ }bb~uPZ
P}R]}vu] ærwæuP]o˙]v]] æruP llP l˙]v]]
~P}Z }bb~uPZ }bb~uPZ
C˙o}b]v~CbZ ærwæuP]o˙]v]] ruP llP l˙]v]]
}bb~uPZ }bb~uPZ
Pru]v}bo]˙o] P}v]o˙}]v]]}bb ruP llP l˙]vr]] r
]~PASZ ~PZ }bb~PZ
Note 18-7
GRv`]oo }vP bR}uvP]u~ıru}vRbZ(}uvP r
uv}(DRrTBXPoblRl]vP`]RRN}voTBC}v}o}PuuX
Refeal
r Criteria
R( oo vb } DOTS uv v (} uvPuv v
u}v]}]vPvGRvN}voTo}b]bP}PuuX
185. Typhoid Fever

Typhoid fever (enteric feverZ ]b b ]o ]oovbbU `R]R
}b `R bv]˙ }v]}vb }} u]hvP }vu]v}v }(
(}}}``]R(bXTR]`R]R˙b R(}r}o
} ]v R ]vbvo òo v b R}PR R o}}bu }
oo }PvbX TR˙ b ]v} R }}o
b v ]v }( ]v(vbX
OPv]bubu˙}vv}bv]vR}}o b }(RoR˙]bU]XX
wı
Standard Trtme
vb`]R}b]}}o b obU u}vRbLuv}R}b
`]Ro}vPrubo]v]o]bbX
I(]u}o˙˙R}]( u˙bo]v}uo]}vbbR
b ]vbvo (}}v `]R ]}v]bU o}}˙ }}ob b U ˙R}b
b ]b
v b ]vbo Ru}o˙b]b o]vP } l]v˙ ]vi˙
~b]oo˙]vGvPD .]v˙ZX
Po] }v }v P}} b}vo R˙P]vU Rv `bR]vP v
}] ]b}bo }( b}o] `b `}o }Lv v R ]bbX
Sv]vP }( (}} Rvob ˙ ˙]vP } }}o b ob } ˘o
] b v (b Rvo]vP }( (}}U (]b v Pob ob}
Ro(ovubbX
sueCa
yy Salmonella typhi and paratyphi
Symptoms
yy F `R]R]vbPoo˙ b }R]PR(vb]b(}
b `lb
~(}bv}b}v}vuo]obZ
yy C}vb}v ]vRo˙Pbb
yy A}u]vo]vv]R}]vR}v b `l}(]oovbb
yy Severe headache
v*TyphoidFever*v
yy D˙}PR
yy Pb˙R}b]b v}v(b]}vu˙}
Signs
yy H]PR(`]Roo˙bo}òb~}b]}voo˙ob]b(b
b]oo˙`]Ru˙}]b}]vbvo(}}vZ
yy A}u]vovvbb
yy H}rbov}uPo˙~vZ
yy Confusion
yy S]Pvb}(Rb]v(}v~vu}v]bZ
Invtiga
se tions
yy FBU C ]+voU
yy RDT lo}}.ou(}uo]b]~}˘ouo]Z
yy Bo}}o
yy Stool culture
yy U]vo
Note 18-8
Notes on Diagnosis
yy D]Pv}b]b}(˙R}]( ]bb}v}vP
b o]v]ob]]}vl˙
yy Bo}}obU}b]]vP.b˙b}((
yy S}}oobU}b]LR˙}R}æR`l
yy U]vobU}b]]vPvv`l
yy TR}b]}}RW]oU b `R]R]bvo]ovo˙
(o
b ]v}v.u]vP]Pv}b]b}(˙R}](
Trtme
ae nt
Tuv}ib
yy T}]R]v(}v
yy T}vuvP}uo]}vb
yy T}vvbu]bb]}v}(]v(}v}}R}o
yy T]b}vP]vP}}˙u](]
]v
E RvPPB
yy C]}G}˘]v U}oU
Adults
æuPR}o˙(}r˙b
Children
uP llPR}o˙(}r˙b
Or
Adults
uPrR}o˙(}r˙b
Children
uP llP~u˘XuPZR}o˙(}r˙b
v*TyphoidFever*v
Note 18-9
C]}G}˘]v bR}o b `]R ]v R]ovX C]}G}˘]v u˙ o˙ b
v]v]bX A R .b b]Pv }( ]v } ]vGuu}vU vb ub ]b}vv
uvvovuv~XPXA]R}u˙]v lCL]˘}v X
Zb
nd
L]vTuv
]v
E RvPPB
yy L]˘}v
C UIVU
Adults
rP]o˙(}wr˙b
Children
uP llP]o˙(}wr˙b
Or
yy A]R}u˙]v U}oU
Adults
æuP]o˙(}˙bw
Children
ruP llP(}˙bw
Refeal
r Criteria
R(˙]oovbvR}b`]R}uo]}vbbR]vb
b vo
(}}vU ]vbo Ru}o˙b]b v ]}v]b } R }]
b]o]bX HoR˙ ]b bR}o ob} ( (} b]o]b
uvPuvX
Standard Trtme
186. Malaria
Malaria ]b ˙ }uu}v ]v(}v ]v GRvX I (}oo}`b R
]v}}v }( }}}v uo] b]b ]v} R o}}bu ˙
R ] }( v ]v( (uo Av}Rob u}b]}X Mo] ]b ui}
b }( b]Pv].vu}]]˙ v u}o]˙ b]oo˙ u}vP ovo
]v]]obU bR b R]ov v æ ˙b }( PU Pvv `}uv
~b}uub `]R b (}o v uvo }}ubZU vb `]R
b]looo]bbv]b]vPv}vrb]vGRv]vbv˘]bX
Bb }v R o]v]o ]˙ b U b }( uo] P}] b
]RRv}uo][}Rb[X]Pv}b A ]b}(uo]vb
}v b Rv[b˙u}ub b vRR˙b]o.v]vPb˘u]v}vX
H}Ù(}.v]]Pv}b]b}uo}}˙~o}} b .ou
vl}R]D]Pv}bTb Zubu}vbRuo]b]b}
R] }u}vvb b]v R o]v]o bv}v }( R }v]}v v
b]u]o } }R }uu}v ]bb bR b ˙R}] ( U ]v˙
]v(}vU u] b U vu}v] v uv]vP]b in both adults and
R]ovvubobU}bu] U}vb]oo]bUX]vR]ovX
Iv GRvU ]Pv}b]b ]b }Pbb]o˙ ]vP bR]L (}u o]v]o }
o}}˙}v.u}vbRb]b(}uvXR]D]Pv}bTb
~RDT u˙ Z }b }v.u]Pv}b]b](u]}b}˙~o}}.ou]bZ v}
v*Malaria*v
]ooX
Pv ubb ]v R }uuv]˙ u]vo˙ P o]u]v}v
}( R ]vb } } v}v }( u}b]} ]b `R]o ]}vo
Ru}}R˙o˘]b]b](}ovo]v]]obX
TR o}uv }( b]bv }( uo] b]b } vruo]o
u]}vb]bu'}(ui}o]RoR}vvXTR]bRv}uv}v
]b oPo˙ R bo }( R}r]Pv}b]b[ v `}vP ]Pv}b]b }( uo]
˙ RoR }vb v vb o]lU `]R ]b 'vv }r
uv v b}uub o } ]v}uo uvU o]vP }
}r˘}b }( R b]b } R vruo]o P ~PZX b
A]}voo˙U u]b A ]v]v C}u]v}v TR˙ ~ACT Z U R Rv
u}v}R˙`]Ru]b]v]v]bU]bvo˙}uuv(}
R uv }( v}uo] uo] } v R o}uv }(
Pb]bvX
I ]b R(} vbb˙ } }]v o}}˙ }v.u}v }(
]Pv}b]b }( uo] (} vP b uvX E˘}vb } R]b
]v]o R]ov v æ ˙b v b }( b b
uo] `R o}}˙ }v.u}v ]b v} ]uu]o˙ }bb]oX Iv
bR ]ubvbU }uo }b }( R }] vruo]o
u]}v~bZubP]vX
sueCa
yy Plasmodium falciparum~}uu}vbvb}vb]o(}u}b}(R
Rbvu}]]˙b}]`]Ruo]]vGRvZ
yy Plasmodium malariae
yy Plasmodium ovale
187. Uv}uo]Mo]
Symptoms
yy F
yy Chills
yy R]P}b
yy S`vP
yy Headache
yy Gvo]}˙vi}]v]v
yy Nauseavl}}u]vP
yy L}bb}(
yy A}u]vo]v~b]oo˙]vR]ovZ
yy I]]o]˙v(bo}(~]v]v(vbZ
Signs
v*Uncomplictea dMalaria*v
yy F
yy Mild pallor
yy M]oiv]
yy Sov}uPo˙
Invtiga
se tions
yy M]}b}˙rR]lvR]vo}}.oub(}uo]b]b
yy R]D]Pv}bTb~RDT Z
yy FBC
yy ORb]v]
Trtme
ae nt
Tuv}ib
yy T}}]}Pbb]}v}uo] b
yy T}o]u]R}v}(R]oovbb
yy T}u]v]u]Ro}uv}(Pb]bvb]b
yy IvR]ovU]b}vP]vP}}˙u
st
L]vTuv
]v
E RvPPA
yy bvA A=Au}]]v U}oU~SToræ}vPUTo
rv}vPUTorw}vPZ
Or
yy uR A A=Lu(v]v U}oU~STor}vPæZ
Or
yy D]R˙}u]b]v]v A= P]]v U }oU ~S To rı }v P
æZ
Standard Trtme
ToræP) bvA A=Au}]]v }ro]b(}uo}v~RP]uv

(}ONCAILY
ED DOSINGZ
W]PR PA Artesunate~æuPobZNu r Au}]]v~æuPb
}(TobT}BG]v obZNu}(TobT}
BG]v
˙D ˙D ˙D ˙D ˙D ˙D
ærlP AM˙ A* A* A* A* A* A*
rlP rv˙
rælP wr˙
ærwlP r
yr
ANwlP AN˙
TR}b]vuP l}˙`]PR]bPAu}]]vuP llPA=bvA uP llPUlvb]vPo
}b]o˙(}R~˙bZ ULuobX
TorvP) bvA A=Au}]]v }ro]b(}uo}v~RP]uv

(}TWICAILY
ED DOSINGZ
W]PR PA Artesunate~æuPobZNu r Au}]]v~æuPb
}(TobT}BG]v obZNu}(TobT}
BG]v
˙D ˙D ˙D ˙D ˙D ˙D
AM PM AM PM AM PM AM PM AM PM AM PM
ærlP AM˙ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼ ¼
rlP rv˙ A* A* A* A* A* A* A* A* A* A* A* A*
rælP wr˙
ærlP
w r˙ A* A* A* A* A* A* A* A* A* A* A* A*
ANwlP AN˙
TR }b ]v uP l}˙ `]PR ]bP Au}]]v uP llP A= bvA uP llPU lv b `}
]]}bb]o˙(}R~˙bZ ULuobX
TorwP) bvA vAu}]]vF]˘D}bC}u]v}v

~SvRP]uvUb]vPR]oo}b]vPvPRb
b Z
Artesunate~ASZA=Au}]]v~AQZ
Nu}(F]˘D}bC}u]v}vTob}P]v
W]PR PA ToD}b]vP ˙D ˙D ˙D
SvPR
AMlP ru}X ASPæuPQ A P
vwXæuP
TorwP) bvA vAu}]]vF]˘D}bC}u]v}v
~SvRP]uvUb]vPR]oo}b]vPvPRb
b Z
ırwlP ræ˙b ASPæuPQ
A P
æuP
rælP vr˙b ASPuP
QA PwuP
ANvlP AN˙b ASPuP
QA PwuP
R
E F]˘D}b C}u]v}vo}v]vb }RbvA ~ASZ v Au}]]v ~AQZU
R }bPb ]v]X TR} lP]vP oo˙]v]b`R]R }b]vPvPR
b o]b
}`R]RPP}XTR maximum daily dose of Artesunate/Amodiaquine is 200 mg/600 mP
TorP) uR
A vLu(v]v~D}b]vPRP]uvZ
uR
A ~uPZA=Lu(v]v~uPZNu}(Tob
T}BG]v
W]PR PA ˙D ˙D ˙D
F]b Second AM PM AM PM
}bD }bD
~L
RbZ
AMælP AMvu} N}}uuv(}vbvælP
ærælP vu}r˙
ærælP r˙
ærælP r˙
ANælP AN˙
TorıP) D]R˙}u]b]v]vvP]]v~D}b]vPRP]uvZ
W]PR PA D]R˙}u]b]v]v~uPZlP]]v~uPbZ
Nu}(TobT}G]v
B
˙D ˙D ˙D
ærlP AM˙ ¼ ¼ ¼
rælP r˙ A* A* A*
vrlP rv˙
rælP wr˙ AH AH AH
vrælP r˙ A* A* A*
ærwlP r˙
ANwlP AN˙
æ
Standard Trtme
188. Severe Malaria

S } R}uo] uo][ v ]b (}u o˙ ]v ]Pv}b]b
} ]v}] uv }( v}uo] uo]X I u}bo˙ }b
]v R]ov v æ ˙b }( PU Pvv `}uv v v}vr]uuv
]v]]obX TR vb b]vP u}b Rb ]v b uo]
o } o ]v}ouv ~o uo]ZU b vu]U
R˙}Po˙u]UR˙}v b Uvo(]ovb]}˙]}b]bX
TR ]Pv}b]b }( b uo] ]b b }v o]v]o (b v
}v.u `]R o}}˙ vP b X N} oo b }( b uo] R
R]PR b]u] v ]v]o o}} .ou ˘u]v}v u˙ vPX
WR R ]Pv}b]b ]b Ub uv ub b `]R}
o˙`R]o`]vP}v.u}vX
Symptoms
yy P}}}o]vl~XPXu]ol b ]vR]ovZ
yy R}(b}u]vP
yy Dl}R}or}o}[]v
yy Pbb]vP}(˙o]'o]v
v*SeverMalaria*v
yy D]8o˙]vR]vP
yy Gvo]b`lvbbU]v]o]˙}òl}b]`]R}b]bv
yy Ao }vb]}bvbb ~RvP }( R]}U }v(b]}vU o]]uU
}u Z
yy RPvo]}vob]}vb
Signs
yy H˙˙˘] ~˘]oo˙uANXæ£CZ
yy E˘uoo}~bvu]VHAMæP loZ
yy Mliv]
yy C]o}˙}oob}bR}l~}oo]ubU`l]obZ
yy Tachypnoea~R]R]vPZ
yy ]}vb C }vRb˘u]v}v
yy S`vP~}R˙}Po˙u]Z
yy Hu}Po}]v]~l}R}or}o}[]vZ
yy Oo]P]
yy S}vv}b v˘o]v R˙ o]vP ~]bbu]v
]vbo}Po}vZ
yy Ao }vb]}bvbb ~RvP }( R]}U }v(b]}vU o]]uU
}u Z
Invtiga
se tions
yy R]]Pv}bb
yy Bo}} .ou (} uo] b]b r R]l v R]v o}} .oub ~bR}o
}v`R]ooZ
yy FBC
yy S]lo]vPb
v
yy Rv}uo}}Po}b
yy BUEvv]v
yy Bo}}P}]vPv}bbruR]vP
yy Lu v ]v R }vob]vP } }u}b v } ˘o
uv]vP]b }vRo]b
Trtme
ae nt
Tuv}ib
yy T}vb]ov}(b]u]
yy T} }] Pv uv (} o]( Rv]vP }uo]}vb }
}v]}vb XPX }vob]}vbU R˙}Po˙u]U R˙}v U vo
]u]uv
yy T}}]}]b}
yy Po vb `R} v}vb]}b } R]vP b]b ]v v
}]}b]}v}vb]}v
]v
E RvPPA
AXPr(ouv
yy ArtesunateUIMU
v*SeverMalaria*v
Adults and ChildrenANlP
XuP llP
ChildrenAMlP
uP llP
Or
yy uR
A UIMU
Adults and Children
XuP llP
Or
yy QuinineU IMU bvA U oU uP llP ~( ]v R]ov
vv˙bVToZ
Or
yy ArtesunateUoUuP llP~(]vR]ovvv˙bV
TorP) D}b]vPRP]uv(}Q]v]v IMIvi}v]v˙}vPCR]ov
W]PR V}ou}(Q]v]v D]R˙}Ro}]

Ivi}v~æuP luo]o}vZ
AMælP Xuo
æXrwXælP Xæuo
wXvrXlP Xuo
XrXælP Xæuo
XvræXlP Xuo
æXrwXælP XæuorRo(}RR]PR
w
Standard Trtme
TorP) D}b]vPRP]uv(}Q]v]v IMIvi}v]v˙}vPCR]ov
wXvrXlP XuorRo(}RR]PR
XrXælP XæuorRo(}RR]PR
XvræXlP æXuorRo(}RR]PR
æXrwXælP æXæuorRo(}RR]PR
wXvrXlP vXuorRo(}RR]PR
TR}bP(}IMQ]v]v ]buP~XuoZlP}(}˙`]PR˙R}bX
Note 18-10
H}`}P]IvuboQ]v]v
IvuboQ]v]v ]vY}vPCR]ovP
yy W]PRRR]o
yy P Q]v]v ]o}v }( æ uP luoP Ub uo ]o
b ˙]vP
b v
vo}`æuob}(]o b `(}]vi}v}bo]v~v}˘}bZX
TRv]v}Rbu˙]vP b ` uP~uoZ(}uvu}o}(Q] r
v]vXTR˙]vP b v}`}v]vbæuPQ]v]vuoX
yy TR}bP]buP~XuoZlP}}˙`]PR˙R}bXCoo
v*SeverMalaria*v
R }ou } P] b }v }˙ `]PRX ~F} ˘uob }( }˙ `]PRb

v }bb ]v R]ov AM lPU bvA U oU uP llP ~( ]v
R]ovvv˙bVZX
yy Au]v]b˙]vubo]vi}v}RR]PRXI(R]o}ou˘ r
buoU]viRo(R}b]v}RR]PRX
IvuboQ]v]v ]vAobP
yy UbQ]v]v ]o}v}(uP luoXT}R]bUùob}(Q]v]v
vuPvuob}(]o b `}bo]v~v}˘}bZ
yy TR }bP ]b uP llP }˙ `]PR }( Q]v]v P]v R}o˙ ˙ IM
]vi}vU}u˘]uu}b}(vuP
yy Suoo ob ~`]PR]vP obb Rv v lPZ bR}o `]PR } oo R
}}bXLPob`]oob]uo˙]Ru˘]uu}b~vuPZ
yy I( R ] }ou ]b u} Rv æ uoU ]] ] ]v} `} v ]vi
separate sites
TorP) RobvA ~PrR(oTuv]vCR]ovZ

W]PR PA Artesunate RP]uv
}bD
ærlP AM˙ æ OvæuPb}b]}˙
ırılP rA*˙b T`}æuPb}b]}]b
rılP A*ræ˙b OvuPb}b]}˙
rılP vr˙b T`}æuPv}vuP
suppositories
ANlP AN˙b T`}uPb}b]}]b
BXTuv]vR(oCv
Note 18-11
Pvovuo]obv(}oo}`r}vuvX
TR v }uuv}v ]b } P] vo vuo]ob ]v R r
uv}(uo]b (}u]v]uu}(R}b~]b}(Rv[b
]o]˙}}o}ou]}vvo Z Rv]bo}}o}ou r
]}v b (}oo}`r}v uvX R}uuv (}oo}`r}v uvb ]vo
CTbA vQ]v]vA=o]vu˙]vX
yy ArtesunateUIV}IMU
Adults and ChildrenANlP
XuP llPR}o˙
G]vuR}~]XX}vu]bb]}vZUR}bvR}b
Then
XuP llP]o˙vovvòo}` b ~u˘X˙bw Z
Then
A (oo r˙ }b }( }uuv }o u]b]v]v }u]v}v
therapy (ACTZ
ChildrenAMlP
v*SeverMalaria*v
uP llPR}o˙
G]vuR}~]XX}vu]bb]}vZUR}bvR}b
Then
XuP llP]o˙vovvòo}` b ~u˘X˙bw Z
Then
A(oor˙}b}(}uuv}oCTA
Note 18-12
bvA }vb}v(}vo]vi}v
R}vb}vP
Ub ˙]vP
b } ` v ]vi R b}ov ~b}]u ]}v æuP luo
b}o}vZ ]v} R ]o }( bv}`X SRlR ]o vo R }` ]b
}uoo˙]bb}ovRb}o}v]boX
F} ]vv}b ]vi}vP A ]R Po}b æ uP luo ~]XX æA9˘}b D solur
}vZ } b}]u Ro}] ı uP luo ~]XX XıA9 N}uo bo]v b}o}vZ } R r
}vb bv b}o}v } uP luo b}o}v }( bvX
`D ] }ou v P] bo}ò˙ ˙ IV } r uolu]vA ]R
Po}b æ uP luo ~]XX æA9 ˘}bD b}o}vZ } b}]u Ro}] ı uP luo ~]XX
XıA9N}uobo]vb}o}v}Z R}vbbvb}o}v}
uP luob}o}v}(bvX`D ]}ouvP]bo}ò˙˙IM
v]}R]PRXI(R]}ou]bu}RvæuoU]]]]v}`}v
]vib]A]RPo}bæuP luo~]XXæA9˘}b D b}o}vZ}
b}]uRo}]ıuP luo~]XXXıA9N}uobo]vb}o}v}Z R}vb
bvb}o}v}uP luob}o}v}(bvX`D ]
}ou v P] bo}ò˙ ˙ IM v]} R]PRX I( R ] }ou ]b u}
RvæuoU]]]]v}`}v]vib]A]RPo}bæuP l
uo ~]XX æA9 ˘}bD b}o}vZ } b}]u Ro}] ı uP luo ~]XX XıA9 N}uo
ı
Standard Trtme
bo]v b}o}vZ } R }vbbv b}o}v } uP luo

b}o}v }( bvX `D ] }ou v P] bo}ò˙ ˙ IM v]}
R]PRXI(R]}ou]bu}RvæuoU]]]]v}`}v]vi
b]bX~SToZToZToZoZX
F}]vubo]vi}vP
A ]R Po}b æ uP luo ~]XX æA9 ˘}b D b}o}vZ } b}]u Ro}] ı
uP luo ~]XX XıA9 N}uo bo]v b}o}vZ } R}vbbvb}o r
}v } uP luo b}o}v }( bvX `D ] }ou v
P]bo}ò˙˙IMv]}R]PRXI(R]}ou]bu}RvæuoU]]
] ]v} `} v ]vi b]A ]R Po}b æ uP luo ~]XX æA9˘D r
}bb}o}v}Z b}]uRo}]ıuP luo~]XXXıA9N}uobo]vb}o}v}Z
R}vbbvb}o}v} uP luo b}o}v }(b r
vX`D ]}ouvP]bo}ò˙˙IMv]}R]PRXI(R]
}ou]bu}RvæuoU]]]]v}`}v]vib]A]R
Po}b æ uP luo ~]XX æA9 ˘}b D b}o}vZ } b}]u Ro}] ı uP luo ~]XX
XıA9N}uobo]vb}o}v}Z R}vbbvb}o}v}
uP luob}o}v}(bvX`D ]}ouvP]bo}ò˙˙IM
v]}R]PRXI(R]}ou]bu}RvæuoU]]]]v}`}v
]vib]bX~SToZToZToZ
TorP) }˘]u
A vb(}]o}v
v*SeverMalaria*v
Route IVIvi}v IMIvi}v

SvPR}(u]]v uP vuP uP uP vuP uP
S}]u]}v Xæ Xæ
æuP luob}o}v(}
}vb}v~uoZ
Go}bæuP luo Xæ æ
b}o}v(}]vi}v
O
S}]uRo}]ı
uP luo(}]vi}v
~uoZ
Total diluent needed v Xæ v
~uoZ
Artesunate
}vv}v~uP l
uoZ
Note 18-13
Coo}v}(}b}(bvA needed (ml):
AobP
F}IV}P
XuP˘}˙`]PR~lPZ
IVbvA b}o}v}vv}vuP luo
ı
F}IM}P
XuP˘}˙`]PR~lPZ
IMbvA b}o}v}vv}vuP luo
CR]ovAMlPP
F}IV}P
uP˘}˙`]PR~lPZ
IVbvA b}o}v}vv}vuP luo
F}IM}P
uP˘}˙`]PR~lPZ
IMbvA b}o}v}vv}vuP luo
P}vbP
yy Ivi]uu]o˙L}vb}vv]b](v}`]R]v
b R}
yy D]b](b}o}v]bv}o
yy D}v}b]vIV]UG]bo}ò˙˙]IV]vi}v}ruolu]v
Or
yy uR
A UIMU
Adults and Children
XuP llPX b
Then ~R}boZ
XvuP llP
v*SeverMalaria*v
Then ~R}bL]v]}v}(uvZ
XvuP llP}v]o˙vovvòo}` b ~}æ˙bZ
Then
A (oo r˙ }b }( }uuv }o u]b]v]v }u]v}v
therapy (ACTZ
Or
yy QuinineUIVU~]v˘}b D saline}]væA9˘}b
D æruollPZ
Adults and Children
uP llP~u˘X}bvuPZ]v(b}rR}bX
R]v(b]}vR}o˙vovvòo}`
b X
Then
yy QuinineU}oUuP llPR}o˙}}uo˙bw }(uv
And
yy C o]vu˙]v U}oUuP llPUR}o˙(}˙bw
N}r
Co]vu˙]v bR}ou]v]b`]R(}}v}]}bu}vb}(`X
QuinineU IVU bR}o o`˙b P]v ˙ bo}` ]v(b]}vU v˙ }ob ]v r
v}b]vi}vbR]bu˙R˙}vb
b ]}vX
Or
yy QuinineUIMU
Adults and Children
uP llP~u˘X}bvuPZUR}o˙vovvòo}`
b
Then
yy QuinineU}oUuP llPR}o˙}}uo˙bw }(uv
ı
Standard Trtme
Av
yy Co]vu˙]v U}oUuP llPUR}o˙(}˙bw
Refeal
r Criteria
Pvb]Pv}bR]vPb uo]
b }`R}(]o}b}v}
R}uuvvuo]ou]}vbub(X}] A
uv b ]v] } ub ]v] ]} } vb(]vP R
vX I( (o ]b v} }bb]o ]uu]o˙U }vv R uv
P]uvbR}`v}(}uo] b vo(o]b}bb]oX
189. Malaria in Pregnancy

PPvv˙ ulb `}uv u} o]lo˙ } P uo] } ] (}u
uo]X Mo] ]v(}v ]b u} b ]vP Pvv˙ `R]o
Pvv˙ v ]b }}ub v }u }uo] ˙ ]X TR +b
}( uo] }v R Pvv u}R ]vo b (}u }( R ]oovbbU
vu]U u]b]PU ru o}U v }bru Ru}RPX
R]blb } R (}b ]vo (}o vu]U ru]˙U ]vr]v
v*MalariainPrgna
P}`R ]}vb U o}` ]R `]PRU oo]R b U }vPv]o uo]U v

]vb ]vo u}o]˙X Pv ubb ub uRb]b
~]XXIvb]rNbITNbvIvu]'vPvTuv
e ncy*v
]vPvv˙IPT v]}b}v`R]o
Z }v.uubb
}uo˙X
Tuv}ib
yy T}vb}uv+buvPuv
yy None
AXTuv}(Uv}uo]Mo] in the First Trimester
yy QuinineU }oU ~u˙ P]v b u}v}R˙ ]( Co]vu˙]v is not
]ooZ
uP llP~u˘XvuPZR}o˙(}˙bw
Av
yy C o]vu˙]v U}oUuP llPU`]]o˙(}˙bw
Note 18-15
TR P }( R}] (} v}uo]uo] (} Pvv `}uv ]v R .b
]ub ]b }o Q]v]v X CTbA v} }uuv (} b ]v R .b ] r
ubX H}Ù R] b bR}o v} `]RRo ]v b `R R˙
}vb]} o](rb]vPU}`R}Rvuo]ob}vb]}
vb]oX
ı
BXTuv}(Uv}uo]Mo] in the Second and Third
Trimesters
yy bvA A= Au}]Abv A= Au}]]v }ro]b (}u r
o}v ~RP]uv (} TWICE AILYD DOSINGZ}TR }b ]v uP l}˙
`]PR ]bP Au}]]v uP llP A= bvA uP llPU lv b
`} ]] }bb ]o˙ (} R~Z˙bULuobX To æU T r
ovUTowZ
Or
yy uA (v]v U}oU~SToZ
Or
yy QuinineU }oU ~S b}v Tuv }( Uv}uo] Mo] in
RF]bT]ubZ
C. Treatment of Severe Malaria]vPPvv˙~Aoo]ubbv
puerperium)
]v
E RvPPA
yy ArtesunateUIV}IMU
Then
yy ACTU}oU(}˙b
~Sb}v}vTuv}(RSMo][ }Z
v*MalariainPrgna
Or
yy QuinineUIV}IMU
Then
e ncy*v
yy Q]v]vA=o]vu˙]v}u]v}vU}oU
D. Treatment of Severe Malaria in Pregnancy (Second and Third
trimesters and Puerperium)
yy uR
A UIMU
Then
yy ˙b}(}oCTA
EXIvu]'vPvTuv]vPPvv˙~IPT )
IPT }vb]bb }( P]]vP R .˘r}b }u]v}v u]}v
SoR}˘]v P˙]uRu]v ~SPZ ]v uv }bb .v
]vobL]lv]vP~Pbv }vo`lbZXvC }uuv}v
]b R IPT `]R bo(}˘]vr˙]uRu]v ~IPTrSP Z P]v } oo
Pvv`}uvRbRovvo]b]˘]vPR
.b ]ubX WHO }uuvb bRo }( (} (}b vvo
]b]b (} v}uo Pvv˙X Iv GRvU R v}vo uo] }v}o
P˙
b SP b (}R}b}(]vu]'vvuv
}vo˙X
T}vRo}uv}(Pb]bvUSP]bv}} b
(}}R}bbRuv b }('lb}(uo]X
yy SoR}˘]v ~æuPZrP˙]uRu]v ~æuPZU}oU
ı
Standard Trtme
Note 18-16
C}ru]v]bbD]o˙ObTR˙~DOTZ]vPvvo]b]b}v
ob}b]}vbvu}b}vw}b]}vb
D}b}( Antenatal visit R}uuv HoR`}l}

IPT Pb}vo u]v]b
`lb
IPT F]bANC]b]L v M]`]bUM]o
]lv]vP }8bUFu]o˙
R˙b]]vbUOb]]vb
IPT obA }vu}vR M]`]bUM]o
LR.b}bX }8bUFu]o˙
R˙b]]vbUOb]]vb
IPT obA }vu}vR PR˙b]]vb]bvbU
LR}v b }bX C}uuv]˙HoR
v*Seona
O8bUC}uuv]˙
IPTrw obA }vu}vR UUvU
sa lMalariaChemopvention
Health Nurses
LR}bX
r
Note 18-17
PPvv `}uv `]R R (}oo}`]vP }v]}vb bRoo ˘u (}u b]vP
~SMCZ*v
SPP
yy F]b]ub}(Pvv˙~AM`lbPb}vZ
yy GvPD v˙u.]v˙
yy So]]bb}v˘o]vviv]
yy Kv}`vooP˙}v˙boRPb}ooP˙}˙]uRu]v
yy H]b}˙}(]}b}v}SP
yy Rvuv`]RboRPbR}b r]u}˘}o~`]R]v`lbZ
yy P}brbPvv˙~Pb}v˙}vv`lbZ
yy ]vP
bB
yy b}( A uo]~b}Z
O`]vP } vP}v]bu `v (}o] ] v SPU (}o] ] bouv}v
bR}oo˙v}v b `lLSPu]v]b}vXF}]}vo
]v(}u}v}vIPT vuo]]vPvv˙U(}RobGRvHoR
S]]v]vPuvobvP]o]vb}vRbiX
190. Sb}voMo]CRu}v}v~SMC )
TR]b ]b R ]vu]'v u]v]b}v }( (oo uv }bb
b ]vP R }uuv vruo]o u]]v ]vP l uo]
vbu]bb]}v b}vb } v uo] ]oovbbX A }uo uv
}b ]b P]v } R]ov P `v v æı u}vRb u}vRo˙
]vob } u˘]uu }( }bb ]vP R uo] vbu]bb]}v
b}vXIvGRvUSMC Rbv]uouv]vRN}RvSvvR
b]vPSoR}˘]v rP˙]uRu]vvAu}]]v~SPA=Q A Z
ı
yy SoR}˘]v rP˙]uRu]vU}oU
vA
yy Au}]]vU}oU
191. Mv]vP]b
TR]b ]b v ]v(}v }( R }]vPb }( R ]vU v ]b u}b
}uu}vo˙ b ˙ ]U ]bbU (vP] v }}}X Ov ˙U
}bC ]vo Mv]vP]b (CSMZU b ˙ Neisseria meningitidesU ]b
}uu}v ]v R N}Rv v U RP]}vb }( GRvU v boo˙
}b ]v ]u]b ]vP R Ru'v b}vX TR bv}v u˙
b}uub }v(b `]R o uo]X Mv]vP]b ]b u]o
uPv˙X F]o } }Pv]b v o˙ uvP uv]vP]b
bob]vb]}b}uo]}vbX
Iv(}uP]}vo}]b]RoRR}]b]uu]o˙]v]u]
uv]vP]b X
sueCa
yy ]o B
yy Neisseria meningitides
v*Meningitis*v
yy Escherichia coli~v}vbZ
yy V]bbXPXHb]bb
yy P}}}XPXT}˘}obu ]vHIV rAIDS
yy FvP]XPXCryptococcus neoformans
Symptoms
F}AobvCR]ovANæ˙b
yy F
yy Neck pains
yy Severe headaches
yy PR}}R}]
yy CRvP]vR]}
yy Convulsions
yy V}u]vP
CR]ovAM˙
yy F
yy I]]o]˙
yy Refusal to eat
yy P}}bl]vP
yy V}u]vP
yy }`b D ]vbbv`l˙
ıæ
Standard Trtme
yy F}o}Pvo]}vob]}vbL`R]RRR]o]bbo˙
yy LRP˙
yy BoP]vP(}vvoo
Signs
F}AobvCR]ovANæ˙b
yy F
yy Nl+vb b b
yy P}b]Kv]P [bb]Pv
yy Altered consciousness
yy C}u
CR]ovAM˙
yy Nl}v
yy Pbv}bv}(vl+vb b b
yy Pbv}bv}((
yy BoP]vP(}vvoo
yy C}u
yy Hypotonia or hypertonia
yy Convulsion
Invtiga
se tions
yy FBC
v*Meningitis*v
yy R]]Pv}b~} b ˘oouo]Z
yy Bo}}.ou(}uo]ob]b~}˘oouo]Z
yy Luv~}vo˙L˘o]vP]b]vv]oZb
yy Bo}}ovbvb]]˙
Trtme
ae nt
Tuv}ib
yy T}]v(˙v]R}Pv]b
b ub
yy T}v}uo]}vb
yy To prevent spread to contacts
yy T}u]v]vP}}v]}v
N}vrRu}o}P]ouv
yy T]b}vP]vP
yy KR]`˙o
yy Nb}Pb](]vP](o]o
AX]o
B Mv]vP]b
st
L]vTuv
]v
E RvPPA
yy L]˘}v
C UIVlIMU
Adults
rP]o˙(}wr˙b
Children
AN˙bV rP]o˙(}wr˙b
ıv
AM˙bV æruP llP(}r˙b
NeonatesV ræuP llP}v]o˙(}˙b
vA
yy Vv}u˙]v UIVU
Adults
æuP llPR}o˙(}wr˙b
Children
AN˙bV æuP llPR}o˙(}wr˙b
r˙bV æuP llPR}o˙(}wr˙b
u}vRr˙bV æuP llPR}o˙(}r˙b
AMu}vRV v}}uuv
Or
]v
E RvPPB
yy B v˙ov]]oo]v UIVU
Adults
MUR}o˙(}˙b
Children
XMUllPvR}o˙(}˙b
Av
yy CRo}uRv]}o UIVU
Adults
v*Meningitis*v
PvR}o˙(}˙b
Children
æuP llPvR}o˙(}˙b
TR]b u˙ bvo˙ RvP } }o R˙ `]R b]Pv].v
o]v]o]u}uv
Or
yy CRo}uRv]}o UIMU~}]o˙}vZ
Adults
uP llPb]vPo}b
Children
uP llPb]vPo}b
Note 18-18
N}}uuv(}R]ovo}ù}vRbUvob}(}Pvvvo r
vPu}RbX
C. For penicillin allergy

yy Co]vu˙]v UIVU
Adults
vrıuPR}o˙(}˙b
Children
uP llPR}o˙(}(}˙b
Av
yy CRo}uRv]}o UIVU
Adults
PvR}o˙(}˙b
ıw
Standard Trtme
Children
æuP llPvR}o˙(}˙b
nd
L]vTuv
]v
E RvPPB
yy (}˘]u
C UIVU
Adults
PvR}o˙(}˙bw
Children
AN˙b}}˙`]PRANælPVPvR}o˙
AM˙b}}˙`]PRAMælPVæuP llPvR}o˙
Av
yy Vv}u˙]v UIVU
Adults
æuP llPR}o˙(}wr˙b
Children
AN˙bV æuP llPR}o˙(}wr˙b
r˙bV æuP llPR}o˙(}wr˙b
u}vRr˙bV æuP llPR}o˙(}r˙b
AMu}vRV v}}uuv
D. Prophylaxis for CSM
P}R˙ouv]b}uuv (}vb ˙b ]}}
v*Meningitis*v
]bRPvob}(}R]o}b}vb
yy C]}G}˘]v U}oU
Adults
æuPb]vPo}b~A}]]vPPvv˙Z
Children
ær˙bV æuPb]vPo}b
Or
yy L]˘}v
C UIMU
Adults
æuPb]vPo}b
Children
AM˙bV æuPb]vPo}b
Note 18-19
R}o}(}]b
b P˘uRbD }v }PR
b `]RR.b}b}(R r
}] v]} Rb v (}v } o } ui} }v ]v R]vP o}bb
vR]v}RR]ovvobX
yy ˘uRbD }v UIVUruPvR}o˙(}ær˙bw
Refeal
r Criteria
R( oo vb v} b}v]vP } uv `]R]v R .b
R}b(}b]o]bX
ı
TorP) Suu˙}(uv}}vb(}]o
B Mv]vP]b
PA PR}Pvb o]v
b Eu]]o Aovb
uv ~S]o]bZ
AMæ˙b Mv]vP}}bU L]˘}v
C (}˘]u
C
Pvu}}b U And M}vu
Hu}R]ob Vv}u˙]v Fo}}]v}o}vb
IvGv
ANæ˙b Pvu}}b U L]˘}v
C Fo}}]v}o}v
L]b] U O
GurvP]oo] Au]]oo]v
And
Vv}u˙]v
Hospital StaphylococciU L]]u
C M}vu
Acquired GurvP]oo]U A=lrGvu˙]v Vv}u˙]v
Pvu}}b
Pb}u}vb
v*WormInfetas tion~Intetina
192. W}uIv(b}v~IvbvoZ
Iv(b}v `]R `}ub ]b ˙ }uu}vX P}} R˙P]v } }v
s lZ*v
}( bl]v `]R b}]o ]v `R]R R `}u } ]b PPb o] ]b}bb
]v]]ob}]v(b}vX
sueCa
yy H}}l`}u
yy Ascaris
yy S}vP˙o}]b
yy T`}u
yy TR`}u
yy WR]`}u
Symptoms
yy Gvo]bIR]vP
yy P]vo]R]vP~R`}uZ
yy D˙}PR~`RvRobR}PRRovPbZ
yy WR~`RvRobR}PRRovPbZ
yy A}u]vo]b}u(}v}]v
yy ˙bE (P]o]˙
yy PbbP}(`}u~bZ]vR}}o
b
yy Ao}òR]
yy V}u]vP }(`}ub
Signs
yy Poo}
yy Fb}(uov]}v
ıı
Standard Trtme
yy P}}R˙b]oP}`R]vR]ov
yy LP]bv}uv]vR]ov
yy WR]vP
Invtiga
se tions
yy S}}o(}}v˘u]v}v
yy FBC
Trtme
ae nt
Tuv}ib
yy T}o]u]vR`}ub
yy T}R}uo]}vb}(]v(b}vXPXvu]Uuov]}v
yy T}vb}bv]}v
yy Evb}v]}v
yy P}Rv`bR]vP`]Rb}vvv]vP`
~S o o}` }v RPRu}o}P]o uv }( W}u
Iv(b}vb[Z
Refealr Criteria
R( vb `]R ]vbvo }b}v (}u R˙ o} }(
s lZ*v
`}u
b ]v(b}v}P]o b b]o]bX
PRu}o}P]ouv}(W}uIv(b}vb
W}u Tuv Note Evidence

RvP
H}}l`}u Mv}o U}oU N}}uuv B
Adults (}R]ovo}`
æuPb]vPo}b u}vRbv]v
O Pvv`}uv
uPR}o˙(}˙b
CR]ovANu}vRb
uPR}o˙(}˙b
O N}}uuv B
A ov}o U}oU ]vPPvv˙
AobvR]ovAN
u}vRb
uPb]vPo}b
CR]ovo}ù}vRb
uPb]vPo}b
æ

RvP
Ascaris Mv}o U}oU N}}uuv A
AobvR]ov} (}R]ovo}`
u}vRbV u}vRbv]v
uPR}o˙(}˙b Pvv`}uv
O
æuPb]vPo}b
O N}}uuv A
AobvR]ov}
u}vRb
uPb]vPo}b
CR]ovo}ù}vRb
uPb]vPo}b
WR]`}u Mv}o U}oU N}}uuv B
AobvR]ov} (}R]ovo}`
u}vRbV u}vRbv]v
O
æuPb]vPo}b
s lZ*v
O N}}uuv B
AobvCR]ov}
u}vRb
uPb]vPo}b
CR]ovo}ù}vRb
uPb]vPo}b
TR`}u Mv}o U}oU N}}uuv C
AobvR]ov} (}R]ovo}`
u}vRbV u}vRbv]v
O
æuPb]vPo}b Ruv
L`lb
O N}}uuv C
AobvCR]ov}
u}vRb Ruv
uPb]vPo}b L`lb
CR]ovo}ù}vRb
uPb]vPo}b
æ
Standard Trtme

RvP
S}vP˙o}]b Aov}o U}oU N}}uuv B
AobvCR]ov} ]vPPvv˙
u}vRb Ruv
uPR}o˙(}˙b LR`lbX
CR]ovo}ù}vRb Aovo˙U
uPR}o˙(}˙b wr˙buv
O `]R}]b
T]v}o ~TR]v}oZU oX
}oU
Adults Iuv]bR
XæPR}o˙(}˙b P}(R}]
Children RbRvP
æuP llPR}o˙(}˙b }(]]vP
o](rRv]vP
encephalopathy in
u]}.o]vu]
b X
T`}u P]vo U}oU TlvLo]PR C
AobvR]ovV breakfast
æruP llPb]vPo}bX
s lZ*v
~æuP llPb]vPo}b(}
Hymenolepis nanaV]v
˙bZ
O
N]o}bu] U}oU
AobvR]ov}v
˙bV
Pb]vPo}b
CR]ovAM˙bV C
æuPb]vPo}b
rv˙bV
Pb]vPo}b
CRòbR}b(}
uo
æ
Chapter
yeE Disorsder
ı
193. N}voC}viv]b
~Sb}v}vRN}voC}viv]b[vN}voD]b}bZ
ıX Xerophthalmia
TR]b}v]}v]b}uu}v]vR]ovXI]bb}]`]R]v
]vl}((}}bR}v]vV]u]vA XI]b}uu}vb}(o]vvbb
]vR]ovXI]b]u}v}vR]b}v]}v˙˘u]v]vPR˙b
}(oob]lvuov}]bRR]ovXTR]}(R]ovbR}o]vo
(}}bR}v]vV]u]v~l A Pvo(˙PobXPXvl}v}u]U
˙oo}`(]bvPobUou}]oUu]olUPPbZX
Pvb v }R P]b bR}o ]b}P (}u hvP
v˙]}vo}vbbRRb
b U`b Ubo]U]vUX}
Pb]v}R˙vobb]˙R˙b]]vX
sueCa
yy V]u]vA .]v˙bovP(}u
yy P}]vo}]uov]}v
yy Measles
yy Mob}}vb
Symptoms
yy P}}v]PR]b]}v~]vRo˙Pbb Z
Signs
yy D˙}viv
yy Grey sclera
yy C}vivo(}o]vP~`]vlo]vPZ
yy K}uo] ~o}˙}vUb}Lv˙b o}vZ
Invtiga
se tions
yy Nil
æ
Standard Trtme
Trtme
ae nt
Tuv}ib
yy T}}Pv]v}]u]v.]v˙ A
yy T}v}uo]}vbXPXo]vvbb
yy H]PR]u]v}v]v]vP A (}}bbR}ov}P
G]V]u]vA }R]ovb}}vR
b ]oovb]bb ]Pv}bvob}
]vvb`]Rubobvuov]}v
]vE RvPPA
yy V]u]vA U}oU
Children
Iuu]o˙L]Pv}b]b
rv˙bV UUv]b
vru}vRbV UUv]b
TRv~LR}bZ
rv˙bV UUv]b
vru}vRbV UUv]b
TRv~L`lZ
v*Foreignodb yintheyee *v
rv˙bV UUv]b
vru}vRbV UUv]b
Refealr Criteria
R(ooo]b b R}(
b ˘}RRou]}v˙b]o]b](R
}v]}v]b`]R b vvv}oP]vP}vX
195. Foreign body in the eye

F}]Pv }]b ( } blb }( U
b buoo ]vbb } }R v˙
}ib R P ]v} R ˙bX TR (}]Pv }˙ u˙ ]R ]v R
}vivo bU }v R }v } ]vb] R ˙oo ~]v}oZX A
R]b}˙ }( R o]lo˙ v }( R (}]Pv }˙ ]b ]v ]b }v v
u}oX TR (}]Pv }˙ u˙ bv ˙ (o ]vb}v }( R
}v}}vivobXo]PRvP A ]bv}}vo
(}]Pv}]bX
sueCa
yy Specks of dust
yy Suoo]vbb
yy F}buoo]b~bRb}b`]RuoP]vbZ
yy ORv˙}ib
Symptoms
yy Fo]vP}(b}uR]vP]vR˙`R]Ru˙]]vP
yy Sv]b}u(}}]v b
yy W]vP}(R˙
yy R˙~bZ
æ
Chatep rıP *EyeDisorsder
yy PR}}R}] ]XX]v}ov}o]PR
yy Iv]o]˙}}vR˙
Signs
yy ]v E }((}]Pv}˙
yy C}viv]b
yy T]vP}(R˙b
yy PR}}R}]
yy CRu}b]b
yy Sr}vivoRu}RP
yy IPo ]o ]v vvP ˙ ]vi˙ `]R ]v ]v}o
(}]Pv}˙
yy Bo}}]vRv]}Ru~R˙RuZ
Invtiga
se tions
yy Xr˙}(R}]~buoo] b (}]Pv}˙Z
Trtme
ae nt
Tuv}ib
yy T}u}b.]o(}]Pv}]b
yy T}b}]]vi˙
v*Foreignodb yintheyee *v
yy T}v}uo]}vb
yy WR R (}]Pv }˙ ]b v R ˙o]U R ˙o]
vu}R(}]Pv}˙X
yy I( R (}]Pv }˙vv} u}Uo˙}]o v]}U
R˙vREFER}v˙b]o]bo]v]X
AXF}]Pv}˙]v.}v
yy Tetracaine hydrochlorideUXæA9˙}UIvboo}v}`}}b] r
}}o}v
BXF}˙]]P}v
yy N}uoSo]v UXıA9U
CXPv}v}(]v(}v
st
L]vTuv
]v
E RvPPC
yy CRo}uRv]}o ˙}]vuvUA9}]oU~ALu}o}((}]Pv
}˙Z
D. Pain control
yy Pu}o U}oU
Adults
æuPrPvrR}o˙]b
Children
vr˙bV æræuPvrR}o˙]b
ræ˙bV ræuPvrR}o˙]b
u}vRbr˙V vruPvrR}o˙]b
ææ
Standard Trtme
Refeal
r Criteria
R( vb `]R }vo (}]Pv }]bU ]v}o (}]Pv
}]bUb]bv]vvvbb}(R˙}R˙b]o]bX
196. R˙E
R ˙b ]R R bo }( ]vGuu}v }( }o b }
o]vP ]v} R b }vivo bX TR 'v }( R vbbU
v}( R ]bRPU b}]]v v ]b ]vvb]˙U ]b]}v o}bb v
v }( R }v Ro(o ]v R]b]vP R ˙X R
˙ ]b }voo˙ ˙ b]}b }v]}v b]oo˙ ]v b]}vb `R
Rvbb]b}vR}vX
sueCa
yy C}viv]b
yy C}voo}lb
yy v]} A ]b~]vGuu}v}(RoZ
yy vPo A o}bPo}u
yy E]bo]b
yy So]b
yy S}vivoRu}RP
v*ReyedE *v
ToırP) CR]b]vPR
A ˙E with no history of injury
Diagnosis Predominant Nature of Vision Loss Corneal Ab}]P]v
P'v}( Discharge vA
Rvbb
C}viv r Poo~]vv W˙Uu}]U N]o˘ CoUu˙ N]o}u]o]v

]b o]v]vP}(R u}ov} `Rv}v bR}`v
˙o]bZ purulent is involved epithelial
]vb
b `]R
G}b]v]v
l}}viv r
]b
Corneal Around the W˙}u} r V]o G˙}P˙]bR Severe pain
Uo cornea purulent `R]R
`Rv]o
}(vPo}
v]`Rv
HbS]uo˘
Acute anterir Around the W˙ V]o Co}R˙ Moderately
}U]b cornea severe
AvPo Around the W˙ P}(}v Uv](}uo˙R˙ V˙b
Closure cornea
Go}u
E]bo]b Sectorial N]o}`˙ Nil Clear Mild to severe
So]b Sectorial N]o}`˙ N]o˘ Clear V˙b
`Rvb} r
]`]R
]b
æv
Diagnosis Predominant Nature of Vision Loss Corneal Ab}]P]v
P'v}( Discharge vA
Rvbb
S}viv r Sectorial Nil Nil Clear Nil

oHu r
}RP
ToırP) Suu˙}(R}uu}v˙b}(C}viv]bvR]
management
APvlP}v
B Type of Predominant }v
D Treatment
}(Pvb Discharge type of ocular
discomfort
]o
B AooPb Pov N]o}u]o r`lb Av]}˙
]R]vP}]v drops
V]o AooPb W˙}M r N]o}u]o r`lb S˙u}u
copurulent ]R]vP}]v
AooP] Children and ador S]vP˙u}] IR]vP Chronic inr Mast cell
lescents u]'v ]o]]vP
b
PvbUb}]u
R}u}Po˙
A9
TR}u AooPbUb}] Mucopurulent N]o}u]o u}vR} Tetracycline
`]R]˙U˙U ]R]vP}]v ˙} ˙}]vuv
v*ReyedE *v
dusty and poor u} A]R}u˙]v
v]}vuv tablets
WHOG]vP}(TR}u
Z TF r ob . (}oo]ob ]v R bo }vivX Iv]b ]bb v v
(}uv
ZTIr]vvb]vGuu}vXN(}Pvuv
ZTSr]vP
b P b XOo]v(}vUv}`]v
ZTTrR}u]R]b]bXNP]ob uv
æO
ZC r}vo}]bXV]boo}bb(}u]}b]v(}v
Invtiga
se tions
yy C}vivo `b (} o v bvb]]˙ ~ov }
u}ov]bRPZ
Trtme
ae nt
Tuv}ib
yy T}R]v(}v]vRb}(}viv]b
yy T} o] ]v v ( ]uu]o˙ } R b]o]b (} Pv
uvPuv } v o]vvbb ]v R b }( }vo obU
v]}]bUvPoo}bPo}uU]bo]bv
bo]bX
}viv]b
A
yy W] ]bRPb `]R bU ]b ] v `bR Rvb L R
`]
yy D}v[bR}òb`]R}Rb
yy AobvR]ovbR}o}]o}b}v`]R}RbXPX(}u
æw
Standard Trtme
b R}}o U`}lUuv`]uu]vP
b
AXF}uv}(}viv]b A
st
L]vTuv
]v
E RvPPC
yy TetracyclineUA9}]vuvUo˙v]PR(}˙bw
Av
yy CRo}uRv]}o UXæA9˙}bU
}R}o˙(}R}b
Then
}vrR}o˙(}˙bw
Or
yy C]}G}˘]v UXA9˙}bUr}bvrR}o˙
Refeal
r Criteria
R( }vo obU v]} ]bU vPo o}b
Po}uU ]b]b v bo]b ]uu]o˙} R˙b]o]bX Aob}
(}viv]bU`R]RbR}`bv}]u}uvLR}b}(
uvX
v*Glaoma
197. Glaucoma
uc *v
Go}u ]b v } v}R˙ boo˙ v} o`˙b b}]

`]R ]b ]v}o X b I ]b R }v b o]vP b }(
vo o]vvbb ]v R `}oX CR}v] Go}u u˙ }
b o}bb }( ]b]}v v o]vvbb `]R} ]} `v]vP ˙u}ubb
v ub R(} vb (} ]v oo ob ˙}v R P }(
˙bX A Po}u ]b R}` b}] `]R ˙ R]PR ]v}o
bv˙]v b v]vGuu}v}(R˙vvo
} o]vvbb ]lo˙ ]( v} X WRv }vPv]oU Po}u b
voPuv }( R ˙oo b}] `]R ]vb bvb]]˙ } o]PR
v`]vPX
PRu}o}P]o uv u˙ ˙ (}u v } v
}]vP } o}o ]o]o]˙U +}]o]˙U v ]v]]o b}vb }
uvX
sueCa
yy A o}b }( R ]vP vPo ~ } ]o o}l ]v ]u˙
vPoo}bPo}uZ
yy Iv]vP}(}b(}uRv]}Ru~b]
}v]vPvPob]vR}v]}vvPoPo}uZ
yy N}bo uuv ]v R ]vP vPo ]v ]bRu] ˙
]bbR}o](
b ]v}R˙
yy D]boovb]v}v˙ b vPoo}bPo}u
yy Mo(}u}v}(R]vPvPo]v}vPv]oPo}u
æ
Symptomsandsigns
ToırP) CR]bb}(R]}b˙b}(R}uu}v˙b}(
Glaucoma
S˙u}ub CR}v]}vvPo vPo
A o}b C}vPv]o
vb]Pvb
Ovb Uboo˙˙bv Elderly Iv(vbv}ob
above
S˙u}ub N]ooooRv Sv]boo}bbU PR}}R}] U
}Pbb]]boo}bb S˙]vU˙ `]vPU
]vGu˙U`˙
]bRPURR
v}u]vP
b }uub
Iv}o Uboo˙R]PRUu˙ V˙R]PR H]PR
pressure v}uo
Cornea N}uo H˙ EvoPvR˙
`]Ro]vlb
Invtiga
se tions
yy Gonioscopy
yy CvovoR]lvbbubuv
v*Glaoma
yy V]bo.ovo˙b]b
yy OD]bR}}PR˙
uc *v
yy RvoNF]TR]lvbbAvo˙b]b
yy E˘u]v}v}(R]ovvvbRb]
Trtme
ae nt
Tuv}ib
yy T}v}Pbb]}v}(R]bbvRo(R]}}v
of vision
yy T}v}uo]b]v}ob
yy ]vP D SP˙
yy LbSP˙
yy Go}u ]vP
D ]
yy V]}b}R]uovb
Note 19-1
C}vbov}RRou}o}P]b}vRuv}(Po}uX
st
L]vTuv
]v
E RvPPB
Tuv]b`]R}vu]}v(}u}v}u}}(R(}oo}`]vP
P}bP
yy Lv}}bU˙}bUæu]}Puluo
æı
Standard Trtme
yy B]u}}bU˙}bUu]}Puluo
yy T}}bU˙}bUu]}Puluo
AvlO
yy T]u}o}oXæA9˙}b
yy L}v}o}oXæA9˙}b
yy ˘}o}o
B XæA9˙}b
AvlO
yy B ]u}v]]v UuP luo}XæuP luo
AvlO
yy }ou]
A U}oUæuP
yy B]v}ou]U˙}bUuP luo
yy D}}ou]U˙}bUuP luo
AvlO
yy P]o}]vrA9U˙}b
Refeal
r Criteria
R( oo b b }( Po}u } R }RRou}o}P]b (}
buvv]v]ouvX
v*Ctaa ct*
198. Cataract
ar v
I ]b R }]˙ }( R ˙boo]v ovb }( R ˙X I ]b R o]vP

b}(o]vvbb`}o`]X
sueCa
yy OoP
yy Tu}R˙
yy IvGuu}v`]R]vR˙
yy M}o]}v]}vbbRb]buoo]b
yy C}vPv]o
Symptoms
yy V]o ]bv }( ]b]}v ~b}uub `}b `Rv bvv˙ }
]vPZ
yy Gob]oo˙v]PR]vP]]vP
yy M}v}o}o]b]}v]vR+˙
yy CRvP]v(bP
yy u}bR}b]PR~u˙}]bR]LZ
yy u}o}vPb]PR~R˙u}]bR]LZ
yy WR]b}]vR˙~R]ovZ
Signs
yy Lvb}]˙
yy Reduced visual acuity
yy R}vbbvb]]˙
æ
Invtiga
se tions
yy FbvPo}}bP
yy FBC
Trtme
ae nt
Tuv}ib
yy T}]u}]b]}v
yy T}vRo}uv}(uo˙}] in the child
yy Ub}(obb
yy SP]ou}o}(
yy Nil
Refealr Criteria
R(oo}b R˙b]o]bX
199. E˘}bK}R˙
v*ExposureKetop
E˘}bl}R˙ ]bR˙]vP}(R}vbob }(]v]o]˙
} o}b R ˙o]b } o]vl o˙X I( v} v v
ar thy*
a
bo]v}voo}vv(}}vo]vP}o]vvbbX
v
sueCa
yy F]ovob˙XPXBoo[bob˙}o}b˙
yy S]vP}(R˙o]b
yy C}u
yy Thyroid eye disease
yy Pl]vb}v[b]bb
yy P}}b]b
yy SvJ}Rvb}v[bS˙v}u
Symptoms
yy Fo]vP}(˙]vP}(R˙
yy F}]Pv}˙bvb}vb]vR˙
yy PR}}R}]
yy Bo]vP}(]b]}v
Signs
yy LP}RRou}b ~]v]o]˙}o}bR˙bZ
yy Iv}uoo]vl~R˙o]}bv}}R`R}o}v
]vPo]vlZ
yy Iv(vo]vl
yy S.]ov]vb b }vR}v
yy LP}obv}vo]Ro]o(
yy C}voo}v
yy C}vo(}}v
æ
Standard Trtme
Invtiga
se tions
yy Nil
Trtme
ae nt
Tuv}ib
yy T}u}]bvR}v.]oo˙
yy T}vR}uo]}vb}(˙˙b
yy T]vPR˙o]bo}b]vR}u}bv
yy Pob}RR˙
yy }v E }( vb `]R Pl]vb}v[b } R˙}] ˙ ]bb } }
o]vl(vo˙}ov]o˙RRvo˙}vG˘o]vl
L]vTuv
st
]v
E RvPPC
yy H˙}˘˙uR˙o ooo}b U XA9 ˙ }bU r R}o˙ ]vP `l]vP
u
nd
L]vTuv
]v
E RvPPC
v*Strabismus*v
yy P}o˙]v˙oo}R}o UXrA9˙}bUrR}o˙]vP`l]vPu
Av
yy C Ro}uRv]}o UA9˙}]vuvUv]PR(}u
Or
yy TetracyclineUA9˙}]vuvUu
Refeal
r Criteria
R( vb `R}b ˘}b l}R˙ ]b v} ]u}]vP } R
˙b]o]bX
200. Strabismus
S]bub ]b u]bo]Pvuv boo˙ }( }v ˙ vvP
b]uov}b ]`]vP }( v }i˙ }R˙bX Ovb]v R]ov v
w ˙b ]v(b `]R R o}uv }( R ]bo ˙bb u }( R
]vP ˙ ]v R ]v o]vP } uo˙}] X A }vb v }o
Pb }o ]b]}vX D]o}] does not occur in children because of
R ]o]˙ } b R }vb ]uP } o}uv }( uo˙}]X
Auo˙}]}bv}}](R]}vov(}u}v˙}R
}RXTRu}(v˙bR}]}vou]bo]PvuvXEb}}] is
}vPv]}vv˘}}] ]b]Pv]}vX
sueCa
yy C}vPv]ou]bo]Pvuv
yy A]]}v
yy Po˙b]b}(Rv]ovVIUIII}IV
æ
yy F]}b]b]vv˘}oubo
yy M˙bRv]P]b
yy Iv}oob]}vXPXv}ob}uvuob
Symptoms
yy M]bo]Pvuv}(R˙
yy Iu]iPuv}(R}]bv
yy D]o}] or double vision
Signs
yy ]}v D }(R}voo]PRG˘]v}v˙(}uvo}b]}v
yy M}uv }( R ]vP ˙ } l .˘}v `Rv R .˘]vP
eye is covered
yy N}uo˘}o˙u}uv~]vv}vro˙]bb ub Z
yy L]u]}v}(˙u}uv~]vo˙}]b ]bb ub Z
yy H˙u}] }v(}v]vR]ov
yy Rvoob]}vXPXv}ob}u
Invtiga
se tions
v*SickleCellDisseWa Retinopthy
yy C˙o}oP](}v]vR]ov
yy OR b]. b (} b XPX u˙bRv] P]b }
v}ob}u
Trtme
ae nt
Tuv}ib
yy T}]v(˙v}v˙b]Pv].v(}
a *v
yy T}v˙uo˙}]
yy To relieve any diplopia
yy T}}Ru]bo]Pvuv
yy T}v˙vo˙]vP}v]}v
yy So}}v}(v˙(}
yy Tuv }( uo˙}] ]v R ]vP ˙ ˙ R]vP R v}vr
]vP˙
yy Ub}(]bub}}buoo]}vb
yy PR]vP}(R]vP˙}o]]o}]]v}ovb
yy Nil
Refealr Criteria
Aoo vb ]Pv}b `]R ]bb ub ub (} R ˙
b]o]b(}(RuvPuvX
201. Sickle Cell DiseaseWRv}R˙
Symptoms
yy Svo}bb}(]b]}vb]oo˙]vb]loooSSC _vb
æ
Standard Trtme
Refeal
r Criteria
Aoo S]lo Coo SSC _ vb ˙b v } bR}o (
} R˙b]o]b(}v]vP b (}}o](b]lo oov}R˙X
R(oob]looovb`]R˙}uo]}vb}R˙b]o]bX
202. Ev}]vvu}o]]b}b`]R˙}uo]}vb
Refeal
r Criteria
Pvb `]R b]bvo˙ }} o}} Po}b }v}oU }}
o}} b }v}oU (v ]bro u]bb]}vbU ]bo
]u]uvU } v˙ vo RvPbU (}} ob } PvPv U
b]bv}]v]U } }R R}v]}uo]}vb }( ]b bR}o
(}R˙b]o]bX
v*Endocrineandmetaolic
b disorswith
der yee omp
c lictions
a *v
æ
Chapter
EarUNoseandThroat
Disorsder
203. Stridor
Stridor]bvuPv˙}v]}vXIRbR]bv}]b]vR
]vb]}˙ Rb }( R]vPX TR]b }b `Rv R ]b v }b}v
}(R]`˙(}uRvb}Rv˙˘}`v}RRvu]v
}vR]XTR}b}v]bboo˙]vRbPo}hX
I ]b }uu}vo˙ ]o ]oovbbU v u˙ boo˙
˙ R }uu}v }oX Mbob u˙ ob} }uo] ˙
L˙vP}R}}vR]b ~LTBZ X T`} ]u}v b }( ]}b in
R]ov]o}~LTBZv]Po}hbX
Iv R uvPuv }( ]} b U}]b
b u}b (o
b `Rv P]v
`]R]v v R}b }( }vb }( ˙u}ub
b X C}PR ˙bb }v]v]vP }]b
and atropine}v]v]X
STRIDORINCHILDREN
sueCa
yy V]o~o˙vP}R}}vR]bZ
yy ]o
B ]v(}v
yy ]Po}hb
A
yy IvGuu}˙}b}v
yy IvRo}v}(R}(ubXPX]v.}lb
yy AvP]}v}}u
yy R}R˙vPob
yy IvRo}v}((}]Pv}˙
yy C}vPv]ouo(}u}v}(Ro˙v˘XPXo˙vP}uo]
Symptoms
yy L}`P(
yy Hoarse voice
yy Bl]vP}PR
yy R]vP
B ]8o˙
yy Restlessness
Signs
yy Stridor
ææ
Standard Trtme
yy L}`P(
yy RbobRvb
b ]R]o`Rv}b}v]bb
yy Hoarse voice
yy Bl]vP}PR
yy L}R]vPXPXvo b Uo]o
b Uvo
b v
]v}bob}vb
yy Tachypnoea
yy Cyanosis]v}bb }v
yy Reddened throat
Invtiga
se tions
yy Suo
yy Lob}LbXr˙}(vl
yy CRbXr˙
Trtme
ae nt
Tuv}ib
yy T} }] PP}v }( R }b}v `]R R]l } b
}vb
b
yy T}vbo˙vuo˙o](}(}b}v
yy Evb]vPP}}R˙}v]vo]vPo]o}oG]b
v*Stridor*v
yy Evbu˘]uu(} b RR]o
yy o]b Eb R R ]`˙ ˙ ]v}v } R}b}u˙ ]v b
}b}v
AXF}R˙}v}(˙b]lvb`R}vv}]vl
st
L]vTuv
]v
E RvPPC
yy ˘}b
D salineUIVUæA9
B. For restless and distressed children who require oxygen
yy O˘˙Pv UrvL]b ~b}v}˘˙Pv}v
b ooZ
C. For steroid therapy
yy ˘uRb
D }v U}olIMlIVU
Children
XvuP llPXb
Or
yy Bb}v] Uvo]bU
Children
uPXb
Or
yy Pv]b}o}v U}oU
Children
ruP llPX
b
Or
æv
Chatep rP *EarUNoseandThroatDisorsder
yy H˙}}b}v UIVU
Children
uP llPvR}o˙(}r˙b
Note 20-1
S}]bu}b(o
b `RvP]v`]R]vR}b
v }(}vb}(˙u}ub
b XAv r
]}bbR}oP]v]v}v˙
b ]o]v(}vX
C}PR ˙bb }v]v]vP}]bv}]v are contraindicated
X
D Ivb]u}b]o]v(}v
st
L]vTuv
]v
E RvPPC
yy Co}˘]oo]v UIVU
Children
vA
yy Gvu]]v UIVU
Children
r˙bV XæuP llPR}o˙(}˙bw
AM˙V XæuP llPR}o˙(}˙bw
vA
v*Stridor*v
yy M}v]}o UIVU
Children
nd
L]vTuv
]v
E RvPPC
yy (}˘]u
C UIVU
Children
uP llPR}o˙
Av
yy M}v]}o UIVU
Children
E. For severe Croup
yy AdrenalineUPb}o}vUvo]bUuoX
b
Then
RR}o˙](+
STRIDORINADULTS
sueCa
yy IvGuu}˙}b}v
yy ]Po}hb
A
yy L˙vPou}
yy V}o}o˙b]b
æw
Standard Trtme
yy R}R˙vPob
yy IvRo}v}((}]Pv}˙
Symptoms
yy Hoarse voice
yy R]vP B ]8o˙
yy Restlessness
Signs
yy Stridor
yy L}R]vP
yy Tachypnoea
yy Cyanosis]v}bb }v
Invtiga
se tions
yy Lob}LbX˙}(vl
yy CRbXr˙
Trtme
ae nt
Tuv}ib
yy T}vbo˙vuo˙o](}(}b}v
yy o]b Eb R R ]`˙ ˙ ]v}v } R}b}u˙ ]v b
v*Stridor*v
}b}v
st
L]vTuv
]v
E RvPPC
AXF}}˘˙PvR˙
yy O˘˙Pv UrvL]b ~b}v}˘˙Pv}v
b ooZ
B. For steroid therapy
yy H˙}}b}v UIVU
Adults
uPvR}o˙(}r˙b
CXF}b]u}b]o]v(}v
st
L]vTuv
]v
E RvPPC
Adults
vuPR}o˙
Or
XPR}o˙
Av
yy M}v]}o UIVU
Adults
æuPR}o˙(}˙bw
æ
nd
L]vTuv
]v
E RvPPC
yy (}˘]u
C UIVU
Adults
wæuPR}o˙
Av
yy M}v]}o UIVU
Adults
æuPR}o˙(}˙bw
Refeal
r Criteria
R(b`]R}bb }vv}uo]}vb]vR]ov}
P]]]v } ENT b]o]bX Aob}(oo b }(]}
b if there is
v}˘b}]v}(}uR}b}u˙}b]o]bX
X E]Po}hb
A
TR]b]bv vo](rRv]vP]v(}v]v`R]RR]Po}hb
v }v]vP
b b }u o˙ ]vGu v }u}b
b]vP}bb }v}(R]`˙bXTR]bvbb }v
v*AcuteEpiglottitis*v
v˘uo˙]}b~rvR}b}Z b]}˙(]ovRX
I ]b u} }uu}v ]v R]ovX H}Ù R ]v]v Rb
b]Pv].vo˙ } Rv]uuv]b}v bRo `]R R
vov]vX
E˘u]v}v }( R R} ]v vb `]R R]b }v]}v ub
}v}vo˙]vRbv}(}}ov˙}]vX
sueCa
yy Haemophilus influenzae˙B
Symptoms
yy Sv}vb}(R]PR(
yy }}o]vP
D }(bo]
yy D˙bRP]
yy R]vP B ]8o˙
Signs
yy E˘uo˙]oov}˘]R]o
yy F
yy H]bRo(}`}˘vRvl
yy R]vP B ]8o˙
yy Wl}]~v}R}bZ
yy R]v˙}vbo}v
yy Stridor
æı
Standard Trtme
yy Cyanosis in very sick children
yy S`}oovvv]Po}hb
Invtiga
se tions
yy FBC
yy Bo}}o
yy Lob}LbXr˙}(Rvl
Trtme
ae nt
Tuv}ib
yy T}o]}b}v
yy T}u]
yy o]b Eb Ruv}(]`˙](vbb˙˙]v}v}R}b}u˙
AXF}uv}(]o]v(}v
st
L]vTuv
]v
E RvPPB
yy (}˘]u
C UIVU
Adults
v*AcuteEpiglottitis*v
wæuPrXæPR}o˙(}˙bw
Children
æuP llPR}o˙(}˙bw
Av
yy M}v]}o UIVU
Adults
æuPR}o˙(}˙bw
Children
wXæuP llPvR}o˙(}˙bw
nd
L]vTuv
]v
E RvPPB
yy (}˘]u
C UIVU
Adults
rPIV}IMR}o˙(}˙bw
Children
æuP llPR}o˙(}˙bw
Or
Adults
XPR}o˙U
Ivb}XPR}o˙(}˙bw ]v]v(}vb
b
Children
r˙bV v }XPR}o˙U
uP
b
u}vRbr˙bV uP llPR}o˙U
Ivb}uP llPR}o˙(}˙bw ]v]v(}vb
b
æ
˙bw ru}vRbV uP llPR}o˙(}˙bw

PuvAM˙bw V uP llPR}o˙(}˙bw
Note 20-2
TuvbR}o RvP}}ov]}b`Rv}]v}vv r
(}}o}(˙bw
Refeal
r Criteria
R(oo vb ]uu]o˙ } b]o]b ]( R ]b v} ˘b
]oo(}]v}v}R}b}u˙X
205. R}R˙vPobA
TR]b uPv˙ }v]}v (b } }oo}v }( b ]v R
}R˙vPo bX o˙ E ]Pv}b]b v uv `]oo v
u}o]˙X
sueCa
yy G}Ar haemolytic Streptococcus
v*Retrophaynge
yy Ob}u˙o]b}(]o(}uo}b]b
r als*ceAb v
Symptoms
yy F
yy Sore throat
yy D]8o˙]vòo}`]vP
b
yy H˙˘vb]}v}(vl
yy L}vv}]b˙R]vP
Signs
yy F
yy RvR}UoPv]vGuu}vb]ob
yy L}b]}v`]R]v}bo}vb
yy Stridor
yy BoP]vR}b]}R˙vPoòo
Invtiga
se tions
yy FBC
yy TR}`b (}ovbv]˙vP b
yy Z]RorNobv]v b }˘oo}b]b
yy Lob}LbXr˙}(vl
yy CRbXr˙}˘oo}b]b
Trtme
ae nt
Tuv}ib
yy T}]v(}v
yy T}o]R}b}v˙]v]vPRb
yy To relieve pain
æ
Standard Trtme
yy Iv]b]}vv]vP}(bvPvovbRb]
AXF}]vo](
st
L]vTuv
]v
E RvPPB
yy Pu}o U}oU
Adults
æuPrPrvR}o˙
Children
vr˙bV æræuPrvR}o˙
ræ˙bV ræuPrvR}o˙
u}vRbr˙V vruPrvR}o˙
BXF}uv}(]v(}v
st
L]vTuv
]v
E RvPPB
yy (}˘]u
C UIVU
Adults
v*Retrophaynge
wæuPrXæPR}o˙(}wR}b
Children
r als*ceAb v
æuP llPR}o˙(}wR}b
Av
yy M}v]}o UIVU
Adults
æuPR}o˙(}wR}b
Children
wXæuP llPR}o˙(}wR}b
Then
yy (}˘]u
C U}oU
Adults
æuPR}o˙(}˙bw
Children
r˙bV æuPR}o˙(}˙bw
r˙bV æ uP llP ~u˘X æ uPZ R}o˙ (} w
days
u}vRbr˙bV uP llP ~u˘X æ uPZ R}o˙ (} w
days
Av
yy M}v]}o U}oU
Adults
uPR}o˙(}˙bw
Children
nd
L]vTuv
]v
E RvPPB
æ
yy Foo}˘]oo]v UIVU
Adults
æuPvR}o˙(}wR}b
Children
æruP llPvR}o˙(}wR}b
vA
yy M}v]}o UIVU
Adults
æuPR}o˙(}wR}b
Children
wXæuP llPR}o˙(}wR}b
Then
yy M}v]}o U}oU
Adults
uPR}o˙(}˙bw
Children
Av
v*Phayngitis
yy Foo}˘]oo]v U}oU
Adults
r
æuPvR}o˙(}˙bw ](v]bo}òo}`
b
Children
andTonsillitis*v
æuP llPvR}o˙(}˙bw ](v]bo}òo}`
b
Refeal
r Criteria
R(oo}b RENTb]o]bX
206. PR˙vP]b vT}vb]oo]b

TR]b ]b v ]v(}v }( R R} v }vb]obX M}b b} R}b
} ]o ]v(}vb v bR}o NOT `]R v]}b b
R˙ b] `]R]v } æ ˙bX H}Ù ] ]b ]u}v } ]Pv}b
}}o b R˙vP]bb]v]u˙P]]b}b]vRR}
~}R˙vPo v ]}vb]oo bZ b òo b }uo]}vb
R ]v}o }Pvb o]l R l]v˙b v R RX S}}o R}
]v(}vb ] uv `]R v]}b ]v } } R
}uo]}vbv}}X
sueCa
yy V]bb
yy Hu}o˙}}b b
yy ORPu}b]]
Symptoms
yy F
yy D]8o˙]vòo}`]vP
b
yy Sore throat
æ
Standard Trtme
yy Runny nose
yy C}PR
Signs
yy Reddened throat
yy EvoPvv}vb]ob
yy Sb]vR]PRP(
yy Poo}vb]ooo˙uRPovb~b}}oR˙vP]bZ
yy Rvv˙v}b~bPPbb]oZ
yy C}PR ~bPPbb]oZ
yy R˙b~bPPbb]oZ
yy WR]bR˘Rl}(RR}bòob`R]bR}vb]oo
˘
yy Scarlet fever rash
Invtiga
se tions
yy FBC
yy Monospot test
yy TR}`b (}ovbvb]]˙
v*Phayngitis
Trtme
ae nt
r
Tuv}ib
yy T}o]˙u}ub b
andTonsillitis*v
yy T}}Pv]bv}}o b R}]v(}v
yy To relieve pain
yy WuUbo˙`PPob
AXF}]vo](
st
L]vTuv
]v
E RvPPA
yy Pu}o U}oU
Adults
æuPrPvrR}o˙
Children
Or
yy I}(v U}oU
Adults
ruPR}o˙
Children
wr ˙V wXær uP llP vr R}o˙ ~u˘X uP llP } v uP
˙Z
r˙bw VwXæruP llPR}o˙~u˘XuP llP}æuP˙Z
æ
BXF}vPR]v(}v
st
L]vTuv
]v
E RvPPA
yy Au}˘]]oo]v U}oU
Adults
æuPR}o˙(}˙b
Children
AM˙V vXæuPR}o˙(}˙b
Or
Adults
PuR}o˙(}˙b
Children
AN˙bV Ov ælæ uP vPR b oU R}o˙ (}
days
vr˙bV æ uo }( læw uP bvb]}v R}o˙ ~æ uo }(
ælvuPbvb]}v R}o˙(}˙bV}b}o]vb
v*Phayngitis
]v(}vZ
r
rv˙bV æuo}(lXæuPbvb]}vR}o˙(}˙bV
}b}o]v]v(}v
b
andTonsillitis*v
u}vRr˙VXæuo}(lXæuPbvb]}v R}o˙(}
˙bV}b}o]v]v(}v
b
NeonateV Xæ uo }( lXæ uP bvb]}v R}o˙ (}

˙bV}b}o]v]v(}v
b
Or
Adults
vuPrXPR}o˙(}˙b
Children
r˙bV æuP llPR}o˙(}˙b
Or
yy C˙boo]vPv]]oo]vUIVU
Adults
rMUvR}o˙(}˙b
Children
AN˙bV rMUvR}o˙(}˙b
r˙bV XvrXMU~æuP llPZvR}o˙(}˙b
Note 20-3
D}v}P]}r]u}˘}o(}}}o
b R}]v(}vb
ææ
Standard Trtme
nd
L]vTuv
]v
E RvPPB
yy (}˘]u
C U}oU
Adult
æuPR}o˙(}˙b
Children
AN˙bV æuPR}o˙(}˙b
u}vRbr˙bV uP llPR}o˙(}˙b
Or
yy (}˘]u
C UIVU
Adult
wæuPR}o˙(}˙b
Children
AN˙bV wæuPR}o˙(}˙b
u}vRbr˙bV æræuP llPR}o˙(}˙b
CXF}vPR]v(}v]vvbooP]}v]]oo]v
yy E˙R}u˙]v U}oU
Adults
æuPvR}o˙(}˙b
Children
v*AcuteSinusitis*v
r˙bV æuPvR}o˙(}˙b
u}vRr˙bV æuPvR}o˙(}˙b
NeonatesV XæuP llPvR}o˙
Or
yy A]R}u˙]v U}oU
Adults
æuP]o˙(}˙b
Children
ANvu}vRbV uP llP]o˙(}˙b
Refeal
r Criteria
R( vb `]R v }vb]oo]bU }R˙vPo v
]}vb]oo}b vENTb]o]bX
207. AS]vb]b
TR]b ]b v ]v(}v }( R rvbo b]vbbX I u˙ o }
}uo]}vb `]R 'vv u}]]˙ v u}o]˙X o˙ E }Pv]}v
}(R]bo]v]o}v]}v]buv}˙X
S`]uu]vP ]v ]˙ `bU vo ]v(}v } vo ˘}vU
(b]v}o]vPRb]vbbUvbo}b}v(}u}o˙bvooP]
R]v]b ]b}b]vP(}b}o}]vPb]vb]bX
sueCa
yy V]o~}uu}v}oZ
yy ]o B
yy G}ARu}o˙S}}]
æv
yy S. pneumonia
yy S. aureus
yy H. influenzae
yy M. catarrhalis
yy A ooP˙
Symptoms
yy C}PR
yy Nbo}vPb}v
yy Pb]v b R(vR
yy F}voRRb
yy P}bvbo]
Signs
yy Yoo}`}PvR]lvbo]bRPU`R]Ru˙(}obuoo]vP
yy Halitosis
yy Pb]bv(
yy Tvvbb } v o}` R ˙bU `Rv v vb } }
`RvRbo]PRo˙ b
Invtiga
se tions
yy FBC
v*AcuteSinusitis*v
yy Xr˙}(vbob]vbb
Trtme
ae nt
Tuv}ib
yy T}˙u}ub b }(]vv(
yy T}]]v(}v
yy T}v}P]vP}(b]vbb
yy R˙}v A
yy Su]vRo}v
yy T}}R ˘}v v v]} } ~]( vo (}b }( ]v(}v
]bbvZ
AXF}uv}(]o]v(}v
st
L]vTuv
]v
E RvPPB
yy Au}˘]]oo]v U}oU
Adults
æuPR}o˙(}˙b
Children
Or
æw
Standard Trtme
Adults
PR}o˙(}˙bw
Children
AN˙bV OvælæuPoR}o˙(}˙b
vr˙bV æuo}(læwuPbvb]}vR}o˙(}˙b
rv˙bV æuo}(lXæuPbvb]}vR}o˙(}˙b
u}vRr ˙V Xæ uo }( lXæ uP bvb]}v R}o˙V }b
}o]v]v(}v
b
`lbru}vRV Xæ uo }( lXæ uP bvb]}v

R}o˙V}b}o]v]v(}v
b
nd
L]vTuv
]v
E RvPPB
yy (}˘]u
C U}oU
Adults
æræuPR}o˙(}ær˙bw
Children
u}vRbr˙bV æ uP R}o˙U }o ]v b ]v( r
}v
BXF}uv}(]o]v(}v]vvb`]Rv]]oo]v
v*AcuteSinusitis*v
allergy
yy E˙R}u˙]v U}oU
Adults
æuPvR}o˙(}˙b
Children
NeonateV XæuP llPvR}o˙
Or
yy A]R}u˙]v U}oU
Adults
æuP]o˙(}æ˙b
Children
uP llP]o˙(}æ˙b
C. For pain relief
yy Pu}o U}oU~}o]]v](bvZ
Adults
æuPrPvrR}o˙
Children
X
D F}vbo}vPb}v
yy Ephedrine nasal drops
Adults~A9Z
æ
r}b]v}Rv}b]o}ub]o˙`Rv]
Children~XæA9Z
r}b]v}Rv}b]o}ub]o˙`Rv]
Or
yy N}u˙]v XæA9lH˙}}b}v XæA9vbo}bU
Adults
}bR}o˙
Children
}R}o˙
Refeal
r Criteria
R( oo bU `R]R } v} ]u} L `l }( uv }
the ENT Specialist
208. AObM]
TR]b ]bv]v(}v}(Ru]oU`R]R}uuv]b`]RR
R}XI]b]u}v]v(]oR]o}o}}l(}]v]XUv
} }}o˙ uvP b u˙ o } }uo]}vb bR b ub}]]bU
R}v]}bu] U(vbbUuv]vP]b v]vbX
v*AcuteOtitisMedia*v
Pb}b}R]]v(}vb]ob]}˙
]v(}vbX
sueCa
yy Haemophilus influenzae
yy Haemolytic streptococcus
Symptoms
yy F
yy Sudden and persistent ear ache
yy Pov]bRP(}uR
yy V}u]vP
yy D]R}
yy C˙]vPvP]}v
yy Iu]R]vP
Signs
yy Ru
yy D]bRP]vP
yy Ob]}voo˙]vGuR}
yy P(}u
Invtiga
se tions
yy FBC
yy `bE (}ovbvb]]˙
æı
Standard Trtme
Trtme
ae nt
Tuv}ib
yy T}o]˙u}ub
b
yy T}vb}uvv]}R˙
yy T}vR}v]]˙v}R}uo]}vb
yy R˙}v A
yy SP]o]v]vP}(b
AXF}]vo](
st
L]vTuv
]v
E RvPPB
yy Pu}o U}oU
Adults
æuPrPvrR}o˙
Children
v*AcuteOtitisMedia*v
BXF}uv}(]v(}v
st
L]vTuv
]v
E RvPPB
yy Au}˘]]oo]v U}oU
Adults
æuPR}o˙(}˙b
Children
Or
Adults
PR}o˙(}˙bw
Children
AN˙bV Ov ælæ uP o R}o˙ (}
days
vr˙bV æuo}(læwuPbvb]}v R}o˙(}
˙b
rv˙bV æ uo }( lXæ uP bvb]}v R}o˙
(}˙b
u}vRr˙V Xæuo}(lXæuPbvb]}v R} r
o˙V}b}o]v]v(}v
b
`lbru}vRV Xæ uo }( lXæ uP bvb]}v
R}o˙V}b}o]v]v(}vb
b
æ
nd
L]vTuv
]v
E RvPPB
yy (}˘]u
C U}oU
Adults
æuPR}o˙(}æ˙b
Children
æuPR}o˙(}æ˙b
CXF}uv}(]v(}v]vvb`]Rv]]oo]vooP˙
yy E˙R}u˙]v U}oU
Adults
æræuPvR}o˙(}˙b
Children
NeonateV XæuP llPvR}o˙
Or
yy A]R}u˙]v U}oU
Adults
æuP}v]o˙(}æ˙b
v*ChronicOtitisMedia*v
Children
uP llP}v]o˙(}æ˙b
Refeal
r Criteria
R( v } ENT b]o]b ]( R ]b v} b}vb L ˙b
}(uvX
209. CR}v]ObM]
TR]b ]b R}v] ]v(}v }( R u]o `]R (}}v }( R
˙uv] uuv v b ]bRP]vP (}u R (} u} Rv
`lbX
sueCa
yy S}v˙]o]v(}vbP
yy Pseudomonas aeruginosa
yy Proteus vulgaris
yy Pvu}}]
Symptoms
yy CR}v]]bRP~}}R}Z
yy H]vPo}bb
Signs
yy P(}}v}(˙uv]uuv
yy C}vR]vPo}bb
yy ]bE RP
æ
Standard Trtme
Invtiga
se tions
yy `bE (}ovbvb]]˙
Trtme
ae nt
Tuv}ib
yy To keep the ear dry
yy T}v˙˘}vbv}uo]}vbXPXub}]]b
yy R}oo]}(ovb}vP]v}`]lv]vb(oo˙
]v} RX L (} }v u]v Rv u} v o `]R
ov`]lXD}(vo˙~obub˙Z
yy I(o]vP}bU˙]vPRbR}o}b u}]o˙
yy N}R]vPbR}ooL]vR`v`]l]vP
yy }] A `]uu]vP
b }PhvPR]vb]}(R`
yy Rrb`lo˙ b }vbRRu}R]b˙]vPR}o˙
AXF}˘}vb
~Sb}v}vTuv(}RAObM] [Z
BXF}}]ov]}R˙
]vE RvPPB
v*Epistaxis*v
yy Gvu]]v }bUXA9Ur}bvrR}o˙vv]PR
Or
yy C]}G}˘]v ˙l}bUXA9U}vR}o˙]o˙
Refeal
r Criteria
R(ooR}v]oo˙]bRP]vP}b RENTS]o]bX
210. Epistaxis
E]b˘]b ob} oo v}bo ]b }uu}v u]o uPv˙U
`R]R]b}uuvPuv}}]u}]]˙vu}o]˙X
sueCa
yy P]l]vP }( R v}bU b]oo˙ `Rv R ]b v b]}˙
]v(}v
yy Tu
yy S]v}vbovvb}R˙vPov}obub
yy Hypertension
yy Bo]vP disorders
yy }R]
A R]v]b
Symptoms
yy Nose bleed
Signs
yy Nose bleed
æ
yy S]Pvbo}vo˙]vPb
yy S]Pvb}(bR}l~](Zb
Invtiga
se tions
yy FBC
yy S]lo]vPb
yy C}Po}vvb
yy L](v}vb
yy R}]ovb U](]v]
Trtme
ae nt
Tuv}ib
yy T}}b ]b˘]b
yy To detect shock and replace blood if necessary
yy S] v v G˘ R } v o}} vv]vP }`v R}
v]`˙
yy P]vRb}L}(v}b(}u]vb~vubRR}PR
u}RZ
yy Ao˙]rl}vbo]P
v*Epistaxis*v
AXF}Ru}bb]b
st
L]vTuv
yy O˘˙u}o]v Uvbo˙b Ur˙bb v}b]oR}o˙
Or
yy AdrenalineU}]oU~bv}blU}v}'}v`}}oZPb}o}vb
Refeal
r Criteria
R(vb`]Rv}]bb ˘]b}RENTb]o]bX
æ
Chapter
OralandDentalond
C itions
211. Dental Caries

Dvo]b]b}}Rb(]˙˙b ]u]vo]}v
}( }}R R bX I }b b bo ]o }vb]}v }( .v
}R˙b } ]bU `R]R ]v }o}vP }v `]R }}R b(
ob}Ru]vo]b}vXTR]b}b]bb vo˙vov
}Pb}b ˙b v}}Ro}bb}}uo]˙]v(}vX
sueCa
yy A]u]vo]b}v}(R}}Rb(
Symptoms
yy Uboo˙˙u}u b
yy T}}RR]]˙R}U}o}`b (}}b}]vlb
yy P]v u˙ ]vu]'v }U b bR v }vbv ]( R v
v]vPb˘}b
Signs
yy AR}o}olb}u˙]b]o}vv˙b(}(}}R
yy Tvvbb}vb]}v}(R+}}R
Trtme
ae nt
Tuv}ib
yy To relieve pain
yy T}}bb ˙b ˘}vv.oo]vP}(]b
yy T}}vP}}voR]b
yy T}v}uo]}vb
yy RPou}R]vbL.v}R˙]vl
yy BbR]vP}(R(}u
AXF}]vo](
]v
E RvPPC
yy Pu}o U}oU
æ
Chatep rP *OralandDentalond
C itions
Adults
æuPrPvrR}o˙
Children
Or
yy I}(v U}oU
Adults
ruPR}o˙
Children
rw˙bV æ uP R}o˙ ~u˘X wXær uP llP ]o˙
vrR}o˙Z
wr˙V uP R}o˙ ~u˘X wXær uP llP ]o˙
vrR}o˙Z
Refeal
r Criteria
R(v}vb(}.v]uvX
212. Oral Candidiasis
v*OralCandidiasis*v
Oo v]]b]b ~}o RbRZ ]b v ]v(}v }( R u}R ˙ ˙bX
Iu]vo˙+bR˙˙}vPUR˙}o}R}b`R}b]uuv]˙]b
]u]XI}bu}(vo˙]vHIV lAIDS vbURuov}]bRU
]bUvb}vo}vPruv]}bv}}b}]bvR}b
`]R}}}oR˙P]vX
sueCa
Candida albicans~u}v]o] Z
Symptoms
yy WR]Rb]vRu}R
yy Bv]vPbvb}v]vRu}R
yy D]8o˙]vòo}`]vP
b
yy (bB ]bu˙(b}bl
yy S}u}R
Signs
yy Woo .v `R] } uW}o} obb v Rb ]v R
u}R
Invtiga
se tions
yy o B u}bo]vP
b (}(vPoouvb
yy FBS
yy Retroscreen
Trtme
ae nt
Tuv}ib
yy T}]]v(}v
yy T}]v(˙vv˙vo˙]vP}v]}v
ææ
Standard Trtme
yy P}}oR˙P]vv}]ovP
AXF}uv}(v}uo]}ov]]b]b
st
L]vTuv
]v
E RvPPB
yy N˙bv bvb]}vU}oU
Adults
Uv]bvR}o˙L(}}(}˙b
Children
Uv]bR}o˙
v LR((}ob˙bXMlb
]]bòo
b ]vRu}RX
nd
L]vTuv
yy M]}v}o U}oPoU
Adults and Children
Xæuobu}vR}ou}b`]]o˙(}wr˙b
v*AcuteNeotis
cr ingUlctiv
BXF}]uuv}}u}u]bvb`]R}ov]]b]b
]vE RvPPB
yy Fo}v}o U}oU
aer eGingivitis*v
Adults
æruP]o˙(}wr˙b
Children
r˙bV æruP]o˙(}wr˙b
˙br˙bV rvuP llP}v.b˙U
Then
uP llP~u˘XuPZ]o˙(}˙b
wr˙bV rvuP llP}v.b˙
Then
uP llP˙R}b(}˙b
AM˙bw V rvuP llP}v.b˙
Then
uP llP˙wR}b(}˙b
Refeal
r Criteria
R( vb v} b}v]vP } } uv } ]( R
]b R bv }( v vo˙]vP ]oovbb XPX ]b uoo]bU
]uuv}bb]}v}}]b]o]bX
213. AN}b]vPUoG]vP]]b
I ]b b]. Pu ]bb +vP u]vo˙ R ]vvo ]oo
v Pu uP]vX I +b boo˙ RoR˙ ˙}vP ob `]R }} }o
R˙P]vX
æv
C itions
sueCa
yy Spirochaetes
yy GurvP(b](}ub
yy H}b (}b }( }} }o R˙P]vU ]P' bu}l]vP v ]uuvr
suppression
Symptoms
yy GuuP]vb}vbb}]v}(bv}vb
yy Bo]vP
yy Malaise
yy vbB (}oR
Signs
yy ro]l C ob v v}b]b u]vo˙ o]u] } Pu uP]v v
]vrvoP]vP]
yy P}}}oR˙P]v
yy F
yy L˙uRv}voPuv
v*AcuteNeotis
cr ingUlctiv
Invtiga
se tions
yy S`(}ovbvb]]˙
Trtme
ae nt
aer eGingivitis*v
Tuv}ib
yy T}]]o}P}`R
yy T}o]b b RP}}}oR˙P]v
yy To control fever and pain
yy Iu} }o R˙P]v R]b XPX bR]vP ob `} ub ]o˙U
(vvb}o]vb
AXF}uv}(]v(}v
st
L]vTuv
]v
E RvPPB
yy Au}˘]]oo]v~Au}˘˙]oo]vZ U}oU
Adult
PX b
Then
æuPvR}o˙(}˙bw
Children
wr˙bV æuPvR}o˙(}˙bw
rw˙bV æuPvR}o˙(}˙bw
r˙bV vXæuPvR}o˙(}˙bw
B. For Individuals with penicillin allergy
]v
E RvPPC
yy Co]vu˙]v U}oU
æw
Standard Trtme
Adults
æruPvrR}o˙(}˙bw
Children
r˙bV æruPvR}o˙(}˙bw
u}vRr˙bV rvuP llPvR}o˙(}˙bw
C. For pain and fever control
yy Pu}o U}oU
Adults
æuPrPvR}o˙]b
Children
vr˙bV æræuPvR}o˙]b
ræ˙bV æræuPvR}o˙]b
u}vRbr˙V vXæræuPvR}o˙]b
Refeal
r Criteria
v*Bctea rialEndocarditisandProphylaxisinDentistry*v
R(oovbL]v]vPR˙}vbX
X ]o
B Ev}]bvP}R˙o˘]b]vDvb˙
Av]} }R˙o˘]b ]b v o]b
b R ]uv ]v R
uvPuv}(vb`]R]o]bb ]bl}(]o
v}]b]vR}b}(vouv]o}vX
P]b}b]vP ]bl (}b ]vo ]}b R]b}˙ }( ]o
v}]bU R]b}˙ }( R o ]bb v R]b}˙ }( R o
ouvX
sueCa
yy Streptococcus sanguis
yy Streptococcus mitis
yy Streptococcus mutans
yy Streptococcus salivarius
yy OR}o]oG}
Trtme
ae nt
Tuv}ib
yy T}vb]vP}(}o]]vPRvb]vu]
Rb ]vP vo uv]o}v v} ]vr] (b v
valvular lesions
st
L]vTuv
]v
E RvPPB
yy Au}˘]]oo]v~Au}˘˙]oo]v ZU}oU
Adults
PX
b ~R}b(}}Z
Children
æuP llPX
b ~R}b(}}Z
æ
C itions
Or
yy C o]vu˙]v U}oU
Adults
vuPXb ~R}(}}Z
Children
uP llPX
b ~R}(}}Z
Refeal
r Criteria
R( } ]}o}P]b ]( ] b vv} ]v
b }
R]b}˙]bv}oX
215. A]o
B S]o}v]b
]o
B ]v(}vboo˙}(R}PovbXI]bu}bo˙v]ooX
Sv ˘ob]o˙ ]v ]o]U oo˙U R˙vb } `R} R
P}]bbr]v˘}b}u]X
sueCa
v*AcutecteaB rialSialoadenitis*v
yy Anaerobes
yy Streptococcus~}b]}voo˙Z
Symptoms
yy P]v(o}òo]vPb }(bv}vb
yy F
yy Chills
Signs
yy E˙Ru}bòo]vP
b
yy TvbvbR]v˙}o˙]vPbl]v
yy Pov]bRP(}u
Invtiga
se tions
yy FBC
yy Covbvb]]˙}(]bRP
Trtme
ae nt
Tuv}ib
yy T}]v(}v
yy To provide pain relief
yy Ev}Prb
yy G] A ]vl
yy D]b}vvu]}vbRvb˘}b}u]
yy SP]o]vP](]v]
æı
Standard Trtme
AXF}uv}(]v(}v
st
L]vTuv
]v
E RvPPB
yy Foo}˘]oo]v U}oU
Adults
æuPvR}o˙(}wr˙b
Children
ær˙bV æuPvR}o˙(}wr˙b
ræ˙bV æuPvR}o˙(}wr˙b
AM˙V vXæuPvR}o˙(}wr˙b
BXF}uv}(]v(}v]vvb`]Rv]]oo]vooP˙
]v
E RvPPC
yy Co]vu˙]v U}oU
Adults
æruPvrR}o˙(}˙bw
v*Luwig
Children
d [sAnginalCvic
er orFacials*ceAb v
C. For pain relief

yy Pu}o U}oU
Adults
æuPrPvR}o˙]b
Children
Refeal
r Criteria
R(}vbL]v]}v}(uvX
216. L`]P [bAvP]v lC]}rF]obA

I]b]vP
b ]v(}v}]P]vvPboo˙(}uu}o}}R]v}
R (b]o b }( R bro]vPoU bruv]o v rR˙v˘X
TR]b Rvb `Rv ]]o b }b R}PR R o]vPo
}o o }( R uv]o v P]vb b } Rb vl (b]o
bXTR]v(}vvRvl}`vvvRR}˘XAv}R
b} }( ]v(}v ]b R }vb]oo ˙ bX TR ]v]o bv}v
`]R òo]vP
b }( R G}} }( R u}R v U b `]R vl
]v}ouv]buL`]P [bvP]vXAb]b}`vRvlUR
u ]}r(]o b ]b bX TR]b }v]}v ]b v uPv˙ v
ubbRX
æ
C itions
sueCa
yy O}v}Pv]]v(}v
yy rrRu}o˙S}}]
yy Staphylococci
yy ]}b
B
yy Tonsillar crypt abscess
Symptoms
yy F]oòo]vP b `]RG}}}(Ru}Ro`]R}u
yy P}]vP}vP
yy }}o]vP
D }(bo]
yy F
yy Chills
Signs
yy Tvbvvi`òo]vP
b
yy B}ro]l.uvbb}(i`òo]vPb
yy S˙bb u]b
v*Luwig
yy R]bG}}}(Ru}R`]Ro]u]}v}(u}Rro}b]vPvbo]
d [sAnginalCvic
}}o]vP
yy DR˙}v
er orFacials*ceAb v
Invtiga
se tions
yy FBC
yy BUElCR
yy Xr˙}(i`
Trtme
ae nt
Tuv}ib
yy T}R]v(}v
yy T}vR˙}v
yy To control fever and pain
yy R˙}v A
yy Iv}v](]`˙}b}vbv
yy Iv]b]}vv]vP}] b
yy E˘}v}(}}R](]]bRb}}(]v(}v
AXF}uv}(]v(}v]vvbvo}òo}`
b v
toxaemic
st
L]vTuv
]v
E RvPPB
Adults
XPR}o˙(}wr˙b
Children
u}vRbr˙bV uP llP R}o˙ ~u˘X X P R}o˙ (}
æ
Standard Trtme
wr˙bZ
A u}vRbV
M uP llPR}o˙(}wr˙b
vA
yy L]˘}v
C UIVU
Adult
P]o˙(}wr˙bU
Children
nd
L]vTuv
]v
E RvPPB
yy Co]vu˙]v UIVU
Adults
rvuPvR}o˙(}wr˙b
Children
rvuP llPvR}o˙(}wr˙b
vA
v*Luwig
yy L]˘}v
C UIVU
d [sAnginalCvic
Adult
P]o˙(}wr˙b
Children
er orFacials*ceAb v

L]vTuv
]v
E RvPPC
yy P}]vPv]]oo]v UIMU
Adult
vUrUUv]b]o˙
Children
ANwlPV vUv]b]o˙
AMwlPV æUræUv]bllP]o˙
NeonatesV v}}uuv
Av
yy Gvu]]v UIVU
Adults
ruPR}o˙(}wr˙b
Children
r˙bV XæuP llPR}o˙(}wr˙b
AM˙V XæuP llPR}o˙(}wr˙b
Av
yy M}v]}o UIVU
Adults
æuPR}o˙(}wr˙b
Children
wXæuP llPR}o˙(}wr˙b
Refeal
r Criteria
R(}Rb]o]bb}}vb}bb]oX
æ
C itions
217. CR}v]P]}}voIv(}vb
CR}v] ]}}vo ]v(}vb } }o}vP ]o
]v(}v }v R RU `R]R ob } }v
b }( ]}}vo
v }v˙ b}vP b }( R }}RX TR]b boo˙ ob } }l
(}u}vUPub]}vU}}Ru}]o]˙v}o}bbX
sueCa
yy ]B
Symptoms
yy Rv]v(oR`]vP
yy Mobility of teeth
yy Bo]vP PuuP]v
Signs
yy Gub]}v
yy P}l(}u}v
v*ChronicPeriodontalInfections*v
yy L}bb}(b}vP}v˙b
Invtiga
se tions
yy Xr˙}(]v}oRvb}vPb
Trtme
ae nt
Tuv}ib
yy T}}b }}R(v}v
yy T}]v(}v
yy To relieve pain
Non-pharmacological management
yy D]uv
yy R}vbP˙ b
AXAivAvu]}]oR˙
yy Co]vu˙]v U}oU
Adults
ræuPvrR}o˙(}˙bw
Children
Or
Adults
PR}o˙(}r˙b
Children
æ
Standard Trtme
u}vRr˙V XæuollP}˙`]PR}(æl
bvb]}vR}o˙
AMu}vRV XæuollP}˙`]PR}(æl
bvb]}vR}o˙
B. For pain relief
yy Pu}o U}oU
Adults
æuPrPvR}o˙]b
Children
Refeal
r Criteria
R(oovb}Rvob]o]bX
218. M}RUob
M}R ob Pvoo˙ } ]v(}v ~]oU ]o }
v*MouthUlcs*er v
(vPoZU v}v]U uo]Pvv˙ro}uX TR }uu}v }vb

R}bv]oobX
APTHOUSULCERS
Apthous ulcer ]b v o }( v}vr]o }]P]v R }b }v
Ru}ob(b}(R}o]˙XS]]b]ou˙R]u
}(˙Ru`]R˙oo}`]bRbUvo}u]vPP˙]bRRXTR˙
obb]. ]v} u]v}U ui} } R(}u }v o]v]o bv}vX
TR u]v} ]b AM uU v R ui} r u ]v ]uX TR R(}u
}ub]vuoo}b}(ruXTR}PRR]bb vlv}`vU˙bb u]
}v]}vbb}]`]RR}bo]voBR[b˙v}u b UHIV U
V]u]v.]v˙b~]u]vBP}U(}o]]ZX
H(}uob }}(}oR}bobbuo]vP}o
]oobX
BR[b]bb ]bu}vb Pvo]b(}u]v}o]vPR
˙Ubl]vvPv]o]X
sueCa
yy Uvlv}`v
Symptoms
yy T]vPo]vP}vR}ou}b~}}uoRbZ
yy P]v(oo
SIGNS
yy ro]l
C b}Lbo`]R˙oo}`]bRrP˙G}}
yy Tenderness
æ
C itions
Invtiga
se tions
yy Nil
Trtme
ae nt
Tuv}ib
yy To control pain
yy To treat ulcer
yy To control stress
yy T}v}v˙ b ]v(}v
yy P}}oR˙P]v
yy Ro˘}v
AXT}}v}o]v
st
L]vTuv
]v
E RvPPC
yy L}o vbR PoU }oU o] `]R }'}v o}oo˙ } R
ulcer base
v*OdontogenicInfections*v
Adults
Ao]v}obbRv˙ R}bbvvv}u}Rvv
o]}vb]o˙
Children
Ao]v}obbRv˙ R}bbvvv}u}Rvv
o]}vb]o˙X
Av
yy I}(v U}oU
Adults
uPvrR}o˙bv
Children
vr˙bV ruPvrR}o˙bv
ræ˙bV ruPvrR}o˙bv
u}vRbr˙V v}}uuv
Refeal
r Criteria
R(}vb](Ro}bv}Ro`]R]v`lbX
219. O}v}Pv]Iv(}vb
O}v}Pv] ]v(}vb ]v(}vb ]b]vP ]u]o˙ (}u R
}}RXTR]b}bR b bo}(]v}o]P]v]vP}b o
] vo]˙ bR b ]}b ob]}vX TR o vP}b v}b]b
vv}oob
b R}}R˘}uX
sueCa
yy Streptococci
ææ
Standard Trtme
Symptoms
yy P]v}vR`]vP
yy J`òo]vP
b `]Rb]bvPv`]vP]v
yy F
yy Chills
Signs
yy Tooth tenderness to percussion
yy L˙uRv}R˙
Invtiga
se tions
yy Xr˙}(+}}R
Trtme
ae nt
Tuv}ib
yy T}}v}o]v(}v
yy To control pain
yy T}u}b}}(]v(}v
yy T}}b }}R]vP]˙v(v}v
yy R}}voR˙`]R]vPU]uvU]}u˙X
yy Rb}}v}(vb (v}v
AXF}uv}(u]o]v(}v
st
L]vTuvP
]v
E RvPPB
yy Au}˘]]oo]v U}oU
Adults
æuPR}o˙(}˙bw
Children
ær˙bV æuPR}o˙(}˙bw
u}vRr˙V æuPR}o˙(}˙bw
BXF}uv}(u]o]v(}vr]vvbooP]}v]]oo]vb
]v
E RvPPB
yy D}˘˙˙o]v U}oU
Adults
uPR}o˙(}˙bw
Note 21-1
N} }uuv ]v Pvv˙U ovP u}Rb v ]v R]ov AM ˙b
}(PX
CXF}uv}(]v(}v
b
st
L]vTuv
]v
E RvPPB
æv
C itions
Adults
væuPR}o˙(}˙bw
Children
AN˙bV OvælæoR}o˙(}wr˙b
r˙bV æ uo }( læw bvb]}v R}o˙ (}
wr˙b
r˙bV æ uo }( l bvb]}v R}o˙ (}
wr˙b
u}vRbr˙V uP llP~}(u}˘]]oo]vZR}o˙(}wr
days
AMu}vRbV æuP llP~}(u}˘]]oo]vZR}o˙(}wr
days
Or
yy A ]R}u˙]v U}oU
Adults
æuP]o˙(}æ˙b
Children
uP llP}˙`]PR]o˙(}æ˙bX
X
D F}uv}(]v(}v
b r]vvbooP]}v]]oo]vb
]v
E RvPPB
yy A]R}u˙]v U}oU
Adults
æuP]o˙(}æ˙b
Children
uP llP}˙`]PR]o˙(}æ˙b
Or
yy Co]vu˙]v U}oU
Adults
æruPvrR}o˙(}˙bw
Children
u}vRr˙bV rvuPllPvR}o˙(}˙bw
E. For pain relief
]v
E RvPPB
yy Pu}o U}oU
Adults
æuPrPvR}o˙]b
Children
æw
Standard Trtme
Refeal
r Criteria
R( oo vb `]R }}v}Pv] ]v(}vb } vo b]o]b
L]v]}v}(uvX
220. Oral Squamous Cell Carcinoma

TR]b}v]}vbvbv}v
b rRo]vPo}(u}Rv`}`lb
]v R u}RX TR u˙ Pv ]b}b]}v v]}vuvo
b R v ]v.X F} v }o oU `lb }b}v (}
Ro]vP ]b boo˙ X I( b } } v ]v(}vU v
}]vu]}]o]bP]vX
sueCa
yy Uboo˙vlv}`v
yy Ab}]}vbP
yy T}}lovR`]vP
yy Alcohol
yy Su}l]vP
v*OralSqamou
yy HPV ]v(}vb
Symptoms
u sCellcinoma
yy N}vrRo]vPo]vRu}R
Car
yy P]v
*v
yy J`òo]vP
b v(}u]˙
Signs
yy Ivr}oubbo
yy WR]u}boR
yy Nlubb
Invtiga
se tions
yy Iv]b]}vo]}b˙(}R]b}R}o}P˙
Trtme
ae nt
Tuv}ib
yy T}]u}ubbloob
yy To control pain
yy T}˙}.v]uv
Non-Pharmacological treatment
yy SP˙A=lr]}R˙
yy CRu}R˙~A=lrP˙ b A=lr]}R˙Z
Refealr Criteria
R(]uu]o˙}R}v}o}P]b(}(RuvPuvX
æ
C itions
221. Tu}}ruv]oJ}]v ˙b(v}v vub}˙ubo

˙b(v}v
Tu}}ruv]o J}]v ~TMJ Z ˙b(v}v v } ub}˙
ubo˙b(v}v ]b}uo˘}(vPuvb+vP}vo˙Ri}]vU
Rubob}(ub}v}}RXTRR}o}P]o}bbu˙
} i}]v R}R˙U ]b ]bb } vb]}v ]v v}vb v ub}˙
ubob(}uv}uou}uvR]}}}obo]bRu}v˙X
sueCa
yy BR]}o]v˘]bu
v*TemporormandibularJointysd functionandmatic
yy Arthropathy
yy Tu~R˙b]oZ
yy Oobo]bRu}v˙
Symptoms
yy Pr]o]vb}]`]R}v]vPvo}b]vPRu}R
yy Co]l]vPv}]b}v}v]vPvo}b]vP
s tor
yy DooUb]bv]v]vub}˙ubob
a ymucle
s ysd function*v
Signs
yy Tvvbb]vRTMJ b}]`]Ru}R}v]vP
yy Co]l]vP]vTMJ }vu}R}v]vPvo}b]vP
yy Tvvbb]vubob}(ub}v}v}v}v
yy Oobov}uo]b
Invtiga
se tions
yy Xr˙rTMJ ]`b
yy ESR
Trtme
ae nt
Tuv}ib
yy To control pain
yy T}o˘ubob}(ub}v
yy T}}v˙b]v]vP]uov
yy Oobobo]vb
yy Ovro˙b
yy Rbvv}Po˘}v]vub}˙b
AXF}uboo˘}v
st
L]vTuv
]v
E RvPPC
yy D]u U}oU
Adults
æuPR}o˙
æı
Standard Trtme
Children
r˙bV æuPR}o˙
ær˙bV XæuPR}o˙
B. For pain relief
yy I}(v U}oU
Adults
uPR}o˙]b
Children
vr˙bV ruPvrR}o˙]b
ræ˙bV ruPvrR}o˙]b
u}vRbr˙V v}}uuv
Refeal
r Criteria
R(oo}b Rvb(}(RuvPuvX
222. Trigerminal Neuralgia

T]Pu]vovoP] ]b}v]}vR]b˙v]oo(]o
]vR(}oo}`bR]b]}v}(R]Pu]vovXIbvb`]R
v*TrigerminalNealgia
vU bv }vb bRrbR}}vP ]v ]v R ( v u˙ R
]PPr}]vX TR v u˙ bv `]R ul v˘]˙ v u˙
u]u]˙R]]b ]b}X
ur
sueCa
*v
yy DPv
yy IvGuu}˙
yy Pbr]v b
Symptoms
yy SvbRrbR}}vP]v]vR(
yy Sv˘]˙
Signs
yy Av˘]˙
yy H˙bRb]}(+~vb]vZ
Invtiga
se tions
yy Xr˙}o}(}}R
yy MRI}o}]vv]oR}o}P˙
Trtme
ae nt
Tuv}ib
yy T}vb
yy T}oo˙v˘]˙
yy T}uvPRv}R˙
yy Rbvb v}vbo]vP
ææ
C itions
AXF}R}v}o}(v˘]˙
st
L]vTuv
]v
E RvPPC
yy D]u U}oU
Adults
æuPv]PR
Children
r˙bV XæræuPv]PR
ær˙bV XæuPv]PR
B. For treatment of neuropathic pain
st
L]vTuv
]v
E RvPPA
yy Cu]v U}oU
Adults
æræuPR}o˙oob}o}v~u˘XvuPR}o˙Z
Children
r˙bV æruPR}o˙
v*TrigerminalNealgia
Then
Ivb}vuPR}o˙](vbb˙
Then
ur
Ivbbo}ò˙}æuP llPR}o˙
*v
Or
yy PPo]v U}oU
Adults
wæuPR}o˙oob}o}v
Children
N}}uuv
CXF}]}vo]vo](
yy I}(v U}oU
Adults
uPR}o˙]b
Children
vr˙bV ruPR}o˙]b
ræ˙bV ruPR}o˙]b
u}vRbr˙V v}}uuv
Refeal
r Criteria
R(}Rv}o}P]b(}(RuvPuvX
ææ
Chapter
DisorsOf
der The
Muculos
s keletalSystem
223. Ob}R]b
TR]b]bPvooP]b}(
b ]}o}P˙XI
v+ooi}]vbUu}bo˙RR]bvlvbXIu}v]+vob
]voURu}]R]bvo}b]b+vPRi}]vbX
P]u˙ }b}R]b ]b boo˙ Pro ~}o PZU `R]ob
}v˙b }b}R]bu˙}}RbX
sueCa
yy Tu
yy Iv(}vb
yy IvGuu}˙R]b
Symptoms
yy P]v}v]˙vo]˙]v]oo˙ b
yy J}]v+vb b b
yy J}]vòo]vP b
yy L]u]vP
Signs
yy L]u]vP
yy J}]vòo]vP b
yy J}]v+b]}v
yy (}u]bD
yy LPovPR]bv˙
Invtiga
se tions
yy Xr˙}(+i}]v
Trtme
ae nt
Tuv}ib
yy Relieve pain
yy Pv}Pbb]}v
yy Iu}(v}v}(i}]v
yy Pv(}u]b}}uo]}vb
ææ
Chatep rP *DisorsOf
der TheMuculos
s keletalSystem
yy PR˙b]}R˙
yy W]PRo}bb
yy Wol]vP]
yy b B
yy SP˙
yy Ab]}v}(˘bb]˙v}]o
b G]
yy Ob}}u]b
yy AR}obb
yy Arthrodesis
AXF}]vo](
st
L]vTuv
]v
E RvPPA
yy N}˘v U
CE }oU
Adults
æræuPR}o˙]b
Children
Not indicated
Or
v*Osteoathr
yy Co}˘] U}oU
r itis*v
Adults
uPX b
Then
uPrR}o˙]b
Children
Not indicated
Or
yy D]o}(v U}oU
Adults
æuPR}o˙}uPR}o˙
Children
AN˙bV æuPR}o˙
AM˙bV v}}uuv
Or
yy I}(v U}oU
Adults
ruPvrR}o˙]b ~u˘XXP]o˙Z
Children
ræuP llPvrR}o˙]b ~u˘XuPlP]o˙Z
Av
yy D ]o}(v PoU}]oU
Adults and Children
Ao˙R}o˙bvbb˙
Or
ææ
Standard Trtme
yy D]o}(v ˙b U}]oU
Adults and Children
Ao˙R}o˙bvbb˙
nd
L]vTuv
]v
E RvPPC
F}v˙}(R(}oo}`]vPR˙U}vbob]o]b
yy Methyl prednisolone acetateUIvro
yy T]u]v}o}v UIvro
yy uRb B }v UIvro
Refeal
r Criteria
R(}uo]}b R}R}]b]o]bX
X RRu}]R]b
RRu}]R]b ~RA]bZ R}v]˙bb u]]vGuu}˙]bb
}(vlv}`vbXAv˘vo]PP~XPX]P'bu}l]vPU]v(}vU}
u]PPbZ v}]uuv}vUo]vP}˙v}]o b R˙}R˙
vR}v]i}]v]vGuu}vo}vP`]RR}b(}˘ro
v*Rheumatoidthr
uv](b}vbXI]bo]}}]vPvoo˙ob ]v]]ob
vu}}uu}v]vu]oP`}uvX
ar itis*v
sueCa
yy Uvlv}`v
yy }]uuv
A ]b}
yy L]lo˙}u]v}v}(Pvvv]}vuvo(}b
Symptoms
yy J}]v+vb b b
yy P]v(oi}]vb
yy Sòo]vP}(+i}]vb
yy (}u]˙D }(+i}]vb
yy L]u]}v}(u}}v
yy Skin nodules
yy D]8o˙]vR]vP
yy ˙bE (P]o]˙
Signs
yy Pb]bv˙uu] b }o˙R]b ~b˙v}]bZ}(Rvbv(
yy J}]v+vb b b
yy J}]vvvbb
yy J}]vòo]vP b
yy J}]v(}u]˙
yy L]u]}v}(i}]vu}uv
yy RRu}]v}ob
yy S]PvbovP}˘ro]v}ouvXPXovP]bbU]bU
]]o}oo+b]}vb
ææ
Chatep rP *DisorsOf
der TheMuculos
s keletalSystem
Invtiga
se tions
yy FBU C SR
E
yy Cr}]v level
yy RRu}]F} assay
yy AvvoAv}˙~ANA ˙Zb
yy AvALC˙o]C]oo]vP~AvrCCPZ
yy J}]vb]}vvvo˙b]b}(˙v}]o b G]
yy Hb BvbC
yy HIV test
yy Xr˙b}(Rvbv(
yy MRI}(]ob]v~}bo˘}vZ
yy Uob}v}PR˙}(i}]vb
Trtme
ae nt
Tuv}ib
yy T}]vUòo]vP b v+vb
b b
yy T}v(}u]b
yy T}o˙]b}Pb b b]}vvo}vPru}uo]}vb
yy T}Pb]+b
v*Rheumatoidthr
yy Heat and cold therapies
yy OR}bvbo]vb
ar itis*v
yy PR˙b]}R˙
yy O}voR˙
yy ]uv A
yy J}]vr}}v}v
yy C}boo]vPv}v
yy S˙v}}u˙
yy Tv}b˙v}}u˙
yy Tv}vo]Pvuv
yy R}vbP˙ b }R}ob˙
yy Arthrodesis
AXS˙u}ubbvu}Rvv`lb}v}˙}b]
st
L]vTuv
]v
E RvPPB
yy Pv]b}o}v U}oUXæruP llP}˙`]PR
C}vrX
Tl}}b}]bL(}}X
H]PRr}bPo}}}]bu˙b]vb}uv]V]uu]rob(}uo}v
]b˙]oo˙u]v]b]vu}v]vP}}]v]`]R]]vR˙RuX
Av
yy Ou}o U}oU
Adults
uP]o˙
æææ
Standard Trtme
Children
ANlPV uP]o˙
rlPV uP]o˙
ærlPV æuP]o˙
Or
yy Eb }u}o U}oU
Adults
ruP]o˙
Children
r˙bV ruP]o˙
r˙bV ruP]o˙
AM˙V v}}uuv
Av
yy D ]o}(v U}oU
Adults
æuPR}o˙}uPR}o˙]b
Children
AN˙bV æuPR}o˙]b
AM˙bV v}}uuv
v*Rheumatoidthr
Or
yy D]o}(v UoU
Adults
ar itis*v
uPR}o˙]b
Children
AN˙bV wæruP]o˙]b
AM˙bV v}}uuv
Or
yy Co}˘] U}oU
Adults
uPX b
Then
uPrR}o˙]b
Children
AN˙b~ANælPZV uPR}o˙]b
AN˙b~vrælPZVæuPR}o˙]b
AM˙bV v}}uuv
Or
yy Pu}o U}oU
Adults
æuPrPvrR}o˙]b
Children
Av
yy C o]u bouvb
ææv
Chatep rP *DisorsOf
der TheMuculos
s keletalSystem
Adults and Children
As required
B. Maintenance treatment for symptoms present more than 6 weeks
}v}˙}b]
st
L]vTuv
]v
E RvPPB
yy H˙}˘˙Ro}}]vU}vbob]o]b
yy So(bo]vU}vbob]o]b
yy MR}˘U}vbob]o]b
yy LGv}u]U}vbob]o]b
Or
yy vE U}vbob]o]b
yy IvG]˘]uU}vbob]o]b
yy Ao]uuU}vbob]o]b
yy }o]u
C U}vbob]o]b
yy G}o]uuU}vbob]o]b
Or
v*JuvenileIdiopthic
yy R]˘]uU}vbob]o]b
yy Avl]vU}vbob]o]b
yy UA }vbob]o]b
a thr
yy T}]o]uU}vbob]o]b
Ar itis*v
yy T}(]v]U}vbob]o]b
nd
L]vTuv
]v
E RvPPC
yy C˙o}b}]vU}vbob]o]b
yy R]}]v
A U}vbob]o]b
yy G}obobU}vbob]o]b
yy Drv]]oou]vU}vbob]o]b
yy M]v}˙o]vU}vbob]o]b
Refeal
r Criteria
R(oo}b R˙b]]vb]o]b}Ru}o}P]bX
225. Jv]oI]}R]AR]b
Jv]o ]]}R] R]b bob (}u v}uoo˙ Po
]uuv b}vbb R o } ]vGuu}v }( i}]vbU }v]vP b
b v }R }PvbX OLvU v}vrRu ]bb R v b
b]u]o(bv}˘o]vPo}vX
RRu}] R]b ]v R]ov u˙bv]v }v }( R(}ubV
˙bb u] }vb R]b ~Soo[b ]bb Z U }o˙ro }vb R]b ~æ
}u}i}]vbboo˙}(}RoPvbuoo+Z}]ro
}vb R]b ~(` Rv æ }( u]vo˙ oP i}]vb +Z ]R }(
`R]Ru˙Ru}](}}b]}vPXTR}b`]R}b]
ææw
Standard Trtme
AvvoAv}]b~ANA Z bvPo˙Rlb(}]bX
F} R]b }v]}vU ] ]b uv}˙ (} R]b } bv (}
obv`lb(}R]Pv}b]b}uX
sueCa
yy }]uuv
A ]bb
Symptoms
yy M}v]vP+vb b b
yy J}]v]v
yy P]v(o˙b
yy Rash
yy J}]vòo]vPb
yy F
Signs
yy S`}oovùi}]vb
yy Rb]vP}(i}]vu}uv
yy S˙bu]}vb
yy F
v*JuvenileIdiopthic
yy Macular rash
yy H}bov}uPo˙
yy L˙uRv}R˙
a thr
yy S}b]bXPX]]o+b]}v
Ar itis*v
yy Red eyes
Invtiga
se tions
yy FBC
yy ESR
yy BUEvv]v
yy L](v}vb
yy Cr}]v
yy RRu}]F} ~RFZ
yy AvrC˙o]C]oo]vP~CCPZv}˙
yy AvvoAv}]b~ANA Z
yy XrR˙}(+i}]vb
yy So]ou˘u]v}v
yy ORu]v b ˙b]o]b
Trtme
ae nt
Tuv}ib
yy T}}v}o]vv]vGuu}v
yy T}v(}u]bvP}`R}v
yy T}}v}o˘o}uo]}vb
yy T}u]v]u]bPb]+b
yy T}}u]bRv(}v}uob}]oo}uv
yy PR˙b]}R˙
ææ
Chatep rP *DisorsOf
der TheMuculos
s keletalSystem
yy Pb˙R}R˙
yy O}voR˙
yy D]R˙
yy Pv}vboo]vP
AXT}}v}o]vv]vGuu}v
st
L]vTuv
]v
E RvPPA
yy I}(v U}oU
Children
vr˙bV ruPR}o˙]b
ræ˙bV ruPR}o˙]b
u}vRbr˙V v}}uuv
Or
yy Iv}uR]v U}oU
Children
AN˙bV æræ uP r R}o˙ ~u˘X uP
˙Z
v*JuvenileIdiopthic
r˙bV æ u]}Pur uP llP R}o˙ ~u˘X
æuP˙Z
AM˙bV v}}uuv
a thrAr itis*v
Or
yy N}˘v U}oU
Children
ANæ˙bV ærwXæuP llPR}o˙~u˘XP˙Z
AMæ˙bV v}}uuv(}R]b}v]}v
nd
L]vTuv
]v
E RvPPA
yy Co}˘] U}oU
Children
AN˙b~ANælPZV uPR}o˙
AN˙b~vrælPZV æuPR}o˙
AM˙bV v}}uuv
C}vrX
TR o}vPru b }( NSAIDb like diclofenacU v}˘v U v ]}(v ~]XX (}
u}Rv`}`lbZu˙vo
b ]u]uvvPb]bX
R(L`}`lb}(NSAIDbX
BXS}]R˙}}v}o]vGuu}v
~SuvR}}v}o]vv]vGuu}v[]v~AZ}Z
Av
yy Pv]b}o}v U}oU
Children
XæruP llP]o˙}R}o˙~u˘XvuP˙Z
ææı
Standard Trtme
Note 22-1
I(˙u}ub
b }v}]u}L`lb
v }(}]
b bUR}v]
b bX
C. For treatment of chronic symptoms

st
L]vTuv
]vE RvPPA
yy Ivro}}b}]]vi}vU}vbob]o]b
yy MR}˘ U}vbob]o]b
yy EtarneceptU}vbob]o]b
yy IvG]˘]u U}vbob]o]b
yy Ao]uu U}vbob]o]b
yy AnakinraU}vbob]o]b
Refeal
r Criteria
R(oo}b ]]]v}Ru}o}P]bX
226. Back pain

TR]b ]b R }uu}vb b }( } ]v } RoR
(]o]bXM}RvA9}(}o`]ooRob}v]b}]vR]
o](uXM}bv]Pvv`]oob}oXH}ÙA9rvA9`]ooR
v*Bcka ain*
v`]R]v˙XI]b]u}v}]v(˙Uv˙oo}`GPbXI
p v
u˙](]]bobbRvu}vRbvR}v]](]]bu}X
B}˘rP) Notes of back pain
YELLOWGPb
yy Pbb]u]b h }` ]vU ˘bb] ( }( u}uv v ]˙
vo]'oR}(}]u}uv
yy W}lro}oub~XPX]b(}v b U}vG]bZ
yy Eu}}vo}oub~XPXb]}v Uv˘]˙ U`}˙Z
yy Gvo]]v~XPXRRU(PU]]vbbZ
yy Db](}b]uvUo]'o]o]˙}}
yy P]}b]b}b}(o}`l]vR`(}oo}`(}v˘v r
]}}(u
REDGPb
yy Pvb AM ˙b } AN ææ ˙b }( P ˘]v]vP l ]v (} R
.bu
yy Pvb˘]v]vP]vb]Pv].vo˙]+v(}u]}b]b}b
yy P]vR]b}vbv}uv}bv}]b]vPbo
yy Gvouo]bv}}Pvo}v]}v
yy Tu ]vi]bU u}bU }]
b b } ]u} b }( ]uuv}b r
pressants
yy N}o}P]o}u}u]b
yy S]vo(}u]˙
yy P}v}v u}v]vP +vb b b obvP (} o}vP Rv R} vl} R]PR
˙R}˙b]uv}v
sueCa
yy MRv]o ~XPX ]b Pv}vU (U ]vb]o]˙U
æv
Chatep rP *DisorsOf
der TheMuculos
s keletalSystem
vlv}`vbu}bbZ
yy N}Pv]~XPXURv]]bUb]vov}b b ]bU}b}R˙uP
}v}}Z
yy N}vruRv]o b]vo }v]}vb ~XPXU v}obuU ]v(}vbU
]vGuu}˙R]bUPP[b]bbZ
yy R(]bo ]v ~XPXU Pb}]vbvo ]bbU l]v˙ ]bbU
}u]vo}v]buZ
yy OR~XPXU.}u˙oP] Ub}u}(}u]b}US(l]vP _]vZ
Symptoms
yy P]v
yy N}]
yy D]+b]v
yy Neuropathic
yy P]l]vPUvPo]vPU]vbvvob
yy Eo]bR}lb}(bR}}vP
yy H}}v]vP
yy Nuvbb
yy Aobvb}v
yy Radicular pain
yy Iv}vvv}(]vv(b
Signs
v*Bcka ain*
yy (}u]˙D }(b]v
p v
yy Tvvbb]v+P]}v
yy Wlvbb}(R+o]u
yy Mbo`bvP]vR+o]u
yy Aobvb}v]vR+o]u
Invtiga
se tions
C]]rCR
A R}uuv}v
Uv}uo]Uo}`l]v IuP]vPboo˙v}}]
L}`ro}]˙uU}b}}}b]b}PAN MRI}(oub]v`]R}}vb
w˙b usually appropriate
L}`l]vvl}]o}R˙]v
P]o
b }]vv}vov]
Sb]]}v}(vU]v(}v} MRI}(oub]v`]Rv`]R}
]uuv}bb]}v contrast usually appropriate
P]}ouP˙
b
]v
C ˙v}u
b
yy FBUC SR
E U
yy Mv}˘
yy CRbXr˙~](TB]bZb
yy RRu}](}
æv
Standard Trtme
yy HLArBw ~](]vGuu}˙R]b]bZb
yy CT scan of spine
yy CTu˙o}Pu
yy Po]vXr˙b}(b]v
Trtme
ae nt
Tuv}ib
yy P]vo](
yy Pv}v}(v
yy Iv.}v}(v˙oo}`GPb
yy Tuv}(vo˙]vPb
yy Iu}uv}((v}v
yy Splints
yy PR˙b]}R˙
yy W]PRo}bbvo](b˙oibuv
yy Acupuncture
yy SoR˙P]v
yy O}voR˙
v*Bcka ain*
AXF}o](}(l]v
p v
st
L]vTuv
]v
E RvPPB
yy Pu}o U}oUæuPrPvrR}o˙
Av
yy N}˘v U
CE }oU
æræuPR}o˙]b
Or
yy Co}˘] U}oU
uPXb
Then
uPrR}o˙]b
Or
yy D]o}(v U}oUæuPR}o˙}uPR}o˙
Or
yy I}(v U}oUuPvrR}o˙
Av
yy D ]u U}oUæuPR}o˙
Or
yy MR}u}o U}vbob]o]b
Or
yy T]v]]v U}vbob]o]b
nd
L]vTuv
æv
Chatep rP *DisorsOf
der TheMuculos
s keletalSystem
]v
E RvPPB
yy A u]]˙o]v U }oU ~`Rv R v}R] b]Pvb v ˙u
b r
}ubZUæræuP]o˙
Or
yy PPo]vb U}oU}vbob]o]b
Av
yy Tu}o U}oU
æuPX b
Then
Ivb ˙ æræ uP ]o˙ } ær uP v R}o˙ b vbb˙V
~u˘XuP˙Z
Or
yy CodeineU}oUærvuPrvR}o˙]b
Or
yy MorphineboRU}oUæruPrR}o˙
BXF}IvGuu}˙AR]b
yy Pv]b}o}v U}oU}vbob]o]b
yy MR}˘ U}oU}vbob]o]b
yy R]˘]u UIVU}vbob]o]b
v*Fibomya
Refeal
r Criteria
r lgia*v
Iv]]ob u˙ v } ( } R }R}] b]o]bU
v}bP}v}Ru}o}P]b}v b Rv˙oo}`GP]]
}X
227. Fibromyalgia
F]}u˙oP] ]b ]b} }( R}v]U `]b ]v v
vvbbX I ˙]oo˙ bvb ]v ˙}vP `}uv ]v R R] }
u]orP`}uvv+vb}(]R˘b vv˙PX
F]}u˙oP] ]b ]Pv}b]b }(˘ob]}v v }Lv }b ]vvb
`]R }R }v]}vbU bR b }]uuv ]vGuu}˙ R]b v
}b}R]bX TR o]v]o o}v u˙ o }i ]v (}
}R }ru}] ]oovbbU bR b R˙}R˙}]]bu U Ru}] R]bU
˙bb u] ob ˙Ru}bbU }o˙u˙oP] Ru v }R
]vGuu}˙}}]uuv]b}bX
N} o R}R˙b]}o}P]o uRv]bu (} .}u˙oP] has
v o]bb RU ]v bPPbb R R ]b v v}uo]˙ ]v
vo]v}bb]vPX
AoR}PR R ]b v} (} .}u˙oP] U uv v o]
b}u }( R ˙u}ub
b X S]v ˙u}ub
b vu}b v ˙ u}vP
vbU uv }Pub ub ]v]]o] (} R vX
Tuv ]vob v }vU b }vU Po ˘]b
vu]}vbXAo`˙b}u]vRu}o}P]vv}vrRu}o}P]
æv
Standard Trtme
R˙]vRuv}(.}u˙oP]X
sueCa
yy Uboo˙vlv}`v
Symptoms
yy CR}v]`]b]v
yy Uv(bR]vPbovvbb
yy Av˘]˙
yy b]}v D
yy M]P]v or tension headaches
yy Nuvbb}vPo]vP}(]+vb}(R}˙
yy A}u]vo]v
yy C}vb}v or diarrhoea
yy I]oo
Signs
yy Tv P}]vb ~}uu}vo˙ (}v }v R o}`bU bR}obU
lvbUR]bUl}(RRUvRb]b}(R}v
b Z
yy M˙oP] ~u}RvRu}vRbZ
Invtiga
se tions
yy FBU C SR
E
v*Fibomya
yy BUEvv]v
r lgia*v
yy U]vo˙b]b
yy TR˙}]uovP b R}u}voo
yy ærR˙}˘˙]u]vDoo
yy V]u]vB level
yy I}v]bb
yy MPvb]uoo
Trtme
ae nt
Tuv}ib
yy To reduce pain
yy T}PPbb]o˙}ru}]b]}v
yy T}]u}bo
yy T}(P
yy SbbuvPuv
yy E˘]b
yy Bov]
yy Sleep therapy
yy Pb˙R}o}P]lR]}oR˙
AXF}uv}(u]o˙u}ub
b
st
L]vTuv
]v
E RvPPB
æv
Chatep rP *DisorsOf
der TheMuculos
s keletalSystem
yy Pu}o
Adults
æuPrPvrR}o˙]b
Children
ræ˙bV æræuPvrR}o˙]b
u}vRbr˙V vXæuPræuPvrR}o˙]b
Or
yy D]o}(v U}oU
Adults
æuPR}o˙}uPR}o˙]b
Children
AN˙bV æuPR}o˙]b
AM˙bV v}}uuv
Or
yy D]o}(v UoU
Adults
uPR}o˙]b
Children
AN˙bV wæruP]o˙]b
AM˙bV v}}uuv
v*Fibomya
nd
L]vTuv
r lgia*v
]v
E RvPPB
yy Tu}o U}oU
æuPX b
Then
Ivb ˙ æræ uP ]o˙ } ær uP v R}o˙ b vbb˙V
~u˘XuP˙Z
vA
yy Au]]˙o]v U}oU
uPv}
Then
Goo˙]vb}wæuP]o˙]b
B. For treatment of chronic or severe symptoms with anxiety
~SRuv(}u]o˙u}ub
b [b}Z
Av
st
L]vTuv
]v
E RvPPB
yy Co}vu U}oU
Adults
æu]}PuR}o˙~u˘XuPR}o˙Z
Children
N}}uuv(}R]b}v]}v
C. For treatment of chronic or severe symptoms with depression
~SRuv(}u]o˙u}ub
b [b}Z
ævæ
Standard Trtme
Av
st
L]vTuv
]v
E RvPPB
yy Fo}˘v U}oU
Adults
uP]o˙~u˘XuP˙Z
Children
r˙bV uP]o˙~u˘XuP˙Z
AM˙bV v}}uuv
Or
yy Au]]˙o]v U}oU
Adults
Then
Ivb˙æuP˙ræ˙b}u˘X}(æuP
Children
ANv˙bV æræuPR}o˙
AMv˙bV v}}}uuv
Or
yy Do}˘v U}oU
Adults
v*Fibomya
ruPrR}o˙~u˘XvuP˙Z
Children
r lgia*v
wrw˙bV ruP]o˙~u˘XvuP˙Z
D. For treatment of chronic or severe symptoms with myalgia
~SRuv(}u]o˙u}ub
b [b}Z
Av
st
L]vTuv
]v
E RvPPB
yy T]v]]v U}oU
Adults
uPR}o˙
M˙]vb}uPR}o˙L˙bw
Children
N}}uuv
Or
yy C˙o}v]v U}oU
Adults
æruPR}o˙]b
Children
æuPR}o˙]b
E. For treatment of chronic or severe symptoms with neuropathic
pain
~SRuv(}u]o˙u}ub
b [b}Z
vA
st
L]vTuv
æv
Chatep rP *DisorsOf
der TheMuculos
s keletalSystem
]v
E RvPPB
yy PPo]v U}oU
Adults
ærwæuPR}o˙oob}o}v~u˘XuP˙Z
Children
N}}uuv
Or
yy Gvv U}oU
Adults
uP]o˙
Then
Ivb˙uP]o˙}u˘X}(vuPR}o˙
Children
N}}uuv
F. For treatment of chronic or severe symptoms with migraine
~SRuv(}u]o˙u}ub b [b}Z
Av
yy ClonidineU}oU
Adults
ærwæu]}PuR}o˙
Children
v*Fibomya
N}}uuv
r lgia*v
Refeal
r Criteria
R( vb v} b}v]vP } uv } R }]
b]o]bX
F]PrP) Fibromyalgia tender points
ævw
Standard Trtme
228. I]}R]]vGuu}˙u˙}R]b
TR]]}R]]vGuu}˙u˙}R]b~IIM Z˙bb u]}vv
b]bbU`R]RR]˙˙uu]o b U}˘]uoubo
`lvbbU ubo vPR b v R}v] ]vGuu}v ]v ubo
bX TRb ]b}bU v +b u} `}uv Rv uvX
AoR}PR R l P }( }vb ]b ]v R æbU R ]b}b v }
v˙PXTR`}Siv]o_]bb]vRvu`RvR]o]b+
˙u˙}b]bX
Aob `]R ]vGuu}˙ u˙}R]bU R v ]vb ]bl }(
v]vo]vPv}(RovPUU b }bUv}]bX
sueCa
yy Uvlv}`v
yy }]uuv A
Symptoms
yy Mbo`lvbb~}vRvlUbR}obvR]bZ
v*Idiopthic
yy T}oo]u]vP]bb UPhvP(}uU b }R]vP(}}ib

overhead
a inflammatorymyopthie
yy P]v]vRubob
yy CR}l]vP`R]ovP
yy Ab]}v}((}}
Signs
a s*v
yy P}˘]uoubo`lvbb
yy Ab]}vvu}v]
yy G}'}v[bb]Pv }G}'}v[bob ~bR}Rl}(R.vPbU
o}`b}lvbZ
yy SRò b]Pv ~GU v R b }v R lU
bR}obUvl}(RvlZ
yy PR}}bvb]bR
yy Heliotrope rash
yy N]ov}uo]b
yy MRv][bRvb
yy Alopecia
yy IvboovP]bb
yy Co]u }b]b]vRbl]v~o]v}b]bZ
Invtiga
se tions
yy vC l]vboob
yy AvvoAv}]b~ANA Z
yy Hb BvvCb
yy HIV Test
yy Muscle biopsy
yy MRIv b }(Rubob
yy Eo}u˙}Pu~EMGZ
æv
Chatep rP *DisorsOf
der TheMuculos
s keletalSystem
Trtme
ae nt
Tuv}ib
yy T}]u}ubovPR b
yy T}u]v]u]bo}vPruubouP
yy T}v}uo]}vb(}uubo`lvbb
yy T}uvb]+b
yy PR˙b]oR˙vR]o]}v}v}vb
yy }]v A }(˘}b}]bvo]PR
yy }] A (]vPRv]b}vb]}v
AXF}uv}(}v]}v
st
L]vTuv
]v
E RvPPB
yy Pv]b}o}v U}oUXæruP llP}˙`]PR
Av
v*Idiopthic
yy Ou}o U}oU
a inflammatorymyopthie
Adults
uP]o˙
Children
ANlPV uP]o˙
rlPV uP]o˙
a s*v
ærlPV æuP]o˙
Or
yy Eb}u}o U}oU
Adults
ruP]o˙
Children
r˙bV ruP]o˙
r˙bV ruP]o˙
AM˙V v}}uuv
Av
yy C o]u bouvb`]R]u]vD
Adults and Children
As required
Or
yy B]bR}bR}vb
Adults and Children
Consult specialist
BXF}uv}(bR]vu}u˙}b]b
~Suv(}}v]}v]v~AZ}Z
Av
yy H˙}˘˙Ro}}]v U}oU
Adults
ævı
Standard Trtme
ruP]o˙
Children
ærvXæuP llP~u˘XuP˙Z
CXF}uv}(}v]}v`]R}] b b]bv
st
L]vTuv
]v
E RvPPB
yy MR}˘ U}vbob]o]b
Or
yy R]}]v
A U}vbob]o]b
Or
yy Ivv}b]uuv}Po}o]v U}vbob]o]b
Or
yy Mycophenolateu}(o U}vbob]o]b
Or
yy R]˘]u U}vbob]o]b
v*ManagementoftheHotSwollenJoint*v
Refeal
r Criteria
R(oovb}R˙b]]vb]o]b}Ru}o}P]bX
229. MvPuv}(RH}S`}oovJ}]v
TR R} `}oov
b i}]v ]b }uu}v bv}v v Rb ˘vb]
]+vo]Pv}b]bXS}u}(Ru}bb]}bR]b b
~`]R(o]˙
b }(A9vZ olu]]vR]ovXL]Pv}b]b
v}}uvob}i}]vuPvRX
TR }uu}vb + i}]v ]b R ]P }U ˙]oo˙ } P}
vv]Pv}b}vo]v]oP}vbXPvb`]RbR}R]b}˙}(
R}U `}oov
b v v i}]v ~} i}]vbZ `]R ]}v
b }( u}uv
bR}o P b R]vP b R]b vo }v }R`]bX I(
o]v]o b]]}v ]b R]PRU Rv ] ]b ]u } b R]b
v]vRbv}((X
sueCa
yy SR]b
yy RR]b
yy M}v}obv}v}(}o˙R]b
yy IvGuu}˙R]b
yy Gout}˙boR]b
yy HuR}b]b
yy Tu
yy b]bB looo]b
yy Llu] ~]vR]ovZ
yy Hu}R]o]
Symptoms
yy F
yy J}]vòo]vPb ~u}v}R]bZ
æw
Chatep rP *DisorsOf
der TheMuculos
s keletalSystem
yy J}]v]v
yy L]u]u}]o]˙}(+i}]vb
Signs
yy H}`}oov
b vi}]v
yy F
yy J}]vvvbb
Invtiga
se tions
yy FBU C SR
E
yy Bo}}o
yy Bo}}.ou}uuv
yy Cr}]v ~CRPZ
yy Su]] level
yy BUEvv]v
yy L](v}vb
yy S˙v}]oG]b](}u]}b}˙vo
yy Xr˙}(+i}]v
v*ManagementoftheHotSwollenJoint*v
yy MRI}(R+i}]v
yy Uob}v}PR˙}]]Pv}bb]}v
Trtme
ae nt
Tuv}ib
yy To reduce pain
yy T}òo]vP b v+vb
b b
yy T}v(}u]b
yy T}o˙]b}Pb b b]}vvo}vPru}uo]}vb
yy Rb}(+i}]vbb]vPU b bo]vb
yy PR˙b]}R˙
yy J}]vb]}v
AXF}}v}o}(]vv]vGuu}v
st
L]vTuv
]v
E RvPPB
yy D]o}(v U}oU
Adults
æuPR}o˙}uPR}o˙]b
Children
AN˙bV æuPR}o˙]b
AM˙bV v}}uuv
Or
yy D]o}(v UoU
Adults
uPR}o˙]b
Children
æw
Standard Trtme
AN˙bV wæruP]o˙]b
AM˙bV v}}uuv
C}vrX
TR o}vPru b }( NSAIDb like diclofenacU v}˘v U v ]}(v ~]XX (}
u}Rv`}`lbZu˙vo
b ]u]uvvPb]bX
BXF}}v}o}(]vGuu}v]vRbv}(]v(}v
yy Pv]b}o}v U}oU
Adults
XæruP llP]o˙}R}o˙~u˘XuP˙Z
Children
XæuP llP]o˙}R}o˙~u˘XvuP˙Z
Or
yy Ivro}}b}]]vi}vW}vbob]o]b
CXF}uv}(]v(}v]vSR]b
~Sb}v}vRSAR]b[Z
Refeal
r Criteria
R( vb `]R v o˙ `}oov
b i}]v } R }R}]
P}v
b }Ru}o}P]bX
230. Gout
v*Gout*v
TR]b}v]}vU`R]R˙]oo˙+buob`]R]}bo]bl
(}b v `}uv Luv}bUbob (}u R }b]}v }( ]
acid ˙bob ]v i}]vb v ]o bX G} is characterised by
]v v ]vGuu}v }( R + i}]vbX I ]b }LvU v} o`˙bU
b}] `]R ]b o}} ] ] oob v u˙ bv v
`Rv R oo }( ] ] ]v R o}} ]b v}uoU `R]o vb `]R
R]PRoob}(]]u˙v}vbb]o˙R'lb}(P} XIv]]o
P} Gb }Lv ]PP ˙ ]vbb } b ]v ]
] oob `R]R u˙ b}] `]R o}R}o ]vPb}vU
}]voPv ]v (}}b R]PR ]v ]vbU ] `]PR o}bbU R˙}v U
}uX
sueCa
yy O}}v}(]] ]v]b}bRR]PR
b oov}
`]Rob}(]vb(}v]voovo]
yy M˙o}}o](vo˙uR}}o](]b}b
yy Pb}]b]b
yy Hu}o˙vu]b
yy Cooo˙b]b(}uRu}R˙U]oo˙ b R}b}(RRu} r
}]}o˙uR˙bb ub
yy E˘bb]˘]b
yy M}o]˙v}u b ~}b]˙U]bUR˙vb]}vUo
R}ob}oXZ
yy Iu]˘}v}(]]
æw
Chatep rP *DisorsOf
der TheMuculos
s keletalSystem
yy Rvo]u]uv
yy LvR}R˙
yy S}v}R˙}v
yy DPbXPXR]]vo}}]bU˙}}˘]PbU˙]v r
u]
yy Ao}R}o]vPb}v
yy IvR]]vu}o]]b}bXPXLbRrN˙Rv˙v}u
b
Symptoms
yy E˘]vP]vvòo]vP b boo˙}(i}]v~obb]oo˙R]P}
u˙+RlvUvlob}`]bbZ
yy Mooi}]v]v
yy J}]vòo]vP b
Signs
yy IvGuU`}oov b vvi}]v
yy M]P}˙}o˙R]b
yy T}R]]vb}Lb~Ro]˘}(RU.vPbU}bUoobU
}ov}vZ
yy F
Invtiga
se tions
yy FBU C SR
E
yy BUEUv]v
v*Gout*v
yy Su]]
yy Bo}}Po}b
yy Suo]]b
yy Xr˙}(+i}]v
yy J}]vb](}ov}o]bu]}b}˙
Trtme
ae nt
Tuv}ib
yy To relieve acute pain
yy T}i}]v]vGuu}v
yy T}vv'lbvi}]vuP
yy To prevent uric acid˙bo}b]}v]vb}Lb
yy Ou]`]PR
yy R}]v]v]XPXo]Ul]v˙bUbRoo.bRv˙b˘b
yy Ro}R}o]vl}AMv]bl`l~uvv`}uvZ
yy }] A R]PRo˙`v b b}L]vlbv}RPb}(}}b
yy Ev}P}]vlANo]b}(`]o˙v}]R˙}v X
yy A+i}]vbbR}oov˘}b]v}}ov]}vuvX
RBPb[v]lbv+ivb}R˙
yy Ivvb R˙b]o ˘]b bR}o }] u} R˙b]o
˘]bv}P
yy Iv(˙ v vo˙]vP ]}bo ~u}o] ˙v}u b Z
risk factors
æw
Standard Trtme
AX G}
A
st
L]vTuv
]v
E RvPPC
yy D]o}(v U}o
Adults
æuPR}o˙}wæuPR}o˙ORDERSORY
Children
AN˙bV æuPR}o˙
AM˙bV v}}uuv
Or
yy D]o}(vUoU
Adults
uP]o˙
Children
AN˙bV wæruP]o˙
AM˙bV v}}uuv
C}vrX
L}vPru NSAIDb (} u} Rv `} `lbU XPX ]o}(v u˙ b Pb] r
b v bR}o R(} P]v }PR `]R }}v u ]vR]]} XPX
v*Gout*v
}u}oX
nd
L]vTuv
yy ColchicineU}oU
æu]}PuvrR}o˙vo˙u}ub
b o]~u˘XvuP
}bXC}bbR}ov}}`]R]v˙bZ
Or
yy Pv]b}o}v U}oU
Adults
ruP(}r˙b
B. Chronic GoutW(}oo}`]vPuv}(P}
]v
E RvPPB
yy AllopurinolU}oU
uP]o˙
Then
Ivb˙ uP˙ræ`lbUib](vbb˙(}vo
(v}vU vo R RP ~Su U] A] SUA AM
u]}u}olLZ]bR~u˘X}bıuPZ
C}vræX
}D v} b Aoo}]v}o vo r `lb L ]vGuu}v Rb 'o
b } r
v GX B ]v vb o˙ }v oo}]v}oU ] bR}o }vv
vR'lboX
Pb]o}`}bb]vvo}R(]oX
æw
Chatep rP *DisorsOf
der TheMuculos
s keletalSystem
Refeal
r Criteria
R( vb } ]]v (} ]˙ u}].}v v `]PR
]vP]]v}bv}`]PR]v]]obX
Pvb `]R }ru}] }v]}vb bR b T˙ ]bU
R˙vb]}vU ˙bo]]u]U vo ]u]uv } v} b}v]vP
} Aoo]v}o X bR}o ( } R˙b]]v b]o]b }
Ru}o}P]bX
231. Pseudo-gout (chondrocalcinosis)

TR]b (b } 'lb }( ˙v}]b
b ]v ˙ }b]}v }( Co]u
P˙}R}bRD]R˙ ~CPPD Z ˙bobXM}bvb}o(uobX
IRbo]lP} ]vuv˙bUvo]lP}U'lbb]b
o}vPv+Rlvu}b}uu}vo˙X
C}uu}v ]bl (}b ]vo uU P˙ b U b ]oovbbU
R˙}]}u˙U u]}v R˙X C}ru}]]b (} R]b
}v]}v boo˙ ]}boU vo v u}o] ]bb XPX
v*Pseudorgout~chondocr alcinosisZ*v
]buoo]bX
useCa
yy D}b]}v }( Co]u P˙}R}bR D]R˙ ~CPPD Z crystals in
v}vi}]vb
Symptoms
yy J}]v]v
yy S`}oovi}]v
Signs
yy S`}oovi}]v
yy Tenderness
yy J}]v+b]}v
Invtiga
se tions
yy Su]]
yy Xr˙}(i}]v
yy M]}b}]˘u]v}v}(i}]v}bG]b]
Trtme
ae nt
Tuv}ib
yy Relieve pain
yy Pvi}]v+vb b b
yy ]E ]bbv}vo˙]vPu}o]vPuv
yy PR˙b]}R˙
AXF}G
st
L]vTuv
æwæ
Standard Trtme
]v
E RvPPC
yy N}˘v U
CE }oU
Adults
æræuPR}o˙]b
Children
Not indicated
Or
yy Co}˘] U}oU
Adults
uPX b
Then
uPrR}o˙]b
Children
Not indicated
Or
yy D]o}(v U}oU
Adults
æuPR}o˙}uPR}o˙
v*Pseudorgout~chondocr alcinosisZ*v
Children
AN˙bV æuPR}o˙
AM˙bV v}}uuv
Or
yy I}(v U}oU
Adults
Children
Or
yy C }oR]]v U}oU
Adult
æu]}PubvrR}o˙
Children
N}}uuv
nd
L]vTuv
]v
E RvPPC
yy Pv]b}o}v U}oU}vbob]o]b
yy Methyl prednisolone acetateUIvroU}vbob]o]b
yy T]u]v}o}v UIvroU}vbob]o]b
yy uRb
B }v UIvroU}vbob]o]b
L]vTuv
yy P}v] U}vbob]o]b
yy MR}˘ U}vbob]o]b
yy PR}bR}] U}vbob]o]b
yy AnakinraU}vbob]o]b
æwv
Chatep rP *DisorsOf
der TheMuculos
s keletalSystem
Refeal
r Criteria
SvoPb]v(}Ru}o}P]bl}R}]P}v
b X
232. Systemic lupus erythematosus

S˙bu] Lb E˙Ru}bb ~SLE Z ]b R}v] uob˙bu
}]uuv ]vGuu}˙ ]bb R Rb ]o b]Pvb v (}oo}`b
ob]vP v u]hvP }bX M} Rv ıA9 }( b }( SLE } ]v
`}uvU}uu}vo˙}(R]o]vPPX
TR]b }v]}v v o } }uo]}vb bR b } R}v]
vo (]oU b]bU ˙R}b b ]bU o]b˙U oo +b]}vU vu}v]bU
ou}v˙ R˙vb]}vU ]]bU u˙}]bU ol}v]U
o˙uR}v]UR}u}˙}v]v]vboovP]bbX
MvPuv }( SLE }Lv vb }v R ]v]]o v[b
]b]˙
b v]bbuv](b}vbX
sueCa
yy }]uuvA
v*Systemicluythe
yy Gvvv]}vuvo(}b
Symptoms
puser matosus*v
yy FP
yy Malaise
yy F
yy W]PRo}bb
yy Rash
yy Hair loss
yy Mouth sores
yy J}]v]vb
yy Svb]]˙}bvo]PR
yy S]b
yy Nausea
yy D˙bb]
yy A}u]vo]v
Signs
yy L˙uRv}R˙
yy F
yy Malar rash
yy D]b}]bR
yy FP
yy ARoP]
yy Arthropathy
yy M˙oP]
yy AR]b
yy PR}}bvb]]˙bR
æw
Standard Trtme
yy Avu]
Invtiga
se tions
yy FBU C SR E
yy BUEvv]v C
yy U]vo˙b]b`]Ru]}b}˙
yy Cr}]v
yy AvvoAv}]b~ANA Z
yy AvrD}ovb DNA ~bDNA Z
yy C}uouvoob
yy L](v}vb
yy S}U]v}]vlb}v]v}
yy OR}v}˙ A bXPXE˘oNoAvPvb~ENAZ
yy Hb BvvCb
yy HIV screen
yy J}]v]}PR˙
yy CRb]}PR˙
yy R}]}PR˙
E
v*Systemicluythe
yy ]v B MRIlMRA
Trtme
ae nt
Tuv}ib
puser matosus*v
yy T}}v}o˙u}ub b
yy T}o˙}v}ovo˙]vP]bb
yy T}vv}uo]}vb
yy T}}]}bb]oo}vPrub]+b}(RPb
yy }]v A }(˘bb]bvo]PR
yy Rest as appropriate
yy Ao}`r(]`]R.bR}]o
yy }]v A }(}b}Pvr}v]v]vP}v]oob
yy C}vboo]vPv}v E
Note 22-2
V]v}vbP}] Ro][ ]vb ]v vb }v PRv uP v]b} r
o}v vl} ]uuv}bb]bX Iv vb }v ]uuv}bb]bU R
u˙}v]v]v8˙R]bRu}ob}vb
}RbU
B ]vGvvvu}}o]vX
AXG
A vu]vvvR˙
st
L]vTuv
]v
E RvPPB
yy MethylprednisoloneUIV]v(b]}vU~]v(b}R}Z
Adults
P]o˙(}ræ˙b
æw
Chatep rP *DisorsOf
der TheMuculos
s keletalSystem
Children
u}vRr ˙bV r uP llP˙ }R˙ (} v }bb ~u˘X
P]o˙Z
Then
yy Pv]b}o}v U}oU
Adults and Children
XæruP llP}˙`]PR
C}vrvX
Tl}}b}]bL(}}X
H]PRr}bPo}}}]bu˙b]vb}uv]V]uu]rob(}uo}v
]b˙]oo˙u]v]b]vu}v]vP}}]v]`]R]]vR˙RuX
Av
yy Ou}o U}oU
Adults
uP]o˙
Children
ANlPV uP]o˙
rlPV uP]o˙
v*Systemicluythe
ærlPV æuP]o˙
Or
yy Eb}u}o U}oU
puser matosus*v
Adults
ruP]o˙
Children
r˙bV ruP]o˙
r˙bV ruP]o˙
AM˙V v}}uuv
Av
yy D ]o}(v U}oU
Adults
æuPR}o˙}uPR}o˙]b
Children
AN˙bV æuPR}o˙]b
AM˙bV v}}uuv
Or
yy D]o}(v UoU
Adults
uPR}o˙]b
Children
AN˙bV æruP]o˙]b
AM˙bV v}}uuv
Or
yy Co}˘] U}oU
Adults
uPXb
Then
æwı
Standard Trtme
uPrR}o˙]b
Children
AN˙b~ANælPZV uPR}o˙]b
AN˙b~vrælPZV æuPR}o˙]b
AM˙bV v}}uuv
Or
yy Pu}o U}oU
Adults
æuPrPvrR}o˙]b
Children
Av
yy C o]u `]RV]u]vDbouvb
Adults and Children
As required
v*Systemicluythe
Av
TR(}oo}`]vPu]}vb`]oo]v
b ]}v}Ruvb
}vb]o]bX
puser matosus*v
B]}o}P]DMARDb :
yy Bo]uuU}vbob]o]b
yy R]˘]uU}vbob]o]b
yy Ivv}b]uuv}Po}o]vU}vbob]o]b
N}vrB]}o}P]DMARDb :
yy C˙o}R}bRu]U}vbob]o]b
yy MR}˘U}vbob]o]b
yy R]}]v
A U}vbob]o]b
yy M˙}Rv}oU}vbob]o]b
yy C˙o}b}]vU}vbob]o]b
Avuo]obP
yy H˙}˘˙Ro}}]vU}vbob]o]b
Refeal
r Criteria
R(oo}b R˙b]]v}Ru}o}P]bX
TorP) R}uuv}vb(}b}(}vv}vo]uuv}bb]
drugs in lupus
Symptom Medicines to try D}bv}v
RoP]
A N}vrb}]ovr]vGuu}˙ }]
A ]vvo]v}ouv
Pb Ub]G˙
M˙oP] H˙}˘˙Ro}}]v Specialist care
æ
Chatep rP *DisorsOf
der TheMuculos
s keletalSystem
Symptom Medicines to try D}bv}v
LRP˙ AvvovoRlb˙b
o]v
Bb v(vu}v]}]vP(}
R}b`]Rbo]v˙}oub
Rash H˙}˘˙Ro}}]v Specialist care

T}]o}]b
b }T}o]ub
R]b
A Pv]b}o}v Pv]b}o}v PWuP˙]v]oo˙
(}W`lbU]vP]væWuP
]vuvb`lU](v]b
b}v]vPVuv]bo]lo˙}
](}ob u}vRb
H˙}˘˙Ro}}]v Refer to Specialist

MR}˘ in refractory cases
Po]bv]]b NSAIDb ruPv]b}o}v˙Rv r
]vP}bbUo}vPRo]vb}(R]
v*Systemicluythe
uv~}Z
Avuo]ob Refer to Specialist
puser matosus*v
L}`}b}}b}]b
R(}˙brR]}]v U
Mycophenolateu}(o or cyclophosr
Ru]X
}]uuv
A Ru}o˙ r C}}b}]b}Lv}uv] vWuPv]b}o}v(}W`lb
]vu]lR}u}˙ r ˙R]}]v }C˙o}R}bRu] ]vP]vuP]vuvb]v
topaenia response to the blood test results
R]˘]u Refer to Specialist
Renal Pv]b}o}v ob˙o}R}bRu] R(Pvo˙}S]o]b
}u˙}Rv}ou}(o
R]}]v
A }u˙}Rv}o
u}(o(}u]vvv
R]˘]u for refractory cases
Cvov}b˙bb u C}}b}]bobv}] C}v}b]ovWvuPv]b}o}v

PUXPXvvbbvUv}v r daily
obvUX
C˙o}R}bRu] R(Pvo˙}S]o]b
R]˘]u
æ
Chapter
Trumaa AndInjuries
233. Head Injuries

TRb ]vi]b ]v `R]R R ob U blooU uv]vPbU ]vU } R
o}} bob `]R]v R ]v u˙ + o˙ b } }PRX
TR˙ }uu}v b }( R v ]b]o]˙ b]oo˙ ]v ˙}vP
}oX W]R R v }( ]vb b }( u}}]lb b o]
vb}UR]v]vRbP}vXH]vi]bu˙}v}o}bU
u]oU u}}X b S˙u}ub v b]PvbU b òo b Ruv
u}o]˙U`]oov}vR]˙ b }(R]vi˙X
S]Pv].v R ]vi˙ ]b .v b GobP}` C}u So ~GCSZ
}( obb Rv X H}Ù lv u]o ]vi]b b]}bo˙ b Rb u˙
}o`]RuXC}vv}bu}v]}]vP}(Rv]b]bR
b]}vvRvP]lo˙X
C}}b]}b R u}vb v} v.b ]v R uv
}( R ]vi˙ v v} o}vP }uuv (} }v
uvPuvX Sb ub ob} v} P]v ˘ ]v b }(
vb}vPvPPbb]vX
sueCa
yy R}8]vb
yy FoobUb]oo˙(}uR]PRb
yy Bo}`b}RR~.PRbU]vo]vP}ub]}ovU.PRb b Z
yy GvbR}`}vb
yy S`}vb
yy Child abuse
Symptoms
yy Headaches
yy }`b D ]vbb
yy L}bb}(}vb]}bvbb
yy V}u]vP
yy S]b
yy Mu}˙o}bb
yy LlP}(oG]}o]vP(}uRb}v}b]ob
yy Iv}ov}o]PR~R}}R}]Z
æ
Chatep rP *Trumaa AndInjuries
Signs
yy Lo }( }vb]}bvbb r u˙ ˙ (}u (oo˙ }vb]}b } o˙
v}vb]}b~bRGobP}`C}u So`Rv}bb]oZ
yy E˘vo b]Pvb }( ]vi]b r b]}vbU }vb]}vbU o}vbU
lv]vP}vR˙bvRl}(Rb
yy CSF}o}}olP(}uRblv}b]ob
yy P]oo˙v}uo]brvob]U]v}]v}]o
yy F}ov}o}P]o.]bro˙b]bUo}bb}(bR}]b]}v
yy S]Pvb}(]b]vv]obRv]vP b }u U]b]vP
o}}U b bo}`]vP}(Robv]Pob]}v
yy ORb}]]vi]b
yy Ao}R}o]R~]vb}(]v}˘]}vZ
Invtiga
se tions
yy FBC
yy BUEUv]v C
yy Bo}}Po}b
yy Xr˙~blooU]ob]vURbUo]bZ
yy HCTv b ~ob}(}R]ovZ
Trtme
ae nt
v*HeadInjuries*v
Tuv}ib
yy T}v(R]vi˙}R]v
yy T}b}]]vi]b
Note 23-1
C]](}u]bb]}vP
yy L}bb}(}vb]}bvbbRæu]vb
yy Pbv}((}vblooXr˙
yy Pbv}((}oloo]]vPb]Pvb
yy Pb]bvlvRRbU}u]vP }b]b
yy Ov]vi]b
yy CSF}}R}}R]v}R}
yy Eb]oo˙u}vPCR]ovUvRoo˙U}]vR
yy bvA }(o]oo}o}}lLvR}uUobu]
yy Aboo}(}vb]}bvbbv}]}]uv
yy M]v]vo]`˙Ubl}v˙}vb b vb]bvo}v
if necessary
yy M]v]vRo}}~]( b vR˙}vb]}R˙vb]Z
yy PvR˙}Po˙u]
yy Nb`]RRv}(o
yy S]o] R vl `]R }oo oo ]o b]v ]vi˙ Rb v
˘o
yy I(v]bv}vb]}bUv˙R}b
yy R]C v
æ
Standard Trtme
yy Pbb vb}Pb] (} (]vP ]( v ]b v}vb]}bX D} NOT
bvb}Pb] ](R]bb(}(Rbloob
~]X](R]bG]}o}}}u]vP(}uRv}b]obU}bZ
AXF}o}`]vP}(]b]vv]ob
]v
E RvPPB
yy MannitolA9UIVU~u˙P]v}}vu]vbZ
Adults
XæruollP~XærP llPZ
Children
XæræuollP~XærP llPZ
Or
yy Hypertonic salineA9UIV~oo˙(}R]ovZ
Adults and Children
ræuollP}ru]vb~u˘XæuoZ
B. For mild pain management
]v
E RvPPA
yy Pu}o U}oU
Adults
v*HeadInjuries*v
æuPrPvrR}o˙]b
Children
C. For fracture base of skull
]v
E RvPPA
yy Co}˘]oo]v UIVU
Adults
æuPvR}o˙
Children
ær˙bV æuPvR}o˙
ræ˙bV æuPvR}o˙
AM˙V vXæuPvR}o˙
D. For open skull fractures
Adults
vuPR}o˙
Children
æuP llPvR}o˙
vA
yy M}v]}o UIVU
Adults
æuPR}o˙
Children
æ
wXæuP llPR}o˙
Av
]v
E RvPPB
yy B v˙ov]]oo]v UIVU
Adults
XrXPvR}o˙
Children
æuPllPvR}o˙
EXF}PPbb]vb]]vP}v
b
st
L]vTuv
yy HaloperidolUIMU
Adults
ræuPrR}o˙]b ~u˘XuP]vR}bZ
Children
AN˙bV ræuPrR}o˙]b
~u˘XuP]vR}bZ
vr˙bV ruPrR}o˙]b
~u˘Xæu]}PulP˙Z
AMv˙bV v}}uuv
nd
L]vTuv
v*AcuteAbdomen*v
yy L}u UIVlIMU
Adults
æu]}PuruPvR}o˙bv~u˘XuP˙Z
Children
AN˙bV æu]}PurR}o˙bv
~u˘XuP}bZ
Refeal
r Criteria
R( oo vb `]R b]Pv].v R ]vi]b ]uu]o˙ }
v}bP}vX
X A}uv
A }uv ]b bv }vb }( b }u]vo ]vU `R]R
u˙]P]o
b ]vv}vX S}u u]o }v]}vb u˙bv
}u]vo
b ]vX
sueCa
yy IvGuu}˙}v]}vbXPXv]]bUbo]vP]bUR}o˙bb
yy P(}}vbXPX˙R}]UoUu
yy Ivbvo}b}vXPXvPo b Rv]URb]}vbU}oob
yy Hu}RPXPX}]Pvv˙Ubov
yy vbA
yy C}o]bXPX]U]o]˙}]vbvo
yy M]o }v]}vb XPX ] l}]}b]bU Pb}rv]bU
Pb]bU uo]U vu}v]U UTI U b]lo oo ]bbU v}}o
ææ
Standard Trtme
]bbU}R˙]UvR}˙v}u
b
Symptoms
yy A}u]vo]v
yy Av}˘] Uvbv}u]vP
yy D˙bb]
yy F
yy Headaches
yy J}]v]vb
yy D]]vbb
yy VP]vo]bRP
yy D˙b]
yy W˙u}]o}}rb]v}}ob b
Signs
yy DR˙}v
yy F
yy Hypotension
yy Rapid pulse
yy A}u]vo]bvb]}v`]RG]}Pb
yy A}u]voP]o b b
v*AcuteAbdomen*v
yy SvPoRv]~b]oo˙(u}oRv]Z
yy TvvbbU}vvvbbvP]vP
yy bv A }òb}vb
yy Ivb}òb}vb
yy Tvvbb]vR}rb]o}}r]v}R
yy S]Pvb}(bovu}v]}u˙}]o]v(}v
yy Poo}UPvR}R˙U(}vo}bb]vP]vb]looo]bb
Invtiga
se tions
yy FBC
yy Bo}}.ou(}uo]b]b
yy S]lo]vPb
yy CRbXr˙
yy Po]v}u]voXr˙~vb]vZ
yy rv}u]vo
yy Rv}uo}}Po}b
yy U]v˘u]v}v
yy BUEvv]v C
yy Uob}vv b }(}uv
Trtme
ae nt
Tuv}ib
yy T}b]v
yy To relieve pain
yy T}}v}o]v(}v](bv
yy T}Rvo˙]vPb
æv
yy Pbvbb }Pb]vb]R}uR
b ]vP]o
b
cases
AXF}b]}v
]v
E RvPPC
yy IVG]b
Or
yy Bo}}vb(b]}v
B. For pain management
yy Pu}o UIVU
Adults
ANælPV PvR}o˙]b
AMælPV PR}o˙]b ~u˘XP]o˙Z
Children
r˙b~ANælPZV PR}o˙]b ~u˘XP]o˙Z
r˙b~AMælPZV æuP llPR}o˙
v ]b ~u˘XwæuP
}bZ
v ]b ~u˘XwæuP l
v*AcuteAbdomen*v
lP l˙Z
Or
yy PR]]v UIMU
Adults
æruPR}o˙]b ~u˘XuP l˙Z
Children
XæruP llPR}o˙]b
Or
yy MorphineUIVlIMU
Adults
ræuPR}o˙]b
Children
æru]}PullPR}o˙]b
CXF}]v(}b}vb]}vbU(}}vbv]vbvo}b}v
st
L]vTuv
]v
E RvPPB
yy Gvu]]v UIVlIMU
Adults
rXæuP llPR}o˙
Children
XæuP llPR}o˙
D} v} P] ]( ]v } ]b obb Rv uolR}X }]
A ]v vo
]u]uvX
Av
yy M}v]}o UIVU
Adults
æw
Standard Trtme
æuPR}o˙
Children
wXæuP llPR}o˙
nd
L]vTuv
]v
E RvPPB
yy L]˘}v
C UIVU
Adults
rP]o˙
Children
æuP llP]o˙
FRuv`]oov}vR]Pv}b]bX
Av
yy M}v]}o UIVU
Adults
æuPR}o˙
Children
wXæuP llPR}o˙
L]vTuv
]v
E RvPPB
v*AbdominalTrumaa *v
yy C]}G}˘]v UIVU
Adults
uP r R}o˙ ]v(b } rv u]vb ~u˙ (}
˙R}](}}vZ
Children~Ub}vo˙`Rvv.}`]PRbR]blZ
ær˙bV uP llPR}o˙
ræ˙bV æuP llPR}o˙
AM˙V v}}uuv
Av
yy M}v]}o UIVU
Adults
æuPR}o˙
Children
wXæuP llPR}o˙
Refeal
r Criteria
R( oo b } R }] b]o]b v]vP }v R
]Pv}b
b ]bX
235. A}u]voTu
TR]bu˙bvbov}vvP]vi˙}R}uvX
sueCa
yy R}8]vb
yy Gunshots
yy V]}ov
æ
yy Tu}R}uv
Symptoms
yy P]v
yy V}u]vP
yy D]bv}uv
Signs
yy D]bv}uv
yy Tenderness and rebound tenderness
yy G]vP
yy T˙uv]b]}vb}v
yy R}bv}òb}vb
yy P}]v}(v}v
Invtiga
se tions
yy Po]vv}u]voXr˙
yy A}u]voCTv b
yy BUEvv]vC
yy A}u]voob}vv b
yy D]Pv}b]}vooP
v*AbdominalTrumaa *v
Trtme
ae nt
Tuv}ib
yy T}}(]vo}o˙]uov
yy T}}ubb}ò
yy T}]uP]bb
yy T}v]v(}v
yy To relieve pain
yy IvbvNG
yy SP]o]}(uP]bb](vbb˙
AXF}]v(}v}v}o
st
L]vTuv
]v
E RvPPA
yy (}˘]u
C UIVU
Adults
wæuPR}o˙(}wr˙b
Children
ANu}vRb æ uP llP }˙ `]PR R}o˙ (} wr
days
Av
yy M}v]}o UIVU
Adults
æuPR}o˙(}wr˙b
æı
Standard Trtme
Children
wXæuP llPR}o˙(}wr˙b
Refeal
r Criteria
R(oo}b PvoP}v
b X
236. Closed Fractures

TR]b ]b l ]v R }vv]˙ }( R }v˙ }˘ `]R b}]
b}L b ]vi˙X Ab }}b } }v (b ~S b}v }v ROv
(b[ZU o}b (b } v} }uuv] `]R v ]Ro]o
b(o]lbl]vU}òu}bUou}bX
Rbb]}v v]o]b
b }v }( Rv]bu}vX Pvb
bR}ovbv(}]uP]vPvobbRu}˙vu]oo˙ob X
sueCa
yy R}8]vb
yy D}ub]}ov
yy W}lo]vi]b
yy PR}o}P]o(b
yy Foo(}uR]PR
v*ClosedFrctua s*re v
yy Assaults
Symptoms
yy P]v
yy Sòo]vP
yy Iv]o]˙}u}R
Signs
yy P]v
yy Sòo]vP
yy (}u]˙D
yy Iv]o]˙}u}R
yy Crepitus
yy SR}l](RRbvb]Pv].vo}}o}bb
yy C}v(b]}v](R]bbR}l}b}]R]vi˙
Invtiga
se tions
yy Hu}Po}]v
yy Bo}}(}P}]vPv}bbuR]vP
yy Xr˙b}(}b ]voi}]vb}vo}`
yy Tu b]b Xr˙b ~C]o b]vU CRb v Po]bZ ]( ]vi˙ ]b
u}b ](v]b}v(b}v}vb]}b
yy CTv b ~(}(b]v}o]vPR(}oo}`]vPbZP
yy Head
yy Spine
yy Po]b
yy Fb }vi}]vb
æı
yy CTvP]}Pub~](b]Pv].vbo]vi˙]bZb
yy MRI~}b]vo}vb}Lb]vi]b}(RlvZ
yy A}u]voUSG~](]vr}u]vo]vi˙]bZb
Trtme
ae nt
Tuv}ib
yy T}b]Rv~bo](.bZrTLSA }}}o~ABCDEZ
yy T}R b +o]u~bZ~bo]uv˘Z
yy T}}b (v}v}(R+o]u~bZ
yy So]vvP
yy PXOXPXlbo
yy P(]bo]vb
yy }u]
Cb bo]v
yy Eo}v}(o]u~bZ
yy N]o }b vo .vo ]b]}v } P]o b } v}vrbP]o
uvPuvRbvu
yy Mv]o}vUvAvbRb]~MUAZ](}bb]o
v*ClosedFrctua s*re v
AXF}]vo](
]v
E RvPPA
MorphineUIVlIMU
Adults
ræuPR}o˙]b
Children
æru]}PullPR}o˙]b
Or
yy PR]]v UIVlIMU
Adults
Children
XæruP llPR}o˙]b
Or
yy Pu}o UIVU
Adults
ANælPV PvR}o˙]b
Children
v ]b ~u˘XwæuP
}bZ
v ]b ~u˘XwæuP l
lP˙Z
Or
yy D]o}(v UIMU
Adults
æı
Standard Trtme
ærwæuPrR}o˙~u˘XæuP]o˙Z
Children
N}}uuv
nd
L]vTuv
]v
E RvPPB
yy I}(v U}oU
Adults
ruPvrR}o˙]b ~u˘XuP]o˙Z
Children
ræuP llPvrR}o˙]b ~u˘XuP llP]o˙Z
Or
yy N}˘v U
CE }oU
Adults
æræuPR}o˙]b
Children
Not indicated
Or
yy Co}˘] U}oU
Adults
uPXb
v*OpenFrctua s*re v
Then
uPrR}o˙]b
Children
Not indicated
Or
yy CodeineU}oU
Adults
ærvuPrvR}o˙]b
Children
N}}uuv
Refeal
r Criteria
R( ]v]]ob `]R R (}oo}`]vP }v]}vb b}] `]R
o}b (b } v }R}] P}v
b V ]8o }vU (b
`]R ]v o ˘vb]}vU (b }v P}`R ob v `Rv
R]bv}rbo}u}u]bX
237. Open Fractures

Ov (b ]uo˙ }uuv]}v }( R ( Ru}u
`]R v ]Ro]o b( o]l bl]vU }ò u}bU o u}b X
TRu]v}ouR]b]v(}vUvR(}U˙+}bR}o
u }v ]X Iv b}u bU R P }( }v o}bb u˙ `v
u}vX E˘o v}o}P]o .] b]oo˙ `Rv R ]vi˙ ]b
˘vb]X I ]b v } l R}}PR }( R + ~bZ (}
}uv}vvu]}roPo}bbX
æı
PvbbR}ovbv(}]uP]vPvobbRu}˙vu]oo˙
ob X
sueCa
yy R}8]vb
yy D}ub]}ov
yy Assaults
yy W}lo]vi]b
yy Foo(}uR]PR
Symptoms
yy L}o]b]v
yy Sòo]vP
yy Bo]vP
yy E˘}b}vUubov(b]
yy Iv]o]˙}u}R
Signs
yy Sòo]vP
yy (}u]˙D
yy Bo}}
yy L}v}R(
v*OpenFrctua s*re v
yy Crepitus
yy SR}l](RRbvb]Pv].vo}}o}bb
yy Confusion or unconsciousness if there is shock or associated head
]vi˙
Invtiga
se tions
yy Hu}Po}]v
yy Bo}}(}P}]vPv}bbuR]vP
yy Xr˙b}(}b ]voi}]vb}vo}`
yy Tu b]b Xr˙b ~C]o b]vU CRb v Po]bZ ]( ]vi˙ ]b
u}b ](v]b}v(b}v}vb]}b
yy CTv b ~(}(b]v}o]vPR(}oo}`]vPbZP
yy Head
yy Spine
yy Po]b
yy Fb }vi}]vb
yy CTvP]}Pub~](b]Pv].vbo]vi˙]bZb
yy MRI~}b]vo}vb}Lb]vi]b}(RlvZ
yy A}u]voUSG~](]vr}u]vo]vi˙]bZb
Trtme
ae nt
Tuv}ib
yy T}b]Rv~bo](.bZrTLS A }}}o~ABCDEZ
yy T}R b +o]u~bZ~bo]uv˘Z
yy T}vv]]v(}v
yy T}}b (v}v}(R+o]u~bZ
æı
Standard Trtme
yy Ru}oo(}]Pv}]b
yy C}`]R]ob b]vP
yy So]vvP}(+o]u~bZ
yy PXOXPXlbo
yy P(]bo]vb
yy }u]
Cb bo]v
yy Eo}v}(+o]u~bZ
yy o˙ E vP}(u}}vR˙b]}R˙
yy K v]o }b vo .vo ]b]}v } uvPuv Rb v
uX
yy SP]orvPvovbRb]
yy I]P}v
yy D]uv
yy E˘vo.˘}v}lbo
AXF}uv}(]v(}v
st
L]vTuv
]v
E RvPPA
v*OpenFrctua s*re v
yy (}˘]u
C UIVU
Adults
wæuPR}o˙
Children
æuP llP}˙`]PRR}o˙
Or
yy Co]vu˙]v UIVU
Adults
rvuPvR}o˙(}`lb}voo]v]o]u}uv
Children
B. If the fracture is in perineal region
yy A}v]}b]vb}vAX
Av
yy M}v]}o UIVU
Adults
æuPR}o˙(}˙bw
Children
C. Tetanus prophylaxis
Aoovb`]R}v(bubRvb}R˙o˘]bX
~S}]b}vZX
Refeal
r Criteria
R( }uo] (b XPX o] v ]vroU v
uoo]vi]b}v}R}]P}v b X
æı
238. D]bo}}vb
TR]b (b } R ]bb}]}v }( o b(bX S]v R
]u}v v}rbo b }v u}b i}]vbU ] ]b ]u}v
}bv}uvRv}rbob}(Ro]u~bZ]v}o
L]bo}}vX
sueCa
yy R}8]vb
yy D}ub]}ov
yy Assaults
yy W}lo]vi]b
yy S}b]vi]b
yy Foob
yy Convulsions
Symptoms
yy P]v
yy Sòo]vP
yy Iv]o]˙}u}R
v*Disloctions
Signs
yy Tenderness
a *v
yy Sòo]vP
yy Iv]o]˙}u}R
Invtiga
se tions
yy Xr˙}(+~bZ
yy CTv b }MRI](]oo
yy CT vP]}Pu } D}o v b ~]( bo b buv ]b
v}uoZ
Trtme
ae nt
Tuv}ib
yy So](.brTLS A ~vuo](b}Z
yy So]u
yy AR]}vPvo˙i}]v
yy AR]ob }v}(R]bo}i}]v
yy Pvi}]v+vb b b
yy T}v
yy So]vvP}(+
yy Kv]o}bvo}vRbvR]
yy o˙ E vP}(u}}vR˙b]}R˙
æıæ
Standard Trtme
AXAvoPb](}]bo}}vb
]v
E RvPPA
yy MorphineUIVlIMU
Adults
ræuPR}o˙]b
Children
æru]}PullPR}o˙]b
Or
yy PR]]v UIVlIMU
Adults
Children
XæruP llPR}o˙]b
Or
yy Pu}o UIVU
Adults
ANælPV PvR}o˙]b
Children
v*Disloctions

v ]b ~u˘XwæuP
}bZ
a *v
r˙b~AMælPZV æuP llPvR}o˙b]~u˘XwæuP

lP˙Z
Or
yy D]o}(v UIMU
Adults
Children
N}}uuv
nd
L]vTuv
]v
E RvPPB
yy I}(v U}oU
Adults
ruPvrR}o˙]b ~u˘XuP]o˙Z
Children
ræuP llPvrR}o˙]b ~u˘XuP llP]o˙Z
Or
yy N}˘v U
CE }oU
Adults
æræuPR}o˙]b
Children
Not indicated
Or
yy Co}˘] U}oU
æıv
Adults
uPX b
Then
uPrR}o˙]b
Children
Not indicated
Or
yy CodeineU}oU
Adults
ærvuPrvR}o˙]b
Children
N}}uuv
Refeal
r Criteria
R(oo}uo]]bo}}vb}v}R}]b]o]bX
239. A}R}]]v(}vb
v*Acuteorthopaedicinfections*v
A }R}] ]v(}vb U `R]R }Lv bv b uPv]bU
]vo }b}u˙o]b U b R]b U ˙}u˙}b]bU
r}vrR}v]}b}u˙o]b Uvr}vrR}v]R]b b X
A }b}u˙o]b v b R]b v }r˘]b ]v R bu
]v]]oXTR˙u}}uu}v]vR]ovv]vvb`]Rb]lor
oo ]bbX WRv R ]Pv}b]b ]b u ]v v oU ] ]b ]u}v }
˘o]uuvrbb]}vX Staph. aureusv]u]]b account for
Rui}]˙}(R}]v(}vbXTR}uu}vb}}(]v(}v]b
Ru}Pv}bvu˙}]P]v(}ubl]vob]}vbvENT]v(}vbX
I ]b ]u}v } } u]]oo˙ `]R }] v]}b
`]R}vbb]o˙`]vP(}Rovbvb]]˙}X
sueCa
yy Staph. aureus
yy SRX]u]]b
yy Sou}voo ~}uu}v]vb]loroo]bbZ
yy Strept. pyogenes
yy SX(o]b
yy E. coli
yy Ov(b
yy I}Pv]
yy IuovP˙ b
yy J}]vb]}vb
yy Fu}obo}b
yy Ivr}bb}b]v(b]}vbvvb(b]}vb
yy Uu]o]oboR]}v
æıw
Standard Trtme
Symptoms
yy F
yy P]v
yy Iv]o]˙}u}+o]u
yy Sòo]vP
yy LRP˙
yy R(bo}(~R]ovZ
Signs
yy F]o
yy Sòo]vP
yy Iv]o]˙}bRo]u
Invtiga
se tions
yy FBU C SR
E
yy S]lo]vP
yy CRP
yy Bo}}o
yy Xr˙}(+
yy Uob}v v b }( + ~u˙ ob} b (} P]

b]}vZ
yy Gu]v b vo}(b]
yy MRI~](]ooZ
yy Radionuclide scans
Trtme
ae nt
Tuv}ib
yy ]E ]v(}v
yy Pvo}uv}(R}v]]˙
yy Pv}uo]}vb
yy So]vvP
yy Uob}vP]b]}v
yy Iv]b]}vv]vP
AX Avr]v(R˙
st
L]vTuv
]v
E RvPPB
yy C o}˘]oo]v UIVU
Adults
æuPvR}o˙(}r`lb
Children
vA
æı
Adults
uPrR}o˙(}˙b
Children
uP llP~u˘XuPZR}o˙(}˙b
Note 23-2
M}v]} BUE v v]v v (}u ]}˙ ˘u]v}vb `lo˙ `R]o
}vPvu]]v
nd
L]vTuv
]v
E RvPPB
yy Co]vu˙]v UIVU
Adults
uPvR}o˙(}˙bw
Children
Or
Adults
XPR}o˙
b
Children
r˙bV vuP}XPR}o˙U
b
b
B. F}]v]]ob`]Rv]]oo]vbvb]]˙
st
L]vTuv
]v
E RvPPB
yy Co]vu˙]v UIVU
Adults
uPvR}o˙(}˙bw
Children
Av
yy Gvu]]v UIVU
Adults
ruPR}o˙(}˙b
Children
C. For individuals with sickle cell anaemia
]v
E RvPPB
yy Co}˘]oo]v UIVU
æıı
Standard Trtme
Adults
æuPvR}o˙(}r`lb
Children
vA
yy C]}G}˘]v UIVU
Adults
ruPR}o˙(}r`lb
Children
uP llPR}o˙(}r`lb
X
D AvoPb]
st
L]vTuv
yy I}(v U}oU
Adults
Children
ræuP llPvrR}o˙~u˘XuP llP]o˙Z

Or
yy D]o}(v U}oU
Adults
æuPR}o˙}uPR}o˙
Children
AN˙bV æuPR}o˙
AM˙bV v}}uuv
Or
yy D]o}(v UIMU
Adults
Children
N}}uuv
Or
yy MorphineU}oU
Adults
æruPrvR}o˙]b
Children
ræu]}PubllPrvR}o˙]b
Or
yy MorphineUIVlIMU
Adults
ræuPR}o˙]b
Children
æru]}PubllPR}o˙]b
Or
yy CodeineU}oU
v
Adults
ærvuPrvR}o˙]b
Children
N}}uuv
E. For control of fever
yy Pu}o U}oU
Adults
æuPrPvrR}o˙
Children
Or
yy Pu}o UIVU
Adults
v*ChronicOsteomyelitisandChronicSetic
ANælPV PvR}o˙]b
Children
v ]b ~u˘XwæuP
}bZ
r˙b~AMælPZV æuP llPvR}o˙b]~u˘XwæuP
p thr
Ar itis*v
lP˙Z
Refeal
r Criteria
R(}v}R}]b]o]b](R]b}oo}v}(bvv}
]u}uv]vvR}bX
X CR}v]Ob}u˙o]b vCR}v]SAR]b
TRb boo˙ (}u ]vo˙ ]b}bU `R]R
]vo }b}u˙o]b U b R]b U r}vrR}v]
}b}u˙o]b Uvr}vrR}v]R]b b XS}uu˙]b(}u
R}vbbR}v]]v(}v}u˙}]}(vP]X
TR v ]b boo˙ v} ]ooro}}l]vP vobb R ]b v
˘}vX
sueCa
yy ]o A ]v(}vb}(}vvi}]vb
yy Mycobacterium tuberculosisv(vPo]v(}vb
yy Iv(}R}]]uovb
yy I}Pv]
Symptoms
yy CR}v]]bRP]vPb]vbb
yy P]v
yy (}u]˙
D
v
Standard Trtme
Signs
yy Sòo]vP
yy Tenderness
yy (}u]˙D
yy S]vP
yy CR}v]]bRP]vPb]vbb
yy H˙r]Puv}v}(R]v}o
Invtiga
se tions
yy FBU C SR
E
yy Xr˙
yy CT scan
Trtme
ae nt
Tuv}ib
yy ]E ]v(}v
yy Rb}(v}v
yy Pvv}(}u]b
yy W}vb]vP
yy So]vvP
p thr
yy SP˙
Ar itis*v
yy Sb}u˙
yy Iuovu}o
AXF}G}(]v(}v
st
L]vTuv
]v
E RvPPB
yy Co}˘]oo]v UIVU
Adults
æuPvR}o˙(}r`lb
Children
Av
yy C]}G}˘]v UIVU~}]v(b}vu]vbZ
Adults
uPrR}o˙(}˙b
Children
uP llPR}o˙(}˙b
BXF}G}(]v(}v]vvb`]Rv]]oo]vbvb]]˙
st
L]vTuv
]v
E RvPPB
v
yy Co]vu˙]v UIVU
Adults
uPvR}o˙(}˙bw
Children
Av
Adults
uPrR}o˙(}˙b
Children
uP llPR}o˙(}˙b
CXF}G}(]v(}v]vvb`]Rb]looo]bb
st
L]vTuv
]v
E RvPPB
yy Co}˘]oo]v UIVU
Adults
æuPvR}o˙(}r`lb
Children
Av
p thr
Ar itis*v
Adults
uPrR}o˙(}˙b
Children
uP llPR}o˙(}˙b
nd
L]vTuv
]v
E RvPPB
yy Co]vu˙]v UIVU
Adults
uPvR}o˙(}`lb}voo]v]o]u}uv
Children
vA
Adults
uPrR}o˙(}˙b
Children
uP llPR}o˙(}˙b
Or
Adults
XPR}o˙U
b
Children
v
Standard Trtme
r˙bV vuP}XPR}o˙U
b
b
vA
Adults
uPrR}o˙(}˙b
Children
uP llPR}o˙(}˙b
D. For pain relief
~Sb}v}v]vo](]vRAOR}]Iv(}vb[Z
Refeal
r Criteria
AoovbbR}o(b}}v}bb b]o}v}R}]
b]o]bX
X Cooo]b
v*Cellulitis*v
Cooo]b ]b v ]v(}v }( bl]vU b].oo˙ R u]b v

v}bb boo˙(}oo}`]vPl]vRbl]vbR]v( b
`}v}]l˙]vUv]oUR}vU]vb]}lb`vR}b
(}uRob[b(}}X
I u˙ + v˙ }( R }˙U ] +b R oPb u}bo˙X
Ob]˙ v oPòo]vP
b ]bl (}bX I ]b ]u}v} o }
}b}u˙o]b Uv}]vP(b]]bvDV]vTR}u}b]b~DVT ZX
sueCa
yy Streptococcus pyogenes~R}uu}vbbZ
Symptoms
yy P]v}+
yy Sòo]vP}(R+b
yy Rv]vP}lv]vP}(R}o˙]vPbl]v
yy Bo]b]vP
yy Uob
yy F
yy R]P}b
yy Malaise
yy V}u]vP
yy Confusion
Signs
yy Sòo]vP}(+
v
yy Bo]bb
yy L}o]bvvbbvbl]v}o}RvP
yy L}o]bùR
yy Uob]vo]vPR`b
yy EvoPvvP]}voo˙uRv}b
yy Uvo˙]vPb
yy O+vb]`}v
yy F
Invtiga
se tions
yy FBU C SRE
yy CRP
yy Bo}}o
yy FbvPo}}Po}b
yy Gu]v b vo}(]bRP
yy Xr˙}(+
Trtme
ae nt
Tuv}ib
yy To relieve pain
yy T}}v}ov]R]v(}v
yy T}]b}b]vP}v]}vb
v*Cellulitis*v
yy T}v}uo]}vbo]lo}vv}b}u˙o]b
yy RbvoR+](}bb]o
yy Covvbv˙}v`}vb
yy Iv]b]}vv]vP](b(}ub
yy D]uv
yy So]bl]vPL~](]v]Z
AX F}]vo](
]v
E RvPPB
~S b}v (} ]v o]( ]v RCo}b (b[ v Tu v
Ivi]bZ
BX Av]}R˙(}]v]]obob v}PR}b
}vb
st
L]vTuv
]v
E RvPPC
yy Au}˘]]oo]v U}oU
Adults
æuPrPR}o˙(}˙bw
Children
væ
Standard Trtme
Av
yy Foo}˘]oo]v U}oU
Adults
æuPvR}o˙(}˙bw
Children
AN˙bV æræuPvR}o˙(}˙bw
AM˙bV vXæræuPvR}o˙(}˙bw
nd
L]vTuv
]v
E RvPPC
yy C}ru}˘˙o U}oU
Adults
væuPrR}o˙(}ær˙bw
Children
r˙bV væuPrR}o˙(}ær˙bw
vr˙bV æwuPrR}o˙(}ær˙bw
ræ˙bV uPrR}o˙(}ær˙bw
AM˙V uPrR}o˙(}ær˙bw
F}Iv]]ob`]Rv]]oo]vooP˙
]v E RvPPC
yy E˙R}u˙]v U}oU
v*Cellulitis*v
Adults
æræuPvR}o˙(}˙bw
Children
rw˙bV æuPvR}o˙(}˙bw
AM˙bV æuPvR}o˙(}˙bw
Or
yy Co]vu˙]v U}oU
Adults
æruPvrR}o˙(}˙bw
Children
CX Av]}R˙(}vb`R}]u]bb]}v
st
L]vTuv
Adults
XPR}o˙U
Ivb}XPR}o˙]v]v(}vb
b
Children
r˙bV vuP}XPR}o˙U
Ivb}XPR}o˙]v]v(}vb
b
Ivb}uP llPR}o˙]v]v(}vb
b
˙bw ru}vRbV uP llPR}o˙
v
PuvAM˙bw V uP llPR}o˙
Then
Adults
PR}o˙
Children
AN˙bV ælæuPR}o˙
r˙bV æuo}(læwuPbvb]}vR}o˙
r˙bV æuo}(luPbvb]}vR}o˙
u}vRbr˙VuP llP~}(u}˘]]oo]vZR}o˙
AMu}vRbV æuP llP~}(u}˘]]oo]vZR}o˙
And
]v
E RvPPB
yy C o}˘]oo]v UIVU
Adults
æuPvR}o˙
Children
ær˙bV æuPvR}o˙
ræ˙bV æuPvR}o˙
AM˙V vXæuPvR}o˙
Then
v*Cellulitis*v
yy Foo}˘]oo]v U}oU
Adults
æuPvR}o˙
Children
ær˙bV æuPvR}o˙
ræ˙bV æuPvR}o˙
AM˙V vXæuPvR}o˙
ndL]vTuv
Adults
XPR}o˙U
Ivb}XPR}o˙]v]v(}vb
b
Children
r˙bV vuP}XPR}o˙U
Ivb}XPR}o˙]v]v(}vb
b
Ivb}uP llPR}o˙]v]v(}vb
b
˙bw ru}vRbV uP llPR}o˙
PuvAM˙bw V uP llPR}o˙
Then
Adults
PR}o˙
Children
AN˙bV ælæuPR}o˙
vw
Standard Trtme
r˙bV æuo}(læwuPbvb]}vR}o˙
r˙bV æuo}(luPbvb]}vR}o˙
u}vRbr˙VuP llP~}(u}˘]]oo]vZR}o˙
AMu}vRbV æuP llP~}(u}˘]]oo]vZR}o˙
Av
yy C o]vu˙]v UIVU
Adults
uPvR}o˙}vuPR}o˙
Children
rvuP llPvR}o˙
Then
yy Co]vu˙]v U}oU
Adults
æruPvrR}o˙
Children
r˙bV æruPvR}o˙
u}vRr˙bV rvuP llPvR}o˙
D. For methicillin resistant Staph. aureus
]vE RvPPB
v*Neotiz
yy Vv}u˙]v UIVU
cr ingFaciitis
Adults
PR}o˙˙bo}`]v(b]}v}R}~u˘XP]o˙Z
s
Children
u}vRr˙bV uP llP ˙ ]v ]] }bb vr
*v
R}o˙~u˘XP]o˙Z
Refeal
r Criteria
R( oo b `]R uv (]oU }uo]}vb } o}v
]]vP]uvvPL]vP}ob}PvoP}v b X
X N}]vPFb]]b
I ]b ]o˙ }Pbb] ]vGuu}˙ ]v(}v }( R (b] `]R
}Pbb]}v b }( R bl]v vv}b b b ~ob} lv}`v
bRGbRrvP []bbZX
I ]b o]( RRv]vP }v]}v v ]( v} }o˙ uvP u˙
(oX I ub uvP b v uPv˙X I ]b }uu}v ]v R
]uuvr}u}u]bXP b X]bUHIV Uuo]Pvv]bX
sueCa
yy M]˘]o]v(}vb
yy SXb
yy SRXb
yy Co}b]]u(]vPvb
yy }]b B
v
Symptoms
yy P]v
yy F
yy Sòo]vP
yy D]bRP
Signs
yy F
yy Sòo]vP
yy D]bRP`R]Ru˙}bb vP]v}b}ov
yy Sl]v}o}RvP
Invtiga
se tions
yy FBU C SR E
yy CRP
yy Bo}}o
yy Rv}uo}}bP
yy HIV v]vP b
yy Gu]v b vo}(]bRP
yy Xr˙
v*Neotiz
yy BUEvv]v C
cr ingFaciitis
Trtme
ae nt
yy Rbb]~So](.bZ
s
yy ]E ]v(}v
yy Tvo˙]vPb
*v
yy SP˙
yy D]uv
yy GL]vPv}G}
AXF}]}v}(]v(}v
st
L]vTuv
]v
E RvPPB
yy Co]vu˙]v UIVU
Adults
vuPR}o˙(}`lb}voo]v]o]u}uv
Children
Av
Adults
XPR}o˙(}`lb}voo]v]o]u}uv
Children
r˙bV v uPrX P R}o˙ (} `lb } vo
o]v]o]u}uv
u}vRbr˙bV uP llPR}o˙U(}`lb}voo]v r
vı
Standard Trtme
]o]u}uv
˙bw ru}vRbV uP llPR}o˙(}`lb}voo]v] r
o]u}uv
PuvAM˙bw V uP llPR}o˙(}`lb}voo]v r
]o]u}uv
nd
L]vTuv
]v
E RvPPB
yy Vv}u˙]v UIVU
Adults
PR}o˙˙bo}`]v(b]}v}R}~u˘XP]o˙Z
Children
u}vRr˙bV uP llP ˙ ]v ]] }bb vr
R}o˙~u˘XP]o˙Z
Note 23-3
yy D}b]vPM}].}vb
Rvo]u]uvPæuP llP]v]oo˙V(R}b}v b vo(v}vU
bu P ooU v ]vb}vo}}}oV }b]vP ]vobvP (}u ˙
}ıvR}bUv]vP}v]˙ b }(]u]uvX
yy D}b]vPC}vb]}vb
v*HandInfections*v
Gvo }b]vP }uuv}vP P l˙ IV ]] vr R}o˙V u˙ ]v r

b }v b]b }( }˙ `]PR } } R] R]PR}PR obV ]vb
}˘]]˙}bPANP l˙
PlobruP v lLV}PRobæruP lLVR}ÙIv(}bD]bb
S}]˙}(Au]v}RP]o]vbP}PRbæruP lL
B. For pain relief
]v
E RvPPB
Ivi]bZ
Refeal
r Criteria
R( oo vb } R obU Pvo } }R}] P}vb
b b
b}}vbRvRbvb]X
X HvIv(}vb
TRb uPv]b v ] o˙ ]Pv}b]b v }u
uvX SRX b b}vb]o (} R ui}]˙ }( b v ] ]b
}uu}v]vuvo`}lbU(ubv.bRu}vPbX
TR˙vobb].b]uo}]v(}vb
b X
v
S]uo]v(}vb S]v(}vb
yy Iv(}vb }( ]bo RovPo yy Sv}b˙v}]b
ob Fo}vb ~ob} ( } b yy Fb]ob
`R]o}`}ob]v(}vZ yy }bA }u˙o]b
yy P}v˙R]~vR}v]Z yy R]b
bA
yy Sr]Ro]o o]bb v r yy A L˙uRvP]b v oo] ]v r
scesses (}vb
yy Herpes yy C}u]v}vb
yy SPvo}ub yy C}uo]}vb}(]v(}vb
yy Cvo ]v(}vb ~(}u b r
u }( R] (}oo]ob v `b
PovbZ
sueCa
yy Staph. aureusv]u]]b
yy Strept. pyogenes
yy FvP]
yy V]bb
Symptoms
yy P]v
yy Sòo]vP
v*HandInfections*v
yy Bo]b]vP
yy F
yy Sl]v]b}o}}v
yy L}bb}((v}v
N}r
IvR}v]˙bRu˙v}]v}(X
Signs
yy F
yy Sòo]vP
yy Tenderness
yy D]bRP
yy S+vbb
Invtiga
se tions
yy FBU C SRE
yy CRP
yy Bo}}o
yy Rv}uo}}bP
yy Gu]v b vo}(]bRP
yy Xr˙
yy N]oo]]vPb(}R}v]}v˙R]
v
Standard Trtme
Trtme
ae nt
Tuv}ib
yy ]E ]v(}vo˙vPPbb]o˙
yy Pv}uo]}vbbR+vb
b }( b Ri}]vbvu]
b
yy Eo}v}(R+Rv
yy BvP]vP
yy P}`
yy PR˙b]}R˙
yy SP]o]vP}(b
yy Fb]}}u˙]v}uuv˙v}ub
AXF}uv}(b]uo Staph.infections
st
L]vTuv
]v
E RvPPB
yy Foo}˘]oo]v U}oU
Adults
æræuPvR}o˙(}wr˙b
Children
v*HandInfections*v
nd
L]vTuv
]v
E RvPPB
yy Co]vu˙]v U}oU
Adults
æruPvrR}o˙(}wr˙b
Children
r˙bV æruPvR}o˙(}wr˙b
u}vRr˙bV rvuP llPvR}o˙(}wr˙b
B. For treatment of suspected severe Staph. infections
st
L]vTuv
]v
E RvPPB
yy Co}˘]oo]v UIVU
Adults
æuPvR}o˙(}wr˙b
Children
nd
L]vTuv
yy Co]vu˙]v UIVlIMU
Adults
v
rvuPR}o˙(}˙b
Children
˙br˙bV ærvwæuPvR}o˙(}˙b
u}vRr˙bV XwærvXæuP llPvR}o˙(}˙b
C. For treatment of chronic paronychia
st
L]vTuv
]v
E RvPPB
yy I}v}o U}oU
Adults
uP]o˙(}˙bw
Children
AN˙bV uP]o˙(}˙bw
u}vRr˙bV ræuP llP]o˙(}˙bw
C}vrX
M}v]}o](v}v`R]o}vo}vPuR˙X
Av
yy M]}v}o vU}]oU
Adults and ChildrenAN˙b
Ao˙R}o˙}+
v*HandInfections*v
nd
L]vTuv
]v
E RvPPB
yy Fo}v}o U}oU
Adult
æruP`lo˙
Children
r˙bV æruP`lo˙
˙br˙bV rvuP llP`lo˙
Or
yy C o}]u}o U}]oU
Adults and Children
Ao˙rR}o˙}+
Or
yy N˙bv uU}]oU
Adults and Chidren
Ao˙rR}o˙}+
Or
yy }v}o
E uU}]oU
Adults and Children
Ao˙rR}o˙}+
Or
yy C]o}]}˘ uU}]oU
Adults
Ao˙rR}o˙}+
Children
AN˙bV o˙rR}o˙}+
v
Standard Trtme
AM˙bV v}}uuv
vL]vTuv
]v
E RvPPC
yy GriseofulvinU}oU
Adults
æuP]o˙~}o]v]v(}v
b Z(}`lb
Children
r˙bV æ uP }v ]o˙ } ]v `} ]] }bb
~u˙}o]v]v(}vb
b Z(}`lb
`}]]}bb(}`lb
vA
yy M]}v}o vU}]oU
Adults and Children
Ao˙R}o˙}+
X
D F}uv}(Pvo}u b
st
L]vTuv
yy Copper sulphate stone (blue stoneZU}]oU
Adults and Children
Ao˙}R+b]R}o˙
v*HandInfections*v
Or
]vE RvPPB
yy H˙}}b}v uUXærXæA9U}]oU
Adults~XærXæA9Z
Ao˙rR}o˙}+~bZ
Children~XærA9Z
Ao˙rR}o˙}+~bZ
Or
yy Clobetasol propionateu~XæA9ZU}]oU
Adults
Ao˙rR}o˙}+~bZ
Children
AN˙bV o˙rR}o˙}+~bZ
AM˙bV v}}uuv
Or
yy uRb B }v ]}]}vu~XæA9ZU}]oU
Adults and ChildrenAM˙b
Ao˙R}o˙}+~bZ
Refeal
r Criteria
R(}}]b]o]bb](v}bv}]u}X
v
X Tuberculosis in orthopaedics
Tuberculosis v + oo }vb v i}]vbX TR b]v ]b +]v
æA9}(oobXI+booPb}uu}v]vR˘ub}(PX
M˙ }r˘]b `]R ou}v˙ TB ]v b}u b v ob} ]v HIV }b]
vbX
TRu˙}b]R]b}˙}(}v`]RTB]v(vX
sueCa
yy Mycobacterium africanum
yy Mycobacterium bovis
Symptoms
yy P]vb]oo˙v]PR
yy Sòo]vP
yy (}u]˙D
yy N]PR`bb
yy L}`P(
v*Tuculos
yy CR}v]}PR
ber isinorthopaedics*v
yy W]PRo}bb
Signs
yy Sòo]vP
yy Tenderness
yy (}u]b D
yy D]bRP]vPb]vbb
yy Cold abscesses
yy Mbo`bvP
Invtiga
se tions
yy CRbXrR˙}o}ou}v˙TB
yy Xr˙}(Rb
yy SulPb]`bR]vPb(}AFBb
yy FBU C SR
E
yy MRI}(b~](]ooZ
yy B}vvb}Lb]}b˙(}ovR]b}o}P˙
yy Mv}˘ test
Trtme
ae nt
Tuv}ib
yy ]E ]v(}v
yy Pvv}(}u]˙
yy Pv+vb b b
yy PR˙b]}R˙
yy So]vbl}bbl}˙ilb
væ
Standard Trtme
yy ]v]vP
D }(b
yy D]uv
yy Arthrodesis
AXF}}vvi}]vo}b]b
~Sb}v}vRTo}b]b[Z
B. For pain relief
]v
E RvPPB
Ivi]bZ
Refeal
r Criteria
R(}}]b]o]bb}}vb]Pv}b]b]buX
æX R]lb and Osteomalacia

Rickets ]b b ˙ (]o }( }b}] } o](˙ ]v P}`]vPb}v
v*RicketsandOsteomalacia*v
b ovP ]v b}Lv]vP v `lv]vP }( }vbU } ˘u }

}o}vP]u]vrD.]v˙X
Ob}uo] ]bbvoo˙]b]ov]vRblooo˙uX
sueCa
yy V]u]vrD .]v˙}P
yy R]vl~v]}vo]bR}uu}vbZ
yy Mob}}v
yy Rbvo]PR
yy V]u]vrD resistance
yy V]u]vrD dependence
Symptoms
yy Uboo˙v}v
yy P]v]vR`]bb
Signs
yy Mov}]bR`]R]b}o}R]
yy (}u]bD
yy Suoo(}P
yy Sòo]vP}(`]bb
yy RR]}b˙
Invtiga
se tions
yy Su]u]vrDoo
yy Suo]u
yy Suv]vR}bRoob
yy Xr˙}((}u}vb
v
Trtme
ae nt
Tuv}ib
yy C}u}o]vPuv
yy Pvv(}u]b
yy N]}vob}v]
yy SP]o}}v
AX For rickets
st
L]vTuv
]v
E RvPPA
yy V]u]vrD U}oU
Adults and Children
æræ u]}Pu ~æ r Uv]bZ ]o˙ (} r u}vRb vo
Ro]vP]bòoo]b
b R
B. F}]lb]vvb`]Ruob}}v
yy V]u]vrD UIMU
v*RicketsandOsteomalacia*v
Adults and Children
r˙bV rUv]b]o˙
r˙bV ræUv]b]o˙
Or
yy V]u]vrD U}oU
Adults and Children
rUv]b]o˙b}v]˙
b }(}v]}v
Av
yy C o]u U}oU
Adults and Children
ræuP]o˙
CXF}vb`]R}b}uo]
st
L]vTuv
yy V]u]vrD U}oU
Adults
ræ Uv]b ]o˙ (} r u}vRb vo Ro]vP ]b òo b r
lished
Or
yy V]u]vrD UoMU
Adults
Uv]b]o˙(}ru}vRbvoRo]vP]bòoo]b b R
Refeal
r Criteria
R( } ]]]v v }R}] P}vb }v ]Pv}b]b ]b
uX
vw
Standard Trtme
vX Scurvy
Scurvy ]b uorb˙bu ]bbU `R]R u˙ bv `]R }v˙
(}u]b v b}L b ]vPX I ]b b ˙ ]˙ .]v˙ }(
V]u]vrC ~b}] ]ZX I ]b Po}oo˙ bv ]v R o}`ru]o
]v}u}v]bX Pbv}v u˙ uU }v R ]Pv}b]b
]buURuv]b+v`]vPX
sueCa
yy V]u]vrC .]v˙
Symptoms
yy P]vvòo]vPb }(o}vP}vb
Signs
yy Tvvbb}(RoPb
yy Bo]vP Pub
yy Sòo]vP}(o}vP}vb
Invtiga
se tions
yy Xr˙
yy V]u]vrC assay
Trtme
ae nt
v*Scvy*
Tuv}ib
ur v
yy C}.]vb
yy C}(}u]˙
yy F]b]R]vV]u]vrC XPX}vPb
yy SP˙}}(}u]b
AXF}b˙
st
L]vTuv
]vE RvPPC
yy V]u]vrC U}oU
Adults
æuPrR}o˙~u˘XP]o˙Z
Children
r˙bV æuPrR}o˙~u˘XP]o˙Z
r˙bV æuPrR}o˙~u˘XæuP]o˙Z
u}vRr˙bVæuP]o˙rR}o˙~u˘XæuP]o˙Z
Refeal
r Criteria
R(oo}b ]]]vv}R}]b]o]bX
v
wX Osteoporosis
Ob}}}b]b ]b˙bb u]bloo]bR]
b ˙o}`}v
ubb v buoo b }(]}}v }( }v bU `]R }vbv
]vb]v}v(P]o]˙v]o]˙ b }(XR]bl}((b]b
R]PR]voo˙]v]]ob`]R}}òl]vPovv]b]}vX
S}u ]bl (}b ]vo vo R] (bU v
P r b]oo˙ `}uv L uv}bU bu}l]vPU o}R}o bU
]uu}]o]}vU ]v ]vl }( ]u]vrD v o]uU }o}vP
}] b bU R˙R˙}]]bu U R˙R˙}]]buU ˙rI ]b
uoo]bURu}]R]bUuob}}v˙v}ub b Uvo}`(u}o
vlB}vM]voDvb]˙~BMDZX
useCa
yy Iuov`vv`}v(}u}vv}o}vl}`v
yy B}vu]voo}bb
yy L}`}vvb]˙
Symptoms
yy Bl]v
yy Iv]o]˙}òlL˙]]o(oo
v*Osteoporosis*v
Signs
yy (}u D o]ub
yy Fb
yy S}}]vPvb
Invtiga
se tions
yy Xr˙b}(`]bblR]b
yy B}vM]voDvb]˙~BMDv Zb
yy QvCTv b
Trtme
ae nt
Tuv}ib
yy MvPuv}(vo˙]vP]bl(}b
yy Pv}v}((b
yy o˙ E uv}((b
yy D]˙~]vl}(o]uv]u]vrD}v]v]vP(}}bZ
yy TR L](b˙o CRvPb ~( } ]bl (}b ]v R uo
}Z
AXF}o}`(]bl
st
L]vTuv
]v
E RvPPA
yy Co]u `]RV]u]vrD U}oU
Adults
vı
Standard Trtme
ruP]o˙}(Co]u vrIU]u]vrD]o˙
B. For moderate fracture risk
]v
E RvPPA
yy Co]u `]RV]u]vrD U}oU
Adults
ræuP]o˙}(Co]u vrIU]u]vrD]o˙
C. For high fracture risk
Note 23-5
F}v˙}(RR]bo}Ù}vbob]o]b
yy H}u}vouvR˙~HRT Z
yy }Pv Eb R˙ ~ETZ
yy B]bR}bR}vb
yy Calcitonin
yy So}Pv b }u}o}b (SERMsZ
yy Dv}bu
v*SicklercellVaos rocclusiveCrisis*v
yy S}vu
yy T]
Refeal
r Criteria
R(oo}b R˙b]]v}}R}]b]o]bX
X Sickle-cell Vaso-occlusive Crisis

TR]b ]b ]v(o }uo]}v }( b]loroo ]bbU ]v ˙
}b}v }( buoo o}} bob ˙ ˙boo] b]lo oob o]vP
} ]bRu] ]vi˙ } ob }PvbU ]vo]vP }vX TR }v ]v ]b
boo˙]8o}]bvP]bR(}u}b}u˙o]b X
sueCa
yy P˙}Pv]]v(}v
yy Malaria
yy DR˙}v
yy Svu]
yy Sbbvv˘]˙
Symptoms
yy B}v]v
yy F
yy S]loroovu]
Signs
yy B}vvvbb
yy F
v
Invtiga
se tions
yy FBU C SR
E
yy CRP
yy S]lo]vPvHEo}R}b]b~](v}]}bo˙lv}`vZ
yy Bo}}.ou}R]D]Pv}bTb ~RDT Z(}uo]b]b
yy U]vo˙b]bvo
yy BUEvv]v C
yy Bo}}ovbvb]]˙
Trtme
ae nt
Tuv}ib
Ev}PG]]vl
AXTuv}(vo˙]vPMo]
~Sb}v}vRMo] [Z
v*Acula
BXF}uv}(}R]v(}vb
sa v rNeoscr is*v
~S}]b}vZ
CXF}R˙}v
~Sb}v(}Ru}o}P]ouv]vRS]loCooD]bb [Z
D. For analgesia
~Sb}v(}Ru}o}P]ouv]vRS]loCooD]bb [Z
Refeal
r Criteria
R( oo vb `]R }uo]}vb } ]]]vU R˙b]]v
b]o]b}Ru}o}P]bX
ıX boA N}b]b
TR]b]b}vR˙b o}}bo˙X
sueCa
yy N}vru
yy S]loroovu]
yy Iv(}vWR]b
b
yy So] ]o (u}o ]R˙bb l bo] (u}o
epiphyses
yy HIV
yy P}o}vP}] b b
yy Alcohol abuse
yy Vbo]b
yy I]}R]
v
Standard Trtme
yy o}uvo
D ˙bob]}(R]
yy Tu
yy D]bo(u}ovl(b
yy D]bo}}vb }(i}]vb
Symptoms
yy P]v]vR+i}]v
yy L]u]vP
Signs
yy L]u]vP
yy Tvvbb}vi}]vu}uv
yy (}u]˙D
yy LPovPR]bv˙
Invtiga
se tions
yy Xr˙
yy MRI
Trtme
ae nt
Tuv}ib
yy Tvo˙]vPb
v*Acula
sa v rNeoscr is*v
yy Pv}Pbb]}v
yy Ev}P}˙
yy P]vo](
yy PR˙b]}R˙
yy Wol]vP]`Rvo}ò]u]b]v}o
yy SP˙
yy C}}ubb]}v
yy Ob}}u]b
AXF}]vo](
st
L]vTuv
]v
E RvPPA
yy N}˘v U
CE }oU
Adults
æræuPR}o˙]b
Children
Not indicated
Or
yy Co}˘] U}oU
Adults
uPX b
Then
uPrR}o˙]b
Children
v
Not indicated
Or
yy D]o}(v U}oU
Adults
æuPR}o˙}uPR}o˙
Children
AN˙bV æuPR}o˙
AM˙bV v}}uuv
Or
yy I}(v U}oU
Adults
Children
BXF}v}v}(}v}oob
Pu]}v U}vbob]o]b
AlendronateU}vbob]o]b
Refeal
r Criteria
v*OsteogenesisImperfecta*v
R(}vR]Pv}b]b]bu}}R}]b]o]bX
250. Osteogenesis Imperfecta

TR]b ]b ob} lv}`v b ]'o }v ]bbX I ]b Pv ]b}
R]b˙o}`}vubbUbloo(P]o]˙vv(bX
sueCa
yy Gvu}vo]vP}(}ooPv(}u}v
Symptoms
yy Ivbbv˙]vP
Signs
yy Bo]bRbo
yy Dvv}Pvb]b ]u( ~o]bRrP˙ } ˙oo}`]bRr}`v
}o}}v}(RZ
yy Moo(b`]Roob(}u}v
yy B}v(}u]b
Invtiga
se tions
yy Xr˙W˙B rPu~uoo(b]+vPb
b Z
Trtme
ae nt
Tuv}ib
yy MlR]o}u(}o
yy Pvv(b
yy Pv(}u]b
v
Standard Trtme
yy Counsel parents
yy Splints
yy ˙B Rvo]vPRv]b
yy SP]ov}vv}}v}((}u]b
AX F}v}v}((b
st
L]vTuv
]v
E RvPPB
yy AlendronateUIVU
Children
Consult specialist
B. For pain relief
yy Pu}o U}o}oU
Children
Refeal
r Criteria
R(b}}v]Pv}b
b ]b]bu}]]]vv}R}]
v*Burns*v
b]o]bX
251. Burns
A v ]b b]oo˙ }v
b }( R bl]vX Iv ]v b]}vb
b bR b v}b
b bU ubo v }v u˙
]v}oXTRvu˙b.]o}v]vP}vR˘v}(
R]vi˙XTR]b}v]}vU `R]RvRvP b +b}v+
}oUvvu}b}(RuXI+b˙}vPv.}o
]vu}bvb R˙ubuvP}o˙b}RR˙vv
}R]v}uoo](X
sueCa
yy D˙R~.Z
yy WR~bobZ(}uR}o]]bUub Ub}bX
yy Eo]o~o}`}R]PR}oPZ
yy CRu]o~]bvolo]bZ
Symptoms
yy P]v~˙]v b b.]o˙vobb]vvbZ
yy Sòo]vP
yy D]8o˙]vR]vP
yy Bo]bb
v
Signs
yy Shock
yy IvRo}vo ]vi˙ ~v vbo R]bU b}} ]v R R}U R}bvbb
}(R}]volob]vbuZ
yy Sòo]vP
yy Bo]b(}u}v
yy CR]vP}(b~vbZ
yy GCE RvPb~o]ovbZ
Invtiga
se tions
yy FBCvb]lo]vP
yy BUEvv]v C
yy W}v`b
yy Bo}}Pbb
yy CRbXr˙
Trtme
ae nt
Tuv}ib
yy Pv(R]vi˙(}uvb
yy Relieve pain
yy Roo}bG]
yy Pv]v(}v}(v`}v
v*Burns*v
yy A]Ro]vP}(Rv`}v
yy }] A }uo]}vb
yy Ru}o}R]vP(}u+
yy P+vvv]vP`](]oooo]vP}b`˙
or it is reduced
yy I( Ru]o ]b ]v }` (}u bR ] }+ R + v
vvv]vP`
yy S]`˙
yy L]vo]bbo}v
yy D}v}o˙v˙ub}}]vuv
yy A+o]ubbR}oo
yy G}}v]}v
yy Pb˙R}o}P]oR˙
yy PR˙b]}R˙
yy Rbvb
AXF}vb`]RT}oB}˙S(~TB
A SAZ}(obbRvA9]v
R]ovvæA9]vob
Note 23-6
yy Uvb}R˙o˘]b
yy ~S}v
b }vRTvb }R˙o˘]b[Z
væ
Standard Trtme
yy L]o}oG]b
yy bvbD `]RS]oSoR]]v
yy OoAvoPb]
yy Pu}o U}oU
Adults
æuPrPvrR}o˙
Children
Or
yy N}˘v U
CE }oU
Adults
æræuPR}o˙]b
Children
Not indicated
Or
yy Co}˘] U}oU
Adults
uPX b
Then
uPrR}o˙]b
v*Burns*v
Children
Not indicated
Or
yy D]o}(v U}oU
Adults
æuPR}o˙}uPR}o˙
Children
AN˙bV æuPR}o˙
AM˙bV v}}uuv
Or
yy I}(v U}oU
Adults
Children
Av
yy Foo}˘]oo]v U}oU
Adults
æuPvR}o˙(}`lb
Children
ær˙bV æuPvR}o˙(}`lb
ræ˙bV æuPvR}o˙(}`lb
AM˙V vXæuPvR}o˙(}`lb
v
BXI(RPvRbvb~TBSAZ}(u}RvA9]vR]ovv
æA9]vob
Note 23-7
yy Au]
yy Uvb}R˙o˘]b
yy ~Sb}v}vRTvb }R˙o˘]b[Z
yy Rbb]˙oovPIVG]b]uvb]vPPlov[b(}uo~˘
TBSA˘W]PR}(PvZP]v]vR(}u}(˙boo}]b
yy Iv ob P] Ro( }( oo }o G] ]v .b R}b (}u R u }(
]vi˙vR}RRo(]vvR}bbR]vPbo
yy Iv R]ov ]o˙ G] ]uv} R ooG] (} b] r
}vvu]v]b}b R]vPb
b ovXA9˘}b]v A- saline
yy bvbD `]Rb]oboR]]v
yy O]}]AvoPb]
yy MorphineUIVU
Adults
XæræuPR}o˙
Children
XuP llP~u˘XæuPZR}o˙
Or
yy PR]]v UIVU
v*Burns*v
Adults
æræuPR}o˙XL}`}b]vRoo˙X
Children
uP llP~u˘XæuPZR}o˙
Av
yy C o}˘]oo]v UIVU
Adults
æuPvR}o˙(}˙bw
Children
BX I(RPvRbvb~TBSAZ}(u}RvA9]vR]ovv
æA9]vobWvooP]}v]]oo]vb
yy Co]vu˙]v UIVU~](v]booP]}v]]oo]vZ
Adults
rvuPvR}o˙(}˙bw
Children
vA
yy M}v]}o UIVU
Adults
æuPR}o˙(}˙bw
vw
Standard Trtme
Children
CXI(RPvRbvb~TBSAZ}(u}RvA9]vR]ovv
A9]vob~}vb]vbb Z
Note 23-8
yy Au]
yy Uvb}R˙o˘]b
yy Rbb]˙oovPIVG]b]uvb]vPPlov[b(}uo~˘
TBSA˘W]PR}(PvZP]v]vR(}u}(˙boo}]b
yy Iv ob P] Ro( }( oo }o G] ]v .b R}b (}u R u }(
]vi˙vR}RRo(]vvR}bbR]vPbo
yy Iv R]ov ]o˙ G] ]uv} R ooG] (} b] r
}v v u]v]b b } b R]vPb o v XA9 ˘}b ]v læ
saline
yy bvbD `]Rb]oboR]]v
yy (}˘]u
C UIVU
Adults
wæuPrXæPR}o˙(}˙bw
Children
v*Burns*v
æuP llPR}o˙(}˙bw
Av
yy M}v]}o UIVU
Adults
æuPR}o˙(}˙bw
Children
wXæuP llPvR}o˙(}˙bw
Av
yy Ou}o UIVU
Adults
uPR}o˙
Or
yy Eb }u}o UIVU
Adults
uP]o˙
F}VTD }R˙o˘]b
yy Ev}˘]v USCU
Adults
uP]o˙
Children
v
Or
yy D o]v USCU
Adults
æv]b]o˙
Children
r˙bV æræv]b]o˙
u}vRr˙bV v]bllPR}o˙
NeonatesV v]bllPR}o˙
D. If a burn is clinically infected
Note 23-9
yy Au]
yy Uvb}R˙o˘]b
yy Tl`}v`bb vo}}(}ovbvb]]˙vP
b
yy G]IVFo]b
yy G]IVAvoPb]b
yy SIVAv]}b
st
L]vTuv
yy Gvu]]v UIVU
Adults
v*Burns*v
ruPR}o˙(}˙b
Children
Or
yy L]]u
C UIVU
Adults
rPR}o˙
Children
u}vRr˙bV æuP llPR}o˙
Neonates
r˙bV æuP llPR}o˙
wr˙bV æuP llPR}o˙
AM˙bw V æuP llP]o˙
Av
yy M}v]}o UIVU~}bb]v]]vb}vBX}Z
Av
yy Co}˘]oo]v UIVU~}bb]v]]vb}vBX}Z
nd
L]vTuv
yy M}vu UIVU
Adults
XærPR}o˙
Children
r˙bV XærPR}o˙
vı
Standard Trtme
u}vRr˙b~ANælPZVXærPR}o˙
u}vRr˙b~AMælPZVruP llPR}o˙
Neonate
AN˙bw V uP llPR}o˙
AM˙bw V uP llPR}o˙
Or
yy Au]l]vUbo}ÌV}ræu]vbU~u}v]}buAu]l]voobZ
Adults
wXæuP llPR}o˙~u˘XXæP]o˙væP}bZ
Children
yy r˙bV wXæ uP llP ˙ R}b ~u˘X æ uP
R}o˙UvæP}bZ
Refeal
r Criteria
R( oo b }( vb `]R R (}oo}`]vP R]bb }
b]o]bX
PorR]lvbbvbu}RvA9}(TBSA
Dvb}(v˙vPX
Bvb ]v}o]vP(URvbU(UPv]o]U]vuU}ui}i}]vb
CRu]ovb
Electrical burns
Av˙v`]R}v}u]vu]v`R]Rv}bPb b ]bl
v*Wounds*v
}v
IvRo}v]vi˙
Iv(vb
Bvb `]Rr˘]bvP]bUvo(]oX
252. Wounds
A `}v ]b l ]v R }vv]˙ }( b ]v R }˙X I u˙
]v}o}o˙]vP]Ro]uo]lbl]vXW}vbboo˙˙b ]vi˙X
T]bb+]vov}bb bUubobvv}vbXI
u˙ buoo } oP v u˙ } b.]oX I u˙ oU u˙
}vu]v`]R]v}R(}]Pvu'v}u]v(X
sueCa
yy MRv]oPvbXPX(}uobb}lv](UPvbR}U]vbU
}vb]}v (}u ov ]vi˙X W}vb u˙ (}oo}` bvl } ]vb
]bUv]uo}Ruv]b
yy CRu]oPvbXPX}vP b ]b}olo]bU}R}}b]Ru]ob
yy TRuo]vi˙bovP]vvb
Symptoms
yy L}o]v
yy Bo]vP
yy D]bRP}(b](]v(
v
Signs
yy L}oòo]vP b vvvbb
yy L}}l(}}R]vi]bXPXURURbU}uvU}vUvb
yy u]v D R R˙b]o R]bb }( R `}v XPX b]U b]U
shape and depth
Invtiga
se tions
yy Hu}Po}]voo](vRbo
yy G}v}bbruRo}}](]v]
yy Xr˙ }( ]vi u˙ ] } o } }b}u˙o]b v
bone fractures
yy W}v`b (}ovbvb]]˙](`}v]b]v(
Trtme
ae nt
Tuv}ib
yy T}}v}oo]vP
yy To relieve pain
yy T}v}]v(}v
yy T}}P]vbvb
yy T}}u}`}vRo]vP
yy Ao˙]o b b]vP}o]vPb]v]bR]vi
v*Wounds*v
}}v}oo]vPX
yy I(o]vPo b v]v.U]bR}oo]PX~R}(
b
}v]}}b o]vP]b]b}PZ
yy Bo]vP(}u}}Rb}lrbuoo]}(]o b P]vR
b}lvblRv}]}v]X
B}˘rP) Wound management
yy Iuu]o}b}(`}vb]bP}}UR]b]bv}]bo](R`}v
]b]˙}o]lo˙}}u]v(XPXPvbR}`}vbUv]uovRuv
]bv`}vb}vR}b}oXTR˙bR}ov}`v b X
yy WbR Rvb òo v ` ]o b Po}bX Cov R `}v `]R vb
b}o}vXS]˙`}vb`]Rvbb}o}vv]]P`]R]o
R˙}Pv}˘]vbo]vX
yy I(R]b}(PoUPob}b ]]vR`}vUu}RuPvo˙XL]L
oo Gb }( bl]vU ov v RuU ˘]b oo b v } R
`}v`]R]o b PX
yy AvbRb]u˙]X
yy D}v}bE}oU`R]R]b}R]]vv˘}bbv}vvbb˙
} oob bD ]v( `}v b }Lv b v `]R v}uo bo]v
} }]}v ]}]v o}}vX Tl`}v `b (} ov bvb]]˙ b
]( }bb]o v b Au}˘]]oo]v ~Au}˘˙]oo]vZ `R]o `]vP (} bob }(
`}vo
st
L]vTuv
]v
E RvPPC
v
Standard Trtme
yy Tvb }R˙o˘]b (} oo }voo˙ }vu]v `}vbU (}o r
o}`˙}}b}b}( b vb}˘}]}]
b ~Sb}v
}vRIuuv]b}v[Z
vA
yy Pu}oU}oU
Adults
æuPrPvrR}o˙
Children
u}vRr˙V vruPvrR}o˙
vA
yy IVG]bvo}}vb(b]}v]b X
vA
yy Au}˘]]oo]v~Au}˘˙]oo]vZU}oU
Adults
æuPR}o˙
Children
vr˙bV æuPR}o˙
ræ˙bV æuPR}o˙
˙V vXæuPR}o˙
v*BitesandStings*v
Refeal
r Criteria
C}uo]`}vb~XPX`}vbb}]`]R(bU]]b]}v
}(v}vbUo}}bobvvbZX
253. B]bvSvPb
SNAKEBITE
M}b bvl ]b v}vr}]b}v}bX V]b R }uu}vb
}( b }]b}v}bbvl]b]v}]oA(]XORbR}bv
`bvlbXAoob}(bvl]b~v}u}blv}vrv}u}bZbR}o
}b (} ob v R}bX Iv(˙ R ˙ }( bvl ]( }bb]oX
D}v[o˙}}uR}v(vPulbVR}ùoo(vPulbboo˙
]v] v}vr}]b}v}b ] `Rb }v } `} (vP ulb bPPb
}]b}v}b ]X I ]b ]u}v } u]v `RR vv}u}v Rb
}XTR}o}(}v]bv]v]b]}v}Rb]}(R]
}v}b]o]bbv}}]X
sueCa
yy Snakes
Symptoms
yy P]v
yy Bo]vP
yy Sòo]vP
v
yy F]vvP
yy Dlr}o}]v
yy Headache
yy Muscle ache
yy F
yy L}bb}(}vb]}bvbb
Signs
(Poisonous snake bites)
Cardiovascular:
yy H˙}vb]}vUbR}lU]R˙Ru]b
yy S}vv}b ˙bb u] o]vPU (}u ] b]U u}b v }o
`}vbURu]
yy Dl]v(}uu˙}Po}]v]v]vboRu}o˙b]b
Neuromuscular:
yy v]o
C vo˙b]br}b]bU}Rou}oP]UbobR
yy Bo b]}˙ o˙b]b r }}o]vPU v ]v]o]˙ } R
properly
yy Iu]}vb]}bvbbUb]b
yy Mv]vP]bu
v*BitesandStings*v
yy Tvv+ b ubob
L}o+bP
yy R]}Pbb]}v}(òo]vP
b }u}RvRo(}(]'vo]u
yy Bo]b]vPUv}b]bv]b]vP
yy Fb]o}uuvo]b}v}v]'v]P]b
Invtiga
se tions
yy Fooo}}}v
yy Rvo(v}vb
yy u]vb `R}o o}} o}hvPb~oræ uo }( o}} ]v ]
X
b F]o}o}Lu]vb]uo]b]v}Pooo}}Z
yy L](v}vb
Trtme
ae nt
Tuv}ib
yy T}o]]vvv˘]˙
yy T}b}Rb]}v}]o}v](]v]
yy T}}vRvb +}(Rbvlv}u
yy T}v}v˙ b ]v(}v
F]bA]
yy Iuu}]o]}vlbo]vvP}(R+o]uX D}v}u}Ro]u
R Rb v ]'v r R u} ] ]b u}U R (b R }]b}v
bXC˙Rb}v}vR b vRo]u}]PR b
] }( `}}X I( ] ]b ]ooU ` ]b ]v o}R v o ]
v
Standard Trtme
}vR]X
yy CovR`}vvR b vX
R
A R}b]o
yy U bB U
b lù
yy Ab v[b ]`˙U R]vP v ]o}v ~ABC }(
b]}vZ
F}}ov}u}b]bP
yy Covb]}(]`]Rvbo}}v}b}v`
yy D}v}'u}bl}ulv˙]v]b]}vbRb]}(R]
yy L `}v }vV v `}vb b]oo˙ o]lo˙ }
]v(X
yy I( R bvl ]b ]v. b v}vr}]b}v}b } R ]b bv }(
òo]vP
b }˙bb u]b]PvbLvR}bR
b v
yy SP]o]uv`Rv]
st
L]vTuv
]v
E RvPPB
AX Iv]}v(}vrv}uuv
Pbv }( ˙u}ub
b v b]Pvb }( o}o v ˙bb u] +b }(
v*BitesandStings*v
vv}u}vX
yy Avrbvlbu~ASSZr}o˙ov
Hb]}v˙˙~vo]vPZ
Tb}brXuoUv}b b U}(} b vR˙o˘]b
ASS ær uo ~ær u}obZ v]vP }v ]˙
b ˙ IV ] ]v
XıA9 NlS } æA9 ˘}b
D } r R}bX M}v]} b]Pvb v
as required
Note 23-10
N]vivrv}u]v}}l.vP
M}v]}vv}P
yy H˙}}ou]bR}lr˙boo}]bl}oo}]blo}}
yy (bD }( Ru}bb]b r o}hvP (}bl(bR (}v Pobulo r
lets
yy Rb]}˙]bbr}˘˙Pvl]vlvo
yy AvrvbR˙U
yy Tv}oUIMUXæuoX b
Av
yy D]uU}oUæruPX b
B. For Pain relief
yy Pu}oU}oU
Adults
æuPrPvrR}o˙
Children
v
Or
yy M}R]vUIVUIMUSCU
Adults
uPX b
Children
AN˙bV u]}PubllP
AM˙bV ru]}PubllP
CXPv}v}(}v˙b ]v(}v
Adults
æuPR}o˙(}æ˙b
Children
vr˙bV æuPR}o˙(}æ˙b
ræ˙bV æuPR}o˙(}æ˙b
˙V vXæuPR}o˙(}æ˙bN
Note 23-11
v*BitesandStings*v
C}}b]}b}(o]'o}v}o]vP}]b}v]vP˘]vvPv r
R˙o]b]bX}]
A v}v]vb]b}(Pvo]o]vPX
Refeal
r Criteria
R(oovb`]Rb]}˙(]oUR(]oUvo(]oU
uboo˙b]bUubov}b]bUo]vP}]vboRu}o˙b]b}
P]}voR}b]o(}b]o]bX
SNAKESPITINTHEEYES
TR olrvl } } R b]hvP } ˙bb ]b v}u ]v}
R˙b}(]b]uX
I]]}v
b }(R˙bvu˙}viv]b
b vv
o]vvbb](v}`bR`˙]uu]o˙X
Trtme
ae nt
yy I]PR˙`]Rv˙o]]]oo~Ùu]olUbo]vZX
yy Ivbo ]o vrv}u ~}v } . b }( S}]u CRo}]
XıA9ZX
yy T}vo b b]}v`]R}]ov]}b~Sb}v}vRE˙
Ivi]b[Z
SCORPIONSTING
S}]}v vPb
b o b]vPo ulU v R vPb
b ˘uo˙
]v(oX
Symptoms
yy P]vRb]}(]
væ
Standard Trtme
yy L}o]òo]vP
b
yy V}u]vP
yy A}u]vo]v
Signs
yy E˘bb]bo]}v
yy S`vP
yy R]b]}v
yy S]vPorv`}v
Trtme
ae nt
Tuv}ib
yy To relieve pain
yy T}u]v]vR˙}v
yy T}vb
yy ]v D (}}b}vX
yy P]}ubb}vRX
yy G]Rvov˙}(G]b}]vl
v*BitesandStings*v
st
L]vTuv
]v
E RvPPC
yy Pu}oUAb]]vUI}(v}D]o}(vU}oU
Av
yy A9L]}]v~L]Pv}]vZUræuo(}o}o]v.o}v}o]]v
BEANDWASPSTINGS
Mi}]˙ }( v `b vPb
b }vo˙ } o}o] ]vX TR˙
u˙ }b]}voo˙ b ooP]}vbU `R]R u˙ o} vR˙o˘]b
`]R o}o ]vU Pvo] ]U R˙}vb]}vU v ]8o˙ ]v
R]vP b o }( }vR}bbu v }u }( R Po}hbX R D
u˙}X
Symptoms
yy L}o]]vRb]}(vP b
Signs
yy Sòo]vPb]
yy U]
yy Hypotension
yy D]8o˙]vR]vP
yy }vR}bB bu
Trtme
ae nt
Tuv}ib
yy To relieve pain
yy T}uvPvR˙o˘]b](vbb˙
v
yy ]v
D (}}b}v
yy P]}ubb}vR
yy G]Rvov˙}(G]b}]vl
yy IvR}( b vPb u}vP
b (}ubl]v˙]vP
b XD}v}
pull it out
st
L]vTuv
]v
E RvPPC
yy vo]v
A USCU~PZXæruoX b
yy P}uR]vUIMU
Adults
æuPX b
Children
XæræuPX b
yy H˙}}b}vUIVUruPvR}bo](vbb˙
For shock
yy IVG]b
For pain
v*BitesandStings*v
yy Pu}oU}oU
Adults
æuPrPvrR}o˙
Children
Refeal
r Criteria
R( oo vb `]R vR˙o˘]b `R} v} b}v]vP }
uv
HUMANBITES
Huv ]b ~`R]R boo˙ } ]vP .PRbZ o } ]v(}vbU
`R]R ]( vPoU ou}b ]v]o˙ } R]PRo˙ U b
v}]vP ob]}v }vu]v ˙ u]˘ }( }] v v}]
}Pv]bubX A o]o˙ ]vG] ] }v R Rv } ob`R bR}o
}vb]}vu]v
b X
Symptoms
yy P]v
yy Sòo]vP
yy Bo]vP
yy FU](]bP]v(
Signs
yy TR]ubb]}v}v]'vb]
vw
Standard Trtme
yy W}v
Trtme
ae nt
Tuv}ib
yy To relieve pain
yy T}v˙}v˙ b ]v(}v
yy Cov`}vR}}PRo˙
st
L]vTuv
]v
E RvPPC
yy Tvb}R˙o˘]b~Sb}v}vRTvb}R˙o˘]b[Z
yy Foo}˘]oo]vU}oU
Adults
æuPvR}o˙(}˙bw
Children
AN˙V vXæuPvR}o˙(}˙bw
Av
v*BitesandStings*v
Adults
æuPR}o˙(}˙bw
Children
Av
yy Pu}oU}oU
Adults
æuPrPvrR}o˙
Children
Note 23-12
AbPvooU}v}`}vb
b (}uRuv]X
Refeal
r Criteria
R(](R]bv}b]vP(b]]bX
DOGANDOTHERANIMALBITES
MuuobU ]vo]vP }PbU u˙ ˙ R ]b ]bX So] (}u
v ]v( v]uo }v]vb oP vub }( R ]b ]b `R]R ]b
]v}oR}PR ]Uo}vU} l]vRbl]vXTR]bob}
v
]bl }( vb v }R ]o ]v(}v (}oo}`]vP R ]b }( v˙
uuuoX
Symptoms
yy P]v
yy Sòo]vP
yy Bo]vP
yy FU](]bP]v(
Signs
yy TR]ubb]}v}v]'vb]
yy W}v
Trtme
ae nt
Tuv}ib
yy T}o}v
yy T}v]b]v(}v
yy T}v}R]v(}vb
yy T}v˙}v˙ b ]v(}v
Immediate local care
v*BitesandStings*v
yy WbRb]`]Rb}v`
yy Aoo]vi]brbl]vPu]v}]bvRb b Uui}]bv
Rb
b ]v R bu `˙ ˙ R}}PR ]]P}v `]R
}]}b u}vb }( bo]v b}o}v } ovb]vP `]R ]u] ob
Ro}R˘]]vb}o}v
st
L]vTuv
]v
E RvPPA
yy Foo}˘]oo]vU}oU
Adults
æuPvR}o˙(}˙bw
Children
AN˙V vXæuPvR}o˙(}˙bw
Av
Adults
æuPR}o˙(}˙bw
Children
U } }] ~]( v} ]}bo˙ ]uuv]bZ vb
Iuuv]b}v~Sb}v}vRTvbIuuv]b}v[Z
vı
Standard Trtme
Iv]}v(}b}(R]bIuuv}Po}o]vvR]b]v
I bR}o uu R v} ˙ v]uo ]b ]bU
oR}PRR}bb]]o]˙bR}o}v]vu]v(}˙v]uo]XTR
uv}]]bvv}v}RR]v˙}(Rbv}(
R]b]b]vRv]uovRIuuv]b}v}(b RvX
TorP) Iv]}v(}b}(R]bIuuv}Po}o]vvR]b]v
C}v]}v}(Av]uo Tuv
uA }('l D]vP}b}v V]v}v Iuuv}Po}o]v
procedure u]v]b}v
N}uo N}RvPL D}v}]v G].b}b
˙b
N}uo C}v.ub]Pvb}( Iv]]v}v G]}]vP}
]bL˙b ]vv}v.b P]o]vbo}`
b]Pv}(]b]v
v]uo
v}v.ub]Pv]v ]v]]v}v P]}]vP}

v*BitesandStings*v
v]uo }b ](v]uo]b P]o]vb

v}uo}v˙æ
}vv P]}]vP}
S}vPb]]}v}( ]v}vP]u P]o]vb
rabies R]b}v.u
]uu] P]}]vP}
]v}v P]o]vb
Rabies
R]bIuuv]b}v}b˘}b
Pvb]v`]R]vobR˙b
Day 0
Iv.o`}vv}v`}v`]R
yy R]b]uuv}Po}o]v~IUllP}˙`]PRZV
vA
R]bIuuv}Po}o]v~IUllP}˙`]PR˙Z IM]vi}vV
uoR]b]v˙IM]vi}v
˙D ~}v˙˙} ˙wZ
uoR]b]v˙IM]vi}v
Pvb`]Rv}]v}v}u}Rv˙bb]v
]v}v
Day 0
Iv.o`}vv}v`}v`]R
yy R]b]uuv}Po}o]v~IUllP}˙`]PRZV
v
Av
yy R]bIuuv}Po}o]v~IUllP}˙`]PR˙Z IM]vi}vV
uoR]b]v˙IM]vi}v˙bD UwUU
Note 23-13
]v
E bR}`bR`RvR]b]v]b]vi]v}RPooP]}vR
]b }}b}vbX Ao`˙b b R o}] uboU } ]v buoo R]ov R v r
}ooR]PRU}P]RIM]vi}v}(]b]vX
Ao`˙b}uoR]b]vu}v]}]vP(}uXCRl]o]o]˙}( r
uv(}Rv˘v
F]b}b }( vr]b]v u˙ P]v `R]ob}b]vP (}bv }
bv}(]b]vR}P
TRbP]o]vb`]R}b R}( b R]bIuuv}Po} r
o]v}(Ruv}]P]vvRuv]o}]oo]b]vX
F}R}( b }R}bbl]vP]v(}uRPRu]b}
SMOPo]HoR]RRP]}vo}D]b]ooX
RABIESIMMUNISATION
P}R˙o ]uuv]b}v bR}o }+ } R}b R]PR ]bl
~PXo}}˙+ b `}l]vP`]R]b]bUv]uoRvobU]v˙
P}vb
b U v `]oo]( }8b o]lo˙ } ˘}b } ]b }( }bb]o˙
]v(`]ov]uobZX
yy R]b ]vU IMU uo }v R }( ˙b U w v B}}b}bb
v*Shock*v
bR}oP]v˙r˙b
Refeal
r Criteria
R(}˙v`Rv˙u}ub
b }(]b]v
b X
æX Shock
SR}l]bo]v]o}( b ooo˙b(v}vbob }(b
]ovP o}} }ou o]vP } }v ]v o]˙ }( }˘˙Pv v
}R v]vb } ]o }Pvb `R]R ]( }o}vP ob } ]b]o
uoo}Pv(]oX
sueCa
yy H˙}}ou]XPXRu}RPU}u]vPU]R}U]vbvo
}b}v
yy ]}Pv]
C XPXu˙}]o]v(}vUMbb]ou}v˙u}ob
yy ObXPXP]]ou}vUvb]}vvu}R}˘
yy Severe sepsis
Symptoms
yy Thirst
yy Fo]vP(]v
yy Po]}vb
yy S`vP
yy Restlessness
v
Standard Trtme
yy Co}]vP}(}vb]}bvbbU}v(b]}v
Signs
yy Aobvb}]u
yy Poo}
yy C}o˘u]b
yy Collapsed peripheral veins
yy TR˙]UobANıu
yy H˙}vb]}vUS˙b}o]BPAMıuuHP
Invtiga
se tions
yy Svb ](b]b]bb
yy CXRUGCE vR}]}Pu
E ](]}Pv]bR}lb
yy S}b o]lFBU C BUEUv]v
C v LFT ]b }v }
v˙vPuvv}Ru
Trtme
ae nt
Tuv}ib
yy To reverse shock
yy T}]`˙ b UR]vPv]o}v
yy T}v}uo]}vbvuoo}Pv(]o
yy To prevent death
v*Shock*v
yy Raise foot end of bed

]v
E RvPPC
AX H˙}}ou]bR}l
Ivb R oPb } vvo ~b] } vZ ]v R oPb ]v
]b]oXT`}vvou˙]vbb]bb (}]IV]v(b]}v
R]b]vb }P
b }]vb]v(b]}v
yy Give colloids
yy Iv Ru}RP]b }bbruR o}} ]b ( ]v R
uvub]`]R˙boo}]bXPXv}uobo]vX
yy R]vPboUIVU
Adults
wuollP}˙`]PR
Children
~Sb}v}vRMvPuv}(R˙}v b [Z
yy N}uobo]vbR}oP]v]lo˙vbo}`}vo˙`RvBP]bb
v]vG}`]bX
Adults and older children
XæruollPR}}(]v
SuooR]ov
uollPR}}(]v
yy R]b
C Ro}u}v]}R]v}X
yy O˘˙PvUvboo˙}˙(]oublbUvLlu]v
v
yy C}vv}u}v]}BPUobv]v}
MULTIPLEORGANYSFUNC D TIONSYNDROME
TR]b]bo](rRv]vP}uo]}v}(bR}lXD]+v}Pvbu˙
+u}o˙}o˙ b ]vR}bb(}oo}`bP
yy CNSrEvRo}R˙
yy HrTR˙R˙Ru]b
yy Pou}v˙rRb A ]}˙F]o
rARDS
yy K]v˙rTo A N}b]b
yy Gb}]vbvorIobUPvb
yy L]rIbRu]Rb
yy Bo}}rD]bbu]vIvboC}Po}v
yy M}o]rH˙Po˙u]UH˙}Po˙u]
yy Iuuv˙bb urIuuvb]}v
Refeal
r Criteria
R(oovb}R}]R˙b]]vb]o]bX
v*Shock*v
v
Chapter
Geneal
r Emeger ncies
255. AAooP]R}v~AvR˙o˘]b )
Av ooP] }v } vR˙o˘]b ]b o](rRv]vP
]o˙ b]o }v]}v ]( }uo˙X AvR˙o˘]b can
o} `]R]v u]vb }( ]vi}v } ]vPb}v }( u]]vb } }v
`]R ooPvX Pb}vb `R} ` }( R ]bl }( vR˙o˘]b }
]v(}u }( }]v ubbU v u˙ PR R b }( v
]vR]v~vo]vZvX
sueCa
yy B}}R]vbvPb b
yy DPbXPXv]]oo]vbUboR}vu]b
yy V]vb
yy AvbXPXbvlbuUvrvbbu
yy Ivv}b}vbu]
yy F}}bo]l(}} b UP}vvbU(]X
Symptoms
yy S]R]vP
yy U]obR
yy F]ov]r}oòo]vP b
yy D]8o˙]vR]vP
yy WR
yy Collapse
yy Syncope
Signs
yy AvP]}r}u
yy D]8o˙]vR]vP
yy }vR}bB bu`]R`R
yy Tachycardia
yy Hypotension
yy C}oouu˙˘u]b
yy F]o}u
yy U]
yy Cyanosis
v
Chatep rP *Geneal
r Emeger ncies
Invtiga
se tions
yy FBC~}b]v}R]o]Z
yy Sl]v]l(} b b].ooPvb
yy Sub].IPE
Trtme
ae nt
Tuv}ib
yy S]`˙bUR]vPv]o}v
yy Rb˙u}ubb
yy Ru}R}+v]vPb](}bb]o
yy R]o˙]vvv}v}uo]ob]Pvb
yy }] A RooPv
yy Rbb]}v
AX AvR˙oR}v
v*AcuteAllegic
st
L]vTuv
]vE RvPPB
r Rection
yy O˘˙Pv
a ~AnaphylaxisZ*v
˙B vbo}vPb rvLlu]v
Or
Fubl rLlu]v
Or
N}vrRublU ræLlu]v
Av
yy Adrenaline~E]vR]vZUIMU
Adults
XrXæ uo }( P b}o}v ~]XX ræ u]}PubZ ](
vbb˙ ˙ u]vb v `R]o u}v]}]vP o}} b
and pulse
Children
Xuo}(Pb}o}v~]XXu]}PubZ
Rb(}obX
Av
yy H˙}}b}v UIVU
Adults
ruPvrR}o˙U}}v}ov˙oooP]}vRu˙
occur
Children
AooPbV uP llPvR}o˙(}}bbUv}}˘
æuP l˙
Then
yy Pv]b}o}v U}oU
Adults
væ
Standard Trtme
uP]o˙(}˙bv}+
Children
uP llP]o˙(}˙bv}+
Av
yy P}uR]v R˙}Ro}]UIMU
Adults
æuPLR}b](vbb˙U
Then R}o˙(}R}b
Children
˙br˙bV vXærXæuPrR}o˙(}R}b
AM˙bV v}}uuv
Or
yy CRo}Rv]u]v UIMU
Adults
æruPvR}o˙~u˘X}(uP]o˙Z
Children
vr˙bV æuP}u˘X}(}bb]vR}b
v*AcuteAllegic
vu}vRbrv˙bV XæuPU
AMvu}vRV æu]}PullP~u˘XXæuPZ
r Rection
a ~AnaphylaxisZ*v
BXAvR˙oR}v`]R]`˙ b }b}v
Av
yy Sou}o Uvo]bU
Adults
æuPrvR}o˙vob}o
Children
XæuPrvR}o˙vob}o
Or
yy Au]v}R˙oo]v UIVU
Adults
æuP}u]vbURv}vv}b]v(b]}v˙(b}Xæ
uP llP lR}(}R}b](vbb˙
Children
ræuP llP}u]vbbo}`}ob]vi}v}˙]v(b]}v]v
æuoS}]uCRo}] XıA9UIVUrvR}o˙(}R}b
CXAvR˙oR}v`]RR˙}vb b ]}v
Av
yy N}uo bo]v U XıA9U IVU Lr LU u]v ˙ o]v]o b r
uv
Refeal
r Criteria
R( } ]b] } P]}vo R}b]o ]( ˙u}ub
b }( vR˙o˘]b
b]bL]o]]vP
b RvvP]]vP]v]ouvX
v
Chapter
AntibioticProphylaxisIn
Suger yr
æ
256. Av]}P}R˙o˘]b]vSP˙
Av]} }R˙o˘]b (b } R u]v]b}v }( v]}b ]v
vb } R ]bl }( ]} b]bX TR u]v b }(
u}]]˙vu}o]˙]vP˙ b ]b]v(}b}uo]}vbX
Av]} }R˙o˘]b ]b ]v]]v b `Rb]b ]b ˘
v}oR]b}bb o}o}Pvo]b+bX
F} }R˙o˘]b } +U v]}b ub P]v (}
}vu]v}vlbo}Ro]b}bb]ou(}]v(}v
]bo]b
b RXF}P˙ b UR(}U]ubP]vIV}Ru}(
]v}v}(vbRb]Ub}R`]R b Rv]}
(}}vu]v}v}bX
sueCa
yy StreptococcusbX
yy Enterobacteriaceae~GIZ
yy Anaerobes~GIZ
yy C}Pob vP R˙o}}] b ~b]oo˙ ] P˙
b Uv
]uov}vP˙b ZUX
Objectivse
yy Pv]v(}vb
yy Pv}uo]}vb
Indictions
a
P}vIv]}vb
yy v]]b A v]vbvo}b}v
yy SP˙}vR}o}vvu
yy SP˙}vR]o]˙
yy Gb}r}b}RPov}}rR˙vPoP˙ b (}]v}u
yy H˙b}u˙
yy SP˙]vRbv}(b
yy Pvb`]RRuR]bb
yy Pvb`]R}vPv]oR]bb
vw
Standard Trtme
Iv]}vb
A
yy IuovP˙ b `R}bRb]bv]]uovbb
yy ]}b C oP˙ b
yy vCb b}v
P}bb]oIv]}vb
yy TR}]P˙ b
yy N}bP˙
yy SP˙}vRPv]}r]v˙
yy TuP˙ b
ChoiceofAntibiotics
TRv]}R}bvubP
yy Hv]o]˙P]vbRv]R}Pvb
yy N}b]o˙]vvu]}]ob]bv
yy HR]PR}vv}vRb]}(]v(}v
yy (o˙ Bb u}o]bv˘
yy H(`}˘]}}vb b
yy +}o B
v*AntibioticProphylaxisinSuger yr *v
ToærP) CR}]}(Av]}b(}}R˙o˘]b
SURGICALPROCEDURE REGIMEN
v]}u˙
A l Au]]oo]v UIVU
Uv}uo] Adults
P
v]]b Children
vr˙bVæuP
AMæ˙bVæuP
And
M}v]}o UIVU
Adults
æuPb]vPo}b]v}v}(vbRb]
Children
wXæuP llPb]vPo}b]v}v}(vbRb]
O
M}v]}o Uoo˙U
Adults
P}vR}(}P˙
b
Children
æræuP}vR}(}P˙
b
Rb}v}(R}o}v Gvu]]v §
UIVU
}u}}b æuP llP
}ò And
M}v]}o UIVU
§
Adults
æuP
Children
wXæuP llP
O
v
Chatep ræP *AntibioticProphylaxisInSuger yr
M}v]}o UIVU~}bbub}Z
And
(}˘]u
C §
UIVU
Adults
XæP
Children
vuP llPb]vPo}bX
O
C]}G}˘]v UIVU~}u]v]b}vu]vbZ
Adults
uPrR}o˙
Children
uP llPR}o˙~u˘XuPZ
And
M}v]}oUIVU
Adults
æuPXb
Children
wXæuP llPX
b
B]o]˙P˙
b S]vPo}b}(Gvu]]v UIVU~bub}Z
And
(}˘]u
C UIVU~bub}Z
S]vPo}b}(M}v]}o UIVU
H˙b}u˙ æuP
Dvo}b(} UvL}oAvbRb]P
vb`]RRo Au}˘]]oo]v ~Au}˘˙]oo]v ZU}oU
}bRbbURu Adults
R]bU
b ob P}vR}(}}
defect and patent ductus Children
arteriosus vr˙bVXæP
æ˙bVwæuP
Pvb`]RPv]]oo]vooP˙}`R}R]u}
Rv}v}bPv]]oo]v]vR]}bu}vRV
Co]vu˙]v U}oU
Adults
v uP
Children
ær˙bVuP
AMæ˙bVæuP
Pvb`R}RR]}bEv}]b
Adults
Au]]oo]v UIVUP
And
Gvu]]v UIVU
uP]v}v
Then
Au}˘]]oo]v U}oU
æuPvR}boX
vı
Standard Trtme
Children
Au]]oo]v UIVU
vr˙bVæuP
AMæ˙bVæuP
And
Gvu]]v UIVUuP llP
TRv~vR}boZ
Au}˘]]oo]v U}oU
vr˙bV æuP
AMæ˙bV æuP
UvGvoAvbRb]P
Au}˘]]oo]vA=Coov]A] UIVU
Adults
XP]v}v
Then
Au}˘]]oo]v U}oU
æuPvR}boX
Children
ær˙bVA*}(o}b
AMæ˙bVAH}(o}b
I(vRb}bRo}]}bo˙R
v}]bUAu]]oo]v UIVvGvu]]v UIVX
Pvb`R}ooP]}v]]oo]v}`R}RR
u}Rvb]vPo}b}(Pv]]oo]vIv]}bu}vRP
Co]vu˙]v UIVU
Adults
uP}obu]vb]v}v}æu]vb
(}}URv
Co]vu˙]v U}o}IVUæuPvR}bo
Children
vuP llPX
b uP llPvR}bo
væ
Chapter
ManagementofcuteA Pain
v
257. MvPuv}(P]v
A
P]v ]b v vobv bvb}˙ v u}}vo ˘]v b}]
`]Ro}}vouP b XMv˙(}b]vGvR(o]vP
vu}}v}(]vvRb(}b˙(}ub}v}b}vXP]v]b
`RRv˙bb ]]bX
A]v~b}}b}R}v]]vZ]b.vbobvP(}obb
RvRu}vRbv]b }v}˘]}buo] b (}u]v.ob
bRub UP˙
b U}]oovbbX
MvPuv }( ]v ub ]v]]o] } R v
v bR}o ]vo voPb] b òo b uv }( R vo˙]vP
}v]}vX S]o 'v}v ub P]vU v }vb lv ]v
}]]vP ]vo]( ]v R]ovU R oo˙UPvv `}uvU b òo b
R}b`]R}vvR}vo]bbUvR}b`R}}]
}ov}RR]b}˙}(vb bX
sueCa
yy Tuubo}bloo]vi˙
yy SP˙
yy Bvb
yy L}vo]˙
yy Headache
yy S]loroo]b]b
yy M˙}]o]v(}v
yy }uv A XPXvb
yy J}]v]vGuu}v
yy ORb
Symptoms
yy Dv}vRvo˙]vPb
Signs
yy Dv}vRvo˙]vPb
Invtiga
se tions
yy Dv}vRvo˙]vPb
væ
Standard Trtme
Trtme
ae nt
Tuv}ib
yy Rbb]Rv](vbb˙
yy Relieve pain
yy Tv˙vo˙]vP]b}
yy Po+]vu}b}u(}o}b]}v`R}]
yy Eo}v}(+`R]v]
yy So]vvP`Rv]v]
yy C}o}ù}ubb`R]v]
yy Reassurance
yy Pu}o
yy N}vrS}]oAvrIvGuu}˙DPb~NSAIDSZ
yy O]}]b
yy No}lb`]Ro}ovbRb
yy Mou}ouv
v*ManagementofcuteA Pain*v
AXPu}o ~Au]v}Rv )
Adults
Oral:
XærPvR}o˙~u˘XP lR}bZ
F} ob }˙ `]PRAM v lPU }b ]b æ uP llP v R}o˙ ~u˘X v
uP llP lR}bZ
RoP
PvR}o˙~u˘XP lR}bZ
F} ob }˙ `]PR AM vlPU }b ]b æ uP llP v R}o˙ ~u˘X v
uP llP lR}bZ
IV (Intravenous):
SR}oP]vbo}ò˙}æu]vb
PvR}o˙~u˘XP lR}bZ
F} ob }˙ `]PRAM v lPU }b ]b æ uP llP v R}o˙ ~u˘X v
uP llP l˙Z
P]]}bb
Oral:
ChildrenP æuP llPvR}o˙~u˘XvuP llP lR}bZ
Neonates P r æ uP llP r R} o˙ ~u ˘ X uP llP l
R}bZ
RoP
Sub}o}b}o}]vP}b]bP]v~F]b}b
}vo˙Z
L}]vP}b(}R]ovvFoouv}vb]buP llPX
IV (Intravenous):
SR}oP]vbo}ò˙}æu]vb
Children}˙`]PRANlP`]PRP
æuP llPvR}o˙~u˘XvuP llP lR}bZ
væ
Chatep rvP *ManagementofcuteA Pain
Children}˙`]PRAMlPv}RP}(u}vRbP
wXæuP llPvR}o˙~u˘XuP llP lR}bZ
BXN}vrS}]oAvrIvGuu}˙DPb~NSAIDSZ
Note 26-1
NSAIDb bR}o b `]R }vX (}
B vP
b v˙ v }v NSAIDbU
}v ubulbRv]b v} o]lo˙ +˙Rb+b
}(RNSAIDSX
S}u}(R+b b }(NSAIDSPr
yy E˘bo]bb
yy Cboo˙b(v}v
yy A+bvo(v}vWvo b o}}G}`
yy T]PPb}vR}bbu]vb}uRu b vb
yy CbG]v}v
TRb NSAIDS bR}o not P]v } ob P}b }( vbU ]vo]vP R

(}oo}`]vPPr
yy Pvb`]Ro]bb
yy Pvb`]R}Po}v}o]vP}oub
yy Pvb`R}]bl}(}b}o]vPP}vb]oo}u]b
yy Pvb`]R]u]vo(v}v}vb`R}]bl}(P}]vP]v}
vo(]o~Pvbb Z
yy Pvb`]RR(]oX
yy PPvv`}uvUoo˙]vRR]]ubU]b o˙b o}b
of the patent ductus arteriolosis
yy SR}ob`]R]vb}v]voo˙vbX
TR Rv }vvb } R]}bo (˙
b }( R OX
C r bo r
]vR]]} P} }( NSAIDSX TR }uuv}vb R R]b P} }(
PbbR}ov} P]v}vb`]R]bRu]R]bb}} r
bo]bbX
Adult
yy D]o}(v U}oUæræuPR}o˙}wæuPR}o˙
Or
RoUæuPR}o˙}uPR}o˙
Or
IMUæræuPR}o˙}wæuPR}o˙~u˘XæuP l˙Z
yy I}(v U}oU
Adult
uPvrR}o˙
Children
ruP llP]o˙]v]]}bb~u˘XXP˙Z
C. Opioids
TRbb(}]v
b X
yy Tu}o
Adults
væ
Standard Trtme
OroUæruPrvR}o˙~u˘XuP]o˙Z
yy PR]]v UIMU
Adults
æræuP~}˘XuP llPZR}o˙XL}`}b]vRoo˙
Children
uP llP~u˘XæuPZR}o˙
yy PR]]v UIVU
Adults
æuP](vbb˙`]R}v
yy MorphineUIVU
Adult
ruP}ob](
b vbb˙`]R}v
yy MorphineUIMU
Adults
æruPR}o˙
Children
XuP llP~u˘XæuPZR}o˙
X
D No}lb`]Ro}ovbRPvb
yy L]}]v
yy B]]v
EXMou}oTuv
Note 26-2
D]+vP}b}(Pbv}PR
b }]vXTR]b]vbbR
+vb}(
b ]vo](R
b ]bo]u]}R}bP}(RPRv
P]vXTR]bo]u]b]b+vbb`Rvbo}vX
yy Pu}o AvO]}]
Or
yy Pu}o AvNSAID
Or
yy Pu}o AvNSAIDAvO]}]
Refeal
r Criteria
I(vo˙]vP}v]}v}bv}]u}}]vo](]bv}R]
`]R}uuv}bbX
væ
Chapter
ommon
C Malignancies
w
258. Breast Cancer
bB v ]b R }uu}vb v +vP `}uvX o˙
E
}v }( R]b v ]b }bb]o R}PR u}vRo˙ b bo(r
˘u]v}vv]b}uuv(}`}uv}(R]or]vPPX
P]}]v]vP
b R}PRo]v]o˘u]v}v
b ]b](}
`}uv o}` ˙b ~ ]v ˙ ˙bZ v ˙o˙ (} `}uv }
˙bX Muu}PR˙ ]b }uuv ˙ ˙b (} `}uv
˙bv}X
F]uvu}o]b]ooURv[buv
]b b}vo] v vb }v R ]}o}P]o R]bb }( R
u}UP b }(]bbv}Rv(}bXT`}v}(b
cancers]vGRv}]vuobX
B}˘wrP) R]bl(}b
yy Fuo˘b
yy AP
yy Gv]b}b]}v~Fu]o˙R]b}˙}(vb Z
yy P]}bb}voR]b}˙}(vb
yy P}o}vP˘}b}}b}Pv
yy o˙
E uvR
yy Luv}b
yy Nulliparity
yy Ob}PvR˙~}vbUHRT Z
yy H]PR(]vlUAo}R}ov}}
sueCa
yy Uvlv}`v
Symptoms
yy Lu]vRb
yy CRvP]vb]}bR}(b
yy Sòo]vP]v˘]oo
yy Sòo]vP}(o]u
yy P[}vP
yy Skin nodules
yy Uo}v
vææ
Standard Trtme
yy N]o]bRP
yy N]o}v
yy uE lo}v}(v]o}}o
Signs
yy ou bB
yy P[}vP
yy Sl]vR]vPUv}ob}o}v
yy N]o}v
yy Bo}}˙v]o]bRP
yy Poo˘]oo˙v}b
B}˘wrP) S˙u}ubvb]Pvb}(ub]bb
yy B}v]v
yy PR}o}P]o(b
yy Bl]v
yy PoP]
yy C}PR W(}uLvPubb
yy RobB bvbb(}uoo+b]}v
yy HeadacheU }u]vP o }vb]}bvbbU o}o]]vP b]Pvb W (}u ]v
B
ubb]b
Invtiga
se tions
v*Btsare Cancer*v
yy Muu}PR˙
yy Uob}v}PR˙}(Rb
yy F]vvob]}v(}˙}o}P˙
yy Core biopsy
Trtme
ae nt
Tuv}ib
yy Achieve a cure
yy Pvo}ov]bvubb]b
yy P}o}vPb]o]vub]bb
yy Ro]]vvb+]vP
yy Pb˙R}o}P]ob}v}vboo]vP
yy Poo]
yy SP˙
yy Radiotherapy
yy CRu}R˙
yy H}u}voR˙
yy Iuuv}R˙
Refealr Criteria
Aoo b }( b v ub ( (} b]o]b
'v}vX
væv
Chapter
Geneal
r ManagementOf
Poisoning
259. General Management of Poisoning

P}]b}v]vP bvb R Ru(o +b }( }˘] u}vb }( v˙
vb }vR}˙XIvuv˙bU}vo˙u]o˙u}ub b vb]Pvb`]oo
o}X H}Ù b }]b}v]vP bR}o o`˙b }vb]
u]o uPv˙ b]v R b]}v u˙ ]o˙ }o } }u
]oX
Mv˙Rb}}]b}v]vPvv`]Ro˙]v]}v
}(P}}b}vPvouvubbXS˙u}ubv
b]Pvb }( }]b}v]vP v }v R b]. ˘}bU v u˙ o}oU
˙bb u]U}}RX+b E u˙}]uu]o˙U}ob R}b}˙b
oX
TR ]˙ b vb }v uv˙ (}bU ]vo]vP R type of
vb UR route}(˘}b~]vPb}vU]vRo}vU]vi}vUuo
o]}vU XZU R dose and }v }( ˘}bU v v}
environmental factorsX
O]v]vPR}]P]vo}v]v}buo}(Rvb ]b}Lv
u}bRo(oUo}vP`]RR}}PRR]b}˙vR˙b]o˘u]v}vv
o}}˙ vo˙b]b } o}}l (} R]b (b }( }]b}v]vP `]R
b].PvbX
J]]}b}(
b v}b(}}]b}v]vP`]Rb].vbb u˙
}Pvouvubb}vRb.v]vPbX
A P}]b}v C}v}o Cv ˘]bb ]v GRv } b} RoR
}(bb]}vob ]v o}]vP }vo v uo˙ P]b b (} ]Pv}b]b
vuv}(}]b}v]vPX
sueCa
yy H}bR}oRu]ob
yy Pb]b
yy M]}vb
yy T}˘]ovb
yy Vv}u}b]bvvPb b
yy T}˘]o}R}ob
yy Ivb]oRu]ob
væw
Standard Trtme
Symptoms
yy NauseaU}u]vP
yy D]R}
yy A}u]vo]v
yy D]8o˙]vR]vP
yy Po]}vb
yy Skin rash
yy Headache
yy Confusion
yy LRP˙ U`lvbb
Signs
yy Av}uo]ob]Pvb~obUuUb]}˙Z
yy Suoo]ob~u]}b]bZ
yy LP]ob~u˙]b]bZ
yy E˘bb]`vP
b
yy H˙bo]}v
yy Fv]v}v
v*Geneal
yy D]R}
r ManagementofPoisoning*v
yy WR]vP
yy FobR˙bl]v
yy DR˙}v
yy Shock
yy L}`]v}~}o]P]Uv]Z}v}v
yy A}u]vovvbb
yy Jv]
yy Aouv}v
yy Tu}b
yy S]
yy C}u
Invtiga
se tions
yy Bo}}Po}b~v}uZ
yy FBC
yy BUEvv]v C
yy U]vo˙b]b
yy ECG
yy L](v}vb
yy Co}hvPu
yy C}Po}v}.o
Note 28-1
IvbP}vb bR}o ]v]]o]b } R ˘}bX TR P}]b}vb C}v}o
Cvvl}o]v]oRu}o}P]bu˙]b]vb].bX
væ
Chatep rP *Geneal
r ManagementOfPoisoning
Trtme
ae nt
Tuv}ib
yy P}]b]}v
yy P}]P}}b}
yy Pv}o]u]b}}v
yy EvRvo]u]v}v
yy Pv}uvP}PvuP
yy Pvv
yy A]`˙}}v
yy }vu]v}v
D
yy ]v D v(}o}bu}v]}]vP
yy Rbb]}v`Rvvbb˙
yy Gb]oP](]v]
yy }v E v}vboo]vP
v*Geneal
AXGb}]vbvo}vu]v}vU}]b}v]vPb}v}}o
overdose
st
L]vTuv
]v
E RvPPC
yy R}o
A }` U}oU
Adults and Children
æP]v]oo˙~P llPUu˘XPP]v
Z æ
b P læuobo˙]v`
Then
ræP˙rvR}b]b
Note 28-2
P}vbP
}vbv}}uuvUu}b+`]R]vrR}b}(]vPb}vV
C}v]v]}vbP
yy Av˙b]}v]bl~XPXl}bvU}u Z
yy Pvb ]bl }( Pb}]vbvo Ru}RPU (}}v } }b}v
~XPX]vPb}v}(bZ
~Soo}`}vv}b(}b].}]b}vbZ
TorP) Pbv}v}(}uu}vP}]b}vbvR]Av}b
Class T}˘]˙v}u
b Av}~bZ Evidence
RvP
O]}]b Suoo]obUoRP˙l}u U No}˘}v for A
}òb}vbU respiratory
respiratory depression depression
Bv}]]vb LRP˙ l}u Ub]}˙ Fouv]o for C
depression respiratory
depression
væı
Standard Trtme
Class T}˘]˙v}u
b Av}~bZ Evidence
RvP
OPv} r E˘bb]bo]}vUbU Atropine for A
R}bRl vbU}u]vP U]R}U ˙]U
uC ]v}vU˙]U ˘bb]bo]}vU
Pb]b `R]vPUP]}v}}u U }`R]vP
~CR}o]vP] b]UR˙}vb]}vUubo
PvbZ `lvbbA=lr(b]o}v D]u for A
P]}vUb]
OPv}Ro}]v l Uboo˙}vbP D]u for A
Chlorinated vbU}u]vP U]R}U P]}vUb]
Hydrocarbon ]]vbbURRU CR}ob˙u]v C
Pb]b Rb
b ]UP]}vU Nr˙o˙b]v if C
Roo]v}vU]b U}u U R}uPo˙
~XPXTD U u}U}PRUR˙}vb]}vU
lindaneU ]˙bR˙Ru]UbRU }]
A o]vP
b
heptachlorU voA=lrR(]o Rv}
endosulfanUZ P]]vPvo]vU
v*Geneal
bou}oU
}Ruov
b
u]}vb
P˙R]v and Bv]vP}vPo]vP]vR D]u for A
P˙R}] u}RURb b ]bU P]}vUb]
Ivb]b u}bUb]U}u U S˙u}u
Pb}]vbvoU b
R˙]UR˙}vb]}vU
]R}b]bU˘bb
bo]}vUR˙rG˘]
W(]v rb B]b]vPUo]vP(}u PR˙}uv]}v if B
A v}Povb PubUv˙}Ro]vPU oINR
~XPXuv˙ RRUGvlb} FbRF}vPobu
}]b}vbZ }u]vo]vUoo}U A=lr`R}oo}}
bR}lUorPv}u]b transfusion if severe
o]vP
BoRUb}bU NauseaU}u]vP U}o KNPOvo]v
PvbUv obUu}RlR}l relieved
corrosives (acids }u]vo]vUPb}]v r P}}vu C
olo]bZ vo
b o]vPUbR}lU inhibitor
RobbvbbUR˙] A=lrHro}l~XPX
Rv]]vZ
Avru(}
vbU}u]vP
}]
A P(}ub]bU
R}o U
Pb]oP
v
Chatep rP *Geneal
r ManagementOfPoisoning
Class T}˘]˙v}u
b Av}~bZ Evidence
RvP
Pu}o NauseaU}u]vP U Nr˙o˙b]v B
}u]vo]vA=lr Avrub
vvbbUR(]oU P}}vu B
}Po}R˙UbR}l inhibitors
M˙˙u}u
b
I}v NauseaU}u]vP U (]}˘u]v
Db A
]R}U}u]vo]v Avrub
A=lrvvbbUo}}˙ P}}vu
ub]b}}}ob
b UbR}lU inhibitors
R(]o
P M}Rvl}R}]v N}v}bVP]
~R]]Z A=lrobURobbvbbU ˙u}u
b v
R˙}˘]U`R]vPU b}
}u]vo]vUvo D]o˙b]bu˙
(]oUR(]o indicated
v*Geneal
}]
A Pbouvo
}˘˙Pvvobb
v]bR˙}˘]}
]vu}lb
respiratory distress
T}˘]o}R}ob LRP˙ U}u UbR}lU Ethanol or B
~uRv}o U ]u]]b]}v~uRv}o ZU F}u]}o
R˙ovPo˙}o Z renal failure (ethylene D]o˙b]bu˙
Po˙}oZ indicated
Cyanide HeadacheU}v(b]}vU H˙}˘}}ou]v or B
vbU}u]vP UR r S}]uTR]}bo(
obbvbbUb]U}u U
shock
Refeal
r Criteria
R(vb(}b]o]buvPuv](R˙}v}]u}`]R
Pvob}}](R˙]b].v}bX
v
Chapter
MedicinesUseInTheElderly
ı
260. M]]vbUb]vREoo˙
Pb]]vP (} }o vb bvb v] RoovPbX Mv˙
u]}vbv} b`]Rb]o}vb}(Pro
RvPb]vRb}}vU]b]}vUu}o]buUv˘}v}(R
Pòob R b R˙b]}o}P]+b}(RPXIvoUR˙b]}o}P]
RvPb]v}˙}u}b]}vUvovR(v}vbo˙]o}ob
]vu]v]vPRvPb]vPoobvR]bl}(bPvb
]vRoo˙X
TR ]b ob} R ]bb }( uoru}]]˙ ]v R oo˙U `R]R
ob } R b]]vP }( uoo u]}vbX TR u} u]}vb
b](}voo˙b}vURR]PRR]bl}(+b b v
}RP]v}vbX
TR RBb ]][ ~TR Au]v G]]b S}]˙ bB
C]] U E˘ PvoZ P]b o]b }( u]}vb }vb]
]v}](}}ovbV]R}( b ]v+vb}b R]PR
]bl(}vbb X
sof
ueCa seDrugvAd vents
E
yy P}o˙Ru˙
yy Ub}(]v}]u]}vb
yy Uvo]}v}(}]u]}v
yy Tvb]}vb]vhvPb b
Management
Tuv}ib
yy PvbDP A vbE ~ADEZ
Pvubb
yy }v E }vP(} b Roo˙vR](u]o]b}P]b
yy P}PR]b}˙l]vP˙RRoR}]
yy Qo]˙ubb}(Pb]]vP
yy }]v
A }(]v}]u]}vb
yy }]A b}(]v]u]}vb
yy M}v]}]vP(}b]+bvPoob
v
Chatep rıP *MedicinesUseInTheElderly
yy }]v
A }(PrPvPr(}}]v}vb
yy Iv}ouv }( R vl(u]o˙ v ]vP}v }( v
values
yy M]vvv }( v o]b }( oo u]}vb R v ]b
vo˙b]vP
yy P]}] R}o˙Rv P Rlrb[V ]XX ]vbvb } ]vP oo
]oo }'ob v }v]vb }v R u]o ]b] ~]vo]vP u˙
lb v }v]vbZV Rb bR}o Rl P]vb R
u]}vo]b
yy Pvb bR}o u ` }( }vo P }v(b]}vb ]XX
b}vro]lvubUo}}lro]l]oobUv}u]v}vu]}vb
yy Iv(}uvb}(}RPv]vvvubU]vo]vPboo]vPU
bòobRb}vb(}l]vPR]u]}vb
yy M]]v}Pv]b˙b RRu]bUvob}Ro(o
]vvb]vPRvblR]u]}vb}o˙
B}˘ırP) M]}vQb}vCRlo]b
XIbRo]v]}v(}R]bu]}vM
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b DEZ v˙v`v˙u}u
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Chapter
LocalAnathe
se ticgeA nts
261. L}oAvbRAPvb
L}o vbR ~LAZ Pvb Pb R b]o˙ o}l v
vbu]bb]}vX TR˙ b } }] vbRb] } b]. b }(
R}˙vvob}b(}voPb]X
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u}} `lvbb u˙ } (}oo}`]vP o}o vbRU v]vP }v
Rb]}(o]}vX
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Rb}o}vPR]}vXTRbo}vv}v}(vo]v}
o}ovbR]bPUX
L}o vbRb `]Rvo]v bR}o v b `RR
o}} bo˙ ]b ˙ v ]b XPX bR}o v} b (} ]P]o v
o}lbXTR˙ob}}v]v]]v]vv}bP]}vovbRb]
~IVRAZ X
C}uu}vo˙LAb ]v
b }brP]}vo]Pv}]vv]]vX
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yy vPA r]}vb}(}v
yy }v D r}R}
yy M˘]uu}b}(o]vo]}]vruP llP~}˘XuP]voZ
yy M˘]uu}b}(o]}]v`]Rvo]vrwuP llP
yy L]}]v ]bv}}uuv(}b]vovbRb]
B. Bupivacaine
yy vP
A ro}vPvP
yy D]bvPbr]}}˘]Ubo}`}vb}(}v
yy M˘]uu}b]buP llP~(}}Ro]vv`]Rvo]vZ
Note 30-1
B]]v bR}o`]R
b }vX(}u
A Pvob]u r
bU]vo]]A9]b+(}Ruv}(]}}˘]]˙X
CXR}]]v
yy vP
A ro}vPvPUob]}}˘]
b
yy M˘]uu}b]buP llP
v
Chatep rP *LocalAnathe
se ticgeA nts
Ubb}(o}ovbRPvb
yy Topical
yy L}o]v.o}v
yy Nerve blocks
yy Ivv}bP]}vovbRb]
yy S]vovbRb]~bRv}]o}lZ
yy E]ovbRb]lvoPb]
yy No]b}v(}vbR]vP]`˙
yy Ivv}b}v}(o]Pv}]vbvvR˙Ru]
Pv}v}(o}ovbR}˘]]˙
yy Ao`˙bb](}]vivPU}v]vv]vbo
]vi}v
yy D}v}]vioP}oubu
yy C}v`Rv]vivP]v}b}(R]PRbo]˙
Symptoms and signs of local anaesthesia toxicity
yy P]r}ovPo]vPUvv]bUo]PRRvbb
yy V]bo]bvbUbobR
v*LocalAnathe
yy Ao }vb]}bvbbU b]bU o}bb }( }vb]}bvbbU b]}˙
arrest
yy H˙}vb]}vU]R˙Ru]bU]b
se ticgeA nts*v
Tuv}(o}ovbR}˘]]˙
yy S}]vi}v}(LA
yy SABC ~A]`˙UR]vP
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yy G]M]}ou ~ræuPZ}]u~æruPZ}b]bXI(
b]b b]bU v vbRb v P] R]}v}v r uP llP }
u}u]}ouvo˙bU]vvvov
yy T]}bo ]vb]o]˙ `]R IV G]bU ]v}}bU v `Rv
]]v }}]]v Rb v bU P] Ivo]] A9 b]vP
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Ub}(A9]vo]]]vuv}(o}ovbR}˘]]˙~(}oo}` -
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uo(}wlPvZ
yy Sv]v(b]}v}(A9Ivo]]XæuollP lu]v~}˘Xuo
}u]vb(}wlPvZ
yy R]v]o}ob`]æu]v]vobU](]o}v
has not been restored
yy M˘]uu}b}(uollP}(Ivo]]A9bR}ov}˘
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Chapter
StructuoaredAp chtothe
SeriouslyIllChild
262. S}R
A }RS]}bo˙IooCR]o
A b]}bo˙ ]oo R]o ]b }v `R}b ]ob }u}u]bX A
}R
b ]vu]v]vPRbvbv(o b
uvPuv }( R R]o ]b vbb˙X R] buv v Pv
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uUobb bvbb}]vb ]b]u}vX
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b obb].vR(}oo}`]vP
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]b]o]˙X
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yy P]u˙buv
yy Rbb]}v
yy S}v˙buv
yy EuPv˙uv
yy .v] D
AIRWAYlBRETHING
A PROBLEMS
sueCa
yy SPvu}v]
yy }vR]}o]b
B
yy U]`˙}b}v}]}
b
yy ORb
SignsAndSymptoms
yy Dvb}v}v]}v
oaApr ch
yy P]u˙buv
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yy Cv]v(v˙MIv]b]`˙v˙
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PvvPU]vb]}˙}˘]}˙v}]bbUG]vP}(Rovb]
v
Chatep rP *StructuoaredAp chtotheSeriouslyIllChild
yy +vb
E b }( R]vP ]b b ˙ R b}vbU Rb
˘vb]}vv}u]vo˘b]}v
yy F]vo +b }( ]v b]}v u]v (}u R
RUbl]v}o}vuvob
yy Pob }˘]u˙ b]oX A }v
b }( obb Rv ıA9 `R]o
R]vP]}obbRvıæA9`R]oR]vP}˘˙Pv]b˙o}`
yy H]PR G}` }˘˙Pv bR}o P]v } oo R]ov `]R b]}˙
]8o˙}R˙}˘]XIvR]o`]R]vvo}vUPo
ubl}˘˙Pv}v}]v}vu˙]
Invtiga
se tions
yy CRbXr˙
yy ]o A o}}Pb
yy PlG}`~](Ru b }bb]]o]˙Z
Management
I( R]v o]L } i` Rb v b ]`˙ Rv } b}U }R`]b
v*StructuoaredAp chtotheSeriouslyIllChild*v
}vb]]v}v
RESPIRATORYV ]( o˙ v}]bb RU ]`˙ (oo }( }vbb U
b}v]
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u}o]lo˙}]`˙}b}vUvo]b`]Rvo]v~æuo
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}vb]o˙vPo(}]Pv}˙XCoovENTP}v b ]uu]o˙
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vo]bou}oXæuP}æuP](w˙bobv}˘˙Pv
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]b v} }ou `]R ] }X ]C b }u]vvo˙ }b
}v˙ b } R˙}˘] } R˙}}ou]X P]u˙ u˙}]o ]bb ]b
X
sueCa
yy Heart failure
yy AR˙Ru]b ~RR˙Ruv}uo]bZ
oaApr ch
yy P]u˙buvU`]RP}]o}vV
yy Heart rate
yy Pob}ou
yy C]oo˙.oo
yy Bo}}b
yy L}}l (} R˙]U ˙]U v}uo ob }ouU
R˙}vb]}v } R˙vb]}vU R}uPo˙U uub v
]Ro}u
yy CRlR+b}(]o}˙]v˙}v}R}Pvb˙
vw
Standard Trtme
yy Rl]vPRb]}˙
yy bl]vvvu
yy uvobv]v˙}
Invtiga
se tions
yy Uo}o˙b
yy CRbXr˙
yy ECG
yy Fooo}}}v
yy Bo}}o
Management
yy bA]`˙bvR]vP(}}uuv]vP˘vo]
ubbP
yy I(] } ]b v}b}v]vP} CPRU}vb] R ˙
}(]`˙vR]vPb}
SHOCK~INAQUA
DE TECIRCULATIONZ
sueCa
yy SPb}v]b
yy D]R}
yy Cardiac disease
Management
Rbb]}vW˙R]o]vbR}lbR}oR}˘˙PvR]PRG}`
XVv}b}]v}bb}bbR}o}]vvv]v(b]}v}(
v}uobo]vuollPP]v
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ov
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b V b]Pvb u˙
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G] }obb }( G] } bR}l R]ov ]( .b }v v} +X
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sueCa
yy Sb ]ob ~}vv}b b]b `]R} P]v]vP
}vb]}bvbbZ
yy Mv]vP]b
yy EvRo]b
yy S}lb]vS]loCooD]bb
yy oC uo]
v
Chatep rP *StructuoaredAp chtotheSeriouslyIllChild
Signs
yy Altered conscious level
yy Convulsions
yy Ao]ob]v]˙
yy Av}uo}b
yy Mv]vP]bu
yy P]oo}u
yy Hypertension
Invtiga
se tion
yy Uvo}o˙
yy Bo}}bP
yy Bo}}o
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yy P}o}vP .b W P] o ]uX I( }vob]}vb b]b P]v
b ]ob }}}o b]vP Rv}]}vU Rv˙}]v and
u]}ouIV]vR}X
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yy Iv R]o `]R b }vb]}b oo v }vob]}vb }vb]
uv]vP]b XG](}˘]ulA]o}] X
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CA S
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yy H˙}Po˙u] ~R]vl}(uo]
b Z
yy D]l}]}b]b
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yy RbRU]obR
yy F
yy A}u]vo]v
yy V}u]vP
yy E˘bb]R]b}˘bb]]vl]vP
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yy SR˙}v
yy Dv]b]}v
yy Suoo}(l}vb]vR
yy P]vr}]v]obUoP]ob
yy Tachypnoea
yy S]PR]vPb]}vb
yy H˙}Ru]
yy H˙Ru]
vı
Standard Trtme
Trtme
ae nt
Tuv}ib
yy Dvb}vRb
Note 31-1
I(]Pv}bob}]v}}]b}v]vPRvuPv˙uvvuPv r
˙uv}(b].}]b}vb}ubu}vXI(R]b}˙vb]Pvb}]v
} ] l}]}b]bU Rv v}uo bo]v ]b R ]v]o G] } b}PR
`]R]vbo]vX
yy Reassure or console the child
yy Tu`}l
AXO˘˙Pv therapy
st
L]vTuv
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B. Convulsing child
]v
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yy L}u } ]uU Rv}]}vU } Rv˙}]v } u]}o r
u]vR}
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r Criteria
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FORMS
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MinistryofHealth
Feckaedb onStandardTrtme
ae ntGuidelines~STGZ
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3. Eu]o
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8. }(
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MinistryofHealth
Feckaedb onsentia
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2. PR}v
3. Eu]o
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Medicine
6. C}uuvb}
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7. P]}]˙ H]PR M} L}`

8. }(
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FORMS
REPORTING FORM FOR ADVERSE EVENTS FOLLOWING IMMUNISATION (AEFI)

MOH-Ghana Health Service/Food & Drugs Authority
SMC/SMD/GEN- 10/1.0

Reporting: Sub-District: District: Region
AEFI Reporting ID Number Vaccination Card/Booklet Yes No
Region Code District Code Year Serial Number
If no, state other source of information:

A. PATIENT DETAILS
*Name : *Date of birth (DD/MM/YYYY): _ _/_ _/_ _ _ _
Sex: M F OR Age at onset: Years Months Days
Mother’s Name (if child): OR Age Group: < 1 Year 1 to 5 Years >5
Contact Phone No: Years
*Address (landmarks and other contact information):
Vaccination centre:
Community:
*B. DESCRIPTION OF AEFI

Severe local reaction >3 days beyond nearest joint
Seizures febrile afebrile Date AEFI started (DD/MM/YYYY): __ __ / __ __ / __ __ __ __
Abscess
Time AEFI started Hr Min
Sepsis
Signs and symptoms- please give a summary of the case, including any
Encephalopathy prior disease(s)/condition and patient’s medicines before vaccination)
Toxic shock syndrome
Thrombocytopenia
Anaphylaxis
Fever≥38°C
Other (specify)................................ Indicate treatment given for the AEFI:
*C. OUTCOME OF AEFI

¶
*Serious : Yes No; è If Yes Death Life threatening Disability Hospitalization Congenital anomaly
Other important medical event (Specify________________________________________________ )

*Outcome: Recovering Recovered Recovered with sequelae Not Recovered Unknown
Died If died, date of death (DD/MM/YYYY): __ __ / __ __ / __ __ __ __ Autopsy done: Yes No Unknown

D. DETAILS OF ALL VACCINE (S) ADMINISTERED
VACCINE(S) DILUENT (if applicable)
*Name *Date and time of *Route (if *Lot / Manufacturer Expiry Manufacturer *Lot / Expiry Date and time
Vaccination injection Batch Date Batch Date of
indicate No. No. reconstitution
Date Time L/R site) Date Time
E. REPORTER DETAILS
*Name: Profession/Designation: Tel No.:
Name of Institution: Today’s Date: _ _ /_ _ /_ _ _ _ Signature:
For District Level Office
Date Report Received: _ _ /_ _ /_ _ _ _ Checked by: Designation:
Investigation needed: Yes No If yes, date started: _ _ /_ _ /_ _ _ _
For National/Central Level Office

Date Report Received: ___ /___ /______ Checked by: Designation:
Comments (include results of Causality Assessment):

¶
All serious AEFIs & AEFI clusters (two or more cases of the same adverse event related in time, place or vaccine administered) should be investigated.
*Mandatory fields
Vaccine Safety/AEFI Surveillance Ministry of Health / Ghana Health Service/Food and Drugs Authority April 2017
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Standard

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Indxe
Ob A M] æı
A RRu A F v Uv Uv
AB R]b
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Av}uoVP]voD]bRP w ADHD w
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u]v}Rv A væ vo A Ivb8]v˙ w U
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Aciclovir æ Uæı Uv Uv U Uvı w
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ACT Uı Uı Uı AKI ı U Uæ Uv
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Acupuncture æv Alcoholic Hallucinosis ı
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bvA A=Au}]]v U v}GuR]] B ı Uæ
ARoP] ı Uæw Uæ v]Pv B P}bH˙ob]
Arthrodesis ææ UæææUv v]Pv B P}bH˙ob]~BPHZ Uı
Arthropathy æı Uæw vR]v B v˙ov]]oo]v v Uv
AR}obb ææ vR]v B Pv]]oo]v æ
Ascites v Uı U U Uv Uw U Uæ U Uæ U v}]v B
ı vR˘}o B
Ab]G]uo}v w v}]]vb B væı
ASD U v}]]v B `]Rò ı U
AbR˙˘] v}] B ]}u}v}]vuv æ Uææ
Ab]}vvu}v] Uw Uæv v}˙o B }˘] w
Aspirin Uv Uw Uv Uı U U U U v}]v B Uæ
vw
INDEX
v˙o B v} vı Co]uCRvvoBo}lb æ Uı Uæ
v˙ov]]oo]v B w Uıw Uææ Co]uPo}v ıæ Uı
v˙o B Pv]]oo]v ı Co]u˙}R}bR]R˙~CPPDZ æwæ
ro}lb B ı Uæ Co]u`]RV]u]vbouvb D ævı Uæ
rRu}o˙ B }}]
b ı Cu˙o}
uRb B }v U Uv Uææ Uæw Uææ U Candesartan Uı Uæ
æwv Uv Candida æ Uææ U U Uææ
RuRb B }v æv Candida albicans Uææ
B]o]˙]bb Candidiasis vı Uw Uwv Uææ
B]o]]v æ Uv Uæv U U U U Uæ Cvv]b`]Rò ı U
B]o]]vvRo}R˙ æU U Cu v
B]]]v æ u]v ææ
B]}oD]b} v Cu]v U U Uı Uv Uææ
B]RbR˙˘] ıw C]u}o v
B]RIvi]b Carbocysteine Uw
B]b}˙o C}ov ı U
B]b}}o}o v U Uı Uæ Uæ Uæı ]v}u C }(RC]˘ v
B]bR}bR}vb ævı Uv ]C AR˙Ru]b U
B]v]o(]o~BVFZ Cardiac failure v
Bol}b væ Cardiac neurosis
Bo]vP Uv Uv Uvæ Uv Uvw Uı U U U ]}Pv] C bR}l U U U
w Uıw Uæ Uæw Uæ Uæı Uv ]}uPo˙ C
Bo]vPD]b}b væ ]}u˙}R]b C Uæw
Bo]vPo Carvedilol Uæ
Bo}} vb(b]}v Uvæ Uw Uv U Uw U Cataract Uæ
ı Uæw .˘]u C wv
Bo}v b v (}˘]u C v Uıı Uı Uıı Uæ Uvw
B}]ob æ L]]u C ıı
B}vM}`F]o v L]˘}v C æ Uv U U Uw Uı U U
B}oob]b wv U U U Uıv Uı Uıı Uæ Uæ
˙R˙Ru]b B æv (}˘]u C Uv Uw U U U Uw U
˙] B ı Uæw Uæı Uæ Uæ Uæv Uæ Uæ Uæı U
CvbB vææ æı Uv Uvı
}u}]v B Co}˘] ææ Uææv UææıUæv Uæwv Uæwı Uæı U
}vR]o B Ru
Ab wæ æıv Uv Uv
}vR]b B ]b w Uı Cooo]b ı Uw Uv
B˘]bu æı Cvoo˙vPPvb æ
Bb}v] w Uwı Uæ Uæv CRoRu}u v U U Uæ
Boo}buR]P}] vw }bC ]vouv]vP]b ıæ
Boo}bR}v w }o]u C ææw
B]]v væ Uv C]]b wv
v}R]v B C]}rF]obA æ
Bl]' [bo˙uR}u w ]]v C v Uv Uv Uw Uw Uw
Bvb ı Uv Uv Uvæ ]u] C v Uwv
b]bB æw CRu}b]b ææ
Bo]Uo ı Uı Uæ chest pain Uvı Uæ Uv Uæ Uw U Uw
CRbP]v U
C R]lv}˘ æı
CR]lv}˘ v Uv
CR˘] æ Uw CR]oR}}Iuuv]boD]bb
Cou]vo}}v Uv Uw CRou˙]R}ub v Uw
Calcitonin v Chloral hydrate
Co]u æ Uı Uæ Uæ Uıw U Uıæ Uıw U CRo}uRv]}o w Uıw Uææ Uæ Uæ
ı Uæ Uææv Uæv Uævı Uæ Uvw Uvı Uv CRo}]}˘]
vw
Standard
CRo}R˘]]v v Uwv vı Uvæ
C Ro}R˘]]v b}o}v v Uwv Cocaine U U Uı U
Chlorinated Hydrocarbon v Codeine Uı Uw U Uæv Uæı Uæıw Uv
CRo}Rvu]v w U C}]v}v]v]vP}PR}vb
CRo}Rv]u]v vı Uv Uv Uw Uv Codeine phosphate w
CRo}}u]v U U U Uw C}Pv] BR]} TR˙ æ U U U
Cholera æ æ Uv Uw U U
CR}obiv] v Colchicine v Uæw Uæwv
CR}ob˙u]v w Uv Cold sores æw
Chondrocalcinosis æwæ Colonoscopy
CR}v]HbA C}u U U U U Uı U Uv Uv U
CR}v]Ru Ab w ıv Uæ Uæ Uvæ Uvæı Uv Uv Uv
CR}v]}vR]b B C}u]v }viP }b}Pvb v } r
CR}v]Hb Pb}PvU æ
CR}v] l]v˙ ]bb ~CKDZ w U Uıv U C}uu}vC}o vw
ı Uıı U C}uuv]˙]vu}v] w
CR}v]o˙uR}]olu]~CLLZ wæ C}uoo]vP ]v]}vb (} R R}] }( v r
CR}v]u˙o}]olu]~CMLZ wæ hypertensives ı
CR}v]Ob}u˙o]b v Concentrated red cell transfusion vw
CR}v]ObM] æ C}vPv]oHD]bb
CR}v]P]}}voIv(}vb æ C}vPb](]o~CCFZ
R}v]˙o}vR]b æ C}viP}b}Pvb w Uæ
CR}v]SAR]b v C}viv]b Uææ Uæv Uæw
C]o}]}˘ æ Uææ Uv C}vb}v ı Uv U U Uæv
C]o}]}˘}ou]v æ Uææ C}vDub w Uwı U
C]vv]]v æ Conversion disorder væ
C]}G}˘]v U Uæ Uv Uw U U U Convulsions Uıw U Uıv Uı U Uı U
w U Uı Uæ Uæ Uæ Uv Uv Uv U ıæ UæıæUvı

v Uvı OPD C U U U Uw
C]bov æ Copper sulphate stone v
C]o}u ı C}voUo æv
Co]R}u˙]v Uæ Uæ Uæ C}}v˙HD]bb
Clavulanic acid æw Uvæ C}}v˙b}bbu
Co]vu˙]v w Uı Uw Uwæ Uı Uı U Corona virus vw U
ıw Uæw Uæı Uæ Uæ Uæ Uæw Uæı Uæıı U C}˙v]u]RR] ı
v Uv Uv Uvı Uv Uvw Uvı Uvæ C}br+vbb
Clobetasol propionate v C}b}R}v]b
Co}u](v] C}PR U U Uw U Uvw Uwæ U U
Co}vu ævæ ı Uw Uw Uææ Uæw Uæ Uæw Uvæv
Clonidine Uævw CPPD æwæ
o}]}Po v Crash
Co}]}Po v Uı Cr }]v æ U Uv Uw UæææU
Co}bFb æı ææ Uæw
Co}b]]u(]vPvb v v]v C l]vbrMB~CKrMBZ v U U U
Co}b]]uv] v Uw ææ
Co}]u}o æ Uææ Uæv Uvı U U U Crepitus æı Uæı
wv Uv v]b C u
Co}˘]oo]v ıı U U Uı U Uæw Uæ U Croup æw Uvw
æı Uæıı Uv Uv Uvw Uv Uvw Uvı Cryoprecipitate v
C}PobvPR˙o}}]
b vw C˙}}bv}(}uvb ıæ
C}Po}v(} v CSM ıæ Uı
C}ru}˘]o w Uw U Uv U Uı U CbR]vP [b S˙v}u w Uæ Uw U U U
ı U Uv U U Uæ Uæ Uææ Uæw U
æ Uæ Uæ Uæv Uæ Uæıı Uv Uv Uvw U Cyanide v
vw
INDEX
Cyanosis U Uv Uıw U Uw U Uwv U D]P]oo˘u]v}v
Uæv Uæ Uæ Uv D]P}˘]v w Uı Uæı Uv
C˙o]]v æ Uæ D]R˙}u]b]v]vrP]]v
C˙o}v]v æv D]o}˘v](}
C˙o}R}bRu] ı U Uæ Uæ D]Rv}˘˙o
Cyclosporin æ Uææw Uæ D]RR] Uı Uı
C˙bb æ U Uv Uw U D]RR]v}˘]v ı
C˙}uPo}]b w D]o}] æ Uæ
D]b}]u wı
D D]bo}}vb æıæUv
]b}˙u]
DC}b[b˙v}u b D]b}bO(TRMbo}blooS˙bu ææ
Do]v v U Uvı D]b}bO(TRRb]}˙S˙bu vw
}]v D o( D]b}b}(RSl]v æ
DrD]ub U D]bbu]v ]vbo }Po}v ~DICZ
TD v v Uv Uv
}uvb D o]]R}b]b D]]vbb v U Uæw Uv Uı U U U
D V]v TR}u}b]b ~DVTZ U Uæ U æv
v Uw U U Uv Uv D]]vbbvBol}b v
DR˙}v U U Uæ Uv Uw U U U U DKA æ Uı
Uı Uæ Uvı Uw Uw U U Uæ U U U DMARDb æ
v Uı Uı Uw U U Uv Uw Uı U D}u]v
v Uv Uv Uw Uæ Uæw Uæw Uæv Uv U D}u]}v w Uæ Uæ
væ Uvı D}˘}]]v
Do]]uTuvb~DTZ D}˘˙˙o]v æ Uw Uw Uwv U Uæv
Dob]}vb U Drv]]oou]v ææw
Dv}bu v DPT
DvoC]b æ DPr]vo]]vi˙~DILIZ ææ
b]}v D Uı U Uı Uæ Uv Uw U DPb]bvo}b]b~DRrTBZ vw
U Uv Uw Uvw Uw U Uæv Uæv U DPbvRL] ææ
ævæ Uvæı DP]o]˙ b vPb ~DSTZ w
Dub vw Uw Uwı U U Uæ Uv bDNA æw
DubR(}u]b vw Do}˘v æv
(]}˘u]v Db v D}voob
Dbu}bb]v vw Uv VT D P}R˙o˘]b æ
˘uRb D }v æ U U Uæv Uæw Uı U VT D Tuv æ
æv Uvw D˙bR]
˘}uR}Rv D D˙bo]]u] w U
˘}b D Uw Uw Uı U Uw Uıı U U D˙buv}R æ
Uıı U U Uææ Uıæ Uı Uæ Uı U D˙bb] Uæ Uæw Uæv
ı Uı Uæv D˙bRP] w Uı U Uæı
˘}b D bo]v U Uı Uæv D˙bv} æ U U Uw U Uæ
D]b Moo]b w Uı Uvw Uw U U
Uı Uæ Uı Uıv
D]bMoo]b]vPPvv˙ E
D]K}]}b]b U Uæ Uı Uvı Eæu
D]R} U U Uı Uı U Uı Uw Uı U U E N}bAvTR}D]b}b ææ
ı Uæı Uvæ Uv R˙u}b E ]b v Uı
D]u æ U Uı Uıı Uæ U U U oub E ] ıv U Uæ U U Uı
Uæ U U U Uv U U Uæ U }v}o E v
æı Uææ Uæv Uv uE wæ Uæ Uv Uæ Uvw Uw Uwı U
D]o}(v w Uw Uıæ U Uv Uw U U U U U Uæ Uvæv
ææ Uææ Uææv UææıUæv Uævæ Uæw Uæw Uæw U (]v E v Uv
æwv Uæwı Uæı Uæıv Uv Uv Uv Uvæ Eu˙u Uı Uıæ
vwı
Standard
Eu]]]v v Uv
Enalapril æ F
Ev}}vR]oTB wæ Fwæ v
Ev}]vvM}o]D]b}b w F]ov}v] U
Ev}]v v u}o] ]b}b `]R ˙ FuoIv(o]˙
}uo]}vb æ F]b}]uPo}v}uo˘
Ev}u]}b]b æ U F]v æ Uıı
Endosulfan v F}b(u v Uw
Ev}˘]v ı Uæ Uv U U Uv F}bPo}v U
Evu}R]b}o˙ U U F}bboR v Uw U U
Entecavir F U Uw U Uw Uwv Uw U Uı Uı U
Enteric fever wı ı Uıæ U U U Uæ Uv Uw Uw U U
Enterobacteriaceae vw U Uı Uı U U Uæ Uæw Uæı U
Enterococci v v Uw Uwæ Uæv Uv Uwı U U Uv U
Ephedrine æ w Uw Uw Uwı U U Uıæ Uıv Uæı U
E]u]]b æıw Uv æ Uæ Uæı Uæw Uæı Uæ Uæv Uææ Uæw U
E]u}R˙}v æ æw Uæw Uæw Uæv Uæı Uv Uvı Uv Uv U
Epilepsy Uvæ Uıv U U U U Uæ U vı
Uı U F]}u˙oP] æv Uæv Uævw
E]bo]b æv F]o]b]b ı
E]b˘]b æ F]vb]
E}]v F]IvOv U
]vbE rB w Fo]o˙b]b ı
bPob E ˙ æ Foo}˘]oo]v ææUı Uv U Uv Uæ Uæ U
oE ˙b(v}v U v Uvw Uv Uv
P}u]v E v Fo}v}o ı U U Uwv Uæv Uv
Erysipelas ı Uw Fouv]o væı
E˙Ruuo(}u w Fo}}]v}o}vb ıı

E˙Rbu Uæ Fo}˘v Uæ Uw Uæv

E˙R}u˙]v æ Uæ Uv Uv Uw U Uv U FovR]˘}o
v Uwv Uw Uæ Uæw Uv Uwv Uæv Uæ U FoRv]v
æ Uv Fob}v wı Uæ
Escherichia coli Uv Uıæ Uæıw F}o v bPuvo Po}uo}bo}b]b
Eb}u}o U Uw U Uı Uææv Uævı U ~FSGSZ ı
æwı Uv F}bAvvoC
Esotropia æ F}o.]v˙
D væ
}Pv Eb R˙~ETZ v F}o]A] v Uvæ Uw U Uw U
Etanercept ææw Uæv F}oo]o]b v
Ru}o E w Uwæ F}u]}o v
Ethanol v F}]Pv}˙]vR˙ æ
R]v˙ob E ]}oA=o}v}Pbo w Fb æ Uæı Uæı Uæı Uvı
Ethinylestradiol + norethisterone w FbRF}vPobu æ Uvw Uv Uı Uv
R}b E ˘]u] Fou]vvo](]o
R˙ov E Po˙}o v FvPoSl]vIv(}vb æ Uæ
Etoposide ı U F}bu] Uv Uw U U Uı Uı U
Eusol v ı Uı
E˘RvPvb(b]}v Fvo æ
E˘}}] æ Fvo}b]b v
E˘v P}Puu }v Iuuv]b}v ~EPIZ Fb]]] æ
Uv
E˘}bK}R˙ æ G
E˘vb]CSvu Uæ
E˘r˙u]o}vb Gvv ævw
˙E D]b}b æ GvPv Uv Uæ
v
INDEX
GvooP]vo]b w Haloperidol U U Uw U Uææ
Gastric ulcers Halothane Uææ
Gb}v]b U Uı Uv HvIv(}vb v
Gb}rb}RPoRG˘D]bb æU U HBSC vı
GvoEuPv]b v HBSS vı
Gvo]bAv˘]˙D]b}b HBSWRobu]b vı
Gvu]]v Uw Uıı U U Uı Uvæ U Headache ı Uı Uææ Uı Uı Uæı Uv U
U Uæw Uæ Uæ Uæw Uæıı Uvı Uv U v Uw Uw U Uvæ Uvæv Uvæ Uv
vı Uvæ HIvi]b æ
Gb}vo]b U Uı Heartburn æ Uı
Go}u æv Uæ Uæı HF]o U Uæ U U Uv
Go]vou] ı Uı Helicobacter pylori U Uw
Go]o] ı HELLP ~Hu}o˙b]b Eo L] Ev˙ub
Go]u]] ı L}`PooZS˙v}u ı
Go}uo.o}v~GFRZ ıv Hu]v}]
Go}uo.o}v~GFRZ ıı Hu]R˙}R˙
GoP}v ıı Hu]b]b
Go}brvrR}bR R˙}Pvb ~GvPDZ Heparin v Uæ Uv Uı U
.]v˙ æ Uv Uv U Uv U U Uı U HEvRo}R˙ Uæ Uv Uæ
Uı Hb æ Uv Uw U Uı U U U U Uæ U
Glycerol æv Uw U Uıv U Uı Uı Uv Uv Uv U
Glyceryl trinitrate v Uı w UæææUæv Uæw
Gnathopathy w H}ooo]v}u C æ Uæ
Goitre U Uæ Uv H}uPo˙ v Uw Uæ Uvı U
Gold salts ææw Heptachlor v
G}o]uu ææw Heroine ı
Gonioscopy æı HbS]uo˘Iv(}vb æw
Gonococcus v HbS]uo˘V]b v Uæw Uw Uw
Gonorrhoea wv HbV]b w
G}'}v[bob æv Hb}bZ Uæı Uv Uv Uv
G}'}v[bb]Pv æv H(}uob æ
Gout ı U U Uæw Uæw Uæw Uæwæ Hiatus hernia æ U U
Granisetron æ Uı U H]PR}v˙V]u]vB
G[b]bb æ HLArBw æv
Griseofulvin æ Uæ Uæ Uv H}Pl]v[bL˙uR}u w Uwı
Guaifenesin H}or]vrH
G˙v}o}P]oD]b}b æ H}}l`}u ıı Uæ
H}u}v Rouv TR˙ ~HRTZ æ U
H v Uvææ
H}b]o]vu}v] w
HuR}b]b æw H}`}ORS v
Huub]b æ HRZE w Uw
Hu}o}P]oD]b}b v Huv Iuuv .]v˙ D V]b U Uı U
Hu] v U Uæ U U Uv U Uæ Uæı Uw U Uw U Uw Uıv U U
Hu}o˙b]b æ Uv U Uı æ Uææ Uæı Uv Uw Uwı U Uw Uv U
Hu}R]o]A vw Uv U U U U Uv U Uv U U
Hu}R]o]B v ı Uı Uv Uv Uv Uw Uw Uw Uw U
Hu}R]ob ]vGv ı Uw U Uıæ U wæ Uıæ Uææ Uæ UæææUæv Uæw Uv Uvı U
æı Uæ Uæw Uæı Uæıw væ Uv
Hu}R]obIvGv˙D]bb ı HuvIuuvTvbGo}o]v v
Hu}˙b]b w Uw Uı HuvP]oo}uV]bHPV v Uv Uæ
Hu}RP]S}l HuvTvbIuuv}Po}o]v
Hu}R}]b ı U Uv H˙o]v æ Uæ Uæv U
Hoo]v}vb U Uæ H˙}Ro}}R]] ı
v
Standard Trtme
H˙}}b}v w Uw Uv Uw Uw Uwæ U ˙~IPTZ ı Uı Uı
U U Uæ U Uı U Uæw Uæ U Iv]P} ææ U U
æı Uv Uvæ Uvw Iv]v}v]~IUCDZ w U
Hydrops fetalis w Uwı
H˙}˘˙u] w Ivv}b]uuv}Po}o]v æw
H˙}˘˙Ro}}]v ææw Uævı Uæ Uæ ]vv}bP]}vovbRb]~IVRAZ v
H˙}˘˙}ou]v v Ivb]Pvu}}oD]bb~IPDZ ıæ
H˙}˘˙uR˙oooo}b æ I}]u}u] w Uw Uæ Uvw
H˙}b]v˙o}u] æ IPT `]R bo(}˘]vr˙]uRu]v ~IPTr
H˙]o]]vu] æU U SPZ ı
H˙ou] ı U Uw U I}v.]v˙
D Avu] æ Uv
H˙˙v}'l U U U Uæ I}v˘v v
H˙ub]bG]u I}v~IIIZR˙}˘]P}o˙uo}b}uo˘ w
H˙u}] æ I}v}v
H˙˙˘] v I}v}bb v U
Hypertension Uv Uæ U U U U IbRu]HD]bb æ U Uæw
Uæ U Uæ U Uı Uıæ Uıw Uı U Ib}v]] UææUw Uwæ Uwv
æ Uæ Uvı Ib}b}]D]v] w U
Hypertension in children and adolescents æ I}v}o æ Uæw U U Uv
H˙vb]}vIvPPvv˙
H˙vb]EuPv]b æ J
Hypertensive encephalopathy æ Uæ Uıv U
ı Jv] Uæ Uw Uı U Uı Uæ Uæ UææUv U
H˙R˙}]]bu Uw U U U U U vı Uı Uı U U U Uæ U Uæ Uw U
æ Uvı væ
Hypertonic Saline æ Jv]oI]}R]AR]b ææw
H˙}ou]vu] ı U U Uı
H˙}Po˙u] væ U U U Uı U U K

ıv
H˙}R˙}]]bu ı Uv U Uw Uæw Uw U KDIGO ı
U U Uæv Kb æv
K}uo] æ
K}R˙ æ
I Kv]b æU U U
I}(v w Uv Uv Uıæ U Uv Uæı U Ku]v æ Uæ
Uvı Uæ Uææ Uææ Uææ Uææ Uææ UææıU K}}v}o ææ
æv Uæw Uæwv Uæı Uæıv Uv Uv Uv Uvæ K}}v}obRu}}
I]}R]]vGuu}˙u˙}R]b~IIMZ æv Kob]oo w Uı Uv
Iu]u]v ı Uı Uæ Uw Kob]oovu}v] w Uı
IuuvPo}o]v æ Koul[bPob˙ æ
Iuuv]b}v Uv U U U Uv U Uı U K}o]lb}b
w U K`bR]}l} æ Uæı
IuP} v
Iu}v L
Iv}uR]v ææı
Iv(S}lb Lo}o æ Uææ Uæv U
IvG]˘]u ææw Uæv Lo}b U Uæ
IvGv]b LP}RRou}b æ
INR v Uı U Uæ Uw Uæ Uæv Uæw Uv Uv Uı U Lu]]v Uv Uv Uv
w Uv Lu}]P]v
Ivb}uv] Uw Uı Uı Uıw LPCR}v]Uob væ
Ivbo]vPu]˘ ı L˙vP}R}}vR]b~LTBZ ææ
Iv(}v U Uæ LGv}u] ææw
Ivu]'vPvTuv]vPPvv r LP]}voovu}R]o w
v
INDEX
LRP˙ ı U UææU Uıw Uıv Uæ Uæı U M(vu]] æı Uw Uw U
væ Uvæı Uv M.]b}v v
Llu] wæ Uwv Uæw Melatonin v U
L}R˙}˘]v æ Muv}bvR}R˙ ı
L]Rvovb vw Muv}b}o](Po}uo}vR]b
L]Rvb]uo˘R}v]b vw ~MPGNZ ı
L]}]v væ Uv Mv][b]bb væ
L]Pv}]v v Mv]vP]b Uı Uıæ Uıv Uw Uı Uı Uıv U
L]vv wv Uv Uæ U Uw Uw Uw Uwæ U Uw U
L]]8v U ıæ Uıv Uıı Uæı Uv Uvı Uvw
L]b]v}]o U Uı Uæ Uı U Menopause
L]b] ıı M}vu ıı
L]R]u Uı Uv M}u]v ı Uı
L}ovbR~LAZAPvb v Methadone
o}u] Methanol v
L}]v] v Uv MR]]oo]vb]bvSRXb v
L}u æ Uı U Uv U U U U MR}˘ æ Uææw Uæv Uæv Uæw Uæwv U
Uææ Uvw æ Uæ
L}bv Uı Uæ Uæ U MR}˘˙ }o˙R˙ov Po˙}o }]v
L}`]v˙˙u}ub
b ~LUTSZ Uı
L`]PbAvP]v æ Methyldopa æ U
LvPbA ı Methylphenidate U
L˙uRv}R˙ w Uæv Uææ Uæw Methylprednisolone ææ Uæwv Uæw
M}o}u] w Uæ Uæ Uæ Uı U Uı U
M w U Uv Uv
M}o}v ı
MPvb]uboR Uææ Metoprolol v U Uı Uæ Uæ Uv
MPvb]u]b]o] Uı M}v]}o U U U U Uæ Uw Uw U
Mi}b]}v v Uw ı Uæw Uv Uv Uvæ Uwæ U Uæw Uæ U
Malaria æ Uw U U U Uı Uw U æı Uæ Uæ Uæ Uæ Uæ Uæw Uæ Uæı U
Uı Uı Uv Uv æı Uvw Uv Uvı Uv Uvı
Mo]IvPPvv˙ Uı M]}v}o æ Uææ Uæv Uw U U Uæ U
uob]b (( æ Uææ wv Uæv Uv Uv
Malathion vı Uw M]}b}u æ
Mo]Pvv]b vææ M]}ou ı Uvæ
Mo]PvvL˙uR}u w M]P]v ı Uıæ Uæv
Mov]}v æ Uæı Miliaria vw Uw
MvPuv oP}]Ru (} A P r M]ol}(MPvb]
u}oP}]b]}v]vP æv M]v]uoRvP]b~MCb DZ ı
MvPuv}(P]v A væ Minocycline ææw
MvPuv}(RH}S`}oovJ}]v æw M]v}W]Rò ı
Mania v Uv Uw Misoprostol v Uv Uv Uvw Uv Uvı Uw
Mannitol Uæ Uvı M]bK}o]v
Mv}˘b w Uæv Uvæ Mitral valve prolapse
Mbub æ Uæı MXlvbb]] w
M]iv U U Uı MXuou}vb] w
Mb}˙ubo˙b(v}v æı MXu]} w
MXRo]b æw M}ub}v U Uv
MDRrTB w Monilia Uææ
Measles U U Uæ Uææ Montelukast wı
Mv}o Uæ Uæ M}˘ooRo]b
M]]vbvRK]v˙ Morphine ı Uæ UææUw Uı U Uv U U
M]]vbUbIvTREoo˙ v w Uw Uv Uv Uæv Uæw Uæı Uæıv Uv U
M}˘˙}Pb}v w vw Uvæ
v
Standard
M}RUob æ Uv Uı Uı Uææ Uv
MRSA~MR]]oo]vb]bvZ w Norovirus
MoDPRb]bvrTB~MDRrTBZ w NSAIDrbb}] }vo } Pb] o
Moou˙o}u w vPb}r}vo}b]}vb
Mo]u]v NSAIDb U Uv U Uw Uıv Uıw U U
Mupirocin v Uw ææıUæw Uæw Uæ Uvæ
M˙oP] æ Uæv Uæw Uæ N]}voD]b}b æ
M˙bRv]P]b æ NYHA
M˙}]u(]vu w Uvæ N˙bPub ı U
M˙}]u}]b w Uvæ N˙bv ı Uæv Uv
M˙}]u o}b]b w Uıæ Uv U
v æ O
M˙}]uovb ı
Mycophenolate æw Uæ Uæ Ob]˙ æ Uw Uæ U Uv
M˙}Rv}ou}(o æw Uæ Oobo]bRu}v˙ æı
M˙}obuvu}v] w Uw O}voR˙ æææUææıUæv
O}v}Pv]Iv(}vb ææ
Ob}RPov]]b]b Uı
N Ob}RPouv}u˙
NrA˙o˙b]v æv Uæw U Uv Uv Ob}RPo]v w
No}˘}v væı Ob}RPobu
N}˘v ææ UææıUæv Uæw Uæwv Uæı Uæıv U Ob}RP]b æ
v Uv Ob}Pvu æ
Nausea w UææUæv Uı U U Uææ Uvæ U OP]o]˙v}ub
ı Uv U Uı Uw Uæ Uı U Uæw U O]oub}
væ Uv Uv Oov]v U U Uw U
Nebulised adrenaline vw Oo]P}bu]
N}]vPFb]]b v Ou}o U Uv Uw U Uı UæææUævı U

N]b]b P}v}R} v Uw æwı Uv

N]b]b uv]vP]b ıæ OvR}]b]b vw
N}u˙]v æı Ovvb}v æ Uı U U U
N}vo}viv]b v Uæ }v˙R}u˙}b]b æ
N}voH˙}Po˙u] ı U OvFb æı
N}voJv] æU O]}]`]Rò ı U
Neonate ıw U U U U Uv Uæv Uæ O]bR}}vb v
NR}ob}u OovDvoC}v]}vb æ
NR}S˙v}u v U Uı OoCv]]b]b ææ Uææ
N]vi]b æ OoSu}bCoo]v}u
C æ
Nevirapine ææUv Uv OPv}Ro}]v v
N`}v æ U Uıw U U Uv U U U ORS v Uw Uı
æ Uæw Ob}R]b ææ
N`Y}lHAb}]}v~NYHAZCobb]. r Ob}Pvb]bIu( v
}v Ob}uo] v
N]o}bu] æ Ob}}}b]b vı
Nifedipine æ Uæ Uæ Uææ Ob}}u]b ææ Uv
Nitrofurantoin w Ob u] ı Uæ U U Uı Uıæ Uvw Uı U
N}vr}b]GERD v v U Uæı Uæ
N}vrH}Pl]v[bL˙uR}u w Uwı O`]PR U
N}vrS].Sl]vIv(}vb v O˘˙Pv v Uı Uı U Uv U U Uw U
N}vrSTrbPuv o}v u˙}]o ]v( r w U Uæ Uıw Uæ Uæv Uæ Uvæ Uvw
}v~NSTEMIZ O˘˙PvTR˙ ı
Norethisterone w Uw O˘˙u}o]v æ
N}G}˘]v æ O˘˙}]v v Uv Uv Uvw
N}uoSo]v w Uı U Uæv Uıı Uv Uwæ U
v
INDEX
P]uob wv Uw U
P P]}Po]}v ı
Ploob væ Uw Uwæ Uw Uwı U U P]˙]b]b ææ
P]vO]P]vvP(}uROb}RPb w P]˙]b]bVb]}o} ææ
Pu]}v v P]˙}b}u}]o ææ
Pv]D]b}b v P]˙}b}u}o ææ Uwı
Pbu v Uv Pou}]uuo]
Pu}o U U UææUæv Uæw Uw Uw U U PobuCooM˙o}u w
Uv Uw U Uıæ U Uv Uæ Uv U Pobuouv ı
wæ Uæı U Uvı Uw Uææ Uæ Uæ Uæ U Pobu}]uX See Malaria
æ Uæ Uæ Uæ Uæ Uæw Uææv Uæv Uævæ U Pobu}]u(o]u
æ Uæ Uæw Uæı Uæıv Uv Uv Uv Uvæ U Pobu}]uuo] ı
væ Uv Uvı Pobu}]u}o
Pu}o}˘]]˙ æv PooC}vv v
PoP] w Uvæv red cell concentrate v
P v Poovb(b]}v v Uwæ Uw Uwı
Pl]vb}v[b]bb æ Poo+b]}v Uw Uw Uı
P}u}u˙]v Pvu}}oC}viPV]v~PCVZ ıæ
P}˘˙buov]o
b R˙] æı Pvu}}oD]bb ıæ
PCV Pvu}}o~PCVZ
PCV Pvu}}o P}o˙bR] V]v
P]o}b]b vw Uw ~PPSVZ ıæ
PP˙oIv(}vAoR U Pvu}}b ıı Uæ
PP˙oIv(}vAoR Pvu}˙bbi]}] w
Po] IvGuu}˙ ]bb ~PIDZ wı U U Pvu}v] U U Uvı Uwv Uw Uv
Pvu}R}˘ Uw
Pv]]oo]vooP˙ v U Uæw Uıw Uæ Uæw U P}o]} U
æ Uv P}o]}u˙o]b ı
Pv]]oo]vV v Uv P}o]}]b ı
PvrV]v U }o˙R]b ææ Uæw Uæw
PUoD]bb Uv U U P}o˙˙b}]v˙v}u
b w U
P]]o+b]}v Uw P}o˙ubR]v}v~PCRZ v
P]]b U Uæ Uıw P}o˙]v˙oo}R}o æ
PuR]v v P}bE˘}bP}R˙o˘]b v
Pv]]}bvu] v P}bHNoP] ı Uæı Uv
Pb}vbo]]vP`]RHIV]v(}v~PLHIVZ v P}bb]u]
Pbb]b U P}]}v]}]v v Uv Uwv
Pbb]b]v PPHw Uw Uı
PR] v Uv Uı PPI Uı
PR]]v æ Uv Uv Uæw Uæı Uæıv Uvw U P]vo æ
væ P}b]v æ
PR}R}u}˙}u æ U Pv]b}o}v v Uv Uw Uwı Uv Uwæ U
PR˙vP]b æ ı Uwæ Uæv UæææUææıUæv Uævı Uæw Uæw U
PRv}]o U æwv Uæwı Uæ Uvæ Uvw
PRv}]}v Uıı Uıı U PPo]v v Uææ Uæv Uævw
PRv}˘˙uR˙ov]]oo]v v Uv PPvv˙]vRb]looo]bb
PRv˙}]v ææUıı U Uw Uvı Uvw PuR}(RMuvb æv
PR}bR}] æwv Pu]˙ ıw U U
PR}}R}] ıæ Uææ Uæı Uæ Puo} ı Uæ
PR}}R˙ Uæ PuL}]vPuo]˙ D æ
PR˙b]}R˙ vw Uw Uı Uæ Uææ UæææUææ U P]]bu vı Uwv
æv Uæw Uæwæ Uv Uvæ Uv Uvæ P]u˙Go}uoD]bb ı
PR˙}uv]}v v Uv P]u˙]v(o]˙
PID wı U U P}v] æwv
væ
Standard Trtme
P}]vPv]]oo]v æ R] D]Pv}b Tb ~RDTZ Uæ U U
P}}b}˙ U U Uv
P}}b]Pu}]}b}˙ RE˙Ru w
P}uR]v æ Uæ Uv Uw U Uv U R˙}TR E F}}~RUTFZ v
v Uv R}u]vvF}VIII vw
P}vRo]v}u] æ Red Eye æv
P}]}v]]uvb w RSvP~RSoo Z w
P}v}o}o U Uæ Uıæ Uv Uw Ro˘}v]v]vP æ Uw
P}}b]b æ Rb]}˙S˙v˙oV]b~RSVZ vw
P}˙oR]}]o v Retained placenta
P}b].
b vPv~PSAZ ı Rv}ob}u
P}bbu ı R}R˙vPobA æ
P}]vvP˙uov]}v æ Retrovirus w
P}bu]]o]b v Rhesus Uı Uv Uv Uv Uv Uvw Uv
P}boP]b æ Rhesus factor vw
P}R}u]vu Uv Uw RRbbIb}uuv]}v v
P]P} vw RRuR]bb Uæw Uv
P]b Uv UææUv Uvw Uv U Uıw RRu}]R]b ææ Uææw
PSA ı RRu}](} æææUææ Uæv
Pb}rP} æwæ Rhinoviruses vw
Pb}u}vb w Uıı Uæ Ribavirin
Pb}]bb Rickets v
Pb}]b]b Uæw R](u]]v æ Uw Uæ w Uw
Pb˙R]]D]b}b w Uı R](˘]u]v æ
Pb˙R}}v Uw U R]vP [b o w U U U U U U
Pb˙R}Pv]S]b ı
Pb˙R}b]b U Risperidone U Uw U
Pb˙R}buov`]Rò R]˘]u ææw Uæv Uæw Uæ Uæ

Pb˙R}R˙ ı U U Uw U Uææı R]}˘v v

P]u U Uv Uv U Uı Uı R}˘]v æv
Pou}v˙]oR˙vb]}v Ropivacaine v
Pou}v˙Eu}ob~PEZ U Uw Uv R}bvb U U U
Pou}v˙R}u}u}o]bu Rotavirus U Uı U U
P].(}IX v Rotavirus vaccine ı
P].(}VIII v RPRvæ Uv U
P ı Uv Uv RUTF v
P˙o}vR]b æ Uææ
P˙o}]v}b b ]b ı Uæ Uı Uı Uv Uæw S
P˙]vu] w Uwæ
P˙R]v v Sou}o wv Uw Uw Uwı U Uæ Uææ U
P˙R}] v v Uvw
P˙˘] Salicylic acid w U
P˙]}˘]v w Uwæ Sou}voo U Uæıw
P˙]uRu]v w Uı Sor}}Ruvou]vb}o}v
S˘Po]v ı
Scabies vw Uv
Q SCD Uæ
Quinine w U Uı Uı Uı SR]b}b}uuvb}v] ı
SR]}Rv] ı U
R So]b æv
Scurvy v
R}o Uw Sb}vo Mo] CRu}v}v ~SMCZ
Radiocontrast ı
Ru]]o Uı Uæ S}R}]ub vw
v
INDEX
S}R}]uE wı U SR˙o}}b}R˙b b v
Sv]}o wæ SbE]ob ıı
S]b ı U U U Uææ Uıv Uıw U U SvbrJ}Rvb}v˙v}u b w Uw Uæ
Uı Uı U Uw Uæw Uæ STI Uw Uw Uwæ Uwı
So }Pv b } u}o}b Soo[b]bb ææw
~SERMbZ v Suob}v}oR˙ æ
Sov]uboR] æv U S]bub Uæ Uæ
Senna U SX(o]b æıw
Su] ı Uıæ Uw Uı U U Uv Streptococcus ıæ Uv Uw U Uw Uıæ U
SPvo}u v æı Uæ Uæ Uæv Uæı Uæ Uæı Uæ Uææ U
Sertraline ı Uæ Uw v Uv Uvw
Severe Malaria v S}}bu]b æ
S}}bE ]GERD w S}}bvu}v] w Uæw
S˘oo˙ Tvbu]' Iv(}v ~STIZ w Uıw U S}}bvu}v] ıæ U Uıæ Uæı U
æı
SR' S}}b˙}Pvb w Uw Uæı Uv
SR]Poo Streptococcus salivarius æ
S]lo oo C D]bb v Uvı Uıæ U U
Uæ U S}}bbvP]b æ
w Uæ Uv Uv S}u˙]v æ Uw Uwæ
S]loCooD]bbIvPPvv˙ SX˙}Pvb æıw Uv
S]loCooD]bbWRv}R˙ æ
Stridor Uı Uææ Uæ Uæı Uæ Uv Uvw
S]lorooVb}r}ob]C]b]b v
Stroke Uw U Uı U U U Uv U
S]lv`}v ıw w Uı Uæ Uææ Uæ Uv Uvæ Uv Uw U
S]Pu}]}b}˙ ıv Uıw U Uæ Uı U
Silver nitrate v S}vP˙o}]b ıı Uæ
S]uoo]vb S}vu v
S]ubv U S }RA } R S]}bo˙ Ioo CR]o
Sinus bradycardia æv v
S]vb]b ı Uæv STrbPuv o}v u˙}]o ]v(}v
Sirdalud æv STEMI U U
S]Po]v ı SRv}]Ru}RP Uæ
SLE v Uæw S}vivoRu}RP æv
SoR˙P]v æv SPooHu}RP Uæ
S}]uB]}v Uıæ Uı Uı
SbvUb]b}b ı
S}]u CRo}] vw Uw Uı Uv Uw
U U So(bo]v ææw
U Uv Uı Uv SoR}˘]v ı Uı Uıæ
S}]uTR]}bo( v SoRuR}˘}orP˙]uRu]v~SPZ w
S}]uo} U Uw Uı S.]oFvPoSl]vIv(}vb æ
S}ooIvbo]v ı Uıæ Uı S˙bu]]oR˙vb]}v
S}}R]vPPv~`]R}`]R}}]b b Z S˙bu]LbE˙Ru}bb Uı Uæw
Spirochaetes æw S˙bu]}vbR]b~Soo[b]bbZ ææw
S]}u˙ wv U S˙bu]R}u}u}o]bu æ Uv
Spironolactone w Uı Uæ
Sov}uPo˙ v Uw Uwv Uw U T
Spots Uwv
Squint Tachycardia ı U Uw Uæ U U Uvæ U
SoAvP]v ı U Uv Uı Uv Uv Uv
SovP]v}]b æ Tachypnoea w Uæ U Uwæ Uı Uv U
SoR}v]}vR]b v Uæv Uæ Uvı
SRX]u]]b æıw T}o]ub æ Uæ
Staphylococci v Uıı Uæ Uv Uv Tubo}b]v
Staphylococcus aureus w Uw U Uı U TBuv]vP]b w
æ Uw Uw Uıæ Uæı Uæ Uæw Uæı Uæı U Tu}}ruv]oi}]v æı
æıw Uv Uv Uv Uvw Tu}}ruv]oi}]v˙b(v}v æı
vw
Standard Trtme
Tenofovir Uæ Uv Uv Uv T]R}u}vbP]vo]b w
T}b]v T]R}u}v]b]b wæ
T]v.v æ Uæ Trichophyton æ
T] v T]Pu]vovoP] ı
Tetanol Uv T]Pu]vovoP] ææ
Tetanus Uv Uw U Uı U Uv Uæı Uvæ U T]Pu]voNoP] ææ
vw Uv Uvı T]R˘˙Rv]˙o
TvbP}R˙o˘]b v T]uR}]ulSoRuR}˘}o æ
Tetracaine hydrochloride ææ Troponin v U U Uææ
Tetracycline æ Uw Uæw Uæ Uæ Tuberculosis v Uw Uvæ
To}P˙}(Foo}~TOFZ Tuberculosis in orthopaedics væ
TRo˙A D]bPv ı U T˙R}] F æ Uv Uı Uı Uwı U U
TRUv}vb]}bPv
TR]u]v U
TR]]D]b ı U
TR}u}˙}v] v U U Uv
Thyroid eye disease æ Uv}uo]Mo]
TR˙}}˘]}b]b U Uæw Uæ Uv U U Uv}vb]}bvbb U Uæ Uææ U U
Uæ Uv Uw U æ Uı Uı
TIA ı U Uvæ Uv Uu] æ
T]v}o æ U] ] w U U U Uw Uı Uæw U
TIBC æ æw Uæw Uæwæ
Tinea æv Uæw Uvw U U]v˙ T Iv(}v ~UTIZ ı U U U
T]v]b æ w Uæı U U U U Uw Uææ
Tinea corporis æ U] vw Uw Uw Uw Uv
Tinea cruris æ
T]vuvu æ V
Tinea pedis æ Uæ

T]vVb]}o} æv Uæw V]vrbb}] o˙ }o]}u˙o]b

T]v]}o ~VAPPZ ı
T]}}]u æ VP]v]b wæ Uwv
T]v]]v æv Vobv æ
TMJ æı VooHD]bb
T}]o]u ææw Vv}u˙]v w Uıw Uı Uıı Uv Uv
Tocolysis ææ V]oo æı Uv Uv
T}[bo˙b]b ıw V]ooW}b]b æı
T}(]v] ææw V]}bu wı
T}ou] ı Vb}]o}b æ Uæ
T}vb]oo]b w Uæ Vb}r}ob]}v]v]bb w
T}˘]o}R}ob væw Uv VDRL æ Uvæ Uv
T}˘]]uov}o˙b]b~TENZ w Vu]o v Uæı Uv
T}˘]uorv}oP}] æ VP} ı Uv
T}˘}obu ıæ VboNb æ
TPHA v V]]}R}o
Tu}o æ Uw Uıæ Uæv Uævæ Uvæ V]oPo]v ı
Tv˘u]] v Uw V]v]bv ı U
vb]v]bRu]'l~TIAZ ı V]oSl]vIv(}vb æw
Tvb}b]}v}(RG]bA ~TGAZ V]u]vA æı Uv U Uæ Uæ
TuAvIvi]b æ V]u]vAbouv}v v
TuvIvH˙}Po˙u] ı V]u]vBv w Uwæ
T}vuv æ V]u]v.]v˙BD væ
Tv}]v w V]u]v B ~H˙}˘}}ou]vZ v Uv Uvæ U
T]u]v}o}v ææ Uæwv æv
T]}ou v V]u]vrC v
v
INDEX
V]u]vrC.]v˙ v
V]u]vrD v Uvw Uvı Uv
V]u]vK v Uvw Uv
V}u]vP U Uæ U Uı U U Uæ Uw U
Uı Uæ Uæ Uæv Uæw Uæ U Uı Uıw Uı U U
U Uı Uw Uææ Uvæ Uı U Uı U
U U Uı Uw Uı U Uæ Uv U
v Uv U U Uı Uı Uıv U Uw U
w U Uv Uıæ Uıı Uæı Uæı Uæ Uæ U
æv Uæı Uv Uvæv Uvæ Uv Uv Uv Uvı
V}vW]oovD]bb v Uv
VRSA~Vv}u˙]vb]bvZ w
W
W(]v v Uv Uı Uv
WR]u[bR˙b}u˙ v
WRob w Uw
WR]]o[b}]vuv æ Uææ Uæv Uæ
WHOG]vP}(TR}u æw
W]oubTu}
W}uIv(b}v~IvbvoZ ıı
W}u]v(b}vb v
W}ub ıı Uæ
X
X}RRou] æ
X˙o}u}o]v v
Y
Y`b æ Uæ
Yoo}`F w U Uı
Yoo}`(]b ı
Z
Z]}]v v Uv
Z]RorNobv]v b w Uæ
Z]v æ Uı Uw
Z]v}˘] w
Z]vbouv}v(}]R} æ
vı
Standard Trtme
OtherPublictions
a
yy GRv Abuv }( M]]vb P}uv v So˙ MvP r

uv˙bb ub]vRPo]HoRS}U}v˙ A R}~ıZ
yy Pvb M]vP (} M]]vb P}uv v So˙ MvP r
uv]vGRv~ıZ
yy SvTuvG]o]vb~Z
yy GRvEbvoM]]vbL]b~Z
yy N}voDPbP}o]˙~Z
yy C} }( R]b E v Svb }( P (} T]}vo M]]vb
P}vb]vGRv~Z
yy Sv }( PRuo C (} HoR Ivb}vb ]v GRv
~Z
yy Ivb]vP Ab } M]]vbP Av Abuv v P}o]˙ O}vb
(}GRv~Z
yy AvAbuv}(RPRuoS}]vGRv~Z
yy L}P]bb MvPuv }( Po] S} HoR C}uu}]b ]v GR r
vPvb OvPP}bWRP]}voM]oS}b}S r
]Do]˙P}]vb~Z
yy DPbvTRbC}uu]'~DTCZT]v]vPMvo~Z
yy SvTuvG]o]vb~Z
yy GRvEbvoDPbL]b~Z
yy Bbo]vS˙}vRPRuoS}]vGRv~ıııZ

yy P}uvP}Mvo~ıııZ
yy P}uvT]v]vPMvo
yy R}voDPUbT]v]vPMvo
yy SvTuvG]o]vbUv th
]}v
E U~Z
yy EbvoM]]vbL]bUv th
]}v
E U~Z
vı

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TorP)Suu˙}(uvPuv}(]}bPb b }(CKD �����������������������

Ministry of Health and its agencies

Public Health Programmes

TR G}vuv }( GRvU R}PR R N}vo M]]v P}o]˙U

How to use this book

Prescribing for NHIS reimbursement

R oU o]v]o ]v]}vb (} R]b }X Ub R }o }

(}u b v }vP v Ru}]P]ov ]b vob

Eyes N}uo Sunken V˙bvlvv

TorP) Treatment by Fluid Therapy - Plan B

9. R}]b Disease and Diarrhoea

11. PUo Disease

D. Helicobacter pylori Eradication

v*Gatrs oroeops hagealRefluxDisse*a v

yy Hb vb ~HBbAPU HCV Av}˙U Hb A IPMU Hb E

R( vb `]R ]o˙ }Pbb]vP ˙u}ub

B. Decompensated liver cirrhosis/ Fulminant Liver failure from

N}vrb}vPb}v `]R AvrHBb AM MIUluo L v } u}HBV] r

yy PP˙oIv(}v o(r Uv}b

yy PP˙oIv(}v o(r Uv}b

16. Drugs and the Liver

18. Bleeding Disorders

19. Sickle Cell Disease

20. Plasma Cell Myeloma

22. Malignant Lymphoma

TRv bRo (}}v Iuuv]b}v (} R]ov v æ

B}˘ærP) Notes on Vaccine use

Measles ]b v ]v(}b ]bbU `R]R boo˙ }b ]v

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30. Haemophilus Influenzae type b Disease

31. Pneumococcal Disease

G. For bowel related sepsis

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35. Neonatal Hypoglycaemia

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B}˘vrP) Exchange transfusion

37. Birth Injuries

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X Ischaemic Heart Disease

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X Deep Vein Thrombosis (DVT)

B}˘wrP) Well’s scoring for PE probability

F]PwrP) Flowchart: Stroke

F]PwræP)Flowchart: Heart Failure

X Congenital Heart Disease

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F]PwrP) Flowchart: Hypertension

52. Hypertension in children and adolescents

53. Hypertension in Pregnancy

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57. Dizziness and Blackouts

58. Common Cold

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TorP)Suu˙}(uvPuv}(]}bPb b }(CKD ��

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