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Hospital Care for Adolescents and Adults VOLUME 2 VOLUME VOLUME 2 IMAI DISTRICT CLINICIAN MANUAL: HOSPITAL CAREFORADOLESCENTSANDADULTS HOSPITAL IMAI DISTRICTCLINICIANMANUAL: IMAI District Clinician Manual: Hospital Care for Adolescents and Adults GUIDELINES FOR THE MANAGEMENT OF COMMON ILLNESSES WITH LIMITED RESOURCES For further information please contact: Integrated Management of Adolescent and Adult Illness (IMAI) IMAI Team Department of HIV/AIDS World Health Organisation Avenue Appia, 20 CH–1211 Geneva 27 Switzerland [email protected] www.who.int/hiv/capacity/en WHO FFINALINAL CCoverover VVol.ol. 22.indd.indd 1 228/06/20128/06/2012 17:2617:26 WHO Library Cataloguing-in-Publication Data IMAI district clinician manual: hospital care for adolescents and adults: guidelines for the management of illnesses with limited-resources. 2 v. 1.Community health services - standards. 2.Hospitals. 3.Delivery of health care - standards. 4.Clinical competence. 5.Disease management. 6.Adolescent. 7.Adult. 8.Manuals. 9.Developing countries. I.World Health Organization. ISBN 978 92 4 154831 1 (package) (NLM classifi cation: WA 546) ISBN 978 92 4 154828 1 (vol. 1) ISBN 978 92 4 154829 0 (vol. 2) © World Health Organization 2011 All rights reserved. Publications of the World Health Organization are available on the WHO web site (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@ who.int). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press through the WHO web site (http:// www.who.int/about/licensing/copyright_form/en/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specifi c companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Cover images: © Bahizi Jovan (left), Petra Rohr-Rouendaal (right). Production coordination: L’IV Com Sàrl, Villars-sous-Yens, Switzerland. Printed in Switzerland. FFINALINAL CCoverover VVol.ol. 22.indd.indd 2 228/06/20128/06/2012 17:2617:26 Untitled-1 1 20/11/2009 15:07 VOLUME 2 IMAI District Clinician Manual: Hospital Care for Adolescents and Adults GUIDELINES FOR THE MANAGEMENT OF COMMON ILLNESSES WITH LIMITED RESOURCES Integrated Management of Adolescent and Adult Illness (IMAI) FFINALINAL VVol.ol. 2 CCHH 99-21.indd-21.indd i 229/06/20129/06/2012 115:155:15 Table of contents Foreword ............................................... xiii 9. HIV diagnosis ........................................... 1 9.1 Provider-initiated HIV testing and counselling at the district hospital and the role of the district clinician ................................ 3 9.2 Re-testing and repeat testing .................................... 7 9.2.1 Re-testing for HIV-negative individuals in the context of a generalized epidemic ............................... 9 9.2.2 Re-testing for HIV-negative individuals in low level or concentrated epidemics ............................. 11 9.2.3 Explain to patients the meaning of discordant or HIV-negative test results .. 13 9.3 CD4 testing .............................................. 14 10. Acute and subacute by symptom ........................ 15 10.1 Fever ................................................ 19 10.1.1 Clinical approach .................................. 19 10.1.2 Consider likely differential diagnosis using the DDx tables .......... 22 10.1.3 Initiate treatment(s), monitor response, and reconsider diagnosis ..... 27 10.1.4 Management of severely ill patient with fever ................. 28 10.1.5 Management of fever as an outpatient (not severely ill) ........... 29 10.2 Skin disorders .......................................... 30 10.2.1 Clinical approach .................................. 31 10.2.2 Skin and soft tissue infections ........................... 34 10.2.3 Papular lesions .................................... 38 10.2.4 Vesicular or bullous lesions ............................ 48 10.2.5 Nodular lesions .................................... 49 10.2.6 Maculopapular rash ................................. 52 10.2.7 Plaques ........................................ 53 10.2.8 Pruritus ........................................ 57 10.2.9 Urticaria ........................................ 60 10.2.10 Skin ulcers ...................................... 61 10.3 Weight loss and malnutrition ................................. 69 10.3.1 Clinical approach .................................. 70 10.3.2 Consider the likely cause of loss of weight ................... 75 10.3.3 Treat weight loss and malnutrition and its underlying causes ........ 78 10.3.4 Prevent malnutrition ................................. 81 10.4 Swelling of the limbs ...................................... 84 10.4.1 Clinical approach .................................. 85 10.4.2 Differential diagnosis of oedema ......................... 86 10.4.3 Treatment of limb swelling ............................. 88 10.4.4 Symptom management ............................... 89 10.4.5 Manage lymphoedema ............................... 89 10.5 Lymphadenopathy and lumps ................................. 90 10.5.1 Clinical approach .................................. 90 10.5.2 Classify the lymphadenopathy and consider the differential diagnosis .. 92 10.5.3 Approach to lymphadenopathy in PLHIV ..................... 95 10.5.4 Symptom management of lymphadenopathy .................. 96 ii Vol. 2 • Table of contents FFINALINAL VVol.ol. 2 CCHH 99-21.indd-21.indd iiii 229/06/20129/06/2012 115:155:15 10.6 Chest symptoms: cough and shortness of breath ..................... 97 10.6.1 Clinical approach .................................. 97 10.6.2 Differential diagnosis of chest complaints ...................102 10.6.3 Pneumonia ......................................111 10.6.4 Asthma .........................................115 10.6.5 Chronic obstructive pulmonary disease (COPD) ................118 10.7 Abdominal complaints .....................................123 10.7a Abdominal pain ..........................................123 10.7a.1 Clinical approach ..................................123 10.7a.2 Differential diagnosis of abdominal pain and management of specifi c conditions ...............................126 10.7a.3 Approach to abdominal pain in PLHIV ......................134 10.7b Painful or diffi culty swallowing ................................136 10.7b.1 Clinical approach ..................................136 10.7b.2 Differential diagnosis and treatment of painful or diffi cult swallowing ...137 10.7b.3 Approach to oesophagitis in PLHIV ........................138 10.7c Nausea and vomiting ......................................140 10.7c.1 Clinical approach ..................................140 10.7c.2 Differential diagnosis and treatment of nausea or vomiting .........141 10.7c.3 Symptom management for nausea or vomiting .................145 10.7d Diarrhoea (and constipation)..................................146 10.7d.1 Clinical approach ..................................146 10.7d.2 Classify and manage diarrhoea ..........................148 10.7d.3 Approach to persistent or chronic diarrhoea in PLHIV ............156 10.7d.4 Constipation......................................158 10.8 Jaundice .............................................159 10.8.1 Clinical approach ..................................160 10.9 Ascites ...............................................166 10.9.1 Clinical approach ..................................166 10.9.2 Classify ascites and consider the likely differential diagnosis ........169 10.9.3 Manage ascites according to cause .......................171 10.10 Neurological problems .....................................174 10.10a Neurological defi cit (without meningeal signs) .......................175 10.10a.1 Clinical approach ..................................175 10.10a.2 Classify the neurological defi cit and consider the likely differential diagnosis ..............................177 10.10a.3 Stroke-like syndrome ...............................178 10.10a.4 Spinal cord problem (myelopathy) ........................181 10.10a.5 Peripheral motor or sensory nervous system problem ............182 10.10a.6 Peripheral neuropathy ...............................185 10.10a.7 Common cranial nerve palsies and their differentials ............187 10.10b Headaches ............................................188 10.10b.1 Clinical approach ..................................189
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