ALLERGIES:
Symptoms: itchy eyes, runny nose, dry cough, sneezing, nasal congestion, fatigue
Physical findings: infraorbital edema and darkening due to subcutaneous venodilation (allergic shiners), transverse nasal crease (allergic salute), accentuated lines or folds below the lower eyelids (Dennie-Morgan lines), pale nasal mucosa with turbinate edema
Treatment: avoid allergen if possible. Nasal saline sprays twice daily
Adult – 1st line: loratadine 10mg PO once daily
2nd line: diphenhydramine 25-50mg every 4-6 hours as needed
Children – > 12 years old: refer to adult dosing
Children – 6-11 years old: 1st line: loratadine 10mg PO once daily
2nd line: diphenhydramine 12.5 – 25mg PO every 4-6 hours prn
Children – 2-6 years old: 1st line: loratadine 5mg PO once daily
2nd line: diphenhydramine 6.25mg PO every 4-6 hours prn
Pregnancy – see adult dosing, loratadine preferred
• Saline eye drops 4-6 times per day
Should we consider stocking Zaditor or Pataday? We will have to look into cost, I thought those were expensive, but if they aren’t that would be a great idea.
• Steroid nasal sprays (Flonase/fluticasone) 2 sprays each nostril once daily (do they have nasal steroid sprays in Nicaragua) We can look into this moreNaomi is looking into this
AMEBIASIS:
Intestinal amebiasis is caused by the protozoan Entamoeba histolytica. Transmitted by contaminated food and water.
Symptoms: subacute onset, usually over 1 to 3 weeks. Symptoms range from mild diarrhea to severe dysentery, producing abdominal pain, diarrhea, and bloody stools. Bowel necrosis leading to perforation and peritonitis can occur. About half of patients have weight loss, 40% have fever.
Treatment: *Instruct patients not to drink alcohol while taking metronidazole*
Adults – Metronidazole 500-750mg PO tid x 10 days; alternative is Tinidazole 2g PO qd x 3 days. TAKE WITH FOOD
Children – Metronidazole 35-50mg/kg/day PO divided tid x 7-10 days.
For children with diarrhea, Zinc and Vitamin A supplementation are also recommended
Zinc (has been shown to decrease the severity and duration of diarrhea):
Children <6 months old = 10mg/day for 10 days
Children 6 months to 5 years old = 20mg/day for 10 days
Vitamin A:
For children who have not received Vitamin A supplementation in the last 4 months that have diarrhea.
Infants <6 months: 50,000 international units orally once
Infants 6 to 12 months of age: 100,000 international units orally once
Children >12 months: 200,000 international units orally once
Pregnancy – Metronidazole 500mg PO tid x 10 days, but only for severe illness.
If symptoms not improving with treatment, consider stool sample and treating with luminal agent such as paromomycin
ANAPHYLAXIS:
Symptoms: sudden onset, urticaria, flushing, dyspnea, wheezing, agitation, confusion, stridor, sense of impending doom, abdominal pain, n/v. Two or more organ system involvement.
Physical findings: severe distress, tachycardia, tachypnea, wheezing, hypotension
Treatment:
Treat with Epinephrine (see below for dosing)
Give Benadryl, Steroids, and Zantac and start IV fluids (if you have someone comfortable starting IVs) and
Transfer them to the nearest hospital, the patient should be accompanied by a provider. Bring an extra dose of epinephrine, as a repeat dose may be needed 5-15 minutes after initial dose based on the patient’s response.
Adult – epinephrine (1:1000) IM given ASAP in mid-outer thigh. 1:1000 solution, 0.5mg IM once. May repeat in 5-15 minutes if needed
– diphenhydramine 50mg IM once
– prednisone: 60mg PO (if patient can swallow) once
– Zantac 300mg PO once
– normal saline, IV wide open for 1-2 liters if presenting with orthostasis, hypotension, or incomplete response to epinephrine
Children – Epinephrine (1:1000) IM given ASAP in mid-outer thigh.
<15kg (33 pounds): 0.01mg/kg IM. May repeat dose in 5-15 minutes if necessary.
15-30kg (33-66 pounds): 0.15mg IM. May repeat dose in 5-15 minutes if necessary.
>30kg (66 pounds): 0.3mg IM. May repeat dose in 5-15 minutes if necessary.
– diphenhydramine
2-11 y/o: 1-2 mg/kg IM (max 50mg)
>12 y/o: 25-50mg IM
– prednisone 2 mg/kg PO (if they can swallow)
– Zantac
> 15kg and can swallow pills, 150mg PO once
– normal saline, IV 20ml/kg bolus over 5-10 minutes, repeat if needed. Should be given if orthostasis, hypotension, or have incomplete response to epinephrine
Pregnancy – see adult dose
Additional Information: place patient supine and elevate lower extremities. Insure adequate airway.
ANEMIA:
Symptoms: weakness, fatigue, dyspnea, pica (eating clay, dirt, flour, ice), bruising; female patients may complain of heavy long periods. May be mild/absent if anemia has developed slowly over time.
Physical findings: pale appearance, pale conjunctiva
Lab evidence: < 13g/dL in men, < 12g/dL in women according to WHO
Treatment: need to find and treat the underlying cause.
• Adult: Ferrous sulfate 325mg (65mg elemental iron), 1 PO tid every other day. Should not be given with food. Should be taken separately from calcium-containing beverages and foods. Should be given separately from antacids. Should take with orange juice.
• Children: Ferrous sulfate 3-6mg of Fe (elemental iron)/kg/day PO divided tid (max 200mg/day). Should not be given with food or milk. Ferrous sulfate 325mg = 65mg elemental iron
• Pregnancy: prenatal vitamins with iron daily.
Important to check Hgb after 2-4 weeks of starting iron therapy to assess improvement.
NOTES: Discuss the importance of eating iron rich foods, such as meats, lentils, beans, and green vegetables including spinach and brocolli.
Pearl: Consider hookworm as a cause of iron deficiency
ASTHMA – ADULT:
Symptoms: Dyspnea, wheezing, chest tightness, cough
Physical findings: elevated heart rate and respiratory rate. Decreased or absent breath sounds, wheezing upon auscultation. Use of respiratory accessory muscles, pulse ox can be low.
Well controlled = daytime sx ≤ twice/week, nighttime sx ≤ twice/month
Severity Classification:
Mild intermittent = daytime sx ≤ days/week
nighttime sx/awakenings ≤ 2 times monthly
rescue inhaler use ≤ 2 days/week
no interference with normal activity
Mild persistent = daytime sx > 2 days/week but not daily
nighttime sx/awakenings 3-4 times/month
rescue inhaler use > 2 days/week but not daily
minor limitation with normal activity
Moderate persistent = daytime sx occur daily
nighttime sx/awakenings > 1 time/week but not nightly
rescue inhaler use is daily
some limitation with normal activity
Severe persistent = daytime sx throughout the day
nighttime sx/awakenings often 7 times/week
rescue inhaler use is several times/day
extremely limited with normal activity
Treatment: stepwise approach to maintenance therapy. Step 1= mild intermittent, step 2= mild persistent, step 3 = moderate persistent, step 4 = severe persistent.
Maintenance:
Adults:
(see above for asthma severity classification)
Intermittent asthma:
Salbutamol inhaler 90mcg; dose 2 puffs every 4-6 hours as needed for wheezing
Mild persistent asthma:
Beclometasona 50mcg – 1-4 puffs twice daily (start with 1 puff twice daily and may increase every 2 weeks if needed)
Salbutamol inhaler 90mcg; dose 2 puffs every 4-6 hours as needed for wheezing
Moderate Persistent asthma:
Beclometasona 50mcg – 4-9 puffs twice daily (start with 4 puffs twice daily and may increase every 2 weeks if needed)
Salbutamol inhaler 90mcg; dose 2 puffs every 4-6 hours as needed for wheezing
Severe Persistent asthma:
Beclometasona 50mcg – 9 puffs twice daily
Salbutamol inhaler 90mcg; dose 2 puffs every 4-6 hours as needed for wheezing
Stepwise approach for managing asthma in youths ≥12 years of age and adults
Exacerbations:
Mild-moderate exacerbation:
Salbutamol inhaler 90mcg; dose 2 puffs every 4-6 hours as needed for wheezing
OR
2.5mg nebulized 3 times daily as needed for wheezing
Prednisone 40-60mg daily for 5-7 days
Consider Kenalog 40mg IM after single dose of prednisone 60mg orally in clinic if concern for noncompliance with pills at home.
Keep in mind onset of action of Kenalog is 12-36 hours and duration is 2-4 weeks
Severe exacerbation:
Salbutamol inhaler 90mcg; dose 4-8 puffs every 20 minutes for 3 doses
OR
2.5mg nebulized every 20 minutes for 3 doses; repeat in 1 hour after 3rd dose if needed.
Provide supplemental O2 if possible.
Prednisone 60mg orally x 1 in clinic and continue prednisone 40-60mg once daily for total of 5-7 days.
Consider Kenalog 40mg IM after single dose of prednisone 60mg orally in clinic if concern for noncompliance with pills at home.
Keep in mind onset of action of Kenalog is 12-36 hours and duration is 2-4 weeks
Pregnant Women may take salbutamol
Prednisone has been shown to increase risk of low birth weight and prematurity, however if prednisone required to treat asthma the risk of patient mortality outweighs those risks
ASTHMA – CHILDREN:
Symptoms: cough especially nocturnal cough or cough > 3 weeks duration, dyspnea, wheezing, possible signs of respiratory distress. Approx 80% of children will develop sx prior to 5 y/o.
Physical exam: decreased or absent breath sounds, wheezing upon auscultation. Use of respiratory accessory muscles, pulse ox may be low.
Severity classification: see adult asthma
Maintenance treatment: stepwise approach, similar to adult treatment with ages 5-11
Maintenance:
Children 5-11:
(see above for asthma severity classification)
intermittent asthma:
Salbutamol inhaler 90mcg; dose 2 puffs every 4-6 hours as needed for wheezing
Mild persistent asthma:
Beclometasona 50mcg – 1-3 puffs twice daily (start with 1 puff twice daily and may increase every 2 weeks if needed)
Salbutamol inhaler 90mcg; dose 2 puffs every 4-6 hours as needed for wheezing
Moderate Persistent asthma:
Beclometasona 50mcg – 3-6 puffs twice daily (start with 3 puffs twice daily and may increase every 2 weeks if needed)
Salbutamol inhaler 90mcg; dose 2 puffs every 4-6 hours as needed for wheezing
Severe Persistent asthma:
Beclometasona 50mcg – 6 puffs twice daily
Salbutamol inhaler 90mcg; dose 2 puffs every 4-6 hours as needed for wheezing
Children >12:
(see above for asthma severity classification)
Intermittent asthma:
Salbutamol inhaler 90mcg; dose 2 puffs every 4-6 hours as needed for wheezing
Mild persistent asthma:
Beclometasona 50mcg – 1-4 puffs twice daily (start with 1 puff twice daily and may increase every 2 weeks if needed)
Salbutamol inhaler 90mcg; dose 2 puffs every 4-6 hours as needed for wheezing
Moderate Persistent asthma:
Beclometasona 50mcg – 4-9 puffs twice daily (start with 4 puffs twice daily and may increase every 2 weeks if needed)
Salbutamol inhaler 90mcg; dose 2 puffs every 4-6 hours as needed for wheezing
Severe Persistent asthma:
Beclometasona 50mcg – 9 puffs twice daily
Salbutamol inhaler 90mcg; dose 2 puffs every 4-6 hours as needed for wheezing
Stepwise approach for managing asthma in children 5 to 11 years of age
Mild to moderate exacerbation:
Salbutamol inhaler 90 mcg/dose
4 years and older: 2 puffs every 4-6 hours as needed for wheezing. Use spacer if possible.
Salbutamol by nebulizer:
<2 years old: 0.15mg/mg (Max 1.25mg/dose) every 4-6 hours as needed for wheezing.
2-5 years old: 0.15mg/kg (Max 2.5mg/dose) every 4-6 hours as needed for wheezing
5 years and older: 2.5mg every 4-6 hours as needed for wheezing
Prednisolone: 1-2mg/kg/day by mouth divided into 1 or 2 doses for 3-10 days.
Do we have prednisolone in Nicaragua?
Severe exacerbation:
Salbutamol inhaler 90 mcg/dose; 4 to 8 puffs every 20 to 30 minutes for 3 doses, then every 1 to 4 hours as needed (minimum 2 puffs/dose, maximum 8 puffs/dose). Use VHC spacer. Add mask in children less than 4 years.
Salbutamol by nebulizer: 0.5 mg/kg per hour (maximum 20 mg per hour) by large volume nebulizer. Dose may also be determined based upon body weight as follows:
5 to 10 kg – 7.5 mg per hour divided into 3 doses
10 to 20 kg – 11.25 mg per hour divided into 3 doses
>20 kg – 15 mg per hour divided into 3 doses
**Double check dosing before prescribing.***
• prednisolone: 1 to 2 mg/kg (maximum 60 mg/day) by mouth for the first dose, and then 0.5 to 1 mg/kg twice daily for subsequent doses starting the following day. A 3- to 10-day course is generally given.
BACTERIAL CELLULITIS:
Symptoms: warm, red, swollen skin with indistinct borders. Sometimes accompanied by drainage or systemic symptoms, such as fever or chills (consider MRSA coverage if so).
Treatment: rest, elevate affected limb. If no improvement after 48-72 hours, consider switching antibiotic agent
Adults:
Cellulitis without abscess (purulence)
1st Line: Cephalexin 500mg PO qid x 7 days
2nd Line: Bactrim DS (800mg/160mg): 1 tab PO bid x 7 days
3rd Line: Clindamycin 300mg three times daily for 7 days
Cellulitis with abscess (purulence):
Perform incision and drainage on abscesses
1st Line: Bactrim DS (800mg/160mg): 1 tab PO bid x 7 days
2nd Line: Doxycycline 100mg two times daily for 7 days
3rd Line: Clindamycin 300mg three times daily for 7 days
*uncomplicated cellulitis should be treated for 5-7 days, extend up to 14 days if severe or slowly responding to therapy
Children:
Cellulitis without abscess (purulence):
1st Line: Cephalexin 25-50mg/kg/day divided qid x 7 days
2nd Line: Bactrim (>2 months) 8-12mg of TMP/kg/day divided bid x 7 days
Cellulitis with abscess (purulence):
1st Line: Cephalexin 25-50mg/kg/day divided qid x 7 days
2nd Line: Bactrim (>2 months) 8-12mg of TMP/kg/day divided bid x 7 days
Pregnancy: See adult dosing, but avoid Bactrim and Doxycycline.
NOTE: MRSA rates are increasing in Central America. If the patient has been treated in the past and denies improvement, it is recommended to add Trimethoprim/Sulfamethoxazole 800/160mg pills, bid x 7 days. Avoid Bactrim in pregnancy, use clindamycin instead.
BENIGN PROSTATIC HYPERPLASIA:
Symptoms: difficulty initiating urine stream; increased need to urinate, but painless; nocturia; weak stream; post-void dribbling. Ask about family history of prostate cancer before the age of 50. Ensure no red flag symptoms of weight loss, night sweats, etc.
Physical Findings: Optional examination for enlarged prostate.
Treatment:
Adult – Terazosin 5 mg po nightly. Is it possible to slowly titrate the dose to lower chance of postural hypotension? Note terazosin may lower blood pressure; check for postural BP drop prior to prescribing; Advise patient of possible postural dizziness upon standing. It may take 4-6 weeks treatment of Terazosin to notice clinical improvement.
What is the cost comparison between terazosin and more uro-selective alfuzosin and tamsulosin as they might have less hypotension side effects?
Dr G said they use Doxazosin
Doxazosin: Start 1 mg once nightly; may titrate (by doubling the daily dose [eg, to 2 mg, then 4 mg, then 8 mg]) at 2-week intervals up to 8 mg once daily based on patient response and tolerability (maximum: 8 mg/day).
Reinitiation of therapy: If therapy is discontinued for several days, restart at 1 mg dose and titrate using initial dosing regimen.
CHIKUNGUNYA:
Symptoms: Abrupt onset of high fever and malaise. 2-5 days later, polyarthralgias develop. Polyarthralgias are the distinguishing feature that differentiates Chikungunya from Dengue fever, and are usually bilateral, symmetric, and more common in the distal joints. Can have intense pain. Duration of illness is usually 7-10 days. Transmitted via mosquitos.
Physical findings: may have macular/maculopapular rash on limbs and trunk, usually 3 days or later after onset of illness, and the rash lasts 3-7 days. Macular/maculopapular rash may develop on limbs and trunk, usually 3 days or later after onset of illness and lasting 3 to 7 days.
Treatment: no curative treatment, prevention is key. Symptomatic treatment with acetaminophen. Hydrate with rehydration salts or IV fluids if needed. Do NOT use aspirin/NSAIDS until confirmed patient doesn’t have Dengue.
NOTE: Joint pains may persist long after virus has resolved.
CHOLERA:
Symptoms: copious watery diarrhea. If > 1 liter per hour, the problem is cholera, think “rice-water” stools. Fever is uncommon. Abdominal discomfort and vomiting may also be present. Lethargy indicates severe disease. Transmitted by ingesting contaminated food and/or water. With proper rehydration, diarrhea is most severe in the first two days and ends after 4-6 days.
Treatment:
Adult: Aggressive oral rehydration is first line. Use oral rehydration salts for volume replacement. IV fluid replacement if needed – 30ml/kg over 30 minutes, then 70ml/kg over 2.5 hours. First choice is lactated ringers. Cipro 1g po as single dose or Azithromycin 1g po as single dose.
Children (older than infants): oral rehydration salts as first line for volume replacement. IV fluid replacement, if needed, 30ml/kg over 30 minutes, then 70ml/kg over 2.5 hours.
First Line: Azithromycin 20mg/kg as a single dose
Second Line: >8 years old, Cipro 20mg/kg as a singe dose.
Infants with cholera and dehydration likely need treatment at hospital
For children with diarrhea Zinc and Vitamin A supplementation are also recommended
Zinc (has been shown to decrease the severity and duration of diarrhea):
Children <6 months old = 10mg/day for 10 days
Children 6 months to 5 years old = 20mg/day for 10 days
Vitamin A:
For children who have not received Vitamin A supplementation in the last 4 months that have diarrhea.
Infants <6 months: 50,000 international units orally once
Infants 6 to 12 months of age: 100,000 international units orally once
Children >12 months: 200,000 international units orally once
Pregnancy: see adult for rehydration. Azithromycin 20mg/kg as a single dose.
CONGESTIVE HEART FAILURE:
Symptoms: Dyspnea with exertion, PND, orthopnea, lower extremity edema
Physical findings: Rales or wheezes in lungs, neck vein distention, S3 gallop on auscultation, peripheral edema. Sometimes abdominal fullness due to hepatic congestion.
Supporting data: Chest xray, oxygen saturation, echocardiogram
Treatment: evaluate for cause (ie CAD, HTN), and manage contributing and associated conditions as well
• Adults: furosemide 20-40mg daily. Daily weights to detect fluid retention before it becomes symptomatic. Lifestyle modification (ie, no salt, weight loss, smoking cessation, reduce ETOH consumption). If giving furosemide, must also give KCl 10mEq po daily.
**Will need a follow up appointment to be put on an ACE inhibitor after renal function is checked**
CONJUNCTIVITIS:
Symptoms: depend on etiology (bacterial vs viral vs allergic vs other). In general, there is eye irritation, “sandpaper” or foreign body sensation in the eye. May have itching, especially with allergic etiology. Tearing may be present, especially with allergic, viral, or other. Profuse purulent drainage strongly indicates bacterial etiology.
Physical findings: conjunctival erythema, purulent material if bacterial etiology. Red flag = vision changes
Treatment:
Viral: supportive care and saline eye drops
Allergic: See treatment under protocol for allergies
Bacterial:
Adults:
Ciprofloxacin 0.3% eye drops: 2 drops 4 times daily for 7 days.
Children:
Younger child they may tolerate tetracycline ointment better. Otherwise, use Ciprofloxacin Drops.
Tetracycline ointment 1%: 1cm strip to lower eyelid conjunctival fold 4 times daily for 7 days
Ciprofloxacin 0.3% eye drops: 2 drops 4 times daily for 7 days.
Pregnancy: Ciprofloxacin 0.3% eye drops: 2 drops 4 times daily for 7 days.
Notes: highly contagious. Wash hands frequently.
CUTANEOUS LARVA MIGRANS:
Symptoms: extreme pruritic lesions, caused by hookworms. Infection develops from contact with contaminated soil (from feces from dogs/cats), such as walking barefoot.
Physical findings: linear skin lesions in area of pruritus, “serpiginous linear tracks.” Occur most often in the lower extremities.
Treatment:
Adult: 1st Line: Ivermectin 200mcg/kg as single dose. See chart below.
2nd Line: albendazole 400mg po qd x 3 days, take with fatty meal
Children: 1-2 years old: albendazole 200mg po qd x 3 days;
2-3 years: albendazole 400mg po qd x 3 days.
>3 years old, but less <15kg: albendazole 400mg po qd x 3 days
>3 years old and >15kg: Ivermectin 200mcg/kg single dose (see dosing table above)
Pregnancy: delay treatment until delivery if possible.
NOTE: if patient has extensive/multiple lesions, albendazole should be given for 7 days
DENGUE FEVER:
Symptoms: There is a febrile stage, critical stage, and convalescent phase. Acute fever with myalgias > arthralgias. Called “break-bone fever.” Fever lasts for 5-7 days, and is accompanied by 2 or more: headache, retro-orbital or ocular pain, myalgia and/or bone pain, arthralgia, maculopapular rash, leukopenia, hemorrhagic manifestations (these are common and distinguish from chikungunya, include petechia/purpura, epistaxis or bleeding gums, hematuria, blood in stool, vaginal bleeding, etc). May also have n/v, abdominal pain if more severe.
Supporting data: leukopenia, thrombocytopenia on CBC. Elevated LFTS.
Treatment: Acetaminophen favored.
**Avoid ASA or NSAIDS due to risk of bleeding complications**
No cure. Avoid mosquito contact for prevention. Symptomatic treatment recommended, important to maintain adequate intravascular volume/hydration. Use oral rehydration salts or if patient is moderately or severely ill, use IV fluids. Monitor closely for decompensation, should be evaluated daily. May need hospital transfer in case of decompensation.
DIABETES:
Symptoms: blurred vision, sudden weight loss, polyuria, polydipsia, nocturia
Physical findings: sometimes acanthosis nigricans
Supporting data: Urinalysis will show glucose, fasting glucometer reading > 126.
Treatment:
Adults: 1st Line: Metformin 500-1000mg PO bid (Maximum of 2g daily).
Stop Metformin if GFR <45
2nd Line: If not adequately controlled, add Glimiperide 1-2mg by mouth daily
What should we have max be?
Take with breakfast
3rd Line: If still not adequately controlled, patient needs insulin and needs to be referred to the Alabama Clinic
NOTE: if patient consistently has glucose readings >300 or A1C>10%, they need insulin and should be referred to the Alabama Clinic.
Pregnancy: screening should start at 24 weeks. Many can be managed on dietary changes and moderate exercise. Counsel on proper diet, including 3 small/moderate meals per day with 2 small snacks. Glucose should ideally be checked 4 times daily (fasting, and 1-2 hours after the start of each meal).
1st line: insulin considered treatment of choice, but metformin is a reasonable and
safe first line alternative.
Dose: Start Metformin 500mg BID. May slowly titrate and increase dose
weekly to limit GI upset in pregnancy. Max of 2g – 2.5g daily.
2nd line: if targets not achieved, refer to Alabama Clinic for insulin.
Imaging: ultrasounds at following intervals (ideally).
NOTE: important to continue to monitor for diabetes after delivery.
Children: if < 10 years old, refer out as usually Type 1 which requires insulin. DM Type 2 is on the rise in older children/adolescents. If A1C < 8.5, and the presentation is clinically suggestive of DM Type 2, can start with metformin monotherapy. Dose started at 500mg once daily, can be increased by 500mg increments at one week intervals. If A1C ≥ 8.5, refer out as insulin is needed. Need to take daily multivitamin if on metformin.
NOTES: Arrange for follow-up for any patients treated with diabetes. Make sure that blood sugar gets checked regularly. Also, patients need creatinine checked periodically on metformin. Check twice yearly A1C.
Education is key here. Teaching patients healthy eating habits, including education on low-carb options (ie, fresh vegetables and protein over beans and rice) is very important. Also, teaching patients about how high blood sugars affect other organs (ie, vision, kidneys, neuropathy, etc.) is very important. They should be placed on LRdE’s chronic care list for continued followup.
DIARRHEA:
See individual protocol for appropriate treatment.
**Ensure patient has REAL diarrhea and isn’t just having loose stools. **
If diarrhea lasts longer than 5 days while we are there, order stool cultures for Dr. G to follow up.
EAR WAX IMPACTION:
Symptoms: usually decrease in hearing or ear feeling “clogged.” Sometimes painful.
Physical exam: impaction of cerumen in ear canal
Of note, it is normal to have cerumen in the ear canal. If you are still able to see the tympanic membrane and patient’s ear wax is not causing any symptoms, no treatment is indicated.
Treatment: If possible, try to remove with direct visualization and ear curette. If unable to remove with ear curette, see below
Children > 5 years old and adults use elephant ear washer
There is an elephant ear washer in the clinic cabinet in the private room.
Do not use elephant ear washer if you are concerned of tympanic membrane rupture
How to use elephant ear washer:
Attach tip
Fill bottle with 1 part hydrogen peroxide and 10 parts warm water
Aim the tip upwards into the canal and gently irrigate cerumen out of ear
Reexamine ear once cerumen has been removed
If child >5 or adult does not tolerate ear irrigation, try ear drops
Carbamide peroxide
5-11 years old: 1-5 drops in ear 2 times per day for 4 days
12 years and older: 5-10 drops in ear 2 times per day for 4 days
Glycerin ear drops
3 drops BID x 3 days; at night keeping ear upright for 15 minutes
Recheck in 3 days
Children less than 5
Some infants and toddlers have small ear canals, making it difficult to visualize the tympanic membrane. If hearing is normal, and patient is asymptomatic, observation is appropriate.
If cerumen removal is indicated:
1st line = removal with direct visualization and ear curette.
2nd line = earwax removal drops, such as Debrox (follow instructions on packaging). Alternative: glycerin ear drops, 3 drops BID x 3 days; at night keep ear upright x 15 mins.
If ear still occluded after using drops, attempt curette or gentle irrigation as wax may be softened and now easier to remove.
GASTROENTERITIS – VIRAL:
Symptoms: abdominal pain with nausea, diarrhea, and vomiting. Usually both vomiting and diarrhea are present, but either vomiting or diarrhea can occur alone. May be accompanied by fever
Physical Findings: Mild, diffuse abdominal tenderness. Look for signs of dehydration- dry tongue and mouth, muscle weakness, confusion, sunken eyes, poor skin turgor
Recommended Treatment:
Adult: Ondansetron 4-8 mg by mouth as needed every 8 hours
Promethazine Supp 12.5- 25 mg prn q 8 to 12 hours
Children: Ondansetron: Note: not routinely recommended for children in most cases of acute gastroenteritis. However, can be given as a one time dose (in clinic) based on weight:
8 – 15 kg = 2mg/dose once
> 15-30 kg = 4mg/dose once
> 30 kg = 8mg/dose once
Promethazine supp (only over age 2): 0.25-1mg/kg/dose q 6-8 hours prn (not to exceed 25mg/dose) Use extreme caution utilizing the lowest most effective dose
Pregnancy (nausea and vomiting): Ginger tea, Sea Bands
1st: Start benadryl 25mg every 6 hours as needed for nausea
2nd: If still nauseated add promethazine 12.5-25mg every 6 hours as needed for nausea
3rd: If still nauseated add zofran 4mg every 6 hours as needed for nausea. Use with caution in first trimester.
***MAX DURATION OF ONDANSETRON 3 DAYS***
GIARDIA:
Transmission is waterborne, foodborne, or fecal-oral
Symptoms: Acute giardiasis – diarrhea (sometimes yellow), malaise, foul-smelling and fatty stools (steatorrhea), abdominal cramps and bloating, flatulence, nausea, weight loss.
Chronic Giardiasis – Loose stools but not technically diarrhea, steatorrhea, fatigue, malaise, malabsorption, weight loss (10-20% of body weight), acquired lactose intolerance (up to 40%). Can develop in up to half of patients following acute symptomatic giardia, and symptoms can wax and wane over months. NOTE: The presence of blood in the stool or a fever indicates a diagnosis other than Giardia. Also, breastfed infants may have yellow seedy stools and that can be normal.
Physical findings: Mild abdominal tenderness. Children may sometimes present with weight loss and failure to thrive
Treatment: Symptoms usually resolve within 5-7 days after treatment. Contagious until asymptomatic for 48 hours. PROPHYLAXIS: ALBENDAZOLE 400mg EVERY 6 MONTHS
Adult – Tinidazole 2g PO, single dose
Children: 0-1 year old: metronidazole: 15 mg/kg/day PO divided tid x 7 days (max 250 mg per dose)
1-3 years old: Albendazole 15 mg/kg orally once daily for 5 days (max 400 mg per dose)
>3 years old: Tinidazole: 50 mg/kg orally, single dose (max dose 2 g).
If child cannot swallow pills, may be finely crushed and made into a suspension (shake well).
For children with diarrhea, Zinc and Vitamin A supplementation are also recommended
Zinc (has been shown to decrease the severity and duration of diarrhea):
Children <6 months old = 10mg/day for 10 days
Children 6 months to 5 years old = 20mg/day for 10 days
Vitamin A:
For children who have not received Vitamin A supplementation in the last 4 months that have diarrhea.
Infants <6 months: 50,000 international units orally once
Infants 6 to 12 months of age: 100,000 international units orally once
Children >12 months: 200,000 international units orally once
Pregnancy – 1st trimester: Delay therapy if possible due to risk of medication
adverse effects. If diarrhea is causing weight loss, treat with metronidazole 500mg PO bid x 7 days
2nd and 3rd trimester: Metronidazole 500 mg orally twice daily for 7 days
Breastfeeding – Albendazole 400mg PO once daily x 5 days
HIV:
Symptoms: General – fever, fatigue, and myalgias.
Mouth: Sore throat is a frequent manifestation of acute HIV, although there are multiple more common causes of sore throat.
Lymphadenopathy: Nontender lymphadenopathy primarily involving axillary, cervical, and occipital nodes.
Painful mucocutaneous ulceration: Shallow, sharply demarcated ulcers with white bases surrounded by a thin area of erythema found on the oral mucosa, anus, penis, or esophagus.
Rash: Small (5-10mm) well circumscribed, oval or round, pink to deep red colored macules or maculopapules, most commonly involving the upper thorax, collar region, and face, but the scalp and extremities including palms and soles may be affected as well. Vesicular, pustular, and urticarial eruptions have also been reported, but are not nearly as common as a maculopapular rash.
GI: nausea, diarrhea, anorexia, and weight loss
Neuro: Headache described as retroorbital pain exacerbated by eye movement
If you believe a patient has HIV, arrange for testing and if positive, there needs to be further evaluation set up at another clinic. Likely the Alabama clinic.
GERD AND/OR H. PYLORI:
Symptoms: heartburn, water brash, nausea, epigastric pain. Patients with H. Pylori usually have dyspepsia (upper abdominal discomfort) and less heartburn
Physical Exam: may have epigastric tenderness, sometimes discoloration to back of tongue
Treatment for GERD:
Lifestyle Modification: smaller more frequent meals, eat last meal at least 3 hours before bedtime, elevate head of bed, weight loss, decrease soda, decrease NSAID use, avoid irritating foods
Medications:
-GERD symptoms <2 times per week, calcium carbonate (Tums) is likely sufficient. Patients shouldn’t be using these for extended periods on a daily basis.
-GERD symptoms >2 times per week, start ranitidine 150mg PO bid x 4 weeks.
-If not improving with ranitidine, start omeprazole 20mg once daily x 4 weeks
-If patient not improving with omeprazole 20mg once daily, increase to omeprazole 40mg once daily x 4 weeks
-If patient not improving with omeprazole 40mg once daily, consider testing for H. Pylori fecal/stool test with Los Rayos clinician
Pregnancy: Calcium carbonate (Tums) and Ranitidine are considered safe in pregnancy. Omeprazole is probably safe based on studies and if indicated can be given in pregnant women for relief of symptoms. Use stepwise approach as described above. See dosing above.
Breastfeeding: see above dosing
Treatment for H. Pylori:
Adult – Omeprazole 20mg bid x 14 days
Amoxicillin 1000mg bid x 14 days
Azithromycin 500mg once daily x 3 days
*may substitute amoxicillin with Metronidazole 500mg tid x 14 days if patient has amoxicillin allergy. Do not use metronidazole during 1st trimester of pregnancy or for breastfeeding women
Pregnancy – If possible, defer treatment of H. Pylori until after pregnancy and manage with acid suppression. However, there is some evidence that H. Pylori can cause severe nausea and vomiting in pregnancy, including hyperemesis gravidarum. Thus, if indicated, H. Pylori treatment should be considered in pregnancy. Use adult dosing.
Breastfeeding – adult dosing
HEADACHE:
Symptoms:
Tension headache: dull, pressure, band like pain. Muscle tension in head, neck, or shoulders.
Can be brought on by stress.
Migraine: often unilateral and throbbing. Associated nausea/vomiting. Photophobia or phonophobia. Sometimes accompanied by auras.
Red flag symptoms: “worst headache of life,” sudden onset “thunderclap headache,” visual changes, elderly with headache with no prior history of headaches
Physical Exam: rule out serious underlying pathology and look for other secondary causes of headache.
Red flag findings: visual changes, facial droop, numbness/tingling, weakness, slurred speech
Treatment: make sure patients are staying hydrated. Majority of patients should be given Acetaminophen due to higher risk of side effects from NSAIDs. Try to use Ibuprofen only in patients with more severe symptoms.
Adult – mild to moderate pain: Acetaminophen 325-1000mg acetaminophen q 4-6 hours prn. Max 4g/day.
Moderate to severe pain: Ibuprofen 200-400mg q 4-6 hours prn. Max 2400 mg/day.
Children 6 months – 11 years: mild to moderate pain – Acetaminophen 10-15mg/kg by mouth q4-6 hours prn; Max 75mg/kg/day up to 1g/4 hours and 4g/day
Moderate to severe pain: Ibuprofen 5-10mg/kg q6-8 hours prn; max dose of 40mg/kg/day
Children 12 years and older: mild to moderate pain – Acetaminophen 325mg-650mg PO q4-6 hours prn; max 1 g/4 hours and 4 g/day
Moderate to severe pain: Ibuprofen: 200-400mg by mouth every 4-6 hours as needed; Max 2400mg/day
Pregnancy – Rule out preeclampsia. Acetaminophen 325-1000mg q 4-6 hours prn. Max 4 g/day.
Breastfeeding: Acetaminophen 325-1000mg acetaminophen q 4-6 hours prn. Max 4 g/day. Ibuprofen 200-400mg q 4-6 hours prn. Max 2400 mg/day.
If uncontrolled with acetaminophen and ibuprofen, further evaluation and management at another clinic may be needed.
***Use caution with NSAIDs due to high prevalence of chronic kidney disease in Nicaragua***
HYPERTENSION:
Symptoms: many patients are asymptomatic, but some may present with subtle symptoms such as constant headache.
Red Flag symptoms: If patient presents with severe headache, numbness, tingling, weakness, chest pain, SOB, confusion, or other signs of end organ damage they need to have emergent evaluation for organ damage.
Physical Exam: focus on searching for signs of organ damage and causes of secondary hypertension. For example, evaluate for peripheral edema (CHF), auscultate for bruit in abdomen (renal artery stenosis), auscultate heart and lungs, perform neurologic exam.
Treatment: We acknowledge that current guidelines recommend ACE inhibitors, ARBs, and thiazide diuretics be considered as first-line therapy for patients with hypertension. However, Mesoamerican Nephropathy is prevalent in Nicaragua. A recurring theory for the cause of Mesoamerican Nephropathy is recurrent dehydration due to working in hot environments. There is also a lack of access to clean water for many Nicaraguans. Due to this concern that patients are dehydrated, diuretics are not an ideal first line option for hypertension except in cases of congestive heart failure. ACE inhibitors and ARBs are also contraindicated in Mesoamerican Nephropathy due to concern that blocking the renin-angiotensin system may predispose patients to acute kidney injury in the setting of hypovolemia. Please see the following page for recommendations for treatment of hypertension in non-pregnant and non-lactating adults.
For pregnant women:
Blood pressure goal based on National Institute for Health and Care Excellence
Patients with uncomplicated chronic hypertension:
Keep blood pressure <150/<100
Patients with gestational hypertension or preeclampsia
Treatment is indicated if systolic >150 or diastolic >100
Goal is systolic <150 and diastolic between 80-100
Treatment:
Methyldopa: (sedation is a common side effect)
Initial dose: 250mg two times daily, wait at least 3 days before dose adjustment
If not at blood pressure goal increase to 500mg 2 times daily
If not at blood pressure goal on Methyldopa 500mg 2 times daily start labetalol
Labetalol: (avoid use in patients with asthma, COPD, heart failure, bradycardia, or greater than 1st degree heart block)
Initial dose for Labetalol: 100mg 2 times daily
Recheck within 1 week
If not at blood pressure goal gradually titrate to goal waiting at least 3 days between increasing dose
Increase by 100mg twice daily every 3 days as needed until patient at blood pressure
goal
Effective dose range usually between 100mg twice daily and 400mg twice daily
Screen for preeclampsia in pregnant patient with hypertension:
>2+ protein on urine dip is a sign of preeclampsia
In patients without preeclampsia, but with high risk preeclampsia consider treating with low dose aspirin (between 60 to 150mg/day, use whatever is available in clinic) to help prevent preeclampsia:
Patients considered to be high risk for preeclampsia based on US preventative Services Task Force:
Previous preeclampsia
Multifetal gestation
Chronic Hypertension
Type 1 or 2 Diabetes
Chronic kidney disease
Autoimmunue disorders
In these high risk patients for preeclampsia try to initiate aspirin at ≥12 weeks and ideally prior to 16 weeks of pregnancy
Depending on severity of preeclampsia further evaluation and management may be needed at higher acuity clinic
Patients who are breastfeeding and have hypertension:
If patient is already controlled on Labetalol from hypertension during pregnancy continue Labetalol if necessary.
If patient who is breastfeeding is not already on antihypertensive medication and has hypertension start patient on amlodipine (see dosing in non-pregnant and non-lactating adults). Do not place pregnant patients on amlodipine.
Labetalol: (avoid use in patients with asthma, COPD, heart failure, bradycardia, or greater than 1st degree heart block)
Initial dose: 100mg by mouth 2 times daily
Recheck within 1 week
If not at blood pressure goal of <140/<90 at recheck gradually titrate to goal
Increase by 100mg twice daily every 3 days as needed until patient at blood pressure
goal of <140/<90
Effective dose range usually between 100mg twice daily and 400mg twice daily
Patients already on antihypertensive medication
Patient already on beta blocker:
If blood pressure <140/<90 with no adverse effects continue medication
If blood pressure >140/>90 add Amlodipine and titrate Amlodipine to blood pressure goal prior to increasing beta blocker dose and then follow algorithm
Patient already on ACE Inhibitor (Enalapril) or ARB (Losartan):
If blood pressure <140/90 with no adverse effects continue ACE inhibitor or ARB and check creatinine and potassium. If potassium >5.5 stop ACE inhibitor or ARB and start with Amlodipine as first line treatment. Check creatinine and monitor creatinine at rechecks and consider stopping ACE inhibitor or ARB if creatinine level rising.
If blood pressure not controlled with ACE inhibitor or ARB continue ACE inhibitor or ARB and add Amlodipine. Check creatinine and potassium. If potassium >5.5 stop ACE inhibitor or ARB and start with Amlodipine as first line treatment. Check creatinine and monitor creatinine at rechecks and consider stopping ACE inhibitor or ARB if creatinine level rising.
Patient already on hydrochlorothiazide:
If blood pressure <140/<90 with no adverse effects and patient has access to water and is hydrated continue hydrochlorothiazide and monitor sodium and potassium.
If patient does not have good access to water stop hydrochlorothiazide and start Amlodipine (See recommendations for dosing)
If blood pressure >140/>90 with no adverse effects and patient has access to water and is hydrated continue hydrochlorothiazide and monitor sodium and potassium and start by adding amlodipine (See recommendations for dosing).
IMPETIGO:
The most common cause of impetigo is S. aureus. Beta hemolytic streptococci account for a minority of cases. MRSA can also cause impetigo.
Symptoms: Non-bullous: Lesions start as papules that progress to vesicles surrounded by erythema that enlarge and break down to form thick crust with golden appearance “honey crusted lesions.” Bullous: Lesions start as vesicles that enlarge to form flaccid bullae with clear yellow fluid that later becomes darker. Ruptured bullae leave brown crust.
Treatment:
1st Line: If limited surface area, topical mupirocin, applied TID x 5-7 days. If widespread:
– Adult: Cephalexin 500mg qid x 7 days.
– Child: Cephalexin 25-50 mg/kg/day divided tid x 7 days
2nd Line or if MRSA suspected:
– Adult: Bactrim (sulfamethoxazole/trimethoprim) 800/160mg BID x 7 days
– Child: 8-12 mg/kg, doses on trimethoprim component of Bactrim, divided BID x 7 days
LEG ULCERS: VENOUS, ARTERIAL, and NEUROPATHIC:
Symptoms: Venous ulcers: shallow, irregular border wound/ulcer on malleolar regions (medial > lateral), or thin skin around ankle with dark brown discoloration with edema present.
Arterial ulcers: result in necrosis and ischemic “punched out” ulcers distally on toes and pressure areas (heel, malleoli, shin).
Neuropathic diabetic ulcers: Most common, and are painless over pressure points within a thick callus.
B .
C.
A. Stasis dermatitis often surrounds venous ulcers. B. Arterial ulcer. C. Diabetic Ulcer
Supporting Data/Test: ABIs for Arterial Ulcers.
Treatment:
Adult – ulcer debridement should be performed between each Unna boot application, which is applied just distal to the knee down to the base of the digits. Unna boot needs to be changed every 3-7 days or once unna boot has been saturated with drainage. 3-4 applications may be needed until healed. (see brochure). If Unna boot is not available, then wet to dry dressing changes twice daily with kerlix and sterile water or normal saline. For venous insufficiency, elevate lower extremities as often as possible and place patient on a diuretic. Should we list a recommended med and dose? Once the wound is healed, must follow up with compression stockings/hose.
Children – See above
Additional Information: No routine antibiotics should be used, unless there are signs and symptoms of acute cellulitis or a clinically infected ulcer, such as; increasing erythema of surrounding skin, red streaks up limb, rapid increase in size of ulcer, fever.
**Please see the wound care section for further recommendations.**
LEISHMANIASIS CUTANEOUS:
Vector-borne disease transmitted by sand fly vectors.
Symptoms: typically on exposed areas of skin. Pink colored papule that enlarges into nodule/plaque like lesion, leads to a painless ulcerated lesion with indurated border. May have associated fever, lymphadenopathy, and/or malaise. Non-responsive to antibiotics, but secondary bacterial infection of the ulcer may occur.
Physical Finding: raised inflammatory borders with a depressed center that may be ulcerated. Important to evaluate nares, septum, and oropharynx as well.
Recommended Treatment:
Adult: Diflucan 200 mg po daily for 6 weeks.
MALARIA:
Primarily P. vivax.
Symptoms: cyclic fever for weeks/months. Possible history of seizures, malaise, myalgia, headache, and weakness.
Physical findings: Hepatosplenomegaly
Supporting Data/Tests: Rapid test for Malaria when available, possible anemia with cbc
Treatment:
Adult: Chloroquine 600 mg po as a single dose followed by 300 mg po at 6, 24 and 48 hours
Children: Chloroquine 10 mg / kg as a single dose followed by 5 mg / kg at 6, 24 and 48 hours
Pregnancy: see adult dosing.
There have not been reported cases in our area of Nicaragua. Cases have been reported north of Managua and on the northeast coast.
MALNUTRITION:
Symptoms: irritability, very thin or with edema, may or may not be eating well or have diarrhea; suffer from multiple associated complications including dehydration, infection, vitamin deficiencies.
Physical findings: visible severe wasting OR bilateral edema. May have swollen abdomen, be irritable, apathetic, head that appears large relative to body, with staring eyes, bradycardia, hypotension, and hypothermia. Thin, dry, peeling skin or redundant skin folds.
MUAC (Mid-upper arm circumference) </ 125 mm, weight for height < -2 SD on WHO growth charts for 3 month old to 5 year old
Treatment:
Use mid-upper arm circumference (MUAC) on children between 6 months-60 months
Moderate acute malnutrition (MAM): MUAC 115-125 mm, between -2 and -2 SD on WHO growth charts. Talk to parent/caregiver about food choices for child and about offering a variety of choices; ensure they have card for a follow up visit in 1 month; strongly advise on returning to clinic before 1 month if child quits eating or develops s/s infection; food supplementation, especially peanut butter if possible
Severe acute malnutrition (SAM): MUAC < 115 mm; <-3 SD on growth chart. Talk to Los Rayos staff person for follow-up of malnutrition treatment program; offer child RUTF (Ready-to-use therapeutic food); check blood sugar and temperature; maintain hydration
MUSCULOSKELETAL PAIN:
Symptoms: Non-localizing diffuse muscle pain
Physical findings: No signs of trauma or active joint inflammation; No fevers.
Treatment: Try to avoid ibuprofen if possible due to many patients having chronic kidney disease.
Adult: Muscle rub cream; Acetaminophen 325-500 mg po every 4-6 h PRN or Ibuprofen 400 mg po every 6 hours
Children: Acetaminophen 10-15 mg/kg po every 4-6 hours prn, not to exceed 75 mg/kg/d;
Children > 12 years: 325 -500 mg po every 4-6 h prn, not to exceed 4 g/day
Pregnancy: Acetaminophen 325-500 mg po every 4-6 h prn, not to exceed 4g/day
Additional Information: Exclude a specific joint diagnosis; life in a third world country is difficult and musculoskeletal pain is a common complaint. Joint injections can also be beneficial if this is in your scope of practice.
OTITIS EXTERNA – BACTERIAL:
Symptoms: ear pain, pruritus, with or without drainage, and hearing loss. Most commonly 5-14 years old. Ask about previous ear infections, recent ear instrumentation, use of devices in ear canal, and water exposure. Usually afebrile.
Physical findings: tragal tenderness with tragal pressure or pulling of auricle, ear canal edema and erythema. Debris or cerumen is yellow, brown, white or gray. May have regional adenopathy
Treatment: clean out debris in external canal using ear speculum or with irrigation if the TM is intact. (Can also use Ciprofloxacin 0.3% ophthalmic for ears)
Adults: Ciprofloxacin otic 0.3%, 5 drops affected ear 2 times daily x 7 days
Children >6 months: Ciprofloxacin otic 0.3%, 5 drops affected ear 2 times daily x7 days
Pregnancy: see adult dosing
Can we get an acetic acid/hydrocortisone drop for non bacterial cases or mild cases? Or would this be too expensive?
OTITIS MEDIA:
Symptoms: Ear pain, irritability in children, may be febrile. URI symptoms or allergic rhinitis usually proceeds development of AOM.
Physical findings: Erythematous and bulging tympanic membrane
Treatment:
Adult: 1st Line: Amoxicillin 500 mg PO tid x 10 days
2nd Line: Amoxicillin/clavulanic acid available at local pharmacy if patient fails therapy with amoxicillin.
Penicillin allergic: Azithromycin 500 mg PO once on day 1, followed by 250 mg PO daily x 4 days
Children: 1st Line: Amoxicillin 90 mg/kg/day PO divided bid x 10 days
2nd Line: Cefixime 8mg/kg/day every 12 or 24 hours for 10 days
Maximum 400mg/day
Penicillin allergic: Azithromycin if > 6 months: 10 mg/kg PO once on day 1, followed by 5mg/kg PO daily x 4 days
Pregnancy: 1st Line: Amoxicillin 500 mg PO tid x 10 days
2nd Line: Augmentin available at local pharmacy if treatment failure to amoxicillin
Penicillin allergic: Azithromycin 500 mg PO once on day 1, followed by 250 mg PO daily x 4 days
Additional Information:
Pain control in children: acetaminophen 10-15 mg/kg orally every 4-6 hours, not to exceed 90 mg/kg/day, or ibuprofen 5-10 mg/kg orally every 6-8 hours, not to exceed 40 mg/kg/day.
PARASITE PREVENTION:
Children <12 months: do not give
Children between 12 months – 2 years old: Albendazole 200mg every 6 months
Children >2 and adults: Albendazole 400mg every 6 months
PERIPHERAL NEUROPATHY:
Must find the etiology; diabetes, B12 deficiency, spinal condition, injury, etc.
Symptoms: burning and tingling in the hands, feet and/or legs.
Physical findings: reduced light touch sensation, vibratory sensation, and sense of position. May have loss of reflexes. Consider monofilament testing.
Treatment: lifestyle modifications (for diabetic neuropathy): Daily foot check to ensure no wounds on feet.
Adult: gabapentin 300 mg PO daily. Gradually increase to 300 mg PO tid if needed, and they are < 65 years of age. If Gabapentin needs to be discontinued, make sure to taper dose over 7 – 14 days.
Children: gabapentin is not appropriate for use
**Ensure tight glucose control**
PHARYNGITIS – SUSPECTED BACTERIAL:
Symptoms: fever, chills, throat pain, headache, no cough. Use Centor criteria to screen.
Physical findings: pharyngeal erythema, petechiae on palate, tender anterior cervical adenopathy. Use Centor Criteria if cultures are not available.
Centor Criteria:
Fever
Tender anterior cervical lymphadenopathy
Absence of cough
Tonsillar exudate or swelling
Patients with Centor Criteria ≧3 should receive treatment for bacterial pharyngitis due to lack of strep testing in Nicaragua
Treatment:
Adult: Amoxicillin 500 mg PO bid x 10 days. If penicillin allergy, treat with azithromycin 500mg at clinic and then 250mg daily for the next 4 days.
Children: Amoxicillin 50 mg/kg/day divided bid x 10 days
PINWORMS:
Symptoms: itching around the anus.
Recommended Treatment:
Adult: Albendazole 400 mg PO once, and repeat dose in 2 weeks
Children: 12 months-2 years: Albendazole 200 mg PO once, and repeat dose in 2 weeks
> 2 years: Albendazole 400 mg PO once, and repeat dose in 2 weeks
*Treat Family Members*
Additional Information: Teach the importance of washing hands prior to eating to prevent infection. Ask if they have soap in the house (if not, consider providing soap). Changing of underclothes and bed linens every day is important. Avoid scratching & touching anus.
PREGNANCY:
Refer to Bright Hope intake forms. This will have its own protocol on separate document.
RESPIRATORY TRACT INFECTION; LOWER – VIRAL & BACTERIAL:
Symptoms: feverish, body aches, cough with phlegm, congestion, tightness in chest, loss of appetite.
Supporting Data/Tests: check pulse oximetry if shortness of breath is present, chest xr (not readily available, must ask permission, usually diagnosis based on physical exam)
Treatment:
Supportive treatment – stress the importance of drinking water and staying hydrated. Guaifenesin: 4-5 yrs 50-100 mg po q 6h Max 600 mg/day
6-11 years 100-200 mg po q 6h Max 1200 mg/day
> 12 years 200 – 400 mg po q 6h prn Max 2400 mg/day
Adult: viral or bacterial: anti-tussive symptomatic treatment; Guaifenesin 200-400 mg po q 4h PRN
Suspected Bacterial (bacterial pneumonia): 1st line: Doxycycline 100 mg po BID x 7 – 10 days OR Azithromycin 500 mg po day 1, and then 250 mg po daily x 4 days
2nd Line: Amoxicillin 500 mg po TID x 10 days
Children <1 month: likely need treatment and observation in children’s hospital
– 1 to 6 months: If afebrile and O2 saturation >96%
Azithromycin 20mg/kg once daily for 3 days
If febrile or O2 <96% – needs treatment at children’s hospital
– 6 months to 5 years old: Amoxicillin 90mg/kg/day divided BID x 10 days
Penicillin allergy: Azithromycin 10mg/kg initial dose X1, then 5mg/kg PO daily x 4 days)
≥5 years old: Suspect atypical bacteria (most common in this age group) Azithromycin 10mg/kg initial dose X1, then 5mg/kg once daily x 4 days)
Suspect typical bacteria (more ill appearing, focal auscultatory findings (rales)): Amoxicillin 90mg/kg/day divided bid x 10 days.
Pregnancy: Azithromycin 500 mg po day one, and then 250 mg po daily x 4 days AND Amoxicillin 500 mg PO tid x 10 days
RESPIRATORY TRACT INFECTION; UPPER:
Symptoms: Cold like symptoms, rhinorrhea, nasal breathing, sore or scratchy throat, painful swallowing, cough, fever, headache,
Physical Finding: edematous and/or erythematous nasal mucosa, white secretions on the tonsils, enlarged lymph nodes around the head and neck, redness of eyes, facial tenderness,
Recommended Treatment: The majority of URIs and acute bronchitis are due to a viral infection. Antibiotics are not indicated for the treatment of these conditions. Supportive measures recommended. Increase fluid intake, increase sleep, fresh fruits and veggies.
Adult: Symptomatic treatment
Guaifenesin 200 – 400 mg by mouth every 4h PRN
Children: Symptomatic treatment (fluids, acetaminophen (15mg/kg every 6 hours as needed) or Ibuprofen (10mg/kg every 6 hours as needed) for pain/fever
Guaifenesin: 4-5 yrs 50-100 mg po q 6h Max 600 mg/day
6-11 years 100-200 mg po q 6h Max 1200 mg/day
> 12 years 200 – 400 mg po q 6h prn Max 2400 mg/day
Pregnancy: May take Tylenol (325 mg; two tabs every 6 hrs), Nasal saline spray
***Additional Information: Attempt to avoid unnecessary antibiotics; Symptomatic treatment with cough drops, increased fluid intake. Do not give ibuprofen to patients under the age of 6 months. No cough medications for patients under the age of 4.
SCABIES:
Symptoms: pruritic rash. Itching at common sites including wrist, elbow, armpit, webbing between the fingers, waistline. Itching more noticeable at night or after bathing. In infants and small children, itching and skin irritation may also occur around scalp, neck, and face.
Physical findings: multiple small, erythematous papules, which are often excoriated. May have burrows, which appear as thin, curving tracks as a result of the mite tunneling under the upper layers of the skin. Infants may only have red and inflamed skin, sometimes with small sores.
Treatment: Antihistamines such as Benadryl may be given to relieve itching (or steroid creams)
Adult and children > 3 years: Ivermectin according to the weight scale below. Repeat the dose in 10 days. Do NOT give Ivermectin to children who weigh < 15kg or are < 3
years old.
Children 2 months – 5 years: Permethrin topical 5% cream. Apply to scalp, neck and hairline down to the soles of the feet, and then wash off after 8-14 hours (recommend sleeping in the cream). Repeat in 14 days.
Infants < 2 months: precipitated sulfur 7% in petroleum. Apply to head and entire body on 3 consecutive nights; remove 24 hours after each application
Pregnancy: Permethrin topical 5% cream. Apply to scalp, neck and hairline down to the soles of the feet, and then wash off after 8-14 hours (recommend sleeping in the cream). Repeat in 14 days.
Alternative: precipitated sulfur 7% in petroleum. Apply to head and entire body on 3 consecutive nights; remove 24 hours after each application Is there permethrin or sulfur in Nicaragua?
Additional Information: Bedding and clothing of infested persons and their households should be decontaminated by washing in hot water or by sealing in a plastic bag for at least 72 hours. Scabies mites generally do not survive more than 2 to 3 days away from human skin. All family members should be treated together as scabies is easily passed back and forth from person to person. Itching may continue up to two weeks after treatment. If still itching after four weeks, individual may need additional treatment.
SEIZURES:
Symptoms: syncope; aura with confusion; tonic-clonic movements; urinary incontinence; postictal confusion.
Supporting Data/Tests: If new onset, should be referred to a neurologist or hospital for EEG, CT Scan, complete metabolic panel. While waiting for tests, treat empirically to prevent further seizures. If patient has chronic seizures they still need to follow up with a neurologist.
Treatment:
Adult: Valproate (Valproic acid)
– start with 10-15 mg/kg/day divided TID
– until seizures controlled: increase by 5 to 10 mg/kg/day increments at weekly intervals.
– not to exceed 60 mg/kg/day
Children: Valproate (Valproic acid)
– For children > 10 years old: Start 10-15mg/kg/day divided BID or TID and schedule urgent follow up with neurologist
– If child <10 years old, they need to see a neurologist/go to the hospital as soon as possible
Pregnant Women: Pregnant women having seizures need to be evaluated at a hospital immediately
Additional Information: If fever and seizures, consider Malaria.
If possible refer to a local provider/neurologist
SHIGELLA:
Symptoms: Bloody diarrhea; not high volume. Cramping abdominal pain, fever, tenesmus. May have symptoms of volume depletion.
Physical findings: Generalized abdominal tenderness to palpation; normal or increased bowel sounds; findings of volume depletion
Supporting Data/Tests: Increased specific gravity on urinalysis. Send for stool sample to local lab for bloody diarrhea.
Treatment:
Adult: Rehydrate with rehydration salts or IV fluids;
– Uncomplicated disease: Cipro 500 mg po BID X 5 days or until improved.
If Cipro contraindicated, use Azithromycin 500mg orally once daily for 5 days
– Severe disease: ceftriaxone 1-2g IM once daily until able to take oral medications (should likely be able to tolerate oral medications after 1-2 days)
Children: Rehydrate with rehydration salts or IV fluids:
– Uncomplicated disease: Azithromycin 12mg/kg PO once daily on day 1 (Max dose 500mg), followed by 6mg/kg PO once daily on days 2-5 (Max dose 250mg/day).
– Severe disease: ceftriaxone 50 mg/kg IM once daily (maximum 1.5g) until able to tolerate oral medications (should likely be able to tolerate oral medications after 1-2 days)
For children with diarrhea, Zinc and Vitamin A supplementation are also recommended
Zinc (has been shown to decrease the severity and duration of diarrhea):
Children <6 months old = 10mg/day for 10 days
Children 6 months to 5 years old = 20mg/day for 10 days
Vitamin A:
For children who have not received Vitamin A supplementation in the last 4 months that have diarrhea.
Infants <6 months: 50,000 international units orally once
Infants 6 to 12 months of age: 100,000 international units orally once
Children >12 months: 200,000 international units orally once
Pregnancy: Ceftriaxone 1g every 12 hours x 2 doses, then azithromycin 500mg PO once daily x 3 days
SINUSITIS – ACUTE:
DO NOT TREAT WITH ANTIBIOTICS UNLESS PATIENT HAS FAILED 7 DAYS OF CONSERVATIVE TREATMENT AND SYMPTOMS ARE WORSENING.
Symptoms: nasal congestion, facial pain, purulent sinus discharge, possible fever.
Physical Finding: facial pain with palpation
Treatment: if <7 days, supportive care such as nasal rinses with saline spray + antihistamine (zyrtec, allegra, loratadine). If >7 days AND worsening, consider antibiotics.
Adult: 1st Line: amoxicillin 500mg PO tid x 7 days
2nd Line: doxycycline 100mg PO bid x 7 days.
Children: amoxicillin 90 mg/kg/day PO divided bid x 7 days
Pregnancy: amoxicillin 500mg PO tid x 7 days. Avoid doxycycline.
TINEA:
Symptoms: Flaky or mildly itchy spots on the skin.
Physical Finding: erythematous, pruritic, circular or oval, scaling patch or plaque. Can have “black dot” alopecia if involving the scalp, including bald spots on the scalp. May take on the shape of a ring with central clearing.
Treatment:
Tinea capitis (scalp):
Adult: 1st Line – Griseofulvin 250mg PO bid x 6 weeks
2nd Line – Terbinafine 250 mg PO daily x 6 weeks. Do not give if patient has liver disease.
3rd line – Fluconazole 200 mg po daily x 2 – 4 weeks
Children > 2 years: oral therapy is preferred over topical. Topical agents are not as effective as they do not penetrate the hair shaft where the fungal infection resides.
1st line – Griseofulvin: 125 mg tablets or liquid – 15 mg/kg/day (Max 1 gram) divided bid x 6 weeks
2nd line – Selsun blue or equivalent is a secondary choice – 5 to 10 mL to the scalp twice a week x 2 weeks. Leave each application on scalp for 2 to 3 minutes, then rinse.
Children < 2 years: Selsun blue or equivalent – 5 to 10 mL to the scalp twice a week x 2 weeks. Leave each application on scalp for 2 to 3 minutes, then rinse.
*If severe case – consider fluconazole 6 mg/kg/day (max 400mg/day) PO x 2 – 4 weeks (will require pill cutting to achieve the desired dose).
Pregnancy: avoid treatment with antifungals. May try Selsun blue or equivalent – 5 to 10 mL to the scalp twice a week x 2 weeks. Leave each application on scalp for 2 to 3 minutes, then rinse.
Tinea corporis, cruris, or pedis:
Adult: clotrimazole cream. Apply to the affected area bid x 4 weeks
Children: clotrimazole cream. Apply to the affected area bid x 2 – 4 weeks
Pregnancy: clotrimazole cream. Apply to the affected area bid x 4 weeks
TYPHOID:
Symptoms: High fever that is highest in the afternoon. Dull frontal headache, malaise and extreme fatigue, apathetic or lethargic state. Diarrhea and abdominal pain may be minimal. May have encephalopathy
Physical findings: relative sinus bradycardia may be present but is not pathognomonic. Rose spots in 30% (blanching maculopapular lesions 2 to 4 mm in diameter). No peritoneal signs. Encephalopathy may be present.
Treatment:
Adult: Uncomplicated – cipro 500 mg PO bid x 7 days. If no response, add azithromycin 1000 mg po daily x 7 days
Severe – ceftriaxone 2g once or twice daily until the patient shows improvement and can be transitioned to oral antibiotics for a total of 10 days of treatment.
Children: Uncomplicated – azithromycin 10 – 20mg/kg PO once daily (Max: 1000mg/day)
Severe – Ceftriaxone (50mg/kg/day) in 1-2 divided doses (Max: 4g/day)
For children with diarrhea Zinc and Vitamin A supplementation are also recommended by WHO
Zinc (has been shown to decrease the severity and duration of diarrhea):
Children <6 months old = 10mg/day for 10 days
Children 6 months to 5 years old = 20mg/day for 10 days
Vitamin A:
For children who have not received Vitamin A supplementation in the last 4 months that have diarrhea.
Infants <6 months: 50,000 international units orally once
Infants 6 to 12 months of age: 100,000 international units orally once
Children >12 months: 200,000 international units orally once
Pregnancy: azithromycin 1 gram PO once daily x 7 days
Patients who develop delirium, obtundation, stupor, coma, or shock need to be seen immediately at a hospital.
URINARY TRACT INFECTION:
Symptoms: Pain/burning when urinating, urge to urinate but passing only small amounts, pain or heaviness in lower abdomen, red/pinkish urine, back pain, fever/chills, nausea & vomiting. Combination of dysuria and frequency makes likelihood of UTI 90%
Physical Finding: Check for CVA tenderness
Supporting Data/Tests: Urinalysis
Recommended Treatment:
Adult:
Uncomplicated Cystitis:
First Line: Nitrofurantoin 100mg orally 2 times daily for 7 days
Second Line: Trimethoprim / sulfamethoxazole 160/800: 1 tablet 2 times daily for 3 days
Third Line: Ciprofloxacin 500 mg orally twice daily for 3 days
Pyelonephritis:
First Line: Ceftriaxone + Ciprofloxacin 500mg orally twice daily for 7 days
Second Line: Trimethoprim/sulfamethoxazole 160/800: 1 tablet 2 times daily for 14 days
Children:
Uncomplicated Cystitis (afebrile):
First Line: Cefixime: 8 mg/kg/day in divided doses every 12 or 24 hours for 7 days.
Second Line: Trimethoprim/sulfa (8mg/kg/day of TMP component) BID x 5 days
Third Line: Cephalexin (50mg/kg/day divided into three doses per day) for 7 days
Complicated Cystitis(febrile)/Pyelonephritis:
First Line: Cefixime 8mg/kg/day divided every 12 or 24 hours for 10-14 days
Second Line: Trimethoprim/sulfa (8mg/kg/day of TMP component) BID x 10 days
Third Line: Cephalexin (500mg divided into two doses per day) for 10 days
Pregnant women:
Uncomplicated Cystitis:
First Line: Nitrofurantoin 100mg orally 2 times daily for 7 days
Second Line: Cephalexin 500 mg two times daily for 7 days
Pyelonephritis: Depending on severity of disease may need to go to the hospital
Ceftriaxone 1 gram IM every 24 hours until patient is afebrile for 48 hours and then switch to Cephalexin 500mg three times daily for a total of 10 to 14 days of treatment
SEXUALLY TRANSMITTED INFECTIONS
SYPHILIS – PRIMARY:
Symptoms: genital ulcer – indurated solitary and painless; diagnosis of tertiary syphilis beyond our scope
Physical Finding: genital solitary painless ulcer, may also be found on oral mucosa
Recommended Treatment:
Adult: 1st line = 2.4 million units penicillin G benzathine – make pharmacy run for this, is not stocked due to needing to be refrigerated
2nd line = Doxycycline 100 mg po bid for 14 days,
Pregnant women: treat with Penicillin G and refer to hospital or local provider
Test for other STIs; refer to the community health center for HIV testing. See STI section of protocol for more information.
SYPHILIS – SECONDARY:
Symptoms:
Physical Finding: rash characteristically involves the palms of the hands and the soles of the feet
Recommended Treatment:
Adult: 1st line = 2.4 million units penicillin G benzathine – make pharmacy run for this, is not stocked due to needing to be refrigerated
2nd line = Doxycycline 100 mg po bid for 14 days,
Pregnant women: refer to hospital or local provider
Test for other STI; refer to the community health center for HIV testing
URETHRAL DISCHARGE – MEN:
Symptoms: Pain/burning when urinating, urge to urinate but passing only small amounts, pain or heaviness in lower abdomen, urethral discharge.
**Find out who partners are and ensure they are treated as well**
Physical Finding: none – urethral discharge
Supporting Data/Tests: Urinalysis is not needed to diagnose STI, but may be needed to rule out UTI
Recommended Treatment:
Treat empirically with 1 gram azithromycin in clinic (covers chlamydia) and 250 mg rocephin IM (covers gonorrhea)
If initial treatment fails or if patient has penicillin allergy you can give 2G azithromycin at that time
Give Azithromycin with food
VAGINITIS/VAGINAL DISCHARGE:
Adopted from WHO
BACTERIAL VAGINOSIS:
Symptoms: Most common cause of abnormal vaginal discharge. Vaginal itching or irritation, change in color/odor of discharge. Ask for LMP
Physical Finding: Pelvic exam with swab
Supporting Data/Tests: wet prep if microscope available to exclude trichomonas; KOH test for foul fishy odor to confirm bacterial vaginosis. pH if acid / base strips available.
Treatment:
Metronidazole 500mg twice daily for 7 days.
Pregnant women: may take metronidazole for bacterial vaginosis per CDC
TRICHOMONAS:
Symptoms: Vaginal itching or irritation, change in color/odor of discharge, pain during intercourse. Usually thick white discharge. Ask for LMP
Physical Finding: Pelvic exam with swab
Supporting Data/Tests: wet prep if microscope available; pH if acid / base strips available to exclude bacterial vaginosis
Treatment:
Metronidazole 2g ( Take 4 tab of metroniazole 500mg)
Pregnant women may take metronidazole for trichomonas per CDC
CANDIDIASIS/YEAST:
Symptoms: Vaginal itching or irritation, thick white discharge, change in color/odor of discharge, pain during intercourse, vaginal bleeding, painful urinations. Ask for LMP
Physical Finding: Pelvic exam, identified by clinical evaluation
Supporting Data/Tests: wet prep if microscope available to exclude trichomonas; pH if acid / base strips available to exclude bacterial vaginosis
Treatment:
Fluconazole 150mg tab once, may repeat dose in 3 days if symptoms persist
For pregnant women: Clotrimazole cream vaginally every night for 7 days.
CHLAMYDIA and GONORRHEA:
Symptoms: Vaginal itching or irritation, change in color/odor of discharge, pain during intercourse, vaginal bleeding. Ask for LMP
Physical Finding: Pelvic exam, try to exclude PID
Supporting Data/Tests: wet prep if microscope available to exclude trichomonas; pH if acid / base strips available to exclude bacterial vaginosis
Treatment: Treat empirically 1G azithromycin as well by adding 250 mg rocephin IM to cover for gonorrhea. If recurrent or if patient has penicillin allergy can give 2G azithromycin at that time.
Pregnant women may be treated with Ceftriaxone and Azithromycin
PID:
Symptoms: Vaginal itching or irritation, change in color/odor of discharge, pain during intercourse, vaginal bleeding, abdominal pain, fever. Ask for LMP
Physical Finding: bimanual examination for cervical pain if abdominal pain and if appropriate for clinic setting to exclude PID
Supporting Data/Tests: wet prep if microscope available to exclude trichomonas; pH if acid / base strips available to exclude bacterial vaginosis
Treatment:
Treat empirically: 250mg rocephin IM once. 1g azithromycin at time of appointment, repeat dose AGAIN in 1 week.
Alternative: 250mg rocephin IM once, doxycycline 100mg bid x 14 days if not pregnant
If recent gynecologic instrumentation or concern for BV/trich: add metronidazole 500mg BID x 14 days.
For patients who are pregnant: rare, but can occur in first 12 weeks before mucus plug seals uterus from ascending bacteria. Treatment = hospitalization for parenteral antibiotics
Important to evaluate and treat the sexual partner.
*Send home return appointment card for partner to return to the clinic for treatment.
NUTRITION: VITAMINS and SUPPLEMENTS
VITAMIN A DEFICIENCY – SUPPLEMENTATION:
Symptoms: Reduced night vision and blindness, poor bone growth
Physical Finding: If severe it will cause eye dryness and patches of keratin on the conjunctiva; eye changes not expected in children receiving prophylactic vitamin supplementation
Recommended Treatment: Administer in conjunction with deworming schedule
Children:
WHO does not recommend routine Vitamin A supplementation in all children 0-6 months, but should be given if patient has diarrhea, respiratory disease, or severe malnutrition.
Dose for patients <6 months is 50,000 international units once orally
WHO does recommend supplementation for children >6 months:
6 to 11 months 100,000 International units once orally
> 1 year 200,000 International units orally every 6 months
Adults:
WHO no longer recommends vitamin A in post-partum females as of 2011 publication
Pregnant women should take a prenatal vitamin that has vitamin A not exceeding 10,000 units per day.
Additional Information: Educate parents regarding foods that are high in Vitamin A: dark green leafy vegetables; mango; sweet potatoes; papaya; egg yolk; animal liver; dairy products
Women should also be encouraged to breastfeed children especially during the first 6 months of life
VITAMIN A DEFICIENCY – XEROPHTHALMIA:
Symptoms: dryness of the eyes; loss of vision; night blindness is the earliest symptom of Vitamin A deficiency
Physical finding: eye dryness; keratin patches on conjunctiva (Bitot’s spot), corneal ulceration
Recommended Treatment:
Children <6 months of age 50, 000 IU
6-12 months 100,000 IU
>12 months 200,000 IU
Then treat with same dose the next day and again in 2 weeks.
Pregnant Women:
25,000 IU once weekly for 4 weeks for women with night blindness
If pregnant woman has severe signs of acute xerophthalmia (acute corneal lesions) given 200,000 IU on day 1, 2, and 14.
Additional Information: Educate parents regarding foods that are high in Vitamin A: dark green leafy vegetables; mango; sweet potatoes; papaya; egg yolk; animal liver; dairy products. Refer to LRdE Nutrition Program
WOUND CARE
DIABETIC WOUNDS:
Result of uncontrolled diabetes mellitus. Etiology is peripheral neuropathy and inability to feel wound then uncontrolled sugars cause wound healing issues.
Recommended Treatment:
Adult – All necrotic tissue must be removed/debrided via 15 blade scalpel. If patient is not totally insensate a local block with 1% or 2% lidocaine can be used. Make sure to debride tissue until you get to healthy bleeding tissue. After debridement, daily or twice daily wet to dry dressing changes should be used. The patient should be non weight bearing on the wound until it is healed if wound is on plantar surface of the foot.
Pearls: Ensure to tell these patients to wear shoes. Check their shoes and make sure they fit correctly. No sandals. If patient does not have well-fitting shoes, they should be provided with a pair if available.