Tanzania: National Essential Medicines List (NEMLIT)

LEVELS OF MEDICINES USE A Medicines used at Dispensaries level B Medicines used at Health centers level C Medicines used at Council Hospital level D Medicines used at Regional Referral Hospitals S Medicines used at Zonal Referral, National and Special Hospitals Name of drug Dosage forms and Strengths Level 1.0 Anasthetics, Preoperative Medicines And Medical Gases 1.1 General Anaesthetics and […]

25.7 Bites and Stings

The insect that is responsible for the majority of serious sting related reactions belong to the order hymenoptera. This include bees, wasps, spiders, scorpions, ants and centipedes. Diagnostic Criteria Pain, swelling, redness, and itching to the affected area Non-Pharmacological Treatment Clean the area with soap and water to remove contaminated particles left behind by some […]

25.6 Alcohol Intoxication

It is a physiological state that include psychological alteration of consciousness induced by ingestion of ethanol (alcohol), methanol. Diagnostic Criteria: Nausea, vomiting, abdominal pain, euphoria, slurred speech, ataxia, altered level of consciousness, CNC depression, hypothermia, airway compromise, respiratory depression and hypotension and hypoglycaemia, hypokalaemia and metabolic acidosis and renal failure Investigations: Blood glucose ECG Ethanol […]

25.5 Prevention of Poisoning

Educate the patient on Dos and Don’ts of poisoning prevention. Do’s Keep medicines and poison in proper containers and out of reach of children Use containers with child resistant caps Keep all products in their original container Read medicine labels carefully to avoid mistake Don’ts Leave container open Transfer products from their origin Remove labels […]

25.4 Heavy Metal Poisoning

25.4.1 Lead Poisoning Lead is a heavy metal, ubiquitous in our environment that has no physiologic role in biological systems. Lead toxicity is a particularly insidious hazard with the potential of causing irreversible health effects associated with chronic toxicity. Diagnostic Criteria: The clinical presentation varies widely, depending upon the age at exposure, the amount of […]

25.3 Specific Poisons

25.3.1 Corrosive Compounds Poisoning Examples—sodium hydroxide (Soaps-drain/oven cleaners), potassium hydroxide, acids, bleaches or disinfectants. Non-Pharmacological Treatment Give small volume of water as soon as possible-beneficial within 30mins Give oxygen therapy if respiratory distress Surgical review Arrange for surgical review to check for: Esophageal damage/rupture, if severe. Perforation, mediastinitis and peritonitis if suspected Note: Do not […]

25.2 General Principles of Management of Poisoning

In managing a patient who has been exposed to toxins holistic approach should be considered. These include4. Resuscitation and stabilization Diagnosis Treatment of a poison (specific antidotes) Supportive care Psychosocial intervention The investigations depend on the poison ingested: If the toxin cannot be identified then toxidrome (signs and symptoms) can be used Sympathomimetic toxidrome Signs […]

25.1 Common Poisons

These can be intentional or accidental. Suspect poisoning in any unexplained illness in a previously healthy child/adult. Traditional medicines can also be a source of poisoning. The common poisoning in our setting are: Household agents: Organophosphate e.g malathion (insecticide) Pesticides – nuvan top, rat poison, hydrocarbons e.g kerosene Disinfectants and bleach Medicines – Aspirin, paracetamol, […]

24.5 Not Growing well/Growth Faltering/Failure to Thrive

Children and infants who have either: Unsatisfactory weight gain (growth curve flattening or weight loss) on the Road to Health chart/ booklet. OR Low weight for age, i.e. WHZ < –2 but > –3 Note: Babies who were premature and are growing parallel to or better than the Zscore line, should not be classified as having […]

24.4 Severe Acute Malnutrition (SAM)

Diagnostic criteria for SAM in children aged 6-59 months (any one of the following): Indicator Measure Cut off Severe wasting Weight for height Z-Score (WHZ) <-3 Mid upper arm circumference MUAC <11.5cm Bilateral pitting oedema Clinicasign Severe underweight WHZ < -3 (usually clinically reflective of marasmus) where no other explanation is present, and/or clinically severe […]

24.3 Vitamin Deficiencies

24.3.1 Vitamin A Deficiency (VAD) A condition predominantly affecting the skin, mucous membranes and the eyes. It is most common in children of 1–5 years of age. If associated with measles and diarrhoea there is an increased risk of illness and death. If not identified and treated early, it can cause blindness. Clinical features: include Night […]

24.2 Iodine Deficiency Disorders (IDDA)

Iodine is an essential component of the thyroid hormones (Triiodothyronine-T3) and Tetraiodothyonine-T4 or Thyroxine). The hormones have profound influence on energy metabolism, protein synthesis, growth and development. They also play part in the conversion of carotene to Vitamin A and synthesis of cholesterol. Insufficient level of iodine leads to inadequate production of the hormones. This, […]

24.1 Anaemia

This is a condition characterised by low haemoglobin concentration, clinically recognised by pallor. It is commonly caused by: Nutritional deficiency of iron or folate. Chronic systemic diseases such as HIV, TB, malignancy. Blood loss (bleeding/haemorrhage) e.g. caused by parasites, ulcers, tumours, abnormal menstruation. Other causes include: Vitamin B12 Infiltration or replacement of the bone marrow. […]

23.10 Withdrawal from Substance of Abuse

23.10.1. Heroin Heroin addiction, is a chronic, relapsing brain disease that is characterized by compulsive substance seeking and use, despite harmful consequences. When your body has become dependent on heroin, a number of unpleasant withdrawal symptoms will arise when the drug hasn’t been used for a certain amount of time. Diagnostic Criteria Features include: Myalgia Gooseflesh […]

23.9 Acute Stress Disorder and Post-traumatic Stress Disorder

Acute stress and post-traumatic stress disorder arise in response to stressful events. The patient should have experienced the event as life threatening or as a physical threat to themselves or others, at which time they felt fear and helplessness. Diagnostic Criteria Symptoms associated with both of these conditions include: Re-experiencing of the event, e.g. flashbacks, […]

23.8 Obsessive-Compulsive Disorder

This condition is characterised by the presence of persistent intrusive thoughts or concerns, and is usually associated with compulsions, which are mental acts or behaviours which an individual engages in to attempt to get rid of the obsessions and/or decrease his or her distress i.e. excessive hand washing. Obsessive thoughts and compulsions may interfere with […]

23.7 Panic Disorder

Panic disorder is an anxiety disorder characterized by recurrent unexpected panic attacks. A panic attack is characterised by an acute onset of intense anxiety accompanied by a sense of dread/impending threat, usually for no apparent reason. Diagnostic Criteria The patient will experience significant fear and emotional discomfort, typically peaking within 10 minutes and resolving within […]

23.6 Generalized Anxiety Disorder

Generalised anxiety disorder is characterized by excessive, exaggerated anxiety and worry about everyday life events with no obvious reasons for worry. Diagnostic Criteria Symptoms include Persistent worry Disturbances in sleep Poor concentration Mood disturbances Muscle tension Tremors Non-Pharmacological Treatment Psychotherapy Most patients can be treated as outpatients Pharmacological Treatment Indicated where symptoms are interfering with […]

23.5 Major Depressive Disorder

It is a mood disorder characterised by at least 2 weeks of depressed mood and/or diminished interest and pleasure in activities. It is associated with impairment in level of functioning in different areas including social and occupational. Diagnostic Criteria Psychological symptoms Depressed mood Feeling of worthlessness Guilt Diminished concentration Thoughts of death and suicide Somatic […]

23.4 Bipolar Mood Disorder

It is a lifelong illness, which may have an episodic, variable course. The presenting episode may be manic, hypo manic, depressive or mixed. By definition, a diagnosis of bipolar disorder requires either a current or previous episode of mania or hypomania. Bipolar disorder causes substantial psychosocial morbidity, frequently affecting patients’ relationships within the family as […]

23.3 Schizophrenia

It is characterized by altered thinking process, emotions, drive, behaviour and withdrawal from reality. Symptoms vary from patient to patient and from time to time. Diagnostic Criteria Bizarre appearance Reduced motor activity Social withdrawal Flattened affect Delusions Hallucinations Non-Pharmacological Treatment Family counselling and psycho-education Cognitive Behavioural Therapy (CBT) for stabilised patients Supportive group therapy for […]

23.2 Delirium

Delirium or acute confusion state is a condition characterised by altered level of consciousness, disorientation to time, place and sometimes to person. There may be fluctuating mental status. The patient may also present with behaviour and psychotic symptoms including agitation, hallucinations and paranoia. It is generally caused by organic brain disease including some medical emergencies. Avoid […]

23.1 Aggressive Disruptive Behaviour

These are agitated and acutely disturbed patients, who may or may not have a psychiatric condition. Many acute medical conditions and substance abuse can also present with agitation. Diagnostic Criteria Agitation Aggressive behaviour Non-Pharmacological Treatment Ensure the safety of the patient and those caring for them. Caution is needed with elderly and frail patients as […]

22.10 Oncological Emergencies

Important oncological emergencies include hypercalcemia, superior venous caval obstruction, spinal cord compression and neutropenic sepsis. 22.10.1 Superior vena cava syndrome (SVCS) Superior vena cava syndrome (SVCS) is the clinical expression for obstruction of blood flow through the SVC. Malignancy (90%) is the most frequent cause of SVC obstruction. SVC obstruction is a strong predictor of […]

22.9 Lymphomas

NHLs are a heterogeneous group of diseases which are mainly linked by their origin within the lymphoid system and its different cellular components. They are sub classified based on the stage of maturation (immature vs. mature) and cell of origin [B cell, T cell, or natural killer cell (NK) cell]. Diagnostic Criteria Peripheral Lymph node […]

22.8 Urinary Bladder Cancer

Bladder cancer, as from 2005–2016, affected about 1,537 people in Tanzania. This is according to data available at ORCI. Risk factors for bladder cancer include smoking, family history, prior radiation therapy, frequent bladder infections, and exposure to certain chemicals. The most common type is transitional cell carcinoma. Other types include squamous cell carcinoma and adenocarcinoma. […]

22.7 Carcinoma of the Prostate

Prostate cancer is among the most common malignancies and is the second most common cause of cancer related death in men. However, most men die with their prostate cancer rather than from it and management must balance the potential toxicity of active treatment, with the chances of benefit in a disease with a long natural […]

22.6 Lung Cancer

Worldwide lung cancer is the leading cause of cancer-related death. Approximately 85 %– 90% of lung cancer cases are caused by cigarette smoking. There are 2 main types of lung cancer; Non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC). These 2 types have different prognosis and management approach. 22.6.1 Non-small cell lung […]

22.5 Gastrointestinal Malignancies

22.5.1 Esophageal Cancer Esophageal cancer is the 4th most common cause of cancer death in developing countries and is more common in men. Histologically there are two types; SCC and adenocarcinoma. Tobacco and alcohol abuse are major risk factors for SCC whereas obesity, gastroesophageal reflux disease (GERD) and Barrett’s esophagus are the major risk factors for […]

22.4 Head and Neck Cancers

Cancer of the head and neck include the following: The oral cavity, pharynx, larynx, nasal cavity, para nasal sinuses, salivary glands, and thyroid. In Tanzania there is no national prevalence data about head and neck cancers but data available at ORCI shows that they contribute about 7% of all cancers. These tumours may present with […]

22.3 Cancer of the Skin

Skin cancers are usually classified into non melanoma and malignant melanoma. 22.3.1 Non-melanoma Skin Cancers Basal cell carcinoma (BCC) and squamous cell (SCC) are the most common non melanoma skin cancers. SCC is more aggressive than BCC and has the potential to metastasis. The main cause of these skin cancers is overexposure to Ultraviolet radiation. […]

22.2 Breast Cancer

Worldwide breast cancer is the most common malignancy in women. It is the second commonest female malignancy in sub–Sahara African countries after cervical cancer. It arises from glandular or lobular tissue of the breast. Ductal carcinoma is the commonest histological type followed by lobular carcinoma. Diagnostic criteria A solitary hard lump or mass in the […]

20.5 Hypertension

Hypertension is elevation of Blood Pressure(BP) measured on at least three separate occasions. There is strong association between hypertension and CAD. Hypertension is a major independent risk factor for the development of CAD, stroke, and renal failure 20, 21, 22   Diagnostic Criteria If blood pressure measurements performed on three separate occasions when either The initial […]

22.1 Gynecological Malignancies

S: Doxorubicin 45 mg/m2 IV on day 2 plus cisplatin 50 mg/m2 IV on day 1 plus paclitaxel 160 mg/m2 IV over 3h on day 2 plus filgrastim 5 μg/kg SC on days 3–12; regimen repeated every 21 days OR S: Carboplatin AUC 5–6 IV plus paclitaxel 175 mg/m2 IV over 3 hours on day 1 every 3 weeks Note: […]

21.8 Urolithiasis

This is a calculus which has formed in the urinary tract i.e. calyx, renal pelvis, ureters or urinary bladder as a result of urine which is supersaturated with respect to a stoneforming salt. Diagnostic Criteria Sudden onset of acute colic, localized to the flank, causing the patient to move constantly. nausea and vomiting blood in […]

21.7 Sexual Dysfunction

In Women May involve decrease or increase sexual responsiveness (persistent genital arousal disorder) Decrease responsiveness include absence of sexual desire, sexual arousal disorder, orgasmic disorder, vaginismus and dyspareunia Non pharmacological Treatment Correction of contributing factor (genital lesion, systemic or hormonal factors and drugs e.g. SSRIs) Psychological therapies Use of antidepressants In men It is inability […]

21.6 Nocturnal Enuresis

Enuresis is bedwetting after the age of 5 years. It is a benign condition which mostly resolves spontaneously. It is important, however, to differentiate between nocturnal enuresis and enuresis during daytime with associated bladder dysfunction. Secondary causes of enuresis include: diabetes mellitus urinary tract infection physical or emotional trauma Note: Clinical evaluation should attempt to exclude […]

21.5 Urology Disorders

Are diseases that affect urinary system including urinary incontinence, urolithiasis, benign prostatic hyperplasia, prostate cancer. 21.5.1 Prostatitis It is an infection of the prostate caused by urinary or STI pathogens. Diagnostic Criteria perineal, sacral or suprapubic pain dysuria and frequency varying degrees of obstructive symptoms which may lead to urinary retention sometimes fever Investigations Urine […]

21.4 Urinary Tract Infection (UTI)

Urinary tract infections may involve the upper or lower urinary tract. Infections may be complicated or uncomplicated. Uncomplicated cystitis is a lower UTI in a non-pregnant woman of reproductive age and who has a normal urinary tract. All other UTIs should be regarded as complicated. Note:  Differentiation of upper from lower urinary tract infection […]

21.3 Glomerular Diseases (GN)

Are those which cause glomerular to leak blood or protein into urine. Glomerular disease may be a result of a primary condition of the kidney, or may be secondary to a systemic disorder. Diagnostic Criteria Proteinuria Reduced GFR (and its effects) Haematuria Hypertension Oedema. 21.3.1 Glomerular disease – Nephritic syndrome A non infectious inflammatory process […]

21.2 Acute Renal Failure (ARF)

Is an abrupt or rapid decline in renal filtration function This is (usually) reversible kidney failure, most commonly as a result of: dehydration and fluid loss drugs/toxins, urinary tract obstruction, and acute glomerulonephritis in older children Diagnostic Criteria Oedema Oluguria/anuria Convulsions in children Investigations Serum electrolytes, Urea and Creatinine tests Ultrasound Urinalysis Non-Pharmacological Treatment Give […]

21.1 Chronic Kidney Diseases (CKD)

It is structural or functional kidney damage present for > 3 months, with or without a decreased glomerular filtration rate (GFR). Note: A history of diabetes, hypertension or cardiovascular disease confers the highest risk for developing CKD and individuals who have such a history should be screened Diagnostic Criteria Clinical features depend on the stage […]

20.16 Sinus Bradycardia and Sinus Arrest

This rhythm does not require treatment, unless they are causing symptoms, i.e. syncope, dizziness, tiredness and poor effort tolerance. Sinus bradycardia < 50/minute or sinus arrest with slow escape rhythm, accompanied by hypotension, strongly suggests a treatable underlying cause: Acute inferior myocardial infarct Hyperkalaemia, especially if wide QRS and/or peaked T waves Drugs, especially combination […]

20.15 Heart Block (Second and Third Degree)

Most cases occur in patients over 60 years and is idiopathic, with an excellent long-term prognosis, provided a permanent pacemaker is implanted. Acute, reversible AV block commonly complicates inferior myocardial infarction. The condition may also be induced by metabolic and electrolyte disturbances, as well as by certain medicines. Non-Pharmacological Treatment Emergency cardio-pulmonary resuscitation. External pacemaker […]

20.14 Cardiac Arrhythmias / Dysrhythmias

Always exclude underlying structural cardiac disease in all patients with cardiac dysrhythmias 25, 26 20.14.1 Tachyarrythmias: Narrow QRS Complex Tachyarrythmias (SVTs) Definition Sustained (> 30 seconds) or non–sustained narrow QRS (≤ 0.1 seconds) tachycardias. Atrial fibrillation Acute onset (< 48 hours) Assess clinically, e.g. heart failure, mitral stenosis, thyrotoxicosis, hypertension, age and other medical conditions. […]

20.13 Pulmonary Embolism

20.13.1 Acute Pulmonary Embolism Clinical Spectrum less than two weeks Sudden onset of dyspnoea often with unexplained anxiety (most common) Pleuritic chest pain and haemoptysis Massive embolism: pleuritic chest pain, cyanosis, right heart failure and shock. Minor emboli or pulmonary infarction may herald massive embolism and must be treated vigorously About 90% of emboli are […]

20.12 Acute Rheumatic Fever

It is a non–suppurative sequela of a group A ß haemolytic streptococcal (GABHS) pharyngeal infection. Diagnostic Criteria Jones Criteria updated 1992 See table 20.9 below Definitive Diagnosis Two major criteria or One major criterion with two minor criteria, with evidence of antecedent streptococcal infection Table 20.10: Criteria for Acute Rheumatic Fever Diagnosis Major Criteria Minor Criteria […]

20.11 Infective Endocarditis (IE)

The infective process of endocardial layer of the heart can involve native or prosthetic valve and congenital defects/shunts. Alpha–haemolytic streptococci are the most common causes of native valve endocarditis but Staphylococcus aureus is more likely if the disease is rapidly progressive with high fever, or is related to a prosthetic valve (Staphylococcus epidermidis) 24. Diagnostic […]

20.10 Pulmonary Oedema

Diagnostic Criteria Common cause of pulmonary oedema are cardiac/fluid overload, and th common causes are; Systolic heart failure complicating fluid overload Renal failure complicating fluid overload Iatrogenic fluid overload Other Cause of pulmonary oedema Increased capillary permeability Acute Respiratory Distress Syndrome (ARDS); many causes include; Systemic sepsis–gram negative infection, pancreatitis, head injury, aspiration of gastric […]

20.9 Chronic Heart Failure

Patients who have had HF as defined above for some time are often said to have ‘Chronic Heart Failure’. A treated patient with symptoms and signs that have remained generally unchanged for at least 1 month is said to be ‘Stable chronic heart failure’ Diagnostic Criteria The diagnosis of Chronic heart failure requires the following […]

20.8 Heart Failure

Heart Failure is a clinical syndrome characterized by typical symptoms (e.g. breathlessness, ankle swelling and fatigue) that may be accompanied by signs (e.g. elevated jugular venous pressure, pulmonary crackles and peripheral oedema) caused by a structural and/or functional cardiac abnormality, resulting in a reduced cardiac output and/or elevated intracardiac pressures at rest or during stress23. […]

20.7 Hypertensive Emergency

A marked elevated systolic blood pressure SBP ≥ 180mmHg and/or a diastolic DBP ≥130mmHg associated with life threatening situations one or more of the following: Unstable angina/myocardial infarction Hypertensive encephalopathy e.g. severe headache, visual disturbances, confusion, coma or seizures which may result in cerebral haemorrhage Acute left ventricular failure with severe pulmonary oedema (extreme breathlessness […]

20.6 Resistant (Refractory) Hypertension

Hypertension that remains >140/90mmHg despite the use of 3 antihypertensive drugs in a rational combination at full doses and including a diuretic i.e. thiazide. Consider all correctable causes of refractory hypertension before you refer. Hypertensive urgency. Symptomatic severe hypertension SBP 180mmHg and/or DBP >110 mmHg with evidence of Target Organ Damage or grade III/IV Retinopathy with […]

20.4 Acute Coronary Syndrome (Unstable Coronary Artery Disease)

Unstable Angina (UA) Unstable angina is a medical emergency and if untreated can progress to Non-ST Elevation Myocardial Infarction (NSTEMI) 11, 12, 13. Diagnostic Criteria Presents as chest pain or discomfort like stable angina but with the following additional characteristics: Angina at rest or minimal effort, occurring for the first time, particularly at rest and prolonged > 10 […]

20.3 Stable Coronary Artery Disease (SCAD) | Ischemic Heart Disease (IHD)

Mostly from clinical history characterized by chest pain due to myocardial ischaemia usually inducible by exercise, emotion or other stress and reproducible, relieved by rest but may occur spontaneously and stable in nature. Especially when occurs in high risk patient9, 10. Non-Pharmacological Treatment General Measures Life style modification. See section 20.1 above Prevention of ischaemic […]

20.2 Management of Dyslipidemias

Lowering blood cholesterol levels using statins is recommended to reduce the impact of cardiovascular morbidity and mortality Clinical indication for lipid lowering medicine therapy Established atherosclerotic disease Ischaemic heart disease Peripheral vascular disease Atherothrombotic stroke Note: Lipid lowering medicines should be administered in this setting even if the level of cholesterol is normal Type 2 diabetics […]

20.1 Prevention of Atherosclerotic Ischemic Heart Disease and Stroke

Cardiovascular disease (CVD) prevention is a coordinated set of actions, at the population level or targeted at an individual at risk of developing cardiovascular disease, that are aimed at eliminating or minimizing the impact of CVDs and their related disabilities. Diagnostic/screening Criteria Major risk factors for ischaemic cardiovascular and cerebrovascular disease are: Diabetes mellitus Hypertension […]

19.8 Thyroid Disorders

Thyroid disorders are conditions that affect the thyroid gland. There are specific kinds of thyroid disorders that includes hypothyroidism, hyperthyroidism, goiter, thyroid nodules and thyroid cancer. 19.8.1 Hypothyroidism Hypothyroidism is a condition in which a person’s thyroid hormone production is below normal. Common causes of the disease is chronic autoimmune thyroiditis, post surgery and post […]

19.7 Acute Metabolic Complications

19.7.1 Diabetic Ketoacidosis It is an acute metabolic complication of diabetes mellitus that may present with a decreased level of consciousness Symptoms Nausea/vomiting Thirst/polyuria Abdominal pain Dehydration Shortness of breath Fruity smelling breath Fever Lethargy Obtundation/drowsiness Confusion Altered mental function Coma Note: When you suspect DKA, confirm diagnosis immediately. All patients minimum should be admitted […]

19.6 Hypoglycaemia

Hypoglycaemia is defined as blood glucose <4 mmol/L. Diagnostic Criteria Hunger Sweating Trembling or shaking Anxiety Dizziness Lightheadedness Palpitation Numbness around the lips and fingers Headache Confusion Lack of concentration Weakness Changes in behaviour (eg irritability, tearfulness, crying), paraesthesiae. Patients may also present with convulsions, seizures or coma due to delayed corrective action or impaired […]

19.5 Diabetes and Tuberculosis

People attending TB clinics should be screened for diabetes and those attending diabetes clinics should be screened for TB if presenting with symptoms. Diabetes may be associated with delayed sputum conversion (>60 days), higher probability of tuberculosis treatment failure, higher recurrence and relapse rates, higher overall mortality, higher rates of multi-drug resistance TB and more […]

19.4 Diabetes and HIV

ARVs are associated with increased metabolic dysfunction, including insulin resistance, dyslipidemia and lipodystrophy Protease inhibitors (PIs) increase insulin resistance and reduce insulin secretion by interfering with GLUT–4 mediated glucose transport Standards of treatment and management of diabetes for patients with HIV are generally the same as those for diabetic patients without HIV and patients who […]

19.3 Hyperglycemia in Pregnancy

Gestational Diabetes Mellitus (GDM) is any degree of glucose intolerance first recognized in pregnancy. Diabetes in pregnancy refers to those with pre-existing diabetes, whether dignosed or not. Screening at first antenatal visit Perform screening in all women at the first antenatal clinic attendance if they have: BMI > 25 kg/m2 previous history of GDM glycosuria […]

19.2 Management of Diabetes during Religious Fasting

There are several types of fasting: An absolute fast imposes total abstinence from both food (solid or liquid) and water. This should not go beyond a maximum of three days and is not recommended for those people taking insulin secretagogues or insulin. In partial fast, the subjects abstain from selected foods and drinks. Choosing to […]

19.1 Diabetes Mellitus

Diabetes mellitus is a clinical syndrome characterized by persistent hyperglycemia (blood glucose values higher than the normal range) due to deficiency or diminished effectiveness of insulin. Classification Diabetes mellitus can be classified as follows: Type 1 Diabetes Mellitus (T1DM) – due to autoimmune β-cell destruction, usually leading to absolute insulin deficiency Type 2 Diabetes Mellitus […]

18.3 Injuries

Injury is an insult to the body with the resultant adverse effect. This can be brought up by physical insult, chemical/toxic injury or thermal injury. Usually the patient presents with symptoms upon arrival to the health facility which includes pain, bleeding, swelling or loss of function of the affected organ. 18.3.1 Soft Tissue injuries Diagnostic […]

18.2 Traumatic Brain Injuries (TBI)

It is any episode of trauma to the head (brain). Mortality is high. Diagnostic criteria Head injury may be associated with ophthalmic, ENT and dental injuries which are discussed separately. It is classified into two: Involving scalp only Traumatic brain injury Table 18. 2: Illustration of Traumatic Brain Injuries Mild Traumatic Brain injury Glasgow coma […]

18.1 General Management of Trauma

Trauma may occur as a result of motor vehicle crash, fights, fall, gunshot, sports, animal bites etc. and is associated with head, musculoskeletal, lacerations, visceral and neurovascular injuries. The aim of managing trauma is to prevent life threatening complications that may lead to increased morbidity and mortality. There is a systematic trauma protocol in place, […]

17.3 Low Back Pain

Low back pain is a common presenting complaint especially among the elderly. It may be a mild, transient symptom or chronic and disabling complaint. There are many causes of low back pain but a cause can usually be found from a good clinical history and physical examination. In some patients however, no cause will be […]

17.2 Inflammatory Conditions

These are a group of diverse inflammatory conditions due to different causes which affect joints and other musculoskeletal tissues. General Guidelines The first-line treatment is a non-steroidal anti-inflammatory drug (NSAID). This group includes medicines like aspirin, diclofenac and Ibuprofen, (provide dosage and scientific proof) but does NOT include paracetamol NSAIDs should be used cautiously in […]

17.1 Infections

17.1.1 Osteomyelitis Osteomyelitis is an infection of the bone, and is most common in children under 12 years. Staphylococci are the most frequent responsible organisms. Salmonella osteomyelitis infection is a common complication of sickle cell disease. Tuberculosis osteomyelitis occurs in association with having tuberculosis. Diagnostic Criteria Fever, malaise and severe pain at the site of […]

16.12 Tumours and Tumour-Like Conditions of Oral Cavity and Facial Region

16.12.1 Benign odontogenic tumors Each tumor presents with different cardinal features radiologically and on histopathological diagnosis. Ameloblastoma: Recognized between ages of 30 and 50 years 80% form in the mandible and 70% develop in the posterior molar region and often involve the ramus Painless, slow growing tumor that may be solid or cystic Looseness of […]

16.11 Traumatic Dental Injuries

It may result in loosening, displacement and or loss of teeth, fracture of teeth and or bone, lacerations and bleeding. The commonest causes are falls (in sports and play) at home or school and motor accidents. Most affected are upper incisors. Diagnostic Criteria Type Presentation Tooth concussion Is an injury to supporting tissues of tooth, […]

16.10 Malocclusions

Malocclusion is any variation in the arrangement of teeth leading to abnormal occlusion to the extent that may be functionally harmful or aesthetically objectionable. Diagnostic Criteria There are several forms of malocclusion Class I The sagittal arch relationship is normal. The anterior buccal groove of the lower permanent molar should occlude with the anterior buccal […]

16.9 Tooth Eruption, Shedding and Edentulousness

16.9.1 Eruption of Teeth Eruption of deciduous /primary teeth usually starts at five months of age. Symptoms associated with it like fever and diarrhea are normal and self limiting unless any other causes can be established. The following conditions are usually associated with tooth eruption and should be referred to dental personnel: eruption cysts, gingival […]

16.8 Tooth Sensitivities

Usually due to attrition of teeth, abrasion or gingival recession Non-Pharmacological treatment Recommend brushing teeth with desensitizing toothpaste for sensitive teeth. C: Fluoride gel, apply 12 hourly

16.7 Post Extraction Bleeding

Commonly due to disturbing the blood clot by the patient through rinsing or inadequate compression on the gauze, though at times may be due to bony/tooth remnants. Diagnostic Criteria Bleeding socket can be primary (occurring within first 24 hours post extraction) or secondary occurring beyond 24 hours post extraction. Primary Bleeding Socket Active bleeding from […]

16.6 Aphthous Ulceration

Aphthous or recurrent aphthous stomatitis (RAS) are painful recurrent mucous membrane ulcerations. Usually affect the non-keratinized oral mucous membrane. Diagnostic Criteria There are 3 types of aphthous ulcers as follows: Minor Aphthous Ulcers Small round or ovoid ulcers 2–4 mm in diameter, surrounded by an erythematous halo and some edema It occurs in groups of […]

16.5 Viral Infections

Herpes Simplex Virus This is a viral infection commonly affecting the lips and perioral soft tissues presenting as papulovesicular lesions which ultimately ulcerate. The condition is recurrent following a primary herpes infection which occurs during childhood leaving herpes simplex viruses latent in the trigeminal ganglia. The primary infection affects mainly the gingiva and palate. Diagnostic […]

16.4 Fungal Infections

16.4.1 Oral Candidiasis This is a fungal infection of the oral mucosa caused by Candida infection mainly Candida albicans. Acute oral candidiasis (thrush) is seen most commonly in the malnourished, the severely ill, neonates and HIV-AIDS patients or patients on long term oral corticosteroid use. In chronic oral candidiasis dense white plaques of keratin are formed. Other risks […]

16.3 Odontogenic and Non-Odontogenic Orofacial Infections

16.3.1. Periapical abscess This clinical condition arises as a complication of inflammation of the dental pulp or periodontal pocket. The condition may be acute and diffuse, chronic with fistula or localized and circumscribed. It is located in the apical aspect of the supporting bone. Diagnostic Criteria The patient complains of tooth ache Pain during intake […]

16.2 Dental Caries

Dental caries are caused by bacteria of the dental plaque which feed on sugary food substrates producing acid as by-products which dissolve the minerals of the tooth surface. Diagnostic criteria Early stage–asymptomatic Intermediate stage: black/brown spot which may be visible on any surface of tooth Cavities developing on tooth surface Pain/toothache elicited by hot, cold […]

16.1 Periodontal Conditions

16.1.1 Gingivitis Inflammatory changes in the gingival develop within a couple of days of undisturbed bacterial growth on the gingival margin of the erupted tooth in the oral cavity Diagnostic Criteria: Gingival redness Swollen and shiny gingival tissue Increased tendency of the gingival to bleed on gentle probing or spontaneously, during tooth brushing or even […]

15.6 ENT Malignancies

15.6.1 Cancer of the Larynx It is the commonest ENT malignancy. Risk factors include cigarette smoking, alcohol intake, gastroesophageal reflux disease and human papilloma virus. Diagnostic Criteria Progressive hoarseness of voice Difficulty in breathing (inspiratory stridor) Hemoptysis Referral: Refer the patient to the next facility with adequate expertise and facilities NOTE: Any patient with progressive hoarseness […]

15.5 Throat Conditions

15.5.1 Pharyngotonsilitis Pharyngotonsilitis is an acute inflammation of the pharynx and tonsils, which is characterized by fever and a painful throat. Pharmacological Treatment A: Phenoxymethylpenicillin (PO) 500mg 8 hourly for 7 days. Children up to 5 years: 6 mg/kg 6 hourly for 10 days OR A: Azithromycin (PO) 500mg once daily for 3 days. Children: 10mg/kg […]

15.4 Nose/Paranasal Sinuses Conditions

15.4.1 Acute Rhinitis It is a viral inflammatory condition in the nasal mucous membrane, usually part of a more wide-spread infection of the upper respiratory tract. Non-Pharmacological Treatment Bed rest& warm drinks Pharmacological Treatment A: Ephedrine nasal drops (1% for adults and 0.5% for children) 1–2 drops into each nostril 6 hourly for not more than […]

15.3 Hearing Loss

A child with hearing loss should be detected and intervention started immediately after delivery. New born hearing screening is done using an otoacustic emission machine. Any child suspected of hearing loss (usually presenting with delayed speech development) should be referred to a zonal/national hospital immediately since early intervention has a better outcome.

15.2 Otitis Media (Acute or Chronic)

It is an inflammation of the middle ear cavity. It is considered acute when the inflammation is of less than 2 weeks duration, and chronic when the inflammation is of more than 2 weeks duration with tympanic membrane perforation. Diagnostic Criteria Examine the pinna; Using an otoscope carefully examine the external auditory canal and the […]

15.1 Ear Conditions

15.1.1 Otitis External It is an inflammatory condition of the pinna and external auditory meatus. Diagnostic Criteria Itchy, dry and scaly ear canal and painful ear There may be a water or purulent discharge, debris and reduced hearing Pain may become extreme when the ear canal becomes completely occluded with edematous skin and debris. Non-Pharmacological […]

14.11 Onchocerciasis (River Blindness)

Onchocerciasis is a tissue parasitic infestation caused by a filarial worm, Onchocerca volvulus. The microfilariae invade lymphatic system, subcutaneous and deep tissues producing acute inflammation and chronic inflammation at a later stage. Diagnostic Criteria They are caused by the chronic inflammation which presents with: Skin inflammation with papules Subcutaneous nodules Atypical skin lesions (scarred, saggy, hanging areas […]

14.10 Visual Problems

Visual problems may be due to refractive errors, damage to the eye or optic nerve. This may be an indication of underlying diseases such as diabetes or hypertension. Investigations Look for abormalities of the eye Determine visual acuity accurately in both eyes by Snellen chart If vision is diminished, (less than 6/12), perform the followingPin […]

14.9 Orbital Cellulitis

Orbital cellulitis is an infection of the soft tissues of the orbit posterior to the orbital septum. It may be a continuum of preseptal cellulitis, which is an infection of the soft tissue of the eyelids and periocular region anterior to the orbital septum. Orbital cellulitis may result from an extension of an infection from […]

14.8 Retinitis

Is seen in advanced HIV infection with CD4 count of less 100 cells/mm3 Diagnostic Criteria Presents with characteristic retinal appearance of necrosis (white exudates and haemorrhages at the edge of the exudates Visual loss is irreversible Pharmacological Treatment   S: Ganciclovir 2 mg intravitreal, once a week Once immune function has been restored with antiretroviral therapy, (CD4 […]

14.7 Endophthalmitis

It is an infection of the ocular cavity. It is an ophthalmic emergency that can cause blindness that may occur secondary to bacteraemia (endogenous infection) or following penetrating eye injury of surgery Diagnosis Criteria Loss of vision, may be associated with pain in the affected eye Blood culture should be done to identify the source […]

14.6 Herpes Zoster Ophthalmicus

Occurs when Varicella Zoster Virus reactivates in the trigeminal ganglion and passes down the ophthalmic division of the trigeminal nerve Diagnostic Criteria Presents with painful vesicular rash in the trigeminal V1 area–vesicles on the tip of the nose indicate nasociliary branch involvement and increases the risk of ocular involvement Some patients develop conjunctivitis, keratitis, uveitis, […]

14.5 Dry Eye

It occurs when there is inadequate tear volume or function. Diagnostic Criteria Feelings of dryness, grittiness, burning and foreign body sensation, usually worse during the day Stringy discharge, redness and transient blurring of vision are also common. Exclude allergic conjunctivitis Non-Pharmacological Treatment Control symptoms since the condition is not curable Educate patients to avoid unprescribed […]

14.4 Ocular Oncology

14.4.1 Retinoblastoma It is the commonest childhood malignant tumor of the eyes. It is diagnosed between the first 1–3 years of life. Diagnostic Criteria White pupil reflex (leokocoria) Squint Rarely vitreous haemorraghe Hyphema Ocular/periocular inflammation Secondary glaucoma In late stages proptosis and hypopyon Pharmacological Treatment Staging and treatment is done in specialized centres in consultation […]

14.3 Structural Abnormalities of the Eye

These includes: Squint: eyes are looking in different directions; one eye appears to be turned in or out, in children or in adult. Refer urgently all children who present with squint to Paediatric Eye Tertiary Centre (Muhimbili National Hospital, Kilimanjaro Christian Medical Centre And Mbeya Zonal Referral Hospital). Ocular surface disease: The most common ocular […]

14.2 Painful Red Eyes

The eye conditions shown on Table 14.2 presents with an acute onset of red eyes: ocular trauma, corneal ulcer, uveitis and conjunctivitis. The Table also summarizes the diagnostics of red eyes. Table 14.2: Summary on diagnosis of Red Eyes Disease Condition Visual Acuity Affected Eye Cornea Pupil Pain Discharge Allergic/ viral Conjunctivitis Good Both Clear […]

14.1 Major Blinding Diseases

Blindness according to WHO is defined as a visual acuity of less than 3/60 with the best correction available or central visual field of less than 10º in the better eye. In a simpler way, it is when someone fails to count fingers at a distance of 3 meters in the eye that is considered […]