DM2R1 Code No 64256

Medic's Primary Health Care

Treatment Protocols
Third Edition

Edited by the Army Medical Directorate & HQ APHCS

Prepared under the direction of the
Director General Army Medical Services
Contents

7.5 Rectal Problems...................................... 41

Contents...................................................... 2
7.6 Diarrhoea and Vomiting .......................... 42
Amendments............................................... 4 7.7 Threadworms .......................................... 44
Introduction ................................................ 5 8 Genitourinary Conditions .................... 45
Quick Guide to DMICP ............................... 6 8.1 Urinary Tract Infection/Cystitis ................ 45
8.2 Balanitis .................................................. 46
Treatment Room Triage ............................. 7 8.3 Testicular Pain ........................................ 46
Section 1: Treatment Protocols.................... 8 8.4 Sexually Transmitted Infections .............. 47

D1 Diagnose a Headache........................... 9 9 Gynaecological Conditions ................. 48

9.1 Dysmenorrhoea ...................................... 48
1 Headache .............................................. 10 9.2 Menorrhagia............................................ 48
1.1 Tension or Stress Headache .................. 10 9.3 Vaginal Discharge................................... 49
1.2 Post Head Injury Headache .................... 11 9.4 Candidiasis ............................................. 50
1.3 Migraine .................................................. 12 9.5 Pregnancy in Servicewomen .................. 51
1.4 Sinusitis................................................... 13
2 Ear Problems ........................................ 14 10 Musculoskeletal Conditions .............. 52
2.1 Otitis Externa .......................................... 14 10.1 Neck Pain.............................................. 52
2.2 Otitis media ............................................. 15 10.2 Back Pain.............................................. 53
2.3 Hearing Loss........................................... 16 10.3 Shoulder Pain ....................................... 54
2.4 Ear Wax .................................................. 17 10.4 Elbow, Wrist and Hand Conditions ....... 55
2.5 Auditory Barotrauma ............................... 18 10.5 Knee Pain ............................................. 56
10.6 Ankle Pain............................................. 57
3 Eye Conditions ..................................... 19 10.7 Lower Leg Pain ..................................... 58
3.1 Eye Injury: Trauma.................................. 19
3.2 Eye Injury: Corneal Abrasion .................. 20 D3 Scaly Skin Rash ................................. 59
3.3 Eye Injury: Foreign Bodies...................... 20 D4 Skin Rash – By Distribution.............. 60
3.4 Eye Injury: Chemicals ............................. 21
3.5 Eye Injury: UV Light ................................ 21 11 Skin Conditions .................................. 62
3.6 Infective Conjunctivitis ............................ 22 11.1 Cellulitis................................................. 62
3.7 Allergic Conjunctivitis .............................. 24 11.2 Impetigo ................................................ 63
3.8 Eyelid Disorder: Chalazion...................... 24 11.3 Fungal/Candidal Infections ................... 64
3.9 Eyelid Disorders: Stye............................. 25 11.4 Pitted Keratolysis .................................. 65
3.10 Eyelid Disorders: Blepharitis .................. 25 11.5 Botfly larva infection......... .....................66
11.6 Cutaneous Larva Migrans .....................66
D2 Dental Pain or Trauma....................... 26 11.7 Leishmaniasis ....................................... 67
4 Dental Emergencies ............................. 27 11.8 Cold Sores ............................................ 68
4.1 Traumatic Dental Emergencies............... 27 11.9 Shingles ................................................ 69
4.2 Infective Dental Emergencies ................. 27 11.10 Warts and Verrucae ............................. 70
4.3 Tooth Ache.............................................. 28 11.11 Atopic Eczema ..................................... 71
11.12 Dermatitis............................................. 72
5 Nose and Throat Problems: ................ 30 11.13 Pigmented Lesions .............................. 73
5.1 Nose Bleeds (Epistaxis).......................... 30 11.14 Blisters ................................................. 74
5.2 Sore Throat/Tonsillitis ............................. 31 11.15 Infected Wound/Minor Skin Injury ........ 75
6 Respiratory Conditions........................ 32 11.16 Ingrowing Toenails............................... 76
6.1 The Common Cold and Influenza. .......... 32 11.17 Sunburn ............................................... 77
6.2 Chest Infections ...................................... 33 11.18 Acne………………………………………78
6.3 Asthma (Emergency Treatment)............. 34 12 Skin Infestations................................. 79
6.4 Hay Fever ............................................... 37 12.1 Head, Body and Pubic Lice................... 79
7 Gastrointestinal Problems................... 36 12.2 Scabies ................................................. 80
7.1 Mouth Ulcers........................................... 36 12.3 Ticks...................................................... 81
7.2 Indigestion............................................... 37 12.4 Leech Infestation................................... 82
7.3 Abdominal Pain....................................... 38 13 Infectious Diseases............................ 83
7.4 Constipation ............................................ 40 13.1 Chickenpox ........................................... 83
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13.2 Dengue Fever ....................................... 84 14.3 Snake bites ........................................... 89
13.3 Malaria .................................................. 85 14.4 Scorpion Stings..................................... 90
13.4 Scrub (bush or tick) Typhus .................. 86 14.5 Jellyfish stings....................................... 91
14.6 Stingray Sting........................................ 92
14 Bites and Stings ................................. 87
14.1 Dog, cat or human bite.......................... 87 Section 2 Medic's Intermediate PHC
14.2 Wasp & Bee Stings ............................... 88 Formulary ..................................................... 93

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Amendments

Amendment Date Page Nos Version

Headache algorithm added 10 05 03 9 4.3

Skin algorithms added 18 05 03 10-12 4.3

Glossary re-written 22 06 03 6 4.4

Various amendments to the treatment of 22 06 03 64-72 4.4

Musculoskeletal injuries
Dental pain algorithm 12 07 03 13 4.5

Dental Emergencies Section 12 07 03 105-107 4.5

Large number of factual and textual changes over 17 09 03 See Protocols 4.6
multiple protocols dated 15 09 03
Number of textual changes and amendment of 08 08 04 21, 31, 32, 40, 4.7
formulary 49, 53, 98, 99,
111-116
Edition 2. Complete review of all pages in 30 10 08 All 4.8
consultation with users
Update of information in line with clinical evidence. 23 10 09 All 4.9
Change of format
2nd Edition. Change of format. 25 11 10 All E2.0

3rd Edition 08 12 11 All E3 Draft

3rd Edition 16 12 11 All E3 Draft

V1.0

Table of Contributors

Col DJ Morgan-Jones MBE AD Clin Svcs

Lt Col AJ Everest RAMC SO1 Med (S) HQ Sp Comd

Your support is needed.

This is the third edition of this manual, which will continue to evolve as the role of Cbt Med Tech
changes. Comments and suggestions particularly from those deployed on operations, are always
welcomed. Please email suggestions for protocols that you would wish to see included or send
proposed amendments to: DII: AMD-PersTrg-TDT-OC or Civ: [email protected]

E3 V1.0 4
Introduction of children or pregnant servicewomen and any
individuals that fall into these categories
This manual is one of a set of publications to should be seen by a Medical Officer or Nurse.
be used by Combat Medical Technicians (Cbt For all conditions there must be an element of
Med Techs) in the delivery of Primary Medical safety netting, if the condition is not better
Care. It may also prove useful for Practice within the expected timescale, the patient
nurses, nurse practitioners and GDMOs. In must be referred to a MO and this must be
addition to this manual the following set of documented in the notes.
publications should be used:
Disposal
• Combat Medical Technician Manual. This
provides the main clinical reference Cbt Med Techs should give a maximum of 3
material and is the core teaching at days light duties (B Disposal), normally in 2
DMSTG. separate blocks, i.e. 2 days followed by a
further day on review. More experienced
clinicians should be consulted if problems
• Military Acute Care Manual. This covers all
persist longer than this period. Patients are
acute medical emergencies at ambulance
not to be bedded down (C Disposal) by Cbt
technician level.
Med Techs. Chits can be prepared but are to
be signed off by a senior nurse or GP.
• Combat Medical Technician Continuing
Clinical Exposure (CCE) and Continuing
Clinical Documentation
Professional Development (CPD) portfolio.
This provides a structured format in which
All clinical activity with a patient must be
to record annual clinical experience and
entered either into DMICP or onto an F Med
activity.
965. A quick overview of DMICP has been
included overleaf. This manual provides the
The management of patients has been divided
high level Read codes which must be used.
into Basic and Intermediate levels and this
Free text, symptom codes and options such
reflects the stratification criteria that has been
as “patient reviewed” are not to be used.
used to define the competency levels for Cbt
Med Techs:
Glossary
• Basic (Class 2). The level applies to those
B Light duties
individuals who have completed Phase 2
bd Twice daily
training. They are required to work under
BP Blood Pressure
supervision.
C Bed down
DH Drug History
• Intermediate (Class 1). Cbt Med Techs DSE Display Screen Equipment
who have passed the Class 1 course. FB Foreign Body
They may work in isolation as long as they FH Family History
are working within their competencies. IED Improvised Explosive Device
LD Light Duties
Conventions Used MC&S Microscopy, Culture and Sensitivity
od Once daily
Each condition has been allocated a number PEFR Peak Expiratory Flow Rate
e.g. 1.1 Tension Headache for ease of PMH Past Medical History
reference, for when these protocols are used qds Four times a day
in conjunction with the CCE/ CPD portfolio. RAP Regimental Aid Post
The number next to the title in [H33] brackets ROM Range of Movement
is the Read Code for use with DMICP. RR Respiratory Rate
SH Social History
Protocol Limitations SOB Shortness of Breath
tds Three times a day
The protocols are only to be used for Service PERLA Pupils Equal, Reacting to Light and
personnel aged 16 and over and entitled adult Accommodation
civilians. They do not cover the management WPA Work place assessment
E3 V1.0 5
Quick Guide to DMICP authorised script can be issued and printed by
highlighting the medication requested and
Key function buttons: then selecting Ö Y Ö Issue and Print.

F3 Main Menu Alerts. These are useful for highlighting

F5 Change patient issues to other members of staff and passing
F6 Consultation screen important messages about patients such as
F8 Save “Patient on Risk Register, to see SMO
F9 Prescribing immediately” or “check BP at next
F10 Appointment screen consultation”. From the Medical Summary
F11 Medical Record - Summary Screen choose A Ö Add then 4 Alert. This
alert will appear as soon as anyone accesses
F11 will take the user back to the main the patient records. The wording can be
medical summary screen for any selected coded or free text. To delete, highlight the
patient alert and choose delete from the medical
summary screen Ö F11
Registration. From Main Page chose RD
(Registration Details) Ö Edit Patient Ö Edit Templates. These are useful for many
Registration. The UIN is essential as it will situations, such as recording PULHHEEMS:
facilitate searches for units and subunits. Select FMED143 from the list. Input the
Once the data has been updated save with F8 medical run up values for PULHHEEMS and
save. medical boards.

Results and Health Data. From the medical Audiometry Recording. Insert the date of
summary screen (F11) you need to select V next audiogram in the final box and this will
(Values); all health data will be shown here automatically update the diary entry.
including blood results. Complete the 8MHz box at the top of the
screen.
Immunisation Dates. From the medical
summary screen (F11) select Filters and then Status, Grouping and Combining. These
6 Immunisations, this will show the dates processes should be used regularly to tidy up
they were given. notes. On the MR screen choose P Ö
Problems which are listed in the order
Immunisation Due Dates. From the medical Active, Significant Past, Minor Past and
summary screen (F11) select Diary and 1 All Health Admin. To alter the status, for
Diary Entries. Recording Immunisations is example, changing a vaccination from Active
undertaken from the consultation mode. Add Problem to Health Admin; Left click to
a new consultation, choose Templates and highlight the entry(s), right click and select
search for Vaccinations-Routine-DMICP. This Change Status to select the most
template can be used for routine service and appropriate. Grouping of DMICP entries
immunisations given in basic training, search associated with the same condition means
under the word “Routine”. that each episode can still be seen, for
example recurrent back pain over a number of
Medicals and Health Promotion Clinics. years. Combining has the same function but
Routine Health data and data from medicals the individual episodes are hidden under a
should be recorded on the FMed143 template. single code. Left click to highlight all the
This can be accessed from the medical entries, then right click, select organise and
summary screen or from within a new then either group or combine. Click on the
consultation from the template option. episode with the right date and code to be
used as the top level code. Both of these can
Medication and Printing Scripts. be un-grouped if required.
Medication can be viewed from the medical
summary screen (F11) and M Medications or
from the Consultations Screen. From the
medication screen any current in date

E3 V1.0 6
Treatment Room Triage

This process is to be followed by Medic’s during sick parade particularly if the waiting room is full of
soldiers. The aim is to sort patients quickly into 3 groups: (1) those that need to be seen now; (2)
those that need to be seen today on a routine appointment and finally (3) those that can be seen
on a routine appointment sometime in the following 5 days.

Does the See in Treatment Room once For example:

soldier need to Yes the triage has been • Acute injury.
be seen now? completed. • Gastroenteritis.
• Other acute infectious
diseases.
• A decision needs to be made
No quickly due to demands of
work.

Does the Book a routine appointment For example:

soldier need to Yes either with the MO or the • Non-acute injury.
be seen today? Treatment room for today. • Skin problems.
• Unsure of the diagnosis but
patient not acutely ill/injured.

Book a routine appointment. For example:

No • Known/chronic illness or
injury.

E3 V1.0 7
Section 1: Treatment Protocols

E3 V1.0 8
D1 Diagnose a Headache

Sudden Due to cold ‘Ice-cream’ headache.

onset Yes air or cold Yes Reassure; See Protocol
headache? food/drink? 1.1 if analgesia required.

No
Meningitis?
Neck Vomiting, Refer to MO urgently
Yes Yes
stiffness? rash, fever?

Subarachnoid
No No Haemorrhage?
Refer to MO urgently
No
Worse with
sex, cough or Yes Exertional Headache.
exercise? Refer to MO Routine.

Worse on Subdural haematoma

Yes Head injury? Yes Refer to MO urgently
waking?

No

Severe/ One-sided Migraine

throbbing Yes headache? Yes (See Protocol 1.3)
headache?

No

Worsens Tension headache.

Yes over the Yes (See Protocol 1.1)
Dull ache?
day?
No

Jaw dysfunction.
Jaw ache? Yes Refer to MO

No

Vision Long or short sighted

improved Yes Refer to MO
No (Pin Hole test)

No
Frequently Drug rebound headache
takes Yes Refer to MO
analgesia?

Sinusitis.
Facial Worse on
Yes Yes See Protocol 1.4
Tenderness? bending?

“Pin hole test” tests for refractive errors. Punch a 1-mm hole in a sheet of paper using a pen or large pin. Ask the
patient to look at the eye chart through the pinhole. If their vision improves, they require glasses.

E3 V1.0 9
1 Headache • Skin rash.

1.1 Tension or Stress Headache Investigation

Nil
1.2 Post Head Injury Headache
Management Basic and Intermediate Level
1.3 Migraine
Treatment: Analgesia, Paracetamol 2 x
1.4 Sinusitis 500mg tablets qds and/or Ibuprofen 400mg
tablets tds.

1.1 Tension or Stress Headache Advice: Avoid precipitating factors and

consider Occupational Health aspects.
[E2781]
Last updated: 08 12 11 Consider light duties. B chit 1/7.

General Information, Presentation Refer: Recent head injury or similar symptoms

in preceding month. Refer to MO if no
Headache is a common complaint, only 10% improvement after 24 hours.
have a treatable cause and only 0.5% are
serious. The most common cause is stress, Occupational Health
which may be due to work or family difficulties.
Other causes include eye strain and Ask them to consider duration of work, office
dehydration. lighting, computer use, sources of stress.
They may require an eye test or DSE
History (try using the headache algorithm) assessment, if so, refer to MO for FMED 79 or
ROHT referral.
Ask about:
• Duration; hours, days, weeks or even
months. 1 Immediate referral warning signs
• Site - on top of head pressing down or like
a tight band around the head. • Increasing severity of headache.
• Work environment; long hours, shift work, • Irritability or irrational behaviour.
computer use, deadlines, exams. • Persistent vomiting.
• Uncomfortable work position and/or bad • Photophobia, blurred or double vision.
posture. • Neck stiffness.
• Eyestrain, sleep deprivation. • Decreased conscious level.
• Difficulty in concentrating. • Convulsions.
• Dehydration or hunger, irregular meal The above may be either due to a space
times, caffeine withdrawal. occupying lesion such as intracranial bleed,
• Exposure to cold air or eating cold leading to raised intracranial pressure or if
food/drink may cause an “ice cream associated with a fever may be due to acute
headache”. meningitis.
• Social factors, relationship stress, alcohol
intake, irregular meals.
• Nausea/vomiting; consider Migraine.
• Fever, rash, neck stiffness or photophobia,
consider Meningitis.
• Recent head injury including boxing. See
protocol 1.2.

Examination
Check for:
• Temp, pulse, BP, PERLA and visual
acuity.
• Neck stiffness, neck examination. Chin to
chest.
E3 V1.0 10
1.2 Post Head Injury Headache Advice:
[SC20z-2] • Print and hand the patient the Head Injury
Last updated: 08 12 11 Advice Sheet from DMICP. Read through
the symptoms and make sure they know
General Information, Presentation how to contact medical help if their
Any significant injury or blow to the head will condition deteriorates.
cause a mild brain injury, which is called • Advise them to avoid tiring journeys,
concussion. This usually resolves after driving, contact sports, stress and alcohol
minutes or days but sometimes headaches until the headache has resolved. Good
may persist for months or rarely years. These sleep and gentle exercise may help.
long term headaches are called post traumatic
or post concussion headaches and may be Refer: If the head injury was minor without
associated with changes in mental function loss of consciousness or loss of memory
such as poor concentration and memory. (amnesia) and all observations are normal
then analgesia may be given and routine
History referral made with the doctor within 24 hrs.

Ask about: Occupational Health

• Mechanism of head injury.
No contact sports for a minimum of one week.
• Duration of any loss of consciousness.
Consider restriction on driving, weapons and
• Duration of any pre and post traumatic
use of DSE for short period if any visual or
amnesia.
concentration symptoms.
• Site and nature of pain now.
• Nausea and/or vomiting.
• Visual symptoms e.g. double vision or 1 Immediate referral warning signs
blurring of vision. • Increasing severity of headache.
• Previous head injury or brain surgery. • Irritability or irrational behaviour.
• Persistent vomiting.
Examination
• Photophobia, blurred or double vision.
Check for: • Neck stiffness.
• Temp, pulse, BP, PERLA, and visual • Decreased conscious level or
acuity. Convulsions.
• Check skull for tenderness, bruising, These signs may be due to a space occupying
swelling or cuts. lesion such as intracranial bleed, leading to
• Check movement, sensation and power of raised intracranial pressure or if associated
limbs. Look for any loss of sensation or with a fever may be due to acute meningitis.
power and compare one side to the other.

Investigation
Nil.

Management Basic Level

Document your history and examination
findings and then refer to the MO.

Management Intermediate Level

Treatment:
• Paracetamol 2 x 500mg tablets qds and/or
Ibuprofen 400mg tablets tds.
• Consider LD Chit B 3/7 max. To see MO if
longer period required.

E3 V1.0 11
 • Known migraine sufferers should keep
1.3 Migraine adequate analgesia so that they can self
[F26] medicate as soon as the symptoms start.
Last updated: 08 12 11 • Paracetamol 2 x 500mg tablets qds or
Migraleve tablets. Note: Paracetamol and
General Information, Presentation Migraleve must not be supplied together.
Moderate or severe, mostly unilateral, Migraleve maximum is two pink and 6
headaches associated with nausea and yellow tablets in 24hrs.
vomiting, light sensitivity (photophobia) and • LD Chit B 1/7 if moderate to severe.
increased sensitivity to sound (phonophobia). • C chit if severe. Admit to MRS if living in
One third of migraines are preceded by an single accommodation.
aura which is an unusual visual, olfactory or
other sensory experience. Migraines typically Advice: Lying down in a darkened room may
last from 4 -72 hours. Trigger factors may be helpful. If this does not relieve symptoms
include fatigue, anxiety, stress, depression, after a few hours, refer to MO.
changes in diet such as fasting, irregular
meals, bright lights, noise, hypoxia, strong Refer: If symptoms are more severe than
odours, menstrual cycle hormones and oral previous attacks or otherwise atypical for
contraceptive pill. Certain food items such as patient.
cheese, chocolate or alcohol may also trigger
migraines. Occupational Health
Identify and avoid trigger factors where
History possible.
Ask About: Do not drive until symptoms resolve.
• Gradual development of a unilateral Computer work may exacerbate symptoms.
headache becoming throbbing or pulsating
in nature and made worse by slightest
movement or noise. 1 Immediate referral warning signs
• Early symptoms of tiredness, yawning,
pallor and visual disturbance such as • Loss of tone, power or co-ordination may
spots or flashing lights in front of eyes. occur in migraine but should prompt
• Photophobia, nausea and vomiting, urgent referral to exclude serious causes.
phonophobia. • Refer after 24hrs if no improvement with
• PMH: migraine. analgesia.
• Recent commencement or change of
contraceptive pill.

Examination
Check for:
• Temp, pulse, BP, visual acuity, PERLA.
• Tone, power, co-ordination, sensation.

Investigation
Nil.

Management Basic Level

Document your history and examination
findings and then refer either to a senior
medic or medical officer.

Management Intermediate Level

Treatment:

E3 V1.0 12
 Occupational Health
1.4 Sinusitis
Chronic or recurrent sinusitis may cause
[H01]
employment problems particularly for divers
Last updated: 08 12 11
and aircrew.
General Information, Presentation
Acute inflammation of the mucosal lining of 1 Immediate referral warning signs
the paranasal sinuses. Usually viral in origin, Facial swelling, particularly if red or hot and
causing blockage and retention of mucus. tender to touch over the sinus areas may
This may become secondarily infected by indicate a serious infection and requires
resident bacterial organisms of the nose. urgent referral.

History
Ask about: ! Note
• Headache: facial pain increased by
Up to 70% of cases resolve without any
bending forward.
treatment but some may require antibiotics or
• Nasal congestion, runny nose, sneezing.
corticosteroid nasal spray. Menthol crystals
• PMH: Previous URTI, cough, sputum, and menthol solution are caustic so should be
fever, post nasal drip. used under direction in the treatment room.
They must not be issued to the patient.
Examination
Check for:
• Temp, pulse, BP.
• Palpation for facial tenderness.

Investigation
Nil.

Management Basic Level

Document your history and examination
findings and then refer either to a senior
medic or medical officer.

Management Intermediate Level

Treatment:
• Paracetamol 2 x 500mg tablets qds or
Ibuprofen 400mg tds with food.
• Steam inhalations, antihistamines or
decongestants may be helpful.
• Menthol and Eucalyptus Inhalation BP or
menthol crystals.
Add one teaspoon to a pint of hot, not
boiling, water and inhale the vapour in the
treatment room.
• Consider LD Chit C 1-2/7 or B1-2/7
depending on severity; if bedded down
review prior to returning to work. Admit to
MRS if living in single accommodation.

Advice: Advise to stop smoking.

Refer: Severe pain, fever and/or failure to

improve after 24 hrs of treatment.

E3 V1.0 13
2 Ear Problems Management Basic and Intermediate Level
Document your history and examination
Ear Infection findings and then refer to the medical officer.
2.1 Otitis externa Occupational Health
2.2 Otitis media • Avoid swimming or immersing ears in the
bath whilst inflamed. LD Chit; no
Hearing Loss swimming for 3 days or until seen MO.
• Follow up audiometry one month later if
2.3 Hearing loss hearing loss with episode.
• Specific advice regarding use of ear
2.4 Ear Wax defenders and signallers headsets when
there has been infection or irritation of the
2.5 Auditory Barotrauma external canal.

! Note
2.1 Otitis Externa
[F501] Frequently caused by bacterial pathogens
Last updated: 08 12 11 such as Pseudomonas and Staphlococcus
aureus but may also be caused by fungal
General Information, Presentation
overgrowth especially after antibiotic
Inflammation of the external ear which may be treatment.
due to infection. The infection may be
generalised, affecting the whole outer ear
canal, or localised, as painful boils in the
external canal producing purulent, bloody
discharge. It may be acute (less than 6
weeks) or chronic (more than 3 months).

History
Ask about:
• Unilateral or bilateral pain or discomfort
/itching.
• Discharge.
• Use of cotton buds to clean ears.
• PMH: Eczema.
• Diving, swimming, use of headsets or ear
defenders.

Examination
Check for:
• Auroscope examination of the ears to
exclude foreign body.
• Inflammation of the canal with scaly debris
and sometimes purulent discharge.
• The tympanic membrane is usually
unaffected but can be difficult to visualise.

Investigation
• Swab if copious discharge, as this may
help determine antibiotic sensitivity.
• Audiometry if hearing loss suspected.

E3 V1.0 14
 Consider LD Chit B1-2/7 or C 1-2/7 if severe.
2.2 Otitis media Admit to the MRS if living in single
[F52z] accommodation and if bedded down, review
Last updated: 08 12 11 prior to returning to work.
General Information, Presentation
Advice: Otitis media resolves in 80% of cases
Inflammation of the middle ear usually due to without antibiotics. NB: Antibiotics do not
bacterial or viral infection. Ear infections often reduce the pain in the first 24 hrs, subsequent
arise as a complication of a cold or sore attacks or deafness, but some studies show a
throat, are common and can be associated reduction in overall pain.
with considerable pain. Most are viral and the
only treatment required is adequate analgesia. Refer:
Chronic Otitis Media with Effusion (OME) or • Significant infection or perforation.
“Glue ear” is a common childhood condition • Refer those with significant discomfort,
which may affect hearing or result in fever or diabetes.
perforation of the tympanic membrane. • Sudden hearing loss.

History Occupational Health

Ask about: • Avoid swimming whilst inflamed.
• Unilateral or bilateral ear pain. • Patient with otitis media should not fly until
• Sore throat, cough, runny or stuffy nose. symptoms resolved and normal valsalva
• Fever or vomiting. manoeuvre demonstrated.
• Dizziness, hearing loss. • Arrange follow up audiometry if there is
• Discharge from the ears. any hearing loss with the episode.
• PMH: Ear problems or grommets as a
child.
• Use of cotton buds to clean ears.

Examination
Check for:
• Temp, Pulse.
• Auroscope examination of the ears to
exclude foreign body. Note grommets in
situ, scarring from previous perforation or
foreign body. The tympanic membrane
may be obscured by impacted wax in the
canal.
• Inflamed and bulging tympanic membrane,
injection of vessels, loss of light reflex.
• Perforation may occur with purulent
discharge from the middle ear.

Investigation
Nil.

Management Basic Level

Document your history and examination
findings and then refer either to a senior
medic or medical officer.

Management Intermediate Level

Treatment:
• Paracetamol 2 x 500mg tablets qds or
Ibuprofen 400mg tablet tds with food.
E3 V1.0 15
 Management Intermediate Level
2.3 Hearing Loss
Treatment: See Earwax protocol 3.4 if blocked
[F59] by earwax.
Last updated: 08 12 11
General Information, Presentation Advice: Stress the importance of ear
protection.
Hearing loss may be “conductive” due to a
blockage in the ear canal along its length or
Refer:
“sensorineural” due to nerve damage.
• First presentation of H3 grade.
Conductive deafness may be from an
accumulation of earwax, blockage of the • Unilateral hearing loss.
Eustachian tube during a cold or a foreign
body in the ear canal. Excess noise is a Occupational Health
common cause of work related sensorineural • Check to see if the patient is
hearing loss. Audiometry should be appropriately graded.
performed within 6 months of commencing • Recheck audio in two weeks to confirm
and returning from an operational tour and hearing loss.
annually for all individuals graded H3 or • May need WPA and involvement of SHEF.
significantly noise exposed in the workplace. • Increased frequency of audiograms if
occupational noise exposure or
History current/previous history of hearing loss.
Ask about: • Remove from source of noise especially
• Hearing loss unilateral/bilateral. ranges.
• Sudden/gradual onset. • Use of ear defenders according to HSW
• Duration. guidelines.
• Ear pain.
• Last operational tour date.
• Occupational and social noise exposure. ! Note
• Trauma.
The 8kHz result must be recorded on DMICP,
• Recent cold/flu.
even though this does not contribute to the
• Infection. PULHHEEMS grade. Note the review date in
• Discharge. the bottom box of the template to set the diary
• Tinnitus. entry. Current policy is to downgrade early to
• Balance disturbance/dizziness. prevent further damage but this can have
• Medication. significant career implications.
• Exposure to Explosion/IED.

Examination
Check for:
• Auroscope examination. Look for impacted
wax, signs of infection or perforation.
• Valsalva manoeuvre; pinch the nose and
either swallow or try to blow out with the
mouth closed. Note if the eardrum does
not move.

Investigation
Audiogram including 8kHz measurement.

Management Basic Level

Document your history and examination
findings and then refer to medical officer.

E3 V1.0 16
 • Persistent impacted wax despite
2.4 Ear Wax treatment.
[F504-1]
Last updated: 08 12 11 Occupational Health

General Information, Presentation Arrange follow up audiometry if there is any

hearing loss with the episode.
Earwax is produced by healthy ears and
protects the skin as well as providing some
bactericidal activity. Impacted earwax
! Note
(cerumen) in the external auditory canal is
only a problem if it causes pain or hearing • Ear syringing can cause or exacerbate an
loss. outer ear infection and is no longer
recommended.
History • Consider a foreign body in the ear canal if
Ask about: there is persistent or offensive discharge.
• Hearing loss, often sudden after bath or
swimming.
• Pain or irritation.
• Use of cotton buds.

Examination
Examination with an Auroscope.

Investigation
Nil.

Management Basic Level

Document your history and examination
findings and then refer either to a senior
medic or medical officer.

Management Intermediate Level

Treatment: Soften the wax with warmed Olive
Oil BP drops and remove by gradually
washing out in the shower. Sodium
Bicarbonate 5% ear drops are available but
may be more irritant than olive oil so are not
recommended.

1 Immediate referral warning signs

Do not proceed if there is pain, evidence of

infection, dizziness, nausea or possibility of
perforation.

Advice: Cotton buds should never be used as

they stimulate wax production and usually
push the wax further into the canal, causing
impaction or pain and risking perforation of the
eardrum.

Refer:
• Sudden hearing loss, pain or discomfort.
E3 V1.0 17
 ! Note
2.5 Auditory Barotrauma
[F5] In an acute setting, if the patient shows signs
Last updated: 08 12 11 of significant ear damage then there may also
be corresponding injury to the lungs and
General Information, Presentation gastrointestinal tract.
In a military setting this is most often as a
result of blast injury, particularly from IEDs.
The structures of the ear are designed to
collect and magnify sounds, so that the
tympanic membrane moves with the sounds.
Unfortunately, the ear’s structures also collect
and magnify pressure waves. At a pressure of
about 35 kilopascals (5 PSI), the human
eardrum may rupture. With an overpressure of
100 kPa (14 PSI) almost all eardrums rupture.
At lesser pressures, the overpressure may
cause haemorrhage into the drum without a
rupture. With extremely high pressures, the
drum may be destroyed and the ossicles
dislocated or fractured.

History
Ask about:
• Pain.
• Hearing loss,
• Tinnitus (continuous buzzing or ringing in
the ears).
• Dizziness or loss of balance.

Examination
Examination with an auroscope may reveal
blood in the external canal and show evidence
of the perforation of the tympanic
membrane(s).

Investigation
Nil.

Management Basic and Intermediate Level

Document your history and examination
findings and then refer either to a senior
medic or medical officer.

Occupational Health
• Arrange follow up audiometry.
• No swimming. LD Chit; No swimming for 2
weeks.
• Limit further noise exposure. LD Chit: No
ranges.

E3 V1.0 18
3 Eye Conditions • Head injury including loss of
consciousness and nosebleed.
Eye Injury Penetrating injuries beware:
• Hammer and chisel fragments.
3.1 Trauma • Glass, knives, thorns, darts, pencils.
• Masonry, bullet and missile fragments.
3.2 Corneal Abrasion
Examination
3.3 Foreign Bodies Visually inspect both eyes and check:
• Starting with the tissues around the orbits
3.4 Chemical Burn note any damage/pain, bone tenderness,
in particular inferior orbit and loss of skin
3.5 UV Light sensation below the eye.
• Check the sclera, then the cornea and that
Infections
the pupils are even and round.
• Note the reaction of both pupils to light
3.6 Infective conjunctivitis
and accommodation.
Allergies • Examine the range of eye movements,
comparing the two sides.
3.7 Allergic conjunctivitis • Always check and record the visual acuity.
• Evert the upper lids if trained to do so.
Eyelid Disorders • Subconjunctival haemorrhage, which is a
burst blood vessel on the eye surface, will
3.8 Styes appear as a dramatic red bruise. This
normally resolves without treatment in 1-2
3.9 Chalazia weeks.

3.10 Blepharitis Refer: If there was significant trauma or

corneal abrasion is suspected.

3.1 Eye Injury: Trauma Investigation

[SD8] Nil.
Last updated: 08 12 11
Management Basic Level
General Information, Presentation
Document your history and examination
Any injury in or around the orbital region is findings and then refer either to a senior
classed as an eye injury. The history must medic or medical officer.
detail the mechanism of injury as this will
determine the appropriate course of action. Management Intermediate Level
Blunt injury can result in a wide variety of
injuries from an orbital blowout fracture of the Minor Injury:
skull to dislocation of the lens, retinal tears • Superficial damage to the surrounding
and damage to the iris and anterior chamber tissue with no loss of vision or corneal
of the eye. Penetrating injuries on the other discomfort: Reassure.
hand can be subtle and difficult to detect but • Clean wounds as necessary. Cover with
are just as damaging as blunt injury. eye shield bandage and patch.
• Paracetamol 2 x 500mg tablets qds.
History • Refer To MO.
Moderate or severe injury: Refer immediately.
Ask about:
• Mechanism of injury.
• Pain.
• Haemorrhage and discharge.
• Loss or impairment of vision.
• Double vision.
E3 V1.0 19
Occupational Health Management Intermediate Level
Adequate eye protection, issue sunglasses or Treatment:
goggles, provide UV and foreign body • Irrigate the eye with eyewash, Normal
protection. Saline from an IV giving set or clean water
to wash away debris.
• Review after 24hrs to ensure resolution of
1 Immediate referral warning signs symptoms. There is no evidence to show
that eye patches improve pain relief.
Any high velocity injury must be referred. This
cannot be overstressed as a suspected or Refer: All cases to MO for antibiotic ointment.
obvious penetrating injury resulting in even a
tiny amount of foreign material in the vitreous Occupational Health
humor can lead to scarring and subsequent
blindness. • Adequate eye protection for the task.
• Issue sunglasses or goggles to provide UV
and foreign body protection
3.2 Eye Injury: Corneal Abrasion • Consider LD B chit for weapon handling.
[SD810]
Last updated: 08 12 11 ! Note

General Information, Presentation Use of contact lenses in dusty environments

or for prolonged periods may cause corneal
Corneal abrasions are common. The scratch abrasions.
may result from foreign bodies, fingernails,
vegetation or even prolonged rubbing of an
irritated eye. 3.3 Eye Injury: Foreign Bodies
[SD8]
History Last updated: 08 12 11
Ask about: History of foreign body or
something touching the eye surface. General Information, Presentation
Damage to eye caused by a foreign object.
Examination If the mechanism of injury involves a foreign
Visually inspect both eyes and check for: body travelling at high speed or a metal
• Difficulty opening due to pain. fragment then it is important to consider the
• Watery or purulent discharge. possibility of a penetrating eye injury. Foreign
• Inflammation of the conjunctiva. bodies are common in mechanics working
under a vehicle or activities such as using a
• Note the reaction of both pupils to light
chisel without eye protection.
and accommodation.
Dust or sand are common foreign bodies in
• Evert the eyelid, if trained to do so as the
windy weather on ranges or operations.
FB may be caught under the lid.
• Always check and record the visual acuity.
History
Investigation Ask about:
Nil. • Mechanism of injury or onset of
symptoms.
Management Basic Level • Level of pain.

Document your history and examination Examination

findings and then refer to a MO. The eye may
Visually inspect both eyes and check for:
be irrigated whilst waiting to see the MO.
• Difficulty opening due to pain.
• Watery or purulent discharge.
• Inflammation of the conjunctiva.
• Note reaction of both pupils to light and
accommodation.

E3 V1.0 20
• Evert the eyelid, if trained to do so as the Investigation
FB may be caught under the lid. Nil.
• Always check and record the visual acuity.

Investigation
Management Basic Level
Nil.
Document your history and examination
findings and then refer to a MO.
Management Basic and Intermediate Level
Treatment: Irrigate the eye with eyewash, Management Intermediate Level
Normal Saline from an IV giving set or clean Treatment:
water to wash away debris or remaining • Irrigate the eye with eyewash, Normal
foreign bodies. Saline from an IV giving set or clean water
to wash away chemicals or debris. Keep
Refer: Document your history and irrigating for 15 minutes whilst arranging
examination findings and then refer all cases urgent referral.
to the MO.
• Test the PH level of fluid in eye before and
after irrigation to confirm chemical properly
Occupational Health flushed out.
Adequate eye protection for the task; ensure • Consider B chit for 1/7.
that the sunglasses or goggles provide UV
and foreign body protection. Refer: All cases urgently.

Occupational Health
3.4 Eye Injury: Chemicals
Adequate eye protection for the task.
[SD8]
Last updated: 08 12 11
1 Immediate referral warning signs
General Information, Presentation
Do not delay referral to definitive care whilst
A wide range of chemicals can damage the examining or recording your findings.
eye. Battery acid splashes to face are a Chemical injuries need urgent expert review.
common cause in vehicle mechanics.
Alkali burns are particularly damaging and
may cause a penetrating eye injury. Loose 3.5 Eye Injury: UV Light
bits of lime should be removed from the [SD8]
corner of the eyes. Last updated: 08 12 11

History General Information, Presentation

Ask about: Red painful eye caused by UV light damage
• Type of chemical. from reflected sunlight off snow or water,
• Level of pain. laser or welding damage to eye.
The pain may not be apparent until some
Examination hours after exposure to the damaging UV
rays. Prevention is important. Treatment is the
If chemicals have been splashed into the eye
same as for corneal abrasion.
wash out first then examine.
History
Visually inspect both eyes and check:
• The sclera, then cornea and pupils. Ask about:
• Note both pupils reaction to light and • Pain.
accommodation. • Weeping, discharge.
• Examine the range of eye movements. • Loss or impairment of vision.
• Always check and record the visual acuity.
• Evert the upper lids; if trained to do so. Examination
Visually inspect both eyes and check:
E3 V1.0 21
• The sclera, then cornea and pupils. sore throat or common cold. This condition
• Note both pupils reaction to light and usually settles spontaneously in 1-2 weeks.
accommodation.
• Examine the range of eye movements.
• Record visual acuity. History
Ask about:
Investigation • Contact lens use.
Nil. • Discomfort, gritty or itchy sensation.
• Watery or purulent discharge.
Management Basic Level • Bilateral/unilateral.
Document your history and examination
Examination
findings and then refer either to a senior
medic or medical officer. Visually inspect both eyes and check for:
• Corneal abrasion or foreign body.
Management Intermediate Level • Painful cluster of vesicles around the eye
Treatment: Paracetamol 2 x 500mg tablets (may be shingles).
qds. • Red injected sclera.
• Always check and record the visual acuity.
Advice:
• Isolation in a dark room and cold Investigation
compresses may help. Swab only if persistent or recurrent.
• Remove contact lenses and do not wear Consider Chlamydia swab if not responding to
again until fully resolved. antibiotics.

Refer: Management Basic Level

• All cases, particularly if no improvement
after 24 hrs. Document your history and examination
findings and then refer either to a senior
• If any sign of corneal abrasion.
medic or medical officer.
Occupational Health Management Intermediate Level
Stress use of good eye protection; sunglasses Treatment:
with side shield or protective goggles,
• Clean the eye with eye wash or sterile
particularly at altitude. If vision affected
water.
consider B chit for weapon handling.
• Chloramphenicol 1% eye ointment qds.

3.6 Infective Conjunctivitis Advice: Remove contact lenses, clean

thoroughly and do not wear again until
[F4C0] infection cleared. Care should be taken by
Last updated: 08 12 11
examiner and the patient to avoid cross
contamination from affected to non-affected
General Information, Presentation
eye.
Inflammation of the conjunctiva:
Bacterial conjunctivitis usually presents with a Refer:
sore, itchy, red eye with purulent discharge. In • Infection not clearing after 48hrs antibiotic
most cases bacterial conjunctivitis initially use.
affects only one eye. Rapid spread of infection • Periorbital swelling (cellulitis).
to the unaffected eye is often the result of
direct physical transmission of the infective Public Health
agent. Bacterial conjunctivitis requires
treatment with antibiotics. Conjunctivitis is a contagious condition. Avoid
Viral conjunctivitis usually presents with a sharing towels/face clothes. Light duties may
non-purulent watery discharge commonly be required to excuse weapon handling if
seen in connection with other concurrent viral vision is affected and swimming should be
upper respiratory tract infections such as a avoided until the infection has cleared. Severe
E3 V1.0 22
cases should be seen by the MO and may Management Intermediate Level
require C chit, admit to the MRS if living in
Treatment: Sodium cromoglicate 2% eye
single accommodation.
drops. Instil one drop into the affected eye(s)
four times a day.
! Note
Advice: Avoid allergens, clean make up off
Trachoma is a serious form of conjunctivitis,
thoroughly.
caused by the sexually transmitted disease
Chlamydia. Suspect in young adults with
Refer:
bilateral conjunctivitis with mucopurulent
• Painful red eye with visual disturbance.
discharge and venereal disease. This is a
world wide major cause of blindness. • No improvement in 48hrs.
• Contact lens wearers.

3.7 Allergic Conjunctivitis Occupational Health

[F4C14] Avoid wearing contact lenses on exercise or
Last updated: 08 12 11 deployment, particularly in dry, dusty
environments.
General Information, Presentation
Allergic conjunctivitis may be associated with
systemic allergies such as hay fever or due to 3.8 Eyelid Disorder: Chalazion
chemical irritation from cosmetics, fumes or [F4D2]
eye drops. This condition usually presents Last updated: 08 12 11
with a non-purulent watery discharge, sore
and itchy eyes, usually both, often with a gritty General Information, Presentation
sensation on blinking. Lumps around the eye lids from retained
secretions or infection; a Chalazion is
History generally sterile inflammation of a lipid
Ask about: secreting meibomian gland on the underside
• Itching of the eyelid. They are therefore known as
meibomian cysts. They may develop gradually
• FH: of atopy.
and persist for many months.
• Recent use of chemicals or eye drops.
• Recurrent problem, same time each year.
History
Examination Ask about:
Visually inspect both eyes and check for: • Duration of symptoms.
• Diffuse redness and oedema of • Localised discomfort or pain.
conjunctiva. • Increased tearing.
• “Cobblestone” swelling of the inside of the • Sensitivity to light.
upper eyelid.
Examination
• Clear, watery discharge.
• Always check and record the visual acuity. Visually inspect both eyes and check for:
• Chalazion; a larger lump on underside of
Investigation eyelid.
Nil. • Always check and record the visual acuity.

Investigation
Management Basic Level
Nil.
Document your history and examination
findings and then refer to the MO.
Management Basic and Intermediate Level
Treatment: Chalazion usually settle with
conservative treatment but may take many
months. Antibiotics may be useful in the early
stages, later some may require minor surgery.
E3 V1.0 23
Hot compresses of a towel or cotton wool Public Health
soaked with warm water may relieve the
symptoms. Styes are contagious so advise good hygiene
especially hand washing.
Refer: Infected and/or large chalazia
disturbing vision. ! Note
Avoid wearing contact lenses with any of
! Note these conditions.
Avoid wearing contact lenses with any of
these conditions.
3.10 Eyelid Disorders: Blepharitis
[F4D0]
3.9 Eyelid Disorders: Stye Last updated: 08 12 11
[F4D10].
General Information, Presentation
Last updated: 08 12 11
Chronic inflammation of the margins of the
General Information, Presentation
eyelid. Inflammation of the eyelids, with
Lumps around the eye lids from retained redness, irritation and scaly skin at the
secretions or infection; a Stye or hordeolum, is margins. Blepharitis is a common disorder
an infection of the sebaceous glands at the that is often associated with eczema and
base of the eyelashes. A small lump which scalp dandruff. Chalazia or styes may
appears suddenly and resolves within a week. develop where the glands are blocked by the
scaly skin or crusts.
History
Ask about: History
• Duration of symptoms. Ask about:
• Localised discomfort or pain. • Inflamed lid margins.
• Increased tearing. • Pain or gritty sensation.
• Sensitivity to light. • Pain on eye movements.
• PMH Conjunctivitis.
Examination
Visually inspect both eyes and check for: Examination
• Stye; red, tender swelling at margin of lid, Visually inspect both eyes and check for:
may discharge pus. • Flakes or crusts on eyelashes.
• Always check and record the visual acuity. • Chalazia or styes.
• Always check and record the visual acuity.
Investigation
Nil. Investigation
Nil.
Management Basic Level
Treatment: Stye; hot compresses to help Management Basic & Intermediate Level
“point” the abscess (as above). Treatment: The crust on the lids should be
gently removed with cotton wool buds dipped
Refer: in warm water and a few drops of baby
• Stye that does not respond to treatment. shampoo twice daily.
• If there is an associated fever or signs of
localized infection, particularly orbital Advice: Careful daily face washing.
cellulitis, refer immediately.
Refer: Recurrent symptoms or not settling with
Management Intermediate Level good hygiene.
Stye: Chloramphenicol 1% eye ointment four
times daily.

E3 V1.0 24
Occupational Health
• Recurrent condition exacerbated by
stress, dust or tobacco smoke.
• If frequent recurrences advise re stress
management.

1 Immediate referral warning

signs
If there is an associated fever or signs of a
localised infection or orbital cellulitis refer
urgently to a MO.

E3 V1.0 25
D2 Dental Pain or Trauma

Was the patient

knocked
Treat as suspected
Any history of Yes unconscious? Is Yes Head injury See MO
trauma? the patient
feeling sick?

No

Is the bite abnormal?

Is there any obvious
asymmetry?
Possible Facial Fracture
Is there any intra oral Yes Call DO or MO
laceration?
Is there any sublingual
swelling or bruising?

No

Are there any

missing or Dento-alveolar Injury
broken, Yes See 4.1
displaced or
loose teeth?
No
No

Is the patient in Emergency Pain

SEVERE pain? Yes Management: Call DO

Sick parade in normal

No working hours See 4.1

Is there any Spreading dental

facial swelling or Yes infection: See 4.2
redness?

No

Toothache
Is patient in Yes See 4.3
severe pain?

Sick parade in normal

No working hours: See 4.3

E3 V1.0 26
4 Dental Emergencies Management Basic Level
If there is a history of loss of consciousness or
4.1 Traumatic Dental Emergencies nausea? Treat as head injury and contact the
MO immediately.
4.2 Infective Dental Emergencies Ð
If the patient has any facial swelling, an
4.3 Tooth Ache abnormal bite or lacerations or swelling inside
the mouth contact the DO immediately.
Ð
If patient has any broken, loose, displaced or
4.1 Traumatic Dental Emergencies missing teeth call the DO immediately. Any
[191] teeth that have been knocked out must be
Last updated: 08 12 11 stored in milk or saline solution, not water.
Ð
General Information, Presentation If the patient has none of the above refer to
Patient presents with pain or swelling relating senior Medic or Practice Nurse.
to the teeth or related structures with a history
of facial trauma. Management Intermediate Level
Treatment: As above plus appropriate
History analgesia: Paracetamol 500mg 2 tablets qds
Ask about: or ibuprofen 400mg tds with food.
• Were they knocked unconscious or are
Advice:
they feeling sick?
• Arrange for them to see the DO at the next
• Do they have double-vision?
possible sick parade.
• Was there trauma to any other areas of
• Advise warm salt water mouth rinses for
the head?
minor intra oral soft tissue trauma.
• Can they bite their teeth together
normally?

Examination
Equipment: Gloved Hand, Pocket Torch and If in any doubt call the DO.
Tongue Depressor

Check for:
• Unwell patient; lethargy, decreased
conscious level, nausea. Consider
possibility of head injury. 4.2 Infective Dental Emergencies
• Normal breathing. Consider airway [J0250]
obstruction by tongue, denture, secondary Last updated: 08 12 11
to maxillary fracture, etc.
• Facial asymmetry. General Information, Presentation
• Any broken, missing, loose or displaced The patient presents with a history of pain
teeth. and/or swelling relating to the teeth or related
• Lacerations, bruising or swelling inside the structures not related to facial trauma.
mouth.
• Can the patient open their mouth History
normally?
• Does the bite look grossly normal? Ask About:
• Palpate all of the oral cavity, especially • Traumatic cause.
under the tongue. • Severity, nature and duration of the pain.
Constant or Intermittent, localised to one
Investigation tooth or diffuse.
• Recent dental treatment.
Nil. • Radiation to ear or eyes.

E3 V1.0 27
• Pain worse with hot or cold. must be diagnosed early as these can spread
• Pain made worse by eating. and may be life-threatening. Toothache is
• Can patient swallow normally? managed by simple analgesia and the patient
should attend the next dental sick parade.
Examination
History
Equipment: Gloved Hand, Pocket Torch and
Tongue Depressor. Ask about:
• If related to trauma, go to 12.1 Traumatic
Check for: Dental Emergencies.
• Facial swelling or redness. • If there are signs of swelling, redness or
• Palpate any tender or swollen lymph the patient is systemically un-well go to
nodes. protocol 12. 2 Infective Dental
• Look inside mouth for decayed or broken Emergencies.
teeth. • Now complete the Medics Toothache
• Look at and palpate all soft tissue inside Proforma overleaf.
the mouth for any swelling or discharge.
• Palpate teeth gently with finger and note Examination
teeth that are tender to palpation. Equipment: Gloved Hand, Pocket Torch And
Tongue Depressor.
Investigation
Temperature. Check for:
• Look for obviously decayed teeth.
Management Basic Level • Palpate teeth to see if they are loose.
• Note pain on palpation.
If any signs of swelling, redness, lymph node • Note any puss discharging into the mouth.
involvement, raised temperature or difficulty
• Investigation
swallowing call the DO/MO immediately.
• Temperature.
Ð
If the patient complains of severe pain relating
to the teeth or related structures call the Management Basic and Intermediate Level
DO/MO immediately. Treatment: Appropriate analgesia:
Ð Paracetamol 500mg 2 tablets qds or ibuprofen
If patient is suffering from mild to moderate 400mg tds with food.
pain with no signs of spreading infection refer
to Senior Medic or Practice Nurse. Refer: If the pain cannot be controlled by
simple analgesia then ensure the Medics
Management Intermediate Level Toothache Proforma has been completed
Treatment: As above plus appropriate then call the DO.
analgesia: Paracetamol 500mg, 2 tablets qds Consider LD up to max three days B chit.
or ibuprofen 400mg tds with food.

Advice: Arrange for patient to see the DO at

next possible sick parade.

4.3 Tooth Ache

[1912]
Last updated: 08 12 11

General Information, Presentation

Toothache is a common patient complaint and
is attributable to a number of causes. It is
important to consider trauma and that there
may be associated injuries. Dental infections
E3 V1.0 28
 Medic’s Tooth Ache Proforma
Last updated: 08 12 11

1. How long has the patient had toothache?

[ ] days/[ ]hours.

2. Is the pain
Constant or intermittent?

3. Is the pain affecting the patients sleep?

YES or NO?

4. Is the pain made worse by

Hot, Cold, sweet or all three? If so, for how long?

5. Is the pain made worse by

Chewing or Biting?
6. Which tooth (or teeth) is Upper Right Molars Upper Incisors and Upper Left Molars
the pain coming from? and Premolars Canines and Premolars
(Circle appropriate answer) 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
Lower Right Molars Lower Incisors and Lower Left Molars
and Premolars Canines and Premolars
7. Is the pain relieved by painkillers?

YES or NO

9. Has the patient had a similar problem before?

YES or NO

10. Has the patient had recent dental treatment in the affected area?
YES or NO

Observations

Pulse [ ]bpm Temperature [ ]oC

 Now Phone the Dental Officer

E3 V1.0 29
5 Nose and Throat Problems: • Already significant blood loss.

5.1 Nose Bleeds (Epistaxis)

Occupational Health
5.2 Sore Throat/Tonsillitis Nose bleeds are more common in dry, dusty
environments.
5.1 Nose Bleeds (Epistaxis)
[1C6] 1 Immediate referral warning signs
Last updated: 08 12 11
If the blood loss is severe, sit the patient down
General Information, Presentation and treat for hypovolaemia as appropriate.
Bleeding from the nose. Most nose bleeds are Refer to MO.
trivial but can be distressing for the patient
and need to be dealt with efficiently and
quickly.

History
Ask about:
• Duration of bleed.
• Nose trauma including nose picking.
• Recent cold symptoms or hay fever.
• PMH: Previous episodes.
• Recent medication especially aspirin,
NSAID and alcohol.

Examination
Check for:
• Pulse and BP.
• Local inspection of nose looking for
bleeding point.

Investigation
Nil.

Management Basic and Intermediate Level

Treatment:
• Pinch nostrils and breathe through mouth.
• Lean slightly forward.
• Reassure.
• Ice pack/cold compress or sucking ice
cubes may help.
• Put yellow soft paraffin around the nostril
once bleeding has stopped. This will keep
crusting soft and help stop disturbance i.e.
by picking.
• Consider LD Chit B1/7.

Advice: Do not blow nose for 24 hours.

Refer:
• Failure to control bleeding within 20 mins
with correct technique.
E3 V1.0 30
 Advice: Increase oral fluid intake. Most sore
5.2 Sore Throat/Tonsillitis throats will improve after 3-4 days and do not
[1C9/H03] require antibiotic therapy.
Last updated: 08 12 11
Refer:
General Information, Presentation • Urgently if large unilateral swelling -
Acute inflammation of the throat and / or possible quinsy.
tonsils. Sore throats are usually due to viral • Routine if not improved in 24hrs with
infection. Bacterial infection is less common analgesia and rest or recurrent severe
and treatment with antibiotics has been shown sore throat.
to reduce the duration of fever by only 8 hrs
and is therefore not recommended.
! Note
History
Tonsillectomy is an operation that is still
Ask About: sometimes performed but has unproven
• Duration of sore throat. benefit in adults.
• Pain on swallowing.
• Fever.
• Headache, earache or cough.
• Difficulty swallowing saliva or fluids, or
drooling.
• Recent usage of any prescription drugs
which can cause symptoms of sore throat.

Examination
Check for:
• Temp, pulse, BP.
• Check cervical lymph nodes.
• Examine throat and tonsils for
inflammation, white spots or pus.

Investigation
Throat swabs are generally not helpful.
The MO may consider blood tests for
Glandular Fever if symptoms persist.

Management Basic & Intermediate Level

Treatment:
• Aspirin 300mg dispersible tablets, gargle 4
x daily or Paracetamol 2 x 500mg tablets
qds or Ibuprofen 400mg 1 tablet tds with
food.
• Chlorhexidine 0.2% Mouthwash. Rinse
mouth with 10ml of mouthwash for about
one minute, twice a day. Do not swallow.
• Dequalinium or proprietary throat lozenges
may have a soothing effect on sore throats
but there is no evidence of other beneficial
action. Sucking boiled sweets may be as
effective.
• LD Chit B 2-3/7. If severe or generally
unwell, bed down at home C 1-2/7. Admit
to MRS if living in single accommodation.

E3 V1.0 31
6 Respiratory Conditions • Consider LD Chit depending on severity; B
1-2/7 or C 1-2/7. Admit to MRS if living in
6.1 The Common Cold and Influenza single accommodation.
• If bedded down review prior to returning to
6.2 Chest Infections work.

6.3 Asthma Advice: Steam inhalation or decongestants.

Increase oral fluid intake and discourage
6.4 Hay fever smoking.

Refer:
• Patients with severe symptoms or
6.1 The Common Cold and Influenza. temperature > 38oC.
[H00-1] • If condition worsens or does not improve
Last updated: 08 12 11 within 24 hrs.
• Patients who have recently been in
General Information, Presentation countries where malaria is prevalent.
Viral infection of the upper airways, may affect
the nose, throat. Common colds or coryza, Occupational Health
are spread by droplet infection or hand to Remove soldier from a close work
hand contact, so hand washing is important. environment if possible in order to reduce the
Most are self-limiting, trivial illnesses, which risk of the infection spreading.
complete their course without serious
consequences, usually within a week although
the cough may last a bit longer.
! Note
History Consider malaria in anyone who has recently
been in countries where malaria is prevalent.
Ask about:
• Dry or sore throat.
• Nasal congestion and watery nasal
discharge.
• Sneezing, cough.
• Malaise, muscle or joint pain.
• Fever.
• History of foreign travel.

Examination
Check for:
• Temp, Pulse, RR, PEFR.
• Conjunctivitis.
• Red throat or Inflamed neck glands; see
3.7 Sore Throat/Tonsillitis protocol.

Investigations
Nil.

Management Basic and Intermediate Level

Treatment:
• Paracetamol 2 x 500mg tablets qds
and/orAspirin 2 x 300mg dispersible
tablets, gargle 4-6hrly.

E3 V1.0 32
6.2 Chest Infections Refer:
[H06z0] • Wheeziness or a “tight chest” (see Asthma
Last updated: 08 12 11 protocols).
General Information, Presentation • Persistent or significant symptoms for
greater than 48hrs.
An infection of the lower respiratory tract. The • Cough with blood in the sputum.
majority of chest infections are viral and • Pleuritic pain; sharp pain in the chest on
systematic reviews indicate that antibiotics are taking a deep breath.
of no proven benefit in otherwise healthy • Respirations > 15/min.
young adults. • Fever above 38°C and general malaise.
• O2 saturations < 97%.
History
Ask about:
• Productive cough. Sticky, white, Public Health
green/yellow or blood stained sputum. Smoking cessation advice if appropriate.
• Fever.
• PMH: Chest problems/ asthma/ diabetes/ Occupational Health
splenectomy.
• Smoking history. • Remove from a close work environment if
possible to reduce the risk of the infection
Examination spreading.

Check for:
• Temperature, pulse and BP. ! Note
• Respiratory rate, PEFR. Menthol crystals and menthol solution are
• Auscultation of the chest. caustic so should be used under direction in
• O2 Sat if pulse oximeter available; refer if the treatment room. They must not be issued
<97%. to the patient.
• Chest pain on deep inspiration.
1 Immediate referral warning signs
Investigation
Refer to MO immediately if neck stiffness,
Sputum sample may be taken for culture and
photophobia or significantly unwell.
sensitivity, discuss with MO.

Management Basic and Intermediate Level

Treatment:
• Paracetamol 2 x 500mg tablets qds.
• Menthol and Eucalyptus Inhalation BP or
menthol crystals.
Add one teaspoon to a pint of hot, not
boiling, water and inhale the vapour in the
treatment room.
• Consider LD Chit B 1-2/7 or C 1-2/7
depending on severity. Admit to the MRS if
living in single accommodation.
• If bedded down review prior to returning to
work.

Advice: Increase oral fluids and discourage

smoking. Avoid other paracetamol containing
products such as Lemsip, Nightnurse and
other branded cough, cold and flu products.

E3 V1.0 33
6.3 Asthma (Emergency Treatment) Advice: Discourage smoking.
[H33]
Last updated: 08 12 11 Refer:
• Cough with up to 15% reduction in PEFR;
General Information, Presentation make a routine appointment the same day.
Reversible small airway obstruction • Wheeze with increased RR; urgent referral
characterised by wheeze and breathlessness to MO.
due to constriction of the airways and
increased mucus production. Individuals may Occupational Health
present during peak hay fever periods or • If a known asthmatic, check that the
following strenuous exercise, particularly in soldier has been downgraded.
cold weather. • The hot, dusty environment of some
current operations may exacerbate
History asthma, even in those who have not had
Ask about: symptoms since childhood.
• Wheeze, tight chest, breathlessness, • Check Medical Risk Assessment pre-
cough, especially night time. deployment.
• DH: Current or previous medication,
regular and during this episode. 1 Immediate referral warning signs
• PMH: Known asthmatic. Previous hospital
admissions for asthma.
• FH: Atopy such as asthma, eczema, hay • Moderate asthma attack: PEFR is 50-75%
fever, allergies. best or predicted.
• SH: Smoker (self or in household / • Severe asthma attack: PEFR is 33-50%
workplace). best or predicted.
• Follow the Acute Care Guidelines, contact
Examination the MO and evacuate immediately.
Check for:
• RR. > 25bpm = Acute Severe Asthma.
• Chest auscultation: wheeze or reduced
breath sounds.
• Temp.
• Pulse. If the PR > 110bpm urgent referral
to MO required.

Investigations
PEFR; check this against the appropriate
normogram to work out percentage of
predicted or best.

Management Basic Level

Document your history and examination
findings and then refer to a medical officer

Management Intermediate Level

Treatment: one puff of Salbutamol 100mcg
cfc-free aerosol inhaler, to be used every 15
to 30 seconds for acute episodes or
exacerbations of asthma. 10-20 puffs
delivered via spacer device (use a coke bottle
or a paper cup if a spacer is not available).

E3 V1.0 34
 Advice: Avoid long grass, recently cut lawns,
6.4 Hay Fever tree pollen or known allergens where possible.
[H170] Refer: Severe symptoms not controlled by
Last updated: 08 12 11 medication and affecting lifestyle or work.

General Information, Presentation

A seasonal form of allergic rhinitis, the Occupational Health
symptoms of which are sneezing, runny nose, • Avoid allergens where possible.
red itchy eyes and sometimes sore throat. It • If anti-histamines prescribed consider
is a very common allergic condition where the safety critical roles e.g. driving, cranes,
allergen may be pollen, grasses, animal weapons etc.
dander, foods or other chemicals. It may
therefore occur throughout the year.

History ! Note
Ask about: • Hay fever may be debilitating and prevent
• Runny or blocked nose, sneezing. an individual from carrying out basic tasks
• Tight chest or wheeze. so treatment is essential.
• Watery or itchy eyes. • Some antihistamines may cause
drowsiness and the patient must be
• Dry, itchy throat.
advised accordingly.
• Relationship to weather and time of year.
• Occupation; if aircrew refer to MO.

Examination
Check for:
• Respiratory Rate.
• Chest auscultation: wheeze or reduced
breath sounds.
• PEFR if wheezing present.
• Eyes, nose and throat.

Investigation
Nil.

Management Basic Level

Document your history and examination
findings and then refer either to a senior
medic or medical officer.

Management Intermediate Level

Treatment:
• If patient c/o wheeze or SOB; refer to
Asthma protocols.
• If no wheeze or SOB; start with
antihistamine treatment. Loratadine 10mg
tablets OD or Chlorphenamine 4mg tablets
qds.
• Nasal symptoms not controlled by
antihistamine; refer for nasal spray.
• Eye symptoms not controlled by
antihistamines: Sodium Cromoglycate 2%
eye drops, 2 drops qds.

E3 V1.0 35
7 Gastrointestinal Problems Management Basic Level
Document your history and examination
7.1 Mouth Ulcers findings and then refer to a senior medic or
medical officer.
7.2 Indigestion
Management Intermediate Level
7.3 Abdominal Pain
Treatment:
7.4 Constipation
Small Solitary Ulcer:
7.5 Rectal Problems • Spontaneous recovery usually occurs after
2-3 weeks.
7.6 Diarrhoea and vomiting • Warm saline mouthwashes may relieve
pain. Mouthwashes have a mechanical
7.7 Threadworm cleansing action and freshens the mouth
and should be used at frequent intervals
until the discomfort and swelling subside.
7.1 Mouth Ulcers • Choline Salicylate 8.7% Gel (Bonjela).
[J082-1]
Last updated: 08 12 11 Multiple Ulcers: Choline Salicylate 8.7% Gel
(Bonjela) and/or Chlorhexidine 0.2%
General Information, Presentation mouthwash.
Mouth ulcers are a common complaint in Advice:
general practice and can be caused by
• Maintenance of oral hygiene, avoid spicy
multiple factors including physical or chemical
foods.
trauma, infection and drug reactions. They are
• Smoking cessation.
most commonly on the buccal mucosa (lining
of the cheek).They are also known as apthous
Refer: Multiple or enlarging mouth ulcers of
ulcers or canker sores.
more than three weeks duration. Refer to
Dental officer to identify if cause may be
History
dental issue.
Ask about:
• Duration of symptoms.
• Pain. ! Note
• Smoking history and alcohol intake.
• Recent illness or stress. Mouth ulcers without an obvious physical
• Dental problems. cause may be a symptom of
• Recent medication such as aspirin. immunodeficiency, Inflammatory Bowel
Disease or Coeliac disease.
Examination
Check for:
• Inflammation of affected area.
• Extent of ulceration.
• Neck glands.
• Temperature.
• Examine with white light looking for a
round red lesion with white crater.

Investigation
Nil.

E3 V1.0 36
 • Smoking cessation.
7.2 Indigestion
[1955] Refer:
Last updated: 08 12 11 • PMH Heart disease, breathlessness or
General Information, Presentation radiating pain.
• Persistent symptoms > 48hrs.
Indigestion describes a range of symptoms • If patient on any medication, particularly
from heartburn to severe peptic ulceration. NSAIDs.
Gastro-Oesophageal Reflux Disease (GORD) • Pain or discomfort not resolved by
is a common condition affecting up to 25% of antacids.
the population in their lifetime and some have • Vomiting; urgent MO RV if blood seen.
daily symptoms. Smoking, alcohol and obesity
may contribute.
! Note
History
Ask about: Cardiac pain may mimic indigestion,
• Duration of symptoms. particularly in the elderly. Refer if any
• Site of pain epigastric or lower abdomen. radiation, breathlessness or not resolved with
• Radiation of pain left arm indicates antacids.
possible cardiac nature.
• Exacerbating factors; made worse or
relieved by food/antacids.
• Reflux; worse on lying down flat or
bending forwards.
• Belching.
• Sweating.
• Vomiting (blood).
• Change in bowel habit.
• Weight loss.
• PMH: previous peptic ulcer, surgery.
• DH: NSAID use, smoking history.
• FH: of GI cancer.

Examination
Check for: Temp, pulse, BP.

Investigation
Nil.

Management Basic Level

Document your history and examination
findings and then refer either to a senior
medic or medical officer.

Management Intermediate Level

Treatment: Gaviscon Advance liquid or
tablets.

Advice:
• Regular meals, avoid alcohol and fatty or
spicy foods.
• Prop up the head of the bed if pain on
sleeping flat.

E3 V1.0 37
7.3 Abdominal Pain
[1969]
Last updated: 08 12 11

General Information, Presentation

Pain anywhere in the area between rib cage
and pubic bone or referred from the groin.
Abdominal pain is a relatively frequent
presentation in general practice and varies
from self-limiting problems to life-threatening
illness requiring immediate surgical
intervention. The role of the medic is to
recognise the potential severity of the
condition and refer for diagnosis and
management.

History / Examination / Investigation

Complete attached proforma.

Management Basic & Intermediate Level

Treatment: Make the patient comfortable
whilst awaiting doctor review.

Refer: Prioritise according to symptoms but all

cases should be seen quickly by a doctor,
particularly testicular pain or PV bleeding.

1 Immediate referral warning signs

• Ectopic pregnancy causes severe lower
abdominal pain, which may or may not be
localised to one side. Typically it occurs at
6-8 weeks when the patient may not even
know that she is pregnant. PV bleeding
may occur late.
• Testicular torsion or ovarian cyst torsion
cause cramping abdominal pains and are
both surgical emergencies. Refer
immediately.

E3 V1.0 38
Medics Abdominal Pain Proforma (* circle as appropriate)
Last updated: 08 12 11
When did the pain start? [ ] days / [ ] hours ago.

Systemic upset? fever / headache / dizziness*

Where did the pain start?
(mark on diagram)

Where is the pain now?

(mark on diagram)

When were the bowels last [ ] hours ago

opened?
What makes the pain worse? Movement / BO/ lying still*

What makes the pain better? Movement / BO/ lying still*

Nature of pain? Intermittent / constant / crampy / sharp*

Associated urinary Frequency / last passed urine / dysuria (pain on urinating) /

symptoms discharge / blood in urine / pain in groin or tesicles*
Associated gastrointestinal Loss of appetite / Nausea/ Vomiting / Diarrhoea / Constipation*
symptoms
Associated gynaecological Date of last period/ Possibility of pregnancy/ depot injection or
symptoms IUD / previous ectopic / Vaginal discharge or bleeding*

Relevant history Recent foreign travel/ Contact with others / Previous history of
abdominal problems / Previous abdominal surgery /
appendicectomy*

Observations:

Pulse [ ]bpm BP [ / ] mmHg RR:[ ] minute Temp: [ ] ˚C

Urine: Dipstick and keep for culture. Pregnancy test for all females [pos / neg]

Blood [ ] Glucose: [ ] Ketones: [ ] Protein: [ ]

Nitrites: [ ] Leucocytes: [ ]

 Now Phone or Speak to the Medical Officer

E3 V1.0 39
 Advice: Ensure adequate fluid intake; 6 - 8
7.4 Constipation glasses a day. High fibre diet; fresh fruit,
[19C] vegetables and cereals. Increased exercise
Last updated: 08 12 11 may help.

General Information, Presentation Referral:

Constipation is defined as the infrequent or • No response to simple treatment in 48hrs.
difficult passage of stools. Acute constipation • Poor appetite or weight loss.
is a change from the individual’s normal habit • Severe abdominal pain or bleeding on
for more than 4 days and less than 14 days defecation.
without other symptoms. Chronic constipation • Chronic habitual constipation.
is the passage of three stools or less per week • Any prolonged change in bowel habit > 2
with straining, hard stools or sensation of weeks.
incomplete evacuation. Constipation can
develop secondary to haemorrhoids, as a 1 Immediate referral warning signs
symptom of diverticulosis or irritable bowel
syndrome or secondary to pregnancy.
Serious, but rare causes include bowel A sudden change in bowel habit, blood or
obstruction and bowel cancer. mucus in the stool and weight loss may be
indicative of more serious pathology and
History should be referred urgently.
Ask about:
• Change in bowel habit either frequency or
consistency of stool.
• Duration of symptoms.
• Straining at stool.
• BO 3 times a week or less.
• Fluid intake, dehydration.
• Hard motions, “rabbit droppings”. Bristol
stool chart; Type 1.
• Abdominal pain, bloating or flatulence.
• Sensation of incomplete evacuation.
• Current medication, especially codeine.
• Blood or mucus in the motion.

Examination
Check for:
• BP, pulse.
• Abdominal distension.

Investigation
Nil.

Management Basic Level

Document your history and examination
findings and then refer either to a senior
medic or medical officer.

Management Intermediate Level

Treatment: Lactulose solution 15ml bd with
plenty of water.

E3 V1.0 40
 • Those who have experienced a reaction to
7.5 Rectal Problems a local preparation.
[J57]
Last updated: 08 12 11 External Thrombosed Pile/Perianal
abscess/fistula:
General Information, Presentation
Rectal problems are common in Service Refer all cases.
personnel. Presentation is often late because
of the embarrassing nature of the problem. 1 Immediate referral warning signs
• Haemorrhoids (Piles): Distended veins
inside the anal canal which may prolapse
Bowel cancer can occur in young people.
on straining and be visible as a soft,
Anyone with a prolonged change in bowel
grape-like swelling protruding from the
habits needs referral.
anus. They may cause discomfort, itching
or bleeding, sometimes profuse.
• Thrombosed external Pile: Very painful,
firm, non-reducible pile.
• Anal fissure: Split in the anal skin, often
due to passing hard stools. Pain and
bleeding on defecation.
• Perianal abscess/fistula: Infection from
inside the anus or an ingrowing hair
(pilonidal abscess/sinus) resulting in
painful swelling (abscess) which may form
a fistula.

History
Ask about:
• Itching/discomfort around anal region.
• Pain around anus increased during
defecation.
• Fresh red blood on toilet paper. More than
just a trace must be referred to the MO.

Examination
Refer to MO for any examination.

Investigation
Nil.

Management Basic & Intermediate Level

Haemorrhoids/Fissures:
Treatment: For known haemorrhoids; Anusol
ointment morning, night and after each bowel
movement or suppositories.

Advice: Avoid constipation and straining at

stool by increasing oral fluids and eating a
high fibre diet.

Refer:
• All new cases and those not responding to
treatment.

E3 V1.0 41
7.6 Diarrhoea and Vomiting Advice:
[AO83-1] • Hygiene precautions.
Last updated: 08 12 11 • Reintroduce foods gradually after 24 hrs if
General Information, Presentation symptoms are settling. Avoid milk/dairy
products initially.
Diarrhoea and vomiting is usually a self- • Those taking the Oral Contraceptive Pill
limiting condition, often related to eating food must be advised to use alternative
contaminated with bacteria or viruses or it contraceptive measures but continue with
may be a symptom of other conditions such their OCP.
as appendicitis. Food poisoning may be
obvious from the history if the patient vomits Refer:
within hours of eating the suspect food, which • Significant dehydration.
is often chicken or dairy produce. Frequent • Symptoms persisting after 48 hours of
liquid stools are passed, often associated with treatment.
abdominal cramps and nausea. • Elevated temperature or recurring
diarrhoea.
History • Recent overseas travel to countries where
Ask about: dysentery or cholera is endemic.
• Abdominal pain: location, intensity and • Blood or mucus in the stool or blood or
nature (colicky, relieved by bowel motion “coffee grounds” vomitus.
or vomiting).
• Diarrhoea: frequency, blood and mucus.
Use Bristol Stool Chart. (page 40) Public Health:
• Vomiting: frequency, blood or “coffee • Food handlers must be assessed free
grounds”. from infection before returning to work.
• Other individuals affected, shared meals, • Complete FMed 85.
fast food. • Refer for admission to MRS to prevent
• History of recent foreign travel. spread of infection when living in shared
• When last passed urine; indication of accommodation.
dehydration state. • Consider C chit up to 3/7 to allow 24 hrs
post infection.
Examination
Check for:
• Temp, Pulse and BP. Consider blood
sugar. 1 Immediate referral warning signs
• Abdominal examination; note bowel
sounds, distension and tenderness. Severe vomiting without bowel motions may
• Investigation. indicate abdominal obstruction.
• Stool sample for culture if appropriate.

Management Basic Level

Document your history and examination
findings and then refer to a senior medic or
medical officer.

Management Intermediate Level

Treatment: Mild and symptoms less than 24
hours:
• Drink clear fluids only for 24 hours.
• Anti-diarrhoeals should only be given for
specific travel or operational reasons.
• Consider rehydration salts, such as
Dioralyte, if unable to eat.
E3 V1.0 42
Medics Diarrhoea and Vomiting Proforma (* delete as appropriate)
Last updated: 08 12 11

When did the diarrhoea/vomiting start? [ ] days / [ ] hours ago.

Diarrhoea Frequency (episodes in past 24 Hrs):

Blood Yes/No* Mucus Yes/No*

Stool Type (Bristol Chart)

Vomiting Frequency: (episodes in past 24 Hrs): [ ]

Blood: Yes/No* Coffee Ground Yes/No*

Relevant History Foreign travel/Contact with others with similar/Suspect

food*
Systemic Upset Headache/Fever/Dizziness/Photophobia/Neck Stiffness*

Fluid intake past 24hrs [ ] Litres

On OCP Yes/No*

Abdominal Examination:
Pain: Yes/No* Where is it? (indicate):

When did it start?

[ ] days / [ ] hours ago.

Type e.g. colicky, relieved by passing

stool etc

Bloating Yes/No*
Bowel Sounds Present/Increased/Decreased*

Observations :

Pulse [ ]bpm BP [ / ] mmHg RR:[ ] minute

Temp: [ ] ˚C

Urine: Dip and keep for MSU

Blood: [ ] Glucose: [ ] Ketones: [ ]

Nitrites: [ ] Protein: [ ] Leucocytes: [ ]

 Now Phone or Speak to the Medical Officer or Practice Nurse

E3 V1.0 43
 • Wear pyjama bottoms at night to avoid
7.7 Threadworms anal scratching.
[AC74] Refer:
Last updated 08 12 11 • Pregnant servicewomen.
• Patients with persistent anal itching.
General Information, Presentation
Threadworm (pinworm) infection is the most
common form of helminthic parasite Public Health
infestation in humans. The roundworms • Good hygiene must be followed to prevent
measure up to 13mm in length and look like re-infection.
threads of cotton. Diagnosis is often made by • Food handlers are not to work with
seeing them moving in stools. The most foodstuffs until reassessed free from
common symptom is severe itching around infection.
the anus, particularly at night. They are highly
contagious.

History
Ask about:
• Anal itching.
• Threadworms seen in stool.

Examination
Nil.

Investigation
The Sellotape test: the patient is asked to
stick sellotape around anal margin to pick up
eggs which are laid on the skin around the
anus overnight. Stick the tape to a microscope
slide and send to lab. Alternatively wipe the
anal margin with a cotton bud and send to lab.

Management Basic Level

Document your history and examination
findings and then refer to a medical officer.

Management Intermediate Level

Treatment:
• Mebendazole 100mg single dose.
• Treat entire family as it is contagious and
eggs may live outside the body for some
time.
• Treat all service personnel in close shared
accommodation.
• A second dose may be required after two
weeks.

Advice:
• Follow good hygiene, taking particular
care to wash hands thoroughly after
contact with anus.
• Keep fingernails trimmed short.

E3 V1.0 44
8. Genitourinary Conditions Management Intermediate Level
Treatment:
8.1 Urinary Tract Infection/Cystitis • Potassium citrate tablets make the urine
more alkaline and may be enough to
8.2 Balanitis relieve symptoms without need for any
other treatment.
8.3 Testicular Pain • Consider LD B chit for 1-2/7 to excuse
physical activity.
8.4 Sexually Transmitted Disease
Advice:
• Increase oral fluid intake.
• Double voiding of bladder to prevent
8.1 Urinary Tract Infection/Cystitis
urinary stasis.
[K15] • Voiding after sexual intercourse.
Last updated: 08 12 11
• Good peri-anal hygiene, avoid bubble
bath, vaginal douches, tight underclothes
General Information, Presentation
and synthetic materials.
Infection of any part of the urinary tract from
kidney to urethra. Infection of the bladder is Refer:
called cystitis. Infections are more common in • Female Patients whose symptoms do not
women because of the shorter urethra. improve within 24 hrs of starting treatment.
• All men with UTI.
History • Pregnant women.
Ask about: • Diabetics.
• Frequency of urination (micturition) but • Frequent attacks.
small amounts.
• Pain on urination (dysuria). Public Health:
• Cloudy or foul smelling urine. Consider sexually transmitted infection and
• Blood in the urine (haematuria). refer to Genitourinary Medicine (GUM) clinic if
• Vaginal/urethral discharge. appropriate.
• Fever and vomiting.
• Suprapubic, loin or groin pain.
• PMH: Previous UTI, renal stones, Pelvic 1 Immediate referral warning signs
Inflammatory Disease (PID), Sexually
Transmitted Infections (STI), Diabetes. Fever, nausea and vomiting or flank pain
• LMP, pregnancy. suggest kidney infection (Pyelonephritis)
• SH: Symptomatic sexual partner. which requires urgent referral.

Examination
Check for: Temp, pulse and BP.

Investigation
• Urine dipstick and keep sample for culture.
• Pregnancy test if appropriate.

Management Basic Level

Document your history and examination
findings and then refer either to a senior
medic or medical officer.

E3 V1.0 45
8.2 Balanitis 8.3 Testicular Pain
[K2710] [1A57-1]
Last updated: 08 12 11 Last updated: 08 12 11
General Information, Presentation
General Information, Presentation
Inflammation of the glans penis. Inflammation
Pain in scrotum due to infective and non
may be due to poor hygiene, particularly in
infective conditions. Testicular pain may be
uncircumcised males, overzealous washing,
due to trauma or infection (epididymo-
STIs, use of fragranced soap/shower gels or
orchitis). All testicular pain must be seen by a
diabetes mellitus.
doctor because of the serious consequences
of missing a testicular torsion.
History
Ask about: History
• Itching/soreness. Ask about:
• Erythema and irritation of the glans penis. • Testicular pain, duration and onset.
• Discharge - distinguish from urethral • Swelling, erythema or tenderness of
discharge. testicle or epididymis.
• Sexual history, including symptoms in • Unilateral or bilateral.
partner.
• Dysuria, frequency and haematuria.
Examination • Urethral discharge.
• Fever.
Check for: Check the foreskin and glans. • Abdominal pain, nausea or vomiting.
• PMH: Maldescent/surgery.
Investigation • Recent trauma.
• Dipstick urine for glucose.
• Swabs may help determine the causative Examination
organism. Check for: Temperature, pulse.

Management Basic Level Investigation

Document your history and examination Urine dipstick.
findings and then refer to a senior medic or
medical officer. Management Basic & Intermediate Level

Management Intermediate Level Document your history and examination

findings and then immediate referral to a
Treatment: Clotrimazole 1% cream for fungal medical officer.
infections.

Advice: Good hygiene. Public Health:

Refer: The commonest infecting organism in young
• No response to this treatment within 48 men presenting with epididymo-orchitis is
hrs. Chlamydia. Partner investigation and
• Recurrent balanitis. treatment should be carried out by the
• Suspicion of a sexually transmitted Genitourinary Medicine clinic.
disease.
• Diabetic patient.
1 Immediate referral warning signs
Public Health
Testicular torsion is twisting of the cord
Advice regarding sexual health, including use supporting the testicle causing impairment of
of condoms. Opportunistic Chlamydia its blood supply. This is a surgical emergency
screening if appropriate. and requires immediate referral.

E3 V1.0 46
 • Prevention by wearing a condom and
practicing Safer Sex.
8.4 Sexually Transmitted Infections • Opportunistic chlamydia screening.
[1415-1]
Last updated: 08 12 11 ! Note
General Information, Presentation STI remain high throughout the world despite
Infections transmitted by unprotected sexual medical advances and may be particularly
intercourse. Sexually transmitted infections prevalent in areas of conflict on operations.
are common and 30% of those presenting will
have more than one infection. When possible
all STI should be referred to a Genitourinary
Medicine (GUM) clinic where they are able to
test for a range of conditions, provide rapid
diagnosis and other confidential services such
as contact tracing and counselling. STI may
be serious and some are potentially life
threatening. Failure to treat infections may
result in many more people becoming infected
and complications such as infertility and
malignancy.

History
Ask about:
• Rash or irritation.
• Sores or blisters on vagina, penis or
around anus.
• Pain on urination (dysuria).
• Vaginal/urethral discharge.
• Frequency of micturition.
• Testicular swelling.
• Pain on sexual intercourse
• Fever and vomiting.
• Suprapubic pain.
• Pregnancy.
• PMH: Previous STI.
• PMH: Symptomatic sexual partner.
• Prostitutes/sex workers.

Examination
Refer to MO for examination.

Investigation
Urine dipstick and send sample for culture.
Pregnancy test for females if indicated.

Management Basic & Intermediate Level

Document your history and refer to medical
officer.

Public Health:
• Contact tracing through GUM clinic.

E3 V1.0 47
9 Gynaecological Conditions Management Basic Level
Document your history and then refer to a
9.1 Dysmenorrhoea medical officer if any significant changes or
concerns.
9.2 Menorrhagia
Management Intermediate Level
9.3 Vaginal Discharge
Treatment: Ibuprofen 400mg tablets 3 x daily
9.4 Candidiasis with food. Light duties if necessary. B chit 1/7
up to max 3/7 then refer to MO for further
guidance.

Advice: Rest in comfortable position with

9.1 Dysmenorrhoea knees drawn up. Hot water bottle or hot bath
may be helpful.
[K583]
Last updated: 08 12 11
Refer:
General Information, Presentation • If menstruation is late or pain not
controlled with simple analgesia.
Dysmenorrhoea is painful menstrual cramps • Secondary dysmenorrhoea to investigate
of uterine origin. It may be divided into cause.
primary dysmenorrhoea which is normal • Any patient who does not respond to mild
“period pains” without abnormal pathology and analgesia.
secondary dysmenorrhoea due to identifiable
conditions such as endometriosis or ovarian
cysts.
! Note
History Beware of ectopic pregnancy or miscarriage
• Primary: Cramping lower abdominal
pains, relatively common in young women,
experienced on the first 1-2 days of
menstruation. May be associated with 9.2 Menorrhagia
nausea, vomiting and faintness. [K5920]
• Secondary: New symptoms commonly in Last updated: 08 12 11
the 4th and 5th decade.
• Menstrual history; age of onset, General Information, Presentation
regular/irregular cycles, duration and Menorrhagia is heavy but regular menstrual
amount of bleeding. bleeding. This often affects the quality of life
• Pelvic inflammatory/sexually transmitted and very heavy blood loss may result in iron
disease. deficiency anaemia, particularly in vegetarians
• UTI symptoms. or those with poor diets.
• Vaginal discharge.
• Last Menstrual period (LMP). History
• Contraception used. Ask about:
• Possibility of pregnancy. • Menstrual history; age of onset,
• Obstetric history. regular/irregular cycles.
• Duration of bleeding.
Examination
• Amount of bleeding; frequency of
MO only. changing pads/tampons.
• Pelvic inflammatory/sexually transmitted
Investigation disease.
• Temp, pulse and BP. • Contraception, especially IUCD and
• Urine dipstick and pregnancy test. possibility of pregnancy.

E3 V1.0 48
• Obstetric history particularly recent • Timing with menstrual cycle
delivery or Termination of Pregnancy • Irregular bleeding
(TOP). • Previous episodes.
• Fever.
Examination • Ask about possibility of a retained tampon
Check for: or condom.
• Temp, Pulse (rapid in severe anaemia),
BP. Examination
• Pallor (indication of anaemia). Check for:
• Temp, pulse and BP.
Investigation • Urine dipstick.
Urine Pregnancy test. • Pregnancy test for females if indicated.

Management Basic Level ! Note

Document your history and examination • PV examination only by a trained nurse or
findings and then refer either to a senior medical officer.
medic or medical officer.
Investigation
Management Intermediate Level
MSU.
• As above.
• Light duties B chit 1-3/7 if necessary whilst Management Basic Level
waiting for MO appointment, if no red
flags. Document your history and refer to a medical
officer.

!
Management Intermediate Level
Note
Advice:
Beware of ectopic pregnancy or miscarriage. • Avoid nylon underwear, tight trousers.
• Avoid bubble bath, vaginal douches.
• Avoid biological washing powders.
• Do pass urine after sexual intercourse.
9.3 Vaginal Discharge • Opportunistic sexual health advice
[1A7] Refer: All cases
Last updated: 08 12 11

General Information, Presentation

Normal or abnormal discharge from the
vagina. Glands in the cervix produce a clear
mucus which turns white or yellow as it dries.
The amount of mucus varies with the
menstrual cycle and other factors such as
stress or excitement. Abnormal vaginal
discharge may be due to infection

History
Ask about:
• Amount of discharge.
• Colour: white curd/green/brown.
• Offensive smell, itching.
• Abdominal or pelvic pain.
• LMP.
• Contraceptive use.

E3 V1.0 49
9.4 Candidiasis Refer:
[AB2..] • First episode.
Last updated: 08 12 11 • Recurrence within month of previous
treatment may be indicative of a systemic
General Information, Presentation problem e.g. diabetes.
The primary symptom of thrush is vaginal • Any episode that does not responded to
itching and abnormal cheese-like or watery the treatment above.
vaginal discharge. The most common • Opportunistic sexual health advice.
organism is the yeast Candida Albicans.
Thrush may occur after a course of antibiotics,
during pregnancy or when using the oral 1 Immediate referral warning signs
contraceptive pill. If sexually active, both the
patient and partner should be treated Diabetic and pregnant patients must be
simultaneously to prevent re-infection, even if referred.
the partner has no symptoms.

History
Ask about:
• Amount of discharge.
• Colour; white/curd.
• Odour.
• Itching.
• Abdominal or pelvic pain.
• Timing with menstrual cycle.
• Irregular bleeding.
• PMH: Previous episodes.

Examination
PV examination only by a trained nurse or
medical officer.

Investigation
Dipstick urine and send MSU sample for
MC&S.

Management Basic Level

Document your history and then refer either to
a senior medic or medical officer.

Management Intermediate Level

Treatment:
• Clotrimazole 500mg pessary insert at night
and/or
• Clotrimazole 1% cream twice daily or
• Fluconazole 150mg capsule single dose.

Advice:
• Avoid nylon underwear, tight trousers.
• Avoid bubble bath, vaginal douches.
• Avoid biological washing powders.
• Do pass urine after sexual intercourse.

E3 V1.0 50
9.5 Pregnancy in Servicewomen
! Note
[62-3]
Last updated: 08 12 11 Arrangements should be made for the soldier
to be seen by a MO as soon as possible,
General Information, Presentation particularly on operations.
Pregnancy lasts for approx 40 weeks as the
developing foetus grows in the uterus. The
early stages may be accompanied by morning
sickness, breast tenderness and enlargement
and an increase in appetite. These symptoms
are due to hormonal changes.

History
Ask about:
• Date of last menstrual period.
• PV Bleeding.
• Morning sickness.
• Tiredness.
• Current occupation.
• Drug history.

Examination
Check for:
• BP, pulse.
• Height, weight.

Investigation
• Pregnancy test.
• Routine urine test.

Management Basic Level

Document your history and examination
findings and then refer either to a trained
nurse or medical officer.

Management Intermediate Level

• Consider whether fit to remain in current
occupation if pregnancy confirmed. Light
duties B chit up to 3 days whilst waiting to
see the MO.

Occupational Health
• The working environment can have an
impact on the developing foetus which
must be assessed when taking the history.
• Pregnant service personnel must be
downgraded to protect them and the
foetus.

E3 V1.0 51
10. Musculoskeletal Conditions • Cervical lymphadenopathy.
• Temp to exclude fever if no history of
10.1 Neck Pain trauma.

10.2 Back Pain Investigation

Nil.
10.3 Shoulder Pain
Management Basic Level
10.4 Elbow, Wrist and Hand
Document your history and examination
10.5 Knee Pain findings and then refer to a senior medic or
medical officer.
10.6 Lower Leg Pain
Management Intermediate Level
10.7 Ankle Pain Minor injury (if neck is mobile and no radiation
of pain):

Treatment:
10.1 Neck Pain • Reassure; most neck pain resolves
[1021-2] without treatment.
Last updated: 08 12 11 • Paracetamol 2 x 500mg tablets qds or
Ibuprofen 400mg tablet tds with food.
General Information, Presentation
Pain or spasm in neck muscle occurring either Advice:
spontaneously (wry neck) or after an injury. • Mobility exercises within pain free ROM.
Neck pain is very common, often related to • Warm packs.
posture, occupation or trauma. Neck sprain or • Attention to posture.
“whiplash” injuries frequently occur in road
traffic accidents when a car is shunted from Refer:
behind. Most are self-limiting but may persist • Refer to MO.
for several weeks. • Physiotherapy may be helpful using
manipulation and traction to relieve pain.
History
Ask about:
• Duration, location, nature, onset, radiation Occupational Health
of pain. • Light duties Max 3/7 then needs MO
• Headache. appointment depending on occupation.
• Numbness/paraesthesia/weakness. • Workplace/DSE assessment may be
• Trauma, particularly falls from above required.
shoulder height or RTC.
• Sore throat, fever or rash may indicate
infection such as meningitis. 1 Immediate referral warning signs
• PMH: Previous episodes.
• SH: Occupation. Refer immediately any patient with significant
• DH: Medication. pain with immobility and/or radiation of pain.
Photophobia or fever may indicate infection
Examination such as malaria or meningitis so refer
immediately.
Check for:
• Posture.
• Flexion, extension, lateral flexion and
rotation of neck.
• Tenderness.
• Examine both upper limbs and check
neurological function.

E3 V1.0 52
 • Reassure; most back pain is mechanical
10.2 Back Pain and resolves without treatment.
[N145-2] • Paracetamol 2 x 500mg tablets qds or
Last updated: 08 12 11 Ibuprofen 400mg tablet tds with food.
• May required B chit for 1-2/7 heavy lifting,
General Information, Presentation weighted runs, tabs and competitive
Pain in back muscles or spine due to posture sports.
or injury. 70% of people in developed
countries will experience back pain at some Advice:
time in their lives. Most are self-limiting and • Mobility exercises, weight loss if
90% recover within 6 weeks. About 5% appropriate.
develop chronic pain. • Attention to posture, especially sitting.
• Warm packs may help.
History
Refer: Refer to MO on normal sick parade.
Ask about: Physiotherapy may be helpful using
• Duration, location, nature, onset, radiation manipulation and exercises to relieve pain.
and progression of pain.
• Numbness, weakness or paraesthesia. Moderate to Severe: Refer to MO.
• Changes in bladder or bowel function such
as urine retention.
• Trauma, particularly violent injury such as Occupational Health
RTC.
• Pain on cough or sneeze. • Light duties as appropriate depending on
• Pregnancy. occupation.
• PMH: Previous episodes. • Workplace/DSE assessment may be
required.
• SH: Occupation and how the back pain is
affecting ability to do job.
• Fever, weight loss or other illness.
• DH: Medication taken for pain or other
such as steroids.
1 Immediate referral warning signs
Examination
If immobile or any weakness or bladder
Check for: symptoms refer to MO immediately.
• Record functional ability, rotation, flexion,
extension.
• Radiation of pain into buttocks or back of
legs.
• Examine both lower limbs and check
neurological function.
• Straight Leg Raises (SLR) Left vs Right.
• Temperature.

Investigation
Nil.

Management Basic Level

Document your history and examination
findings and refer to a senior medic or medical
officer.

Management Intermediate Level

Treatment: Minor injury (if mobile and no
radiation of pain), then:
E3 V1.0 53
 LD B chit for max 3/7 whilst waiting for MO
10.3 Shoulder Pain appointment. Recommend the patient does
[N245-7] exercises appropriate to injury.
Last updated: 08 12 11
Advice: For minor injuries active exercises
General Information, Presentation hourly in pain free range.
Pain or stiffness in muscles and ligaments of
Refer: Depending on severity.
shoulder girdle. Serious conditions, such as a
dislocation may be obvious and should be
dealt with as an emergency.
Chronic conditions often require careful Occupational health
diagnosis and long-term treatment. May require workplace / DSE assessment if
recurrence of symptoms
History
Ask about:
• Duration, location, nature, onset, radiation 1 Immediate referral warning signs
of pain.
Shoulder dislocations are extremely painful
• Trauma. and must be dealt with as an emergency.
• Mechanism of injury.
• Instability.
• Tenderness.
• PMH: Previous episodes.
• DH: Medication.

Examination
Check for:
• Compare both sides and check for
deformity such as squaring of shoulder in
dislocation.
• Range of shoulder movement; flexion,
extension, abduction, adduction, internal
and external rotation.
• Muscle wasting.
• Paraesthesia or altered sensation in arm
or hand.

Investigation
Fill out an X-ray request form for the MO if
obviously dislocated or fractured or high index
of suspicion.

Management Basic Level

Document your history and examination
findings and then refer either to a senior
medic or medical officer.

Management Intermediate Level

Treatment: Rest with a sling to relieve pain.
Paracetamol 2 x 500mg tablets qds or
Ibuprofen 400mg tablet tds with food.

E3 V1.0 54
 Refer:
10.4 Elbow, Wrist and Hand Conditions • All hand injuries with lacerations should be
[SK130, SK132, SK140] seen urgently by a doctor to exclude
Last updated: 08 12 11 tendon/nerve injury.
• All suspected fractures.
General Information, Presentation
The wrists and hands are very vulnerable to
injury and difficult to diagnose accurately. Occupational Health
Take a good history but refer to a doctor early • Light duties depending on occupation. B
as the consequences of missing injuries such chit up to max 3/7 whilst waiting for a MO
as a scaphoid fracture may be serious. appointment to determine future
management and further light duties.
History • DSE/WPA may be required if recurrence
Ask about: of symptoms.
• Mechanism of injury. • Consider vibration injury.
• Duration, location, nature, onset and
radiation of pain.
• Bruising or swelling. 1 Immediate referral warning signs
• Loss of function.
• Deformity.
Scaphoid fractures can be easily missed and
• Paraesthesia, numbness or weakness.
are often diagnosed as a ligament sprain.
Anyone who falls and lands on an
Examination
outstretched hand and complains of pain
Check for: around the wrist should be assumed to have a
• Compare two sides against each other for scaphoid fracture and referred to the M.O.
small changes.
• Tenderness.
• Swelling and warmth.
• Deformity, muscle wasting.
• Loss of function; passive and active
movements and power.
• Check circulation and neurological
function.
• Examine neck for range of movement and
tenderness.

Investigation
Fill out an X-ray request form for the MO if
obviously deformed or high index of suspicion
from the history.

Management Basic Level

Document your history and examination
findings and refer to a medical officer.

Management Intermediate Level

Treatment:
• Splints and a sling may relieve pain. Ice
for 10-15 mins if swollen.
• Paracetamol 2 x 500mg tablets qds or
Ibuprofen 400mg tablet tds with food.

E3 V1.0 55
 • Rest: Rest the affected limb as much as
10.5 Knee Pain possible, consider crutches if unable to
[N07] fully weight bear. Light duties.
Last updated: 08 12 11 • Ice: Cool with ice pack for 20 minutes,
every 2-3 hrs.
General Information, Presentation • Compression: Strap and support with
Knee pain is a complex area. Suspected crepe bandage or tubigrip.
ligament or cartilage injury should always be • Elevation: Use a chair or pillows. Keep the
referred to a Doctor. Anterior knee pain is knee as straight as pain will allow.
often from the patellofemoral joint (PFJ) and • Crutches may be required initially but
associated soft tissues. Patella tendon patient should be strongly encouraged to
problems and iliotibial band syndrome are less walk as normally as possible whilst using
common and can be either acute or chronic. the crutches.

History Refer all patients:

• With swelling.
Ask about: • With loss of flexion more than 90 degrees
• Duration, location, nature, onset, radiation and/or unable to fully extend the knee.
and progression of pain. • Unable to fully weight bear.
• Instability, giving way, locking.
• Trauma, mechanism of injury.
• How quickly swelling occurred after injury. Occupational Health
• Unilateral or bilateral pain.
• DH Medication. Consider LD B chit 1-2/7.
• PMH: Previous episodes.
• SH: Occupation, include changes in
training pattern or footwear. 1 Immediate referral warning signs

Examination Immediate swelling at the time of injury may

indicate a significant ligament or cartilage tear
Check for: and should be seen by the doctor
• Range of knee movement, flexion, immediately.
extension.
• Muscle wasting.
• Swelling, effusion.
• Tenderness.
• Ligament stability

Investigation
Nil.

Management Basic Level

Document your history and examination
findings and then refer either to a senior
medic or medical officer.

Management Intermediate Level

Treatment:
• For acute strains and sprains seen within
the first 48 hrs use the PRICE approach:
• Pain Relief: Paracetamol 2 x 500mg
tablets qds or Ibuprofen 400mg tablet tds
with food.

E3 V1.0 56
 Management Basic and Intermediate Level
10.6 Ankle Pain
Treatment: For acute strains and sprains seen
[S550]
within the first 48 hrs use the PRICE
Last updated: 08 12 11
approach:
General Information, Presentation • Pain Relief: Paracetamol 2 x 500mg
Ankle injuries are very common in military tablets qds or Ibuprofen 400mg tablet tds
training. Some protection is afforded by with food.
wearing boots but walking over uneven • Rest: Rest the affected limb as much as
ground, especially at night, carrying weight possible, consider crutches if unable to
often results in ankle sprains. fully weight bear. Light duties.
• Ice: Cool with ice pack for 20 minutes,
History every 2-3 hrs.
• Compression: Strap and support with
Ask about: crepe bandage or tubigrip.
• Mechanism of injury. • Elevation: Use a chair or pillows.
• How quickly swelling occurred after injury. • Crutches may be required initially but
• Duration, location, nature, onset, radiation patient should be strongly encouraged to
and progression of pain. walk as normally as possible whilst using
• Unilateral/bilateral. the crutches.
• PMH Previous episodes; repeated
inversion injuries. Advice:
• SH: Occupation, include changes in • Gentle Mobility exercises and weight bear
training pattern or footwear. as tolerated.
• Practice balance exercises regularly on
Examination injured leg as soon as can fully weight
Check for: bear.
• Functional ability as the patient comes into • The foot should be elevated as much as
the room. possible when at rest.
• Deformity, swelling or bruising.
• Range of ankle movement; Refer: Doctor review if patient unable to fully
plantar/dorsiflexion, eversion, inversion. weight bear or not responding to treatment
• Ligament instability. after 24-48hrs.
• Pulses, note if weak or absent.

Investigation Occupational Health

Ottowa ankle rules: X-rays are only required if Light duties as appropriate depending on
there is bony pain in the malleolar zone and severity of injury and occupation. Max 3/7
any one of the following: whilst awaiting an appointment with the MO to
• Bone tenderness along the distal 6 cm of cionsider future management.
the posterior edge of the tibia or tip of the
medial malleolus.
• Bone tenderness along the distal 6 cm of ! Note
the posterior edge of the fibula or tip of the
Ligament injuries take approx 6 weeks to
lateral malleolus.
recover.
• An inability to bear weight both
immediately and in the emergency
department for four steps.

Fill out an X-ray request form for the MO if

Ottowa ankle rules, above, are complied with.

E3 V1.0 57
 Management Basic Level
10.7 Lower Leg Pain
Document your history and examination
[SK175]
findings and then refer either to a senior
Last updated: 08 12 11
medic or medical officer.
General Information, Presentation
Management Intermediate Level
Lower leg pain is commonly referred to as
Treatment: Paracetamol 2 x 500mg tablets
“shin splints” but there are several, definable
qds or Ibuprofen 400mg tablet tds with food.
conditions that require different treatment. The
diagnosis is made mostly on the history,
Advice:
taking careful note of the nature of the pain
and when it occurs in relation to exercise: • Review training program and footwear with
advice from the Physio or Remedial
• Compartment Syndrome. Local burning
Instructor. They may recommend
pain and tenderness that builds up
stretches and ice cube massage along
gradually during exercise and may persist
painful area of shin.
as a cramping pain after the end of the
session. The muscle bulk may feel tight • Gradual return to training once pain free,
and tender to touch. with graded impact training. The MO may
need to refer for a Podiatry opinion.
• Medial Tibial Stress Syndrome.
Periostitis; inflammation of the muscle
Refer: Next available appointment with MO.
attachments along the medial tibial border.
Pain is felt on exercise, particularly
running up hills but stops as soon as
training ends. Occupational Health
• Tibial Stress Fracture. Pain on each Stress fractures in particular may require
impact, relieved by rest initially but may many weeks or months off impact exercise,
cause constant pain when severe. followed by a graduated return to impact
activities under the guidance of a
History Physiotherapist or Remedial Instructor.
Ask about:
• Trauma. Mechanism of injury.
• Duration, location, nature, onset, radiation, ! Note
relation to impact and stopping exercise.
• Any change in normal exercise routine or Beware of referred pain from hip or knee.
running conditions such as hard surfaces,
carrying weight, changes in footwear or
running in boots.
• Unilateral/bilateral.
• PMH: Previous episodes.
• DH: Medication.

Examination
Check for:
• Swelling, warmth and bruising.
• Tenderness or tight muscle, point on tibia
or percussion of tibia.
• Numbness or paraesthesia (including first
web space on foot).
• Muscle weakness or foot drop.
• Pulses.
• Investigation.
• Pain on hopping indicates Stress fracture
not MTSS.

E3 V1.0 58
D3 Scaly Skin Rash

The patient presents with:

Flaking Finely fissured Winter itch

Skin Yes skin? Yes Itch? Yes (See 11.11)

No

Limited to the Dandruff

Yes Refer to MO
No scalp?

Refer to MO
No

Fissured orange- Seborrhoeic

red Patches Dry or greasy
Yes Yes dermatitis. (See
scales?
11.11)

No

Reddish Scaly Advancing Fungal infection

Yes Clear Centre Yes Yes (See 11.3)
patches edge

No
No No
Pityriasis
Symmetrical Yes rosacea.
Refer to MO

Refer to MO Weeping Contact

Yes dermatitis (See
patches
Protocol 11.11)

No

Silvery scaly Psoriasis

patches Yes Refer to MO

E3 V1.0 59
D4 Skin Rash – By Distribution

The patient presents with:

Raised itchy Family history On

Widespread? Yes Silvery scales? No No medication?
wheal? atopy?

Yes Yes Yes Yes

No
Psoriasis: Urticaria Atopic dermatitis: Drug eruptions:
Refer to MO Refer to MO (See 11.11) Refer to MO

Areas Dermatomal Fever,

Trunk? Yes depigmentatio No distribution? No erythematous
n scaly rash?

Yes Yes Yes

Tinea/pityriasis Viral exanthema
vesicolour. Herpes zoster
Vesicles? Yes (See 11.8) Refer to MO
(See 11.3)

No
No
Macules, Pityriasis
scaly edge, Yes rosacea (MO)
clear centre?

Itchy lumps or
Limbs? Yes vesicles? No Chronic
lesion?

Yes Yes

No Insect bites: Warts:

(See 14.1) (See 11.9)

Face? Yes Vesicles? No Pustules? No Nodule?

Yes Yes Yes

Skin cancer?
No Blackheads,
Golden No Painful ulcer? Refer to MO
whiteheads?
crusts?

Yes Yes Yes

Impetigo: Herpes Simplex Acne:

(See 11.2) (See 11.7) Refer to MO

E3 V1.0 60
D4 Skin Rash – By Distribution (Continued)

No

White nits hair Head lice

Scalp? Yes Yes (See 12.1)
shaft

No

Circular Red moist

Flexures? Yes spreading No itchy patch
lesion, clear

Yes Yes
No
Fungal infection Candida
(See 11.3) (See 11.3)

Yes Yes

Discolouration
Nails? Yes No Ridged nail
distal nail bed

No

Itchy lumps, Erythematous

Penis/ itchy white
Yes red inflamed Yes
Vulvovaginal? patches
base

Yes Yes
No
Scabies Candida
(See 12.1) (See 11.3)

Intense itiching Pinworm

Perianal
Yes worse in the Yes infestation
itching?
morning (See 7.7)

E3 V1.0 61
11. Skin Conditions

Infections Bacterial
11.1 Cellulitis
[MO3]
11.1 Cellulitis Last updated: 08 12 11

11.2 Impetigo General Information, Presentation

Cellulitis is inflammation of the skin and
Infections Fungal subcutaneous tissues due to infection. The
most common bacterial infection is
11.3 Fungal/Candidal infections Staphlococcus or Streptococcus and it may
11.4 complicate wounds sustained in dirty
11.5 Pitted Keratolysis conditions such as on exercise or infected
blisters. Systemic infection occurs when
Infections Parasitic cellulitis spreads via the blood or lymphatic
system and requires treatment with
11.5 Botfly larva infection intravenous antibiotics.

11.6 Cutaneous Larva Migrans History

11.7 Leishmaniasis Ask about:

• Hot, red, painful area often associated with
Infections Viral infected wound.
• Fever, malaise.
11.8 Cold sores • Duration of symptoms, evidence of
spread.
11.9 Shingles • Tetanus status.

11.10 Warts and Verrucae Examination

Check for:
Inflammatory • Swelling of infected area.
• Erythema and warmth.
11.11 Atopic Eczema
• Tracking; red lines radiating out from the
lesion.
11.12 Dermatitis
• Yellow crusting lesions; see impetigo.
Pigmented • Temp, pulse, BP.

11.13 Pigmented lesions Investigation

Urine dipstick for glucose if recurrent
Injury infections.

11.14 Blisters Management Basic Level

11.15 Infected Wounds/Minor Skin Injuries Document your history and examination
findings and refer to a medical officer.
11.16 Ingrown toenails A line may be drawn around the erythematous
area to mark the extent of the infection at
11.17 Sunburn presentation.

Management Intermediate Level

11.18 Acne
Treatment: Paracetamol 2 x 500mg tablets
qds or Ibuprofen 400mg tablet tds with food.
Ensure that the patient is seen by the MO as a
matter of priority.

E3 V1.0 62
 ! Note
Refer: All cases.
Systemic infection may spread rapidly making
the person very ill, refer all cellulites to MO
urgently.

Public Health

11.2 Impetigo Bedding, towels face clothes etc should not be

shared and should be washed on a hot cycle
[MO5] (60o) after use.
Last updated: 08 12 11
Occupational Health
General Information, Presentation
Food handlers should be removed from food
A highly contagious bacterial skin infection. It
handling duty until the condition has cleared.
usually occurs around the face and hands,
Issue LD B Chit to cover this for max 3/7 and
starting as fluid filled blisters, which burst and
must have MO appointment.
dry to leave a golden brown crust. The
infection is easily spread to other parts of the
body or to other persons, unless strict hygiene
precautions are taken. It is caused but
Staphylococcus aureus or Gp A 1 Immediate referral warning signs
Streptococcus, which live on the skin of many
Untreated impetigo may spread and cause the
people.
more serious condition of cellulitis. Refer as
soon as possible for treatment and review to
History
confirm that the treatment is working.
Ask about:
• Previous skin problems. More common
with broken skin from cuts or scratches,
insect bites, eczema or where a helmet
chin strap has rubbed.
• Duration of lesions and their spread.
• Direct contact with known impetigo
sufferer or contact sports.

Examination
Check for:
• Thin walled, fluid filled blisters.
• Yellow, crusted exudate.

Investigation
Nil.

Management Basic & Intermediate Level

Treatment:
• Topical antibiotics are required so refer to
MO.
• Provide appropriate LD chit.

Advice: Patient should be advised not to touch

infected area. Bedding, towels, face clothes
etc should not be shared and should be
washed after use to prevent transmission of
infection. If face affected, no shaving until
infection has cleared up.
E3 V1.0 63
11.3 Fungal/Candidal Infections
[AB..]
Last updated: 08 12 11

General Information, Presentation

Fungal infections can infect the skin, nails and hair. The 2 most commonly seen are tinea cruris
“crotch rot” which tends to flare up in summer and tinea pedis “Athlete’s foot” which is a common
condition predisposed to by poor hygiene and occlusive footwear.

Affects: Presentation Tinea

Trunk or limbs: Single/multiple plaques with scaling and Corporis; Ring Worm
erythema especially at the edges.
Lesions enlarge slowly and clear
centrally, hence “ringworm”.
Groin, M>F Associated with athlete’s foot. Involves Cruris; Crotch rot
upper thigh and occasionally the scrotum.
Red plaque with scaling especially at the
edge. Reddened, moist, glazed skin
would indicate a probable candida
infection which is a yeast. Treatment is
the same as for fungus
Feet, M>F Young>Old: Itchy, maceration between Pedis; Athlete’s foot
toes. Risk factors are swimming,
occlusive footwear and hot weather.

Management Basic Level

Document your history and examination
findings and then refer either to a senior
medic or medical officer. Supply appropriate
footwear chit.

Management Intermediate Level

Treatment: Miconazole nitrate 2% cream or
Clotrimazole 1% cream and/or mycota
powder.

Advice: Fresh air is good so wear loose fitting

clothes and take boots/trainers off whenever
possible.

Refer: Those cases not responding to

treatment.

Public Health:
Reinforce personal hygiene message.

E3 V1.0 64
 footwear and wear socks which effectively
absorb sweat i.e. cotton and/or wool.
11.4 Pitted Keratolysis
[MO7y4] Refer: Those cases not responding to
Last updated: 08 12 11 hygiene measures. Topical antibiotics may be
required or a roll-on antiperspirant, 20%
General Information, Presentation aluminum chloride solution to reduce any
associated hyperhidrosis.
Pitted keratolysis is a skin disorder
characterised by pitting on the soles of the Public Health
feet and, occasionally, the palms of the hand.
The appearance is more dramatic when the Footwear and towels should not be shared
feet are wet. There is a variant of pitted and linen should be washed on a hot cycle
keratolysis where there are more diffuse red (60o) after use.
areas on the soles. It is bacterial infection
caused by several bacterial species,
including corynebacteria, which proliferate in 1 Caution
moist conditions so it affects those who sweat
profusely (hyperhidrosis) especially if they Potassium permanganate crystals and
wear occlusive shoes or boots for long concentrated solutions are caustic and can
periods. The pitting is due to destruction of burn the skin. Even fairly dilute solutions can
the horny cells (stratum corneum) by irritate skin and repeated use may cause
protease enzymes produced by the bacteria. burns. When preparing solutions make sure
The result is very smelly feet, due to sulphur that the crystals or tablets are fully dissolved
compounds produced by the bacteria. in water before using. Potassium
permanganate may leave a brown stain on
History skin and nails as well as the bath or vessel
holding the solution.
Ask about:

• Previous skin problems. Particularly

sweaty feet.
• Duration of lesions and their spread.

Examination

Check for:
• White skin with punched out pits.
• Sulphur smell.
• Excessive sweating.

Investigation

Nil.

Management Basic & Intermediate Level

Treatment:
• Wash feet with soap twice daily.
• Antiseptic soaks with Hibiscrub, Tiseps or
Potassium permanganate. Dissolve 1
permitab (400mg) in 4 litres of water.

Advice: Patient should be advised to wear

boots for as short a period as possible and
wear open-toed sandals whenever possible.
Reduce foot friction by wearing properly fitted

E3 V1.0 65
11.5 Botfly larva infection 11.6 Cutaneous Larva Migrans
[AD40] [AC6z0]
Last updated: 08 12 11 Last updated: 08 12 11

General Information, Presentation General Information, Presentation

The botfly eggs are deposited on the skin A very common tropically acquired skin
either directly by the female fly or by an condition caused by the migration of the
intermediate host such as a mosquito or Hookworm Larva under the skin. In animals
house fly. The warmth of the skin makes the they penetrate the venous system and are
larva hatch and burrow into the skin producing transported to the lungs and then intestine but
a painful, boil like swelling. The mature larvae humans are accidental hosts and they are
emerge from the skin after 6 weeks and drop unable to complete their lifecycle and leave a
into the soil to complete their life cycle. meandering path before dying under the skin.
Botflies occur throughout the world in warm
damp climates such as Belize and Africa but History
have also been noted in England, notably in
Ask about:
Surrey.
• Recent travel to tropical location, walking
barefoot on the beach or similar activity.
History
• Intensely itchy lesions.
Ask about:
• Presence of boils. Examination
• Duration of boil, typically lasts for 6 weeks Check for:
until larva emerges.
• Migration of larvae under the skin
accompanied by red, raised, itchy eruption
Examination
following their course, extending a few mm
Check for: per day.
Boil and evidence of secondary infection.
Investigation
Investigation
Nil.
Bubbles of air in olive oil over the boil confirms
the presence of a larva. Management Basic and Intermediate Level
Treatment:
Management Basic and Intermediate Level
• Apply calamine lotion or Crotaminton 10%
Treatment: The larva has an air hole at the (Eurax) cream for the itch.
skin surface therefore blocking the breathing • Loratadine 10 mg tablets once daily or
tube with white soft paraffin or occlusive tape Chlorphenamine 4mg qds.
will deprive it of oxygen and encourage it to
wriggle out of its hole. It may then be grasped Refer: Refer to MO for Mebendazole (Vermox)
with forceps and encouraged by gentle treatment. Note: Vermox is on the formulary
pressure on either side of the boil, pressing for threadworm treatment but is a prescription
downwards and inwards to pop out larvae. only medication (POM) for all other conditions.

Refer: Refer to MO in all cases. Public Health:

• Prevent by wearing shoes when walking
Occupational Health on sand.
• Avoid beaches where dogs foul.
Wear long sleeves and use insect repellent.
! Note
! Note
Itching of the rash may lead to secondary
The larva has a barbed body so forcible infection or very occasionally a severe allergic
extraction can leave body parts behind and reaction.
lead to secondary infection.

E3 V1.0 66
 ! Note
11.7 Cutaneous Leishmaniasis
[A85] Cutaneous leishmaniasis is the most common
Last updated: 08 12 11 form of leishmaniasis. Visceral leishmaniasis
(kala azar) is a severe form where the
General Information, Presentation parasites infect the vital organs.
Cutaneous Leishmaniasis is an acute parasitic
disease of the Tropics and Sub-Tropics and
endemic in Afghanistan. The protozoa
parasites are spread by sandflies. The skin
infection develops at the site of the sandfly
bite and starts as an itchy papule which crusts
and forms an ulcer. It may take several weeks
to develop and many months to heal with
scarring.

History
Ask about:
• Location.
• Single or multiple lesions.
• Pain or itching.
• Duration of lesion and treatment used.

Examination
Check for:
• Deep ulcer with firm edge, not responsive
to antibiotic treatment.

Investigation
Microscopy (if capability exists locally) of
aspirated material from edge of ulcer.

Management Basic and Intermediate Level

Advice: The lesion is not contagious but may
be covered with a dry dressing to prevent
secondary infection. Most lesions heal after
months but leave scars.

Refer: All patients with suspicious lesions

must be seen by MO for referral to a specialist
hospital clinic.

Public Health:
• Avoid sleeping on jungle floor, wear long
sleeves and trousers, peripel clothing and
use insect repellant.
• Complete FMed 85.

E3 V1.0 67
 Refer: Lesions near to eyes must be seen by
11.8 Cold Sores MO.
[2524]
Last updated: 08 12 11 Public Health:

General Information, Presentation • Reinforce personal hygiene message.

• Opportunistic sexual health advice.
This is a viral infection caused by the Herpes
Simplex virus type 1 (HSV-1). The initial Occupational Health
infection usually occurs in childhood and lasts
about 2 weeks with fever, malaise and local Sunblock should be used if prone to cold
lymphadenopathy. The virus then resides sores or in areas of high sunlight such as
mainly in the dorsal root ganglion and is operational tours.
reactivated by respiratory infection, hence
“cold” sore, sunlight, fatigue or local trauma.
1 Immediate referral warning signs
History
Refer to MO urgently if any eye symptoms.
Ask about:
• Tingling sensation around mouth and lips.
• Pain/discomfort.
• Herpetic lesions around mouth.
• Eye symptoms, refer urgently to MO.
• SH: Contact with infected individual.
• PMH: Recent illness or previous episodes
in same area.

Examination
Check for:
• Multiple fluid filled vesicles.
• Crusts within 24-48hrs.

Investigation
Nil.

Management Basic Level

Document your history and examination
findings and then refer either to a senior
medic or medical officer.

Management Intermediate Level

Treatment:
• Aciclovir 5% cream.
• Paracetamol 2 x 500mg tablets qds or
Ibuprofen 400mg tablet tds with food.

Advice:
• Topical treatment is only effective if started
at onset of symptoms. Advise to present
early with any recurrence.
• Infection may be passed on by direct
contact.
• Sunscreen may reduce recurrence rate.

E3 V1.0 68
 Public Health:
11.9 Shingles
• The virus may be shed from the blister
[A53-1]
Last updated: 08 12 11
fluid and contacts with no previous
exposure may develop chickenpox.
General Information, Presentation • Avoid contact with pregnant women and
young babies.
Shingles is caused by reactivation of the
Varicella Zoster, chicken pox, virus often
decades after the initial infection. The virus
may remain hidden in the nerve cell body of a 1 Immediate referral warning signs
single nerve, hence appears in the Any eye or face lesions should be referred to
dermatome supplied by that nerve when it is the MO immediately.
reactivated. Pain may occur up to 5 days
before the skin lesion appears followed by a
crop of skin blisters. These heal with scarring
in 2-3 weeks but the area may remain painful
for many months. The thoracic dermatomes
are affected in 50% cases .

History
Ask about:
• Burning pain, numbness, oversensitivity or
itching prior to the rash appearing.
• Erythematous rash and grouped vesicles.
• Malaise; headache and fever.
• Diabetes.

Examination
Check for:
• Vesicles; initially yellow fluid then blood
filled before they crust over.
• Single dermatome affected; belt like rash
that does not cross the midline.
• Secondary bacterial infection.
• Eye surface and visual acuity.
• Temp.

Investigation
Nil.

Management Basic Level

Document your history and examination
findings and then refer to medical officer.

Management Intermediate Level

Advice: Pain can be severe and last months
or years.

Refer: Refer all cases for effective anti viral

treatment.

E3 V1.0 69
 Management Intermediate Level
11.10 Warts and Verrucae
Treatment: Salicylic Acid Lactic Acid
[A781-1] (Salactol) Wart Paint (not to be used on face
Last updated: 08 12 11
or genitals). Soak well, especially plantar
warts, then dry. Gently abrade surface with
General Information, Presentation
emery board. Carefully apply a few drops of
Warts and verrucae are both caused by the paint to wart taking care to localise application
human papilloma virus. They are extremely to affected area. Cover with adhesive plaster,
common and easily transmitted by skin to skin if plantar wart. Leave for 24hrs. Repeat daily,
contact with an infected person or for removing old paint.
example, a swimming pool changing room
floor where somebody with a verruca has
trodden. They are often found on the hands Public Health:
but may occur elsewhere on the body. Warts
Spread is by direct contact, sexual contact,
often grow in crops and can disappear
bathrooms or swimming baths. Patients with
spontaneously in a few months but it may take
plantar warts (verrucas) should be advised not
up to 2 years without treatment.
to walk about in shower, bathroom or
swimming pool barefoot.
History
Ask about:
• Duration of symptoms.
! Note
• Location.
• Single, multiple. Pre-teenage girls are now routinely vaccinated
• Pain or itching. to prevent infection with the Human Papilloma
Virus strains that have been linked to the
Examination development of cervical cancer.
Check for:
• Firm, rough, skin coloured, pale or
pigmented papules.
• Black pin point dots on the surface when
pared.

Investigation
Nil.

Management Basic Level

Treatment: Soak in warm water and remove
dead skin gently with emery board.

Advice:
• 30-50% disappear spontaneously within 6
months.
• Genital warts: self-referral to Genitourinary
Medicine (GUM) clinic.

Refer:
• Diabetic patients.
• Warts on face, genitalia and peri-anal
area.
• Warts under finger or toenails.

E3 V1.0 70
 Occupational Health
11.11 Atopic Eczema
Eczema has significant career implications. It
[M111]
is well recognized that the condition
Last updated: 08 12 11
deteriorates in hot, dirty, dusty conditions and
General Information, Presentation secondary infection may be serious. Anyone
with more than the very mildest eczema may
Eczema is a chronic, itchy, scaly inflammation need to be downgraded and unfit to deploy.
of the skin often associated with a family or
personal history of asthma, allergic rhinitis or
eczema. “Atopy” is an inherited tendency to
allergy present in about 15% of the
population. Infantile eczema is relatively
common but most children will not have any
further symptoms after age 15yrs.
Dry skin is particularly common in the winter
months affecting those working outside and in
heated buildings. Treatment is the same as for
atopic eczema.

History
Ask about:
• Dry, itchy rash in skin creases and flexor
surface (inside) of joints.
• Personal or family history of Atopy.
• Hand dermatitis, exacerbated by irritants.
• Exacerbations may be triggered by
psychological stress.

Examination
Check for:
• Inflamed, red skin.
• Itchy, excoriated rash.
• Generalised dry skin with cracking or
flaking, particularly over joints.

Investigation
Nil.

Management Basic and Intermediate Level

Treatment: Moisturising creams and bath
emoillients.

Advise:
• Avoid irritant clothing such as wool and
excessive heat.
• Avoid irritants; cats, dogs, house dust
mite, where identified.
• Keep fingernails short.

Refer:
• Widespread or severe eczema.
• Secondary bacterial infection or if simple
treatment not effective.

E3 V1.0 71
 • Aqueous cream is a useful soap
11.12 Dermatitis substitute.
[M12] • Emollients should be liberally applied at
Last updated: 08 12 11 least twice a day particularly after bathing
and more frequently throughout the day if
General Information, Presentation necessary.
Dermatitis is inflammation of the skin which
may be due to a number of causes; eczema is Refer:
a specific type of dermatitis. Contact • Widespread rash.
Dermatitis is chronic, itchy inflammation of the • Secondary bacterial infection.
skin caused by an external agent. The cause • If simple treatment not effective.
may be an irritant such as abrasives,
chemicals (acids, alkalis), solvents and
detergents or an allergen such as plants, Occupational Health
fragrances, preservatives or metals such as • Avoid contact with irritants. Wear
nickel. Nickel sensitivity is seen in 10% protective clothing e.g. gloves. Adequate
women and 1% men. Individuals with atopic washing and drying facilities should be
eczema are more susceptible to irritants. provided.
Seborrhoeic dermatitis is a common,
• Like eczema, contact dermatitis has
inflammatory skin condition that causes flaky
significant career implications. It is
scales to form on oily areas such as the scalp,
essential not to become sensitised in the
eyebrows or inside the ear. It may be due to
first place as it may be difficult to treat
an overproduction of skin oil and irritation from
once established.
yeast infection.

History
Ask about:
• Area of body affected; often hands or
localised, e.g. watch strap area.
• History of exposure, which may not always
be obvious.
• Rash within hours of exposure or more
chronic.
• Dry, itchy rash.
• FH of atopy.
• DH: Medication/Cosmetic use if
appropriate.
• SH: Occupation, hobbies.

Examination
Check for: Red, excoriated rash sometimes
with blisters.

Investigation
Nil.

Management Basic and Intermediate Level

Treatment: Moisturizing creams and
emollients.

Advice:
• Avoid irritants.
• All soap preparations degrease the skin
and should be avoided.
E3 V1.0 72
11.13 Pigmented Lesions
[M2yC]
Last updated: 08 12 11

General Information, Presentation

Naevi or moles are common proliferations of
one or more of the normal constituents of the
skin. They may be present at birth or develop
later, most commonly during childhood or
adolescence, peaking in number at puberty.
Most are entirely benign, however any
concern or suspicion requires referral.
Malignant melanoma is an increasingly
common form of skin cancer due to sun
exposure and may have spread by the time it
is detected, making treatment difficult.

History
Ask about:
• New lesion or change in size or colour.
• Itching or pain.
• Irregular border.
• Bleeding, crusting or weeping.
• Age (>30yrs)
• History of melanoma.
• Infection.
• Immunosupression.
• Sun exposure.
• Other atypical pigmented lesions.

Examination
Check for:
• Visual examination of lesion looking for the
above.

Investigation
Nil

Management Basic & Intermediate Level

Advice: Most do not require any treatment but
a routine MO appointment is advised.

Refer:
• Any changing, bleeding, painful lesion
• If patient concerned.
• Family history of melanoma.

Occupational Health
Advice regarding skin exposure to sun
especially on first few days of foreign tours
and R&R. Fair skinned/red haired people are
particularly at risk.
E3 V1.0 73
 until the roof of the blister collapses. Leave
11.14 Blisters this roof in place.
[SD-3] • Apply a non-stick dressing.
Last updated: 08 12 11 • If the blister breaks naturally, clean the
area carefully with soap or antiseptic
General Information, Presentation solution. The dead skin can be trimmed
A collection of fluid in a bubble under the outer away after a few days. Apply a sterile non-
layer of the skin, caused by excessive stick dressing.
abrasion. The fluid cushions the layers of skin • Specialist dressings such as Compeed,
under the blister, protecting them as they heal Granuflex, Duoderm or Jelonet / mepitel
and provides a natural barrier to infection. under a dry dressing may be useful.
Activities such as foot drill or route marches
may be responsible, particularly in hot or Advice:
humid conditions. Ill-fitting or unconditioned • During route marches, friction may be
boots increase the likelihood of blister reduced by wearing a double layer of
formation. socks. Foot powder should be used. Ill-
fitting or brand new footwear should be
History avoided
• Feet should be aired out of boots
Ask about: whenever possible at rest.
• Footwear, hygiene and activity level. • Light duties for runs/lower body PT until
starting to heal LD chit B max 3/7.
Examination
Check for: Refer: If signs of infection appear, such as
• Number, size and location of blisters. pus or swelling, consult the MO.
• Note whether the roof of the blister is
intact or has ruptured.
• Clear fluid, blood or pus indicating ! Note
infection.
• Swelling, tenderness or redness of the • Tincture of benzoin has traditionally been
surrounding skin. used by US forces to inject into a blister
that has been drained, this is called a “hot
Investigation shot” It has antiseptic properties but the
alcohol mixture is extremely painful on
Nil. contact with the raw base of the blister and
this is not advised.
Management Basic Level • Cellulitis from infected blisters may spread
Document findings then refer to senior medic quickly and requires referral to the MO for
or MO. treatment with antibiotics.

Management Intermediate Level

Treatment:
• If the blister is small, less than 1cm and
painless, leave it alone.
• If the blister is larger but intact and not
likely to rupture, it is again best to leave it
alone. A blister pad may be applied over it
to prevent rupture.
• If the blister is too big or painful, or is likely
to rupture, it may be aspirated with a
sterile needle and syringe:
• Clean then dry the area.
• Using a sterile needle, puncture the blister
at the lower edge and aspirate the fluid

E3 V1.0 74
 Occupational Health
11.15 Infected Wound/Minor Skin Injury
• Refer for Tetanus booster if necessary.
[M07..]
Last updated: 08 12 11
Note this is now a combined tetanus, polio
and diphtheria vaccination (Revaxis
General Information, Presentation vaccine).
• Food handlers with cuts to the hands
Any injury to the skin where the skin surface is should ensure that they are wearing the
broken may result in secondary infection. In appropriately coloured dressing for cuts
temperate climates minor injuries can be and should not handle food if there is any
treated simply and generally heal with minimal sign of infection.
intervention but in tropical conditions they may
be slow to heal or become infected.

History 1 Immediate referral warning signs

Ask about:
• Cause of injury. Minor wounds with significant tracking or a
• Nature of wound. febrile patient need to be seen by a MO
urgently.
• Duration of symptoms.
• Fever/malaise.
• Tetanus status.
• Allergies.

Examination
Check for:
• Temp, pulse, BP.
• Inflammation.
• Erythema, if significant may indicate
Cellulitis.
• Purulent or blood stained discharge.
• Lymphadenopathy in glands near to the
injury site.

Investigation
If significantly infected, or inflammation not
responding to basic treatment then take a
swab for culture and sensitivity.

Management Basic Level

Treatment:
• Clean and dress the wound appropriately.
• Review at 24 hours.

Refer: Refer to senior medic, nurse or MO if

not improving.

Management Intermediate Level

Treatment: As above.

Refer: Refer to MO for antibiotic therapy if

wound not responding to treatment or cellulitis
suspected.

E3 V1.0 75
11.16 Ingrowing Toenails Refer:
[M2300] • Nail not responding to the above
Last updated: 08 12 11 management within 3 days or one that is
severely infected.
General Information, Presentation • If patient is diabetic.
Pain and discomfort as a result of the toenail
digging into the surrounding skin.
This is a relatively common problem and can Occupational Health
vary from mild discomfort to extremely painful Ingrowing toenails should be dealt with to
infected and inflamed skin around one or prevent recurrent problems. They often
several toes. present when hygiene is difficult such as on
exercise and can be incapacitating.
History
Ask about:
• Duration of current symptoms. ! Note
• Pain.
Diabetics are at risk of serious foot infections
• Discharge.
and should have regular chiropody review.
• Previous episodes and treatment.
• Diabetes mellitus.

Examination
Check for:
• Swollen, red, shiny, inflamed skin at edge
of nail.
• Purulent, bloody discharge.
• Granulation tissue heaped up over nail
edge.
• Fungal nail infection.

Investigation
Nil

Management Basic Level

Document your history and examination
findings including the extent of inflammation
and then refer either to a senior medic or
medical officer.

Management Intermediate Level

Treatment:
• Dry dressing.
• Light duties awaiting MO review.
• Ibuprofen or paracetamol analgesia.

Advice:
• Good hygiene.
• No DIY surgery.
• Cut toenails straight across.
• Appropriate footwear that does not press
on the inflamed area.
• Allow skin to air where possible.

E3 V1.0 76
 • Repeated sunburn may predispose to
11.17 Sunburn cancerous changes.
[M1271]
Last updated: 08 12 11
! Note
General Information, Presentation
Damage to the skin caused by excessive • Those with fair skin and fair or ginger hair
exposure to UV radiation. are most at risk of sunburn.
The skin becomes red, hot and painful. In • Sunblock, a shirt and a hat reduces the
extreme cases blistering may occur. The skin risk of burning. It may be best to avoid the
may peel a few days after burning. sun completely during the hottest part of
Severe sunburn, especially in children, may the day.
increase risk of skin cancer later in life. • Sunblock is issued on deployment and
may be held by the QM at other times.
History • Sunblock should be issued for guard duty.
Ask about:
History of prolonged sunbathing or falling
asleep in the sun or walking with no shirt on.

Examination
Check for:
• Appearance of a superficial burn with
redness of the skin and blistering.
• Painful to touch.

Investigation
Nil.

Management Basic and Intermediate Level

Treatment:
• A cool bath or shower may help.
• Apply after-sun lotion, moisturiser or
calamine lotion.
• If very painful, take Paracetamol 2 x
500mg tablets qds or Ibuprofen 400mg
tablet tds with food.
• If the skin is blistered non adherent
dressings may be used.
• Review the dressing at 24 hours.

Advice:
• Slip on a hat, Slop on sunblock lotion, Slap
on a shirt.
• Keep well hydrated, avoid alcohol.

Refer: Vomiting, fever, headaches or

shivering.

Occupational Health
• Sunburn is symptom of neglect and as
such a punishable offence.

E3 V1.0 77
 • Simple washing with soap and water.
11.18 Acne [M2610] Drying vigorously with a rough towel
Last updated: 08 12 11 helps to remove oil and to break up
black heads.
General Information, Presentation
Black or white spots on the skin of the face and Moderate to severe:
back due to inflammation of the sweat glands.
Refer: Moderate to severe acne should be
Acne is chronic inflammation of the sebaceous
referred to MO or mild cases not responding
follicles. Areas typically affected are the face,
to the treatment above.
neck and shoulders. Increased sebum
production and the occlusion of the follicle
openings in the skin result in the formation of
comedones (white and black heads).
Microorganisms in the skin then break down the
excess sebum into fatty acids which cause
inflammation and irritation.

History
Ask about:
• Distribution; face, shoulders, back and
upper chest.
• Age of onset.
• Relation to menstrual cycle.
• Exacerbations may be triggered by stress.

Examination
Look for:
• Blackheads, whiteheads.
• Pustules or cysts.
• Scarring.

Investigation
Nil.

Management Basic Level

Document your history and examination
findings and then refer either to a senior
medic or medical officer.

Management Intermediate Level

Mild to moderate:
Treatment: Benzyl Peroxide 5% gel. Apply a
thin layer to the whole of the affected area,
once or twice daily after washing with soap and
water. Warn patient to use white
sheets/pillowcases as the gel will bleach the
material.

Advice:
• Avoid scratching / picking spots which
increases scarring.

E3 V1.0 78
12 Skin Infestations Management Intermediate Level
Treatment:
12.1 Head, Body and Pubic Lice • Malathion 0.5% in aqueous solution.
• Chlorphenamine 4mg tablets qds for
12.2 Scabies associated itching.
12.3 Ticks Advice:
• Head lice. Apply to dry hair and scalp until
12.4 Leeches thoroughly moistened. Leave to dry
naturally and after 12 hours shampoo and
rinse hair. Comb hair with a nit comb to
remove dead lice and eggs. Second
application should be used 7 days after
12.1 Head, Body and Pubic Lice first. Supply 2 x 50ml per person
[AD2, AD20, AD22] • Pubic lice. Apply to entire skin surface.
Last updated: 08 12 11 Pay particular attention to hairy areas,
including eyebrows, beards and
General Information, Presentation moustaches. Second application should
Lice are flat, wingless, blood-sucking insects. be used 7 days after first. Supply 2 x 50ml
They lay their eggs (nits) on hair or clothing. per person.
There are two main species: the body louse of • All bedding, clothing and towels must be
which the head louse is a variant and the washed.
pubic louse. Head lice are common and
spread by head to head contact. The body Refer: All cases where treatment has failed.
louse is mainly seen on vagrants living in
unhygienic conditions, spread is by infested
clothing or bedding. The pubic lice is sexually Public Health:
transmitted and mainly found in young adults.
Lice induce intense itching, which can result in • Pubic lice may require referral to GUM
excoriation and secondary bacterial infection. clinic to trace and treat sexual contacts.
• All family members, partners should be
History checked.
• Household contacts should not routinely
Ask about: be treated unless live infestation of pubic
• Duration of itching/discomfort. lice has been confirmed in other members
• Presence of eggs or lice. of the household.

Examination Occupational Health

Check for: Off duties for minimum 24hrs whilst treating.
• Nits, or lice in the hair. C chit for 1/7 to enable treatment.
• Itchy rash, note site.
• Excoriation due to itching.
• Secondary bacterial infection.

Investigation
Nil.

Management Basic Level

Document your history and examination
findings and then refer either to a senior
medic or medical officer.

E3 V1.0 79
 • All bedding, clothing and towels must be
12.2 Scabies [AD30] washed.
Last updated: 08 12 11
Refer: If itching persists after one week or is
General Information, Presentation severe.
An invasion of the epidermis by the scabies
mite. Scabies is a highly contagious skin
infection and is transmitted during prolonged
or frequent skin contact with an infected Public Health:
person. It is not dangerous but causes intense Advise that the whole family, close household
itching which is due to a hypersensitivity contacts and sexual contacts are treated as
reaction and develops 4 -6 weeks after the appropriate.
initial infestation. Classical scabies is not
transmitted by towels and sheets etc, although Occupational Health
this can occasionally occur. Mites can only
Off duties for minimum 24 hrs whilst treating.
survive for a short period away from the
C chit for 1/7 to enable treatment.
human host.

History
! Note
Ask about:
• Itchy rash. Itching may continue for weeks even after the
• Burrows, typically between fingers, inside mite has been killed.
of wrists, ankles and genitalia.
• Excoriaton due to itching and secondary
bacterial infection.

Examination
Check for:
• Thorough visual examination of skin,
particularly the hands looking for burrows
and skin scratching.

Investigation
Nil.

Management Basic Level

Document your history and examination
findings and then refer either to a senior
medic or medical officer.

Management Intermediate Level

Treatment:
• Malathion 0.5% aqueous solution. Apply to
entire skin surface and leave on the skin
for 24 hrs. Wash off in bath or shower.
Second application should be used 7 days
after first. Supply 4 x 50ml per person.
• Chlorphenamine for associated itching.

Advice:
• Remind patient not to wash their hands
after having applied the lotion.

E3 V1.0 80
 Occupational Health
12.3 Ticks
In areas of high risk, take preventative
[A63] measures such as covering up well, wearing a
Last updated: 08 12 11
hat and tucking trousers into socks. Check
body at end of day to ensure no ticks in situ as
General Information, Presentation
risk of disease increases with time of
A tick is a small, spider like creature, which exposure.
feeds on blood by biting the outer skin layer.
The creature remains attached to the skin until
it fills up with blood and then falls off but this ! Note
may take several days. Ticks are vectors for a
number of diseases such as Lyme disease The classic early sign of local infection with
and Rocky Mountain spotted fever, which are Lyme disease is a circular, outward expanding
injected into the skin on biting. rash called erythema chronicum migrans
which appears a few days or up to a month
History after the bite. Early treatment with antibiotics
can prevent serious long term cardiovascular
Ask about: Operations, exercises, walks or
and neurological symptoms although arthritis
recreational activities in woodland or areas
may still occur so refer to MO.
inhabited by deer.

Examination
Check for:
• Tick still present.
• Redness, swelling and pain around the
bite.
• Rash may be the first sign of Lyme's
disease.

Management Basic and Intermediate Level

Treatment: Evidence is in favour of slow
removal in a straight line using tweezers or
forceps, which is less likely to leave
embedded mouthparts than a rotational
method. Chemical methods; white soft
paraffin, meths etc, are less likely to be
effective.

Refer:
• Failure to remove part of tick or redness
around lesion.
• Flu-like symptoms, headache, muscle
aches, neck stiffness, ring-like skin lesion
may indicate encephalitis or Lyme disease
and must be referred to MO.

Public Health:
Ticks can transmit Lyme disease.
In some parts of Northern Europe there may
be a danger of tick-borne encephalitis.

E3 V1.0 81
 ! Note
12.4 Leech Infestation
[AD42] • Leeches secrete an anti-clotting enzyme
Last updated: 08 12 11 into the host’s blood stream which may
cause wounds to bleed profusely and
General Information, Presentation there is a risk of secondary infection of the
Leeches are invertebrates that may live on wound.
land or in water and may live on small • Allergic or anaphylactic reactions are rare.
invertebrates or the blood of larger animals
and humans. Only 10% bite, the rest feed off
open wounds or decomposing bodies. Blood
sucking leeches attach to their host until they
become full when they fall off naturally after
about 20 minutes. They are found among
vegetation of tropical rainforests and breed
near springs.

History
Ask about:
• Site and symptoms.
• Number of leeches.

Examination
Check for: Look for leeches still attached or
bleeding wounds.

Investigation
Nil.

Management Basic & Intermediate Level

Treatment: Some leeches may be removed by
using a fingernail to break the seal of the oral
sucker. Otherwise apply drops of strong salt
solution, alcohol or vinegar around mouth or
apply heat from a lighted match or cigarette to
the body of the leech. This is less advisable
as it may cause the leach to regurgitate its
stomach contents into the wound and
increase the risk of infection. Clean the wound
with soap and water and apply antiseptic.

Refer: Refer to MO if secondarily infected.

Occupational Health
• Prevent by wearing boots and thick
trousers. Leeches are more easily spotted
on light coloured clothing.
• Use of strong insect repellent may help.

E3 V1.0 82
13 Infectious Diseases Management Basic Level
Document your history and examination
13.1 Chickenpox findings and then refer either to a senior
medic or medical officer.
13.2 Dengue Fever
Management Intermediate Level
13.3 Malaria
Treatment:
13.4 Scrub Typhus • Apply calamine lotion or Crotaminton 10%
(Eurax) cream for the itch.
• Loratadine 10 mg tablets once daily or
Chlorphenamine 4mg qds.

13.1 Chickenpox Advice:

[A52-1] • Discourage patient from scratching
Last updated: 08 12 11 blisters.
• Avoid contact with pregnant ladies and
General Information, Presentation young babies.
An acute viral disease caused by the varicella
Refer:
zoster virus that causes blisters of the skin
• Severe cases and all adults.
and the mucous membranes. It is a common
and generally mild infectious disease • Pregnant or less than 4 weeks postnatal.
characterised by a rash and mild fever. The • Urgent referral if severe headache,
virus is spread from person to person in confusion or decreased conscious level,
airborne droplets. Patients are infectious from which may indicate encephalitis.
about two days before rash appears until
about a week later. The Incubation period Public Health
from being infected to developing the disease • C chit 3/7. Admit to MRS or bed down at
is 11 - 21 days. home to minimise the spread of infection.
• F Med 85; Notifiable Disease Report form.
History • The person is contagious 1 - 5 days before
Ask about: the rash appears and until all the blisters
• History of contact. have formed scabs which may take 5 - 10
• Fever. days.
• Malaise; headache, nausea, sore throat,
ear pain.
• Rash. ! Note
• Eczema.
The most common late complication of
• Smoking history.
chicken pox is shingles, caused by
reactivation of the varicella zoster virus
Examination
decades after the initial episode of
Check for: chickenpox.
• Rash on trunk, face and neck
• Clusters of small, red, itchy spots at 1 Immediate referral warning signs
different stages.
• Fluid filled blisters 2-3mm diameter. Pregnant women and smokers may develop a
• Temp, pulse and BP. severe infection and require urgent medical
treatment.
Investigation
Nil.

E3 V1.0 83
 Public Health
13.2 Dengue Fever
• Fumigation and reservoir elimination of
[A61]
Last updated: 08 12 11
mosquito population.
• Use of good repellant.
General Information, Presentation • Complete FMED 85.
• Bite avoidance during the day, long
Dengue fever is caused by the dengue virus, sleeves and trousers.
which is endemic throughout the tropics
including Belize and Brunei. The Flavivirus is
spread by Aedes aegypti mosquito which feed ! Note
during the day. It is prevalent in urban districts
as well as the jungle. It is an self resolving • Often misdiagnosed as Malaria or Typhoid
illness that needs to be distinguished from fever.
Malaria.
• Potentially can lead to the more serious
Dengue Shock Syndrome.
History
• Avoid aspirin/NSAIDs because of bleeding
Ask about: tendency.
• Recent travel to endemic area.
• Sudden onset severe headache, fever,
severe muscle and joint pains, hence the
name “break-bone fever”.
• High fever up to 41 degrees.
• Malaise, nausea, vomiting, diarrhoea,
anorexia.
• Rash with bright red petichiae on legs and
chest.

Examination
Check for:
• Temperature, blood pressure, slow pulse.
• Heamorrhagic signs, bruising or bleeding
from skin or mucosa.
• “Tourniquet sign” skin bruising from
minimal trauma.

Investigation
• The MO may request blood tests to
exclude malaria. The FBC shows low
platelet count and white cell count.
• The Dengue blot test will confirm
diagnosis.

Management Basic and Intermediate Level

Treatment:
• Cool down with tepid sponging and fan.
• Oral fluids to prevent dehydration.
• Paracetamol 2 x 500mg tablets qds.
• Avoid aspirin/ ibuprofen because of
bleeding tendency.

Refer: Refer to MO.

E3 V1.0 84
 Public Health:
13.3 Malaria
• Bite prevention by wearing long sleeves
[A84]
Last updated: 08 12 11
and trousers particularly at dusk. Use of
mosquito nets and DEET insect
General Information, Presentation repellents.Occupational Health
• Compliance with anti-malarial medication
Malaria is an acute parasitic disease of the specific to area of travel. Carry malaria
Tropics and Sub-Tropics. The protozoa warning card.
parasites are transmitted by mosquito bites • Complete FMed 85.
and destroy red blood cells leading to fever
and malaise. Some species can cause fatal
multi-organ failure. Malaria is the most
dangerous parasitic disease of humans ! Note
causing 1 million deaths per year. Incubation Five species of Plasmodium parasite can
time is from 7-14 days up to 2 months. infect humans.

History
Ask about: 1 Immediate referral warning signs
• History of travel to countries where Malaria
is endemic. Plasmodium falcipaum malaria is a life
• Fever, following a pattern of spiking every threatening illness which needs urgent
2-3 days, rigors, shivering. hospital admission.
• Vomiting, diarrhoea and abdominal pain.
• Headache.
• Muscle pain and weakness.

Examination
Check for:
• Temperature, particularly recurrent,
cyclical fevers.
• Blood pressure, pulse.
• Jaundice.
• Anaemia (pale eyes or lips).

Investigation
• The MO may require blood test.
• Blood is taken at the peak of the fever in
FBC bottle and thick and thin blood film.
• Other blood tests for infection may be
done.

Management Basic and Intermediate Level

Treatment:
• Cool down with tepid sponging.
• Paracetamol 2 x 500mg tablets qds for
fever.

Refer: Refer to MO urgently for diagnosis and

possible hospital admission.

E3 V1.0 85
13.4 Scrub (bush or tick) Typhus
[A812] ! Note
Last updated: 08 12 11
Without antibiotic treatment it may cause a
General Information, Presentation fatal infection, but it responds well to
Doxycycline, Chloramphenicol or
Scrub typhus is a tick borne Rickettsial
Azithromycin. Antibiotic resistance is
bacterial infection causing fever and rash. It is
developing and individuals with HIV may be
transmitted by the larval stage of the mite
particularly susceptible.
which are known as “Chiggers” and found in
areas of heavy scrub vegetation or sandy
riverbanks. Severe epidemics of Scrub
Typhus occurred in WWII among British
troops in Burma and Ceylon and the
Americans in Japan.

History
Ask about:
• Recent travel to area of infestation.
• Tick or flea bite.
• Sudden onset of fever, muscle pains,
headache.
• Measles like rash, conjunctivitis.

Examination
Check for:
• Temperature, blood pressure, pulse.
• Black necrotic papule (eschar) around the
site of the tick bite, may resemble a
cigarette burn.
• Measles like rash on trunk.
• Respiratory problems, pneumonia.
• Tender lymphadenopathy.

Investigation
The MO may request the Weil-Felix blood test
which is available but unreliable.

Management Basic and Intermediate Level

Treatment:
• Cool down with tepid sponging and fan.
• Paracetamol 2 x 500mg tablets qds.
• Avoid aspirin or ibuprofen.

Refer: Refer to MO.

Public Health:
Bite avoidance; thick trousers and boots when
walking through vegetation.

E3 V1.0 86
14. Bites and Stings Examination
Check for:
14.1 Dog, cat or human bite. • Pulse and BP, tearing wounds may cause
severe bleeding.
14.2 Wasp and Bee Stings • Tendon injury.
• Bone injury, particularly of the skull.
14.3 Snake Bites • Abdominal wounds may indicate damage
to underlying structures.
14.4 Scorpion Sting
• Foreign bodies such as teeth in the
wound.
14.5 Jellyfish Sting
Investigation
14.6 Stingray Sting
Nil

Management Basic Level

Treatment: Irrigate profusely with soap and
14.1 Dog, cat or human bite.
water or antiseptic solution.
[SD…]
Last updated: 08 12 11 Refer: Refer to MO urgently.
General Information, Presentation Management Intermediate Level
Dog bites are more common than cat bites Treatment:
and these two species account for the majority • Continue to irrigate profusely with soap
of (non-human) animal bite wounds. Dog bites and water or antiseptic solution.
typically cause a crushing-type wound
• Bandage/pressure dressing to stop the
because of their rounded teeth and strong
bleeding.
jaws. Such extreme pressure may damage
• Splint the area if it is an extremity like a
deeper structures such as bones, vessels,
finger or hand.
tendons, muscle, and nerves. The sharp
pointed teeth of cats usually cause puncture • Paracetamol 2 x 500mg tablets qds.
wounds and lacerations which may rapidly
become infected. Human bites may be Refer: As above.
intentional or accidental when somebody is
punched in the face during a fight.
! Note
History
All animal / human bites must be seen by the
Ask about: MO as there is a high risk of infection. For this
• Location and number of bites. reason they are generally not sutured and
• Time of bite. steristrips should be applied with caution as
• Pain and blood loss. they may promote deep infection.
• Type of animal and health, ie vaccinated
pet dog or unwell stray.
1 Immediate referral warning signs
• Location of animal now (to follow up any
possibility of rabies infection).
• Circumstances surrounding the bite ie, Damage to deep structures or profuse
provoked or defensive bite versus bleeding must be seen by the MO
unprovoked bite. immediately. Possible rabies infection must be
• PMH: Diabetes, immunocompromise. treated as a medical emergency as it is
• Vaccination history; tetanus and rabies. generally fatal.

E3 V1.0 87
14.2 Wasp & Bee Stings
1 Immediate referral warning signs
[SD-A/SD-9]
Last updated: 08 12 11

General Information, Presentation Anaphylaxis Guidelines

Stings by wasps or bees can be painful but
Quick Look:
usually only cause a localised inflammatory
reaction. Some individuals may be allergic to
Response Alert to Unresponsive.
stings and have a stronger localised reaction
Eyes: Pupils normal.
or a life threatening anaphylactic reaction.
Skin & Swelling (particularly around
secretions: the eyes, mouth and airway).
History
Warm flushed skin (this may
Ask about: become pale as the condition
• Site and time of sting. worsens) and a widespread
• Pain. blotchy red rash.
• Light headedness, difficulty breathing. Respiratory Rapid; asthmatic features (see
• Known allergy to wasp sting. Rate: 6.3 Asthma).

Examination Airway
Check for:
• Localised weal and oedema.
• Surrounding flare. Breathing Adrenaline: 1mL
• Pallor. 1/1000 solution in a
• Pulse and BP. preloaded syringe.

Investigation
Nil

Management Basic Level

Treatment:
• Remove sting if still in skin.
• Cold compress; ice held against the site
for a few minutes.
• Crotamiton 10% (Eurax) cream.

Refer: Refer to MO or senior medic if any

signs or symptoms of acute anaphylaxis.

Management Intermediate Level

Treatment: If Crotaminton 10% (Eurax) cream
is not effective then: Loratadine 10mg tablets
or Chlorphenamine 4mg tablets qds.

Refer: As above and if signs of infection.

Occupational Health
Chlorphenamine causes drowsiness, so
caution in continuing certain work or driving.
Anyone with a history of allergic reaction to
stings must be seen by the MO to discuss
grading.
E3 V1.0 88
 to delay venom absorption. Do not cut or
14.3 Snake bites use a tourniquet.
[TE62] • Immobilise affected limb but do not elevate
Last updated: 08 12 11 so as to minimise blood returning to the
heart and vital organs.
General Information, Presentation • Remove boots, watch, rings and
Snakes are either venomous or non constrictive clothing.
venomous who kill their prey by constriction. • Do not give any food, drink or medication.
Non venomous snakes may still bite causing • Identify snake where possible.
deep puncture wounds which may become
infected. Venomous snakes can control Refer: Refer to MO urgently.
whether they inject their venom or give a “dry
bite”. Envenomation may cause local effects Have IV access equipment, oxygen, atropine
at the site of the bite and systemic effects or and morphine available for MO.
anaphylaxis which may be life threatening and
need urgent medical care. The outcome of
snake bites depends on the species of snake, Occupational Health
the area of the body bitten, the amount of Wear stout boots and tread carefully.
venom injected and the health of the victim.

History
! Note
Ask about:
• Type of snake, colour, size. Elapids and viper envenomation may cause
• Time since bite. coagulopathy; spontaneous bleeding from the
• Location of bite. mouth, nose and internal organs including the
brain and intestines. The victim may die of
• Lethargy, weakness, nausea, and
blood loss. Venom from elapids, including
vomiting.
cobras, kraits, mambas, sea snakes causes
Examination neurotoxicity. Symptoms include visual
disturbances, paresthesia, difficulty speaking
Check for: and breathing and may lead to fatal
• Blood pressure, pulse. Respiratory rate, respiratory failure. Most venom causes
O2 sats if available. necrosis of muscle tissue which can clog the
• Pain, swelling, redness, blistering at site of kidneys causing fatal renal failure. Spitting
bite. cobras can spit venom in their victims' eyes
• Neurotoxicity: numbness, muscle causing pain and sometimes blindness.
weakness and breathing difficulty.
• Coagulopathy: bruising and bleeding.

Investigation
Nil.

Management Basic and Intermediate Level

Treatment:
• Arrange urgent evacuation. Do not risk
further bites or delay evacuation catching
the snake.
• Keep the victim calm, lie flat. Panic
increases blood flow and spread of
venom.
• Allow bite to bleed freely, clean, apply
Betadine soak.
• Apply direct pressure over bite site using a
pressure bandage proximal to the bite site

E3 V1.0 89
 • Keep the victim calm, lie flat; panic
14.4 Scorpion Stings increases blood flow and spread of
[U182] venom.
Last updated: 08 12 11 • Remove boots, watch, rings and
constrictive clothing.
General Information, Presentation • Cleanse site thoroughly; apply Betadine
Scorpion stings are a major public health soaked gauze.
problem in many tropical countries. For every • Immobilise affected limb below level of
person killed by a poisonous snake, 10 are heart to delay absorption.
killed by a poisonous scorpion. In Mexico, • Have IV access equipment, oxygen,
1000 deaths from scorpion stings occur per atropine and morphine available for MO.
year. Scorpions can be found outside their • Ice packs may slow early absorption of the
normal range of distribution when they venom.
accidentally crawl into luggage, boxes,
containers, or shoes and are unwittingly Refer: Refer to MO immediately for
transported home via human travellers. Out of evacuation to hospital.
1500 scorpion species, only 50 are dangerous
to humans and in general, scorpions are not
aggressive. They are nocturnal creatures Occupational Health
hunting during the night and hiding in crevices Check clothing and boots before putting them
and burrows during the day to avoid the light. on.
Scorpions are shy creatures and only sting if
threatened, cornered, or disturbed by being
sat or stepped upon. Accidental human
stinging occurs when hands and feet are put ! Note
in their hiding places. Some species have life-threatening sting but
do not always use fatal dose of venom.
History Systemic envenomation is more common in
Ask about: children and may occur within minutes.
• Site and time of sting. Antivenom is available for some species.
• Abdominal pain, nausea and vomiting.
• Painful, local reaction around the site of
the sting

Examination
Check for:
• Localised weal and oedema.
• Fast or slow pulse and pallor,
cardiovascular failure.
• Fast respiratory rate, respiratory failure.
• Sweating, increased tears and saliva
production.
• Check temp, pulse and BP which may be
high or low.
• O2 sats if available.

Investigation
Nil.

Management Basic and Intermediate Level

Treatment: Support Airway, Breathing and
Circulation.

E3 V1.0 90
 help and a safety razor or credit card edge
14.5 Jellyfish stings can be used to shave away any remaining
[TE562] nematocysts.
Last updated: 08 12 11
Refer: Refer to MO for analgesia
General Information, Presentation
Evacuate immediately and be prepared to
Jellyfish are found in every ocean and a few
deal with anaphylaxis (see 14.2 above).
species exist in fresh water. They are
generally found near the surface or washed
up on the beach. Stings are generally
accidental and should be suspected if there is Occupational Health
sudden pain and the development of painful Protective clothing such as wet suits or lycra
rash when swimming. The box jellyfish swim suits should be worn in areas of risk.
venom is the most deadly venom in the entire
animal world.
! Note
History
Ask about: • Box Jellyfish stings may be rapidly life
threatening. Multiple stings are
• Colour and shape of Jellyfish.
excruciatingly painful and can cause
• Nausea, vomiting and abdominal pain.
anaphylaxis, collapse, respiratory arrest
• Intense, stinging pain at site of sting. and death. Box jellyfish occur mainly in
• Breathing difficulty or chest pain. Indo-Pacific region.
• Portuguese Man o’ War may cause heart
Examination
failure. Even beached or dying jelly fish
Check for: may still sting.
• Lines of contact red streaks dotted with
wheals with surrounding flare
• Respiratory difficulty or full blown
anaphylaxis.
• Irregular pulse, blood pressure changes,
cardiac arrest.
• Decreased conscious level.

Investigation
Nil.

Management Basic and Intermediate Level

Treatment:
• People stung by jellyfish should be
removed from the sea to prevent
drowning.
• Tentacles should be washed off with
seawater or lifted off carefully wearing
gloves or using tweezers. Fresh water,
alcoholic solutions, ammonia and urine
should be avoided as they may cause the
release of additional venom. Vinegar is
only used for box jelly fish stings, not
Portuguese Man o’ War stings where it
can cause further discharge of stinging
nematocysts.
• Ice packs/sea water or a slurry of baking
soda (sodium bicarbonate) can be useful
for treating UK species. Hot baths may
E3 V1.0 91
14.6 Stingray Sting
! Note
[TE56y]
Last updated: 08 12 11 Stingray stings are rarely fatal unless the
chest or abdomen is pierced when death may
General Information, Presentation occur from blood loss. In these cases, the
barb should be left in place until medical help
Stingrays are not aggressive creatures and
is reached.
most stings are accidental when the flat
creature is stepped upon in shallow water.
Injury is by laceration or puncture wounds
from the serrated spines at the end of the tail.
They also have a stinger apparatus which
contains venom but is not always released.

History
Ask about:
• Intense pain.
• Nausea, vomiting, muscle cramps or chills.

Examination
Check for:
• Swelling and redness at site of wound.
• Low blood pressure.
• Irregular, rapid heartbeat.
• Difficulty breathing or anaphylaxis.
• Convulsions.

Investigation
Nil.

Management Basic Level

Document your history and examination
findings and refer to a medical officer.

Management Intermediate Level

Treatment:
• Remove spine from wound if superficial
(see note below).
• Immerse affected part in water as hot as
the patient can bear for 30 - 90 minutes to
deactivate toxin (avoid burning the
patient). Re-immerse as pain recurs.
• Remove rings or constrictive clothing.

Refer: Refer to MO and prepare casevac.

Occupational Health
Protective clothing such as wet suits or lycra
swim suits should be worn in areas of risk.

E3 V1.0 92
Section 2 Medic's Intermediate PHC Formulary

Contents

Aciclovir 5% Cream (P or GSL - depending on Ibuprofen 400mg tablets (P as pack of 24).........98

brand) .................................................................94
Lactulose solution (P) ........................................98
Anusol Ointment (GSL).......................................94
Loratadine 10mg tablets (POM as pack of 30) ...98
Aspirin 300mg dispersible tablets (Acetylsalicylic
Malathion 0.5% aqueous liquid (Derbac-M) (P).99
Acid outside of UK) (GSL) ..................................94
3.24 Mebendazole 100mg chewable tablet
Aqueous Cream BP (GSL) .................................94
(Vermox) (P - if using for thread worm, POM - if
Calamine lotion BP (Calamine, Zinc Oxide using for all other conditions licensed for) ..........99
Glycerol, Phenol Water, Sodium Citrate) (GSL).94
Miconazole Nitrate 2% cream (Daktarin) (POM ?
Chloramphenicol 1% eye ointment (POM or P 30g tube).............................................................99
dependent on brand) ..........................................95
Migraleve tablets (CD Inv P)..............................99
Chlorhexidine 0.2% (Corsodyl) mouthwash (GSL)
Mycota cream or powder (GSL)....................... 100
............................................................................95
3.28 Olive oil BP (GSL).................................... 100
Chlorphenamine 4mg tablets (Piriton) (P) ..........95
Paracetamol 500mg tablets (Acetaminophen
Choline Salicylate 8.7% gel (Bonjela) (GSL)......95
outside of UK) (GSL) ...................................... 100
3.11 Clotrimazole 1% cream (Canesten) (P- for
Potassium Citrate effervescent tablets (Effercitrate)
vaginal candidiasis, GSL for tinea pedis) ...........96
(GSL) ............................................................... 100
Clotrimazole 500mg Pessary (P)........................96
Salbutamol 100mcg cfc-free aerosol inhaler (POM)
Crotamiton BP 10% cream (Eurax) (GSL).........96 ......................................................................... 101
Dequalinium Chloride 0.25mg lozenge (Dequadin) Salicylic Acid Lactic Acid (Salactol) (P) ........... 101
(P) .......................................................................96
Sodium Bicarbonate 5% ear drops (GSL) ....... 101
Dioralyte sachets (P; box of 20) .........................97
Sodium Cromoglycate 2% eye drops (POM - for
E45 cream (GSL)...............................................97 13.5ml) ............................................................. 101
Fluconazole 150mg capsule (P) .........................97 Yellow soft paraffin ointment (GSL)................. 102
Gavsicon Advance suspension (PO)..................97
Gaviscon Advance tablets (PO) .........................97

E3 V1.0 93
 Contraindications (refer) Hypersensitivity to
Aciclovir 5% Cream (P or GSL - depending Aspirin or any other NSAID-which includes those
on brand) whom attacks of asthma, angioedema, urticaria or
rhinitis have been precipitated by aspirin or any
Indication Herpes simplex viral infection of the other NSAID. Any patient who has suffered/ suffers
lips and face (cold sores). with peptic ulceration, haemophilia, gout, asthma,
angioedema, urticaria, rhinitis, renal/hepatic
Side effects Erythema, stinging or burning, impairment or is on calcium-channel blockers,
itching or drying of skin, contact dermatitis, anticoagulants, antiepileptics, corticosteroids,
immune system disorders, immediate Koalin, NSAID?s, antacids, anti-depressants,
hypersensitivity reactions including angioedema. Cilostazol, Clopidogrel, Methotrexate, breast-
Contraindications (refer) Not to be used on feeding, diuretics, Iloprost, Zafirlukast,
eyes. Avoid in immunocompromised patients. Metoclopramide, Mifepristone, Probenecid,
Avoid in patients hypersensitive to acyclovir, Sibutramine or Sulfinapyrazone products. Not for
Valaciclovir, Propylene glycol and any other age under 16 years.
excipients of the cream. Counselling Dissolve in warm water (not hot) with
Counselling Avoid contact with mucous or after food; Contains Aspirin; Avoid alcohol
membrane. Continue treatment for a minimum of Dose One or two to be dissolved into a glass of
4 days and maximum 10 days. If lesions still water, gargle before swallowing (unless instructed
present after 10 days refer to doctor. Wash hands not to) every 4-6 hours. Max 12 in 24 hours.
before and after applying cream. Avoid
unnecessary rubbing of the lesions or touching Authorised Qty 16 tablets.
them to avoid transference of infection; for external
use only.
Dose: To be applied to the affected areas 5 times Aqueous Cream BP (GSL)
a day.
Indication Dry skin conditions.
Authorised Qty: 2g tube
Side effects Hypersensitivity reactions
Contraindications (refer) Known hypersensitivity
Anusol Ointment (GSL) reactions to ingredients
Counselling For external use only.
Indication Uncomplicated internal and external
haemorrhoids, pruritus ani, proctitis and fissures, Dose Apply to the affected area when required.
post op in anorectal surgical procedures and after
Authorised Qty 30g tube.
incision of thrombosed or sclerosed anorectal
veins.
Side effects Hypersensitivity reactions, transient
Calamine lotion BP (Calamine, Zinc Oxide
burning on application.
Glycerol, Phenol Water, Sodium Citrate)
Contraindications Known hypersensitivity to (GSL)
ingredients, pregnancy.
Counselling (refer) Wash hands before and after Indication The relief of minor skin rashes and
use. irritation.

Dose Apply to the affected area in the morning Side effects Occasional hypersensitivity or irritant
and at night and after each bowel movement. reactions

Authorised Qty 25g tube Contraindications (refer) Hypersensitivity to any

of the ingredients.
Counselling Shake bottle before use; for external
Aspirin 300mg dispersible tablets use only.
(Acetylsalicylic Acid outside of UK) (GSL) Dose To be applied to the affected area as
required.
Indication: Mild to moderate pain, fever.
Authorised Qty 200ml.
Side effects Nausea, vomiting, dyspepsia,
irritation to GI mucosa which may lead to erosion,
ulceration and GI bleeding, urticaria rhinitis,
angioneurotic oedema, increased bleeding time,
bronchospasm and skin reactions in hypersensitive
patients.

E3 V1.0 94
 Dose 10ml to be used as a mouthwash for 1
minute twice a day.
Chloramphenicol 1% eye ointment (POM
Authorised Qty. 300mls.
or P dependent on brand)

Indication Superficial bacterial infections of the

eye Chlorphenamine 4mg tablets (Piriton) (P)
Side effects Sensitivity to product, depression of Indication Symptomatic control of all allergic
bone marrow function when given with other conditions responsive to antihistamines, including
drugs, burning, stinging, itching, eye irritation and hay fever, vasomotor rhinitis, urticaria,
inflammation, aplastic anemia, anaphylaxis, angioneurotic oedema, food allergy, drug and
angioedema. serum reactions, insect bites, itch associated with
Contraindications (refer) Refer patients taking: chicken pox.
Rifampicin, anticoagulants, sulphonylureas, Side effects Drowsiness; inability to concentrate;
Phenytoin, Primidone, Clozapine, barbiturates, lassitude; blurred vision; GI disturbances such as
Ciclosporin, Hydroxycobalamin, Tacrolimus, anorexia, dyspepsia, nausea, vomiting, diarrhoea
contraceptives containing oestrogens. Patients and abdominal pain. Hepatitis including jaundice;
with a history of pre-existing bone marrow urinary retention; headaches; dry mouth;
depression or blood dyscrasias, breastfeeding. dizziness; palpitation, tachycardia, arrythmias,
NB. Systemic effects may arise from absorption of hypotension, chest tightness; thickening of
drugs into the general circulation from conjunctival bronchial secretions; haemolytic anaemia and
vessels or from the nasal mucosa after excess other blood dyscrasias; allergic reactions including
preparation has drained down through the tear exfoliative dermatitis; photosensitivity and
ducts. The extent of systemic absorption urticaria; twitching, muscular weakness and inco-
following ocular administration is highly variable?. ordination; tinnitus; depression, irritability and
nightmares.
Counselling Do not use contact lenses during
treatment and discontinue use of contact lenses Contraindications (refer) Hypersensitivity to
until 24 hours after finishing treatment. Avoid antihistamines or any of the ingredients. Central
touching eye area with applicator tip as infection nervous system depressants e.g. alcohol,
may spread. Eyesight will be blurred for approx. barbiturates, hypnotics, opioid analgesics,
10 minutes after application, during this time avoid monoamine-oxidase inhibitors (MAOI drugs).
driving or hazardous activities i.e. weapon Patients with epilepsy, raised intra-ocular
handling. Advise patient to make “pocket” by pressure, glaucoma, prostatic hypertrophy, severe
pulling down lower lid to apply the ointment. hypertension or cardiovascular disease,
Ointment has little effect if applied to the outer eye bronchitis, bronchiectasis and asthma, breast-
lid. feeding, hepatic disease and thyrotoxicosis.
Dose To be applied to the affected eye(s) three Not for use in Air crew and caution in those
or four times a day for 5 days. handling weapons.
Authorised Qty 4g tube. Counselling May cause drowsiness, dizziness,
blurred vision and psychomotor impairment which
may affect the ability to drive. If affected do not
drive or operate machinery. Avoid alcohol.
Chlorhexidine 0.2% (Corsodyl)
mouthwash (GSL) Dose One tablet to be taken every 4 to 6 hours
(max 24mg/6 tabs in 24 hours).
Indication Oral hygiene and plaque inhibition, Authorised Qty 30 tablets.
mouth ulcers, gingivitis and oral candidiasis.
Side effects Reversible brown staining of teeth,
silicate or composite restorations. Tongue
discolourisation, parotid gland swelling and taste Choline Salicylate 8.7% gel (Bonjela)
disturbances/ burning sensation (GSL)
Contraindications (refer) Hypersensitivity to Indication Mild oral & perioral lesions
ingredients. Anionic agents usage.
Side effects Asthma attack may occasionally
Counselling May be incompatible with some occur in people sensitive to salicylates. Frequent
ingredients in toothpaste, leave an interval of at application may give rise to salicylate poisoning.
least 30 minutes between using mouthwash and Headaches, stomach upset & diarrhoea
toothpaste. Do not swallow. May permanently
stain clothing.

E3 V1.0 95
Contraindications (refer) Patients with a history fever or chills, nausea or vomiting, diarrhea, foul
of asthma; gout; peptic ulcer; sensitivity to aspirin, smelling discharge.
salicylates or any other ingredients. Patients
Counselling May damage condoms and
taking anticoagulant medication. Not to be used
diaphragms, patient must use alternative
for children less than 16 years old.
precautions for at least 5 days after using this
Counselling Not to be applied to dentures - product. Some undissolved pieces of pessary
leave 30 minutes before re-insertion of dentures. discharge is normal, using panty liner for 24 hours
after insertion may prevent staining of
Dose: Gently massage 1cm of gel to the affected
underwear/clothing. Not for oral consumption.
area, not more than every 3 hours.
Wash hands before and after usage.
Authorised Qty 15g tube.
Dose Adults over 16 years and less than 60 yrs.
Insert one pessary into the vagina at night.
Please remove outer wrapper of pessary before
insertion.
3.11 Clotrimazole 1% cream (Canesten) (P-
for vaginal candidiasis, GSL for tinea Authorised Qty 1 x 500mg pessary.
pedis)

Indication: Ringworm (tinea), athlete’s foot,

paronychia, pityriasis versocolor, erythrasma, Crotamiton BP 10% cream (Eurax) (GSL)
intertrigo, candidal vulvitis and candidal balanitis.
Indication: For the relief of itching and skin
Side effects Skin irritation or burning sensation, irritation caused by sunburn, dry eczema, itchy
hypersensitivity reactions to ingredients dermatitis, allergic rashes, hives, nettle rash,
Contraindications Known allergy to product or chickenpox, insect bites and stings, heat rashes
ingredients and personal itching.

Counselling May damage condoms and Side effects: May occasionally cause skin
diaphragms, patient must use alternative irritation or allergy.
precautions for at least 5 days after using this Contraindications (refer) Acute exudative
product. Wash hands before and after use. dermatoses, hypersensitivity to any ingredients,
External use only. not to be used around eye area, broken skin,
Dose Apply to the affected area two to three pregnancy, breast-feeding or genital itching.
times a day. Counselling External use only. Do not use in or
Authorised Qty 20g tube. around eyes, on broken skin, weeping conditions.
Wash hands before and after use unless
treatment is for hand area.
Dose To be applied to the affected area two or
Clotrimazole 500mg Pessary (P) three times a day.
Indication Candidal vaginitis, mixed vaginal Authorised Qty 30g tube.
infections where Trichomonas is present or
suspected. In conjunction with topical preparation.
Side effects Skin irritation or burning sensation, Dequalinium Chloride 0.25mg lozenge
hypersensitivity reactions to ingredients, syncope, (Dequadin) (P)
hypotension, dyspnea, GI disorders, pain, pruritis
& rash. Indication: Symptomatic relief of common
Contraindication (refer) Refer if first time patient infections of the mouth including sore throats,
is experiencing candidal vaginitis or more than glossitis, pharyngitis, tonsillitis, stomatitis,
two candidal vaginitis infections in previous 6 vincentquotes angina, mouth ulcers and oral
months, previous history of STI or exposure to thrush.
partner with STI, pregnancy or suspected Side effects: Allergic reactions such as asthma or
pregnancy, aged under 16 or over 60, known soreness of the tongue.
hypersensitivity to imidazoles or other vaginal
antifungal products, irregular vaginal bleeding, Contraindications (refer): Patients allergic to
abnormal vaginal bleeding or blood-stained Aspirin, patients with inherited problems coping
discharge, vulval or vaginal ulcers, blisters or with carbohydrates or sugars, pregnancy or
sores, lower abdominal pain or dysuria, any breastfeeding.
adverse reaction to the treatment in the past, Counselling Suck do not chew. Maximum 8
lozenges on 24 hours.

E3 V1.0 96
Dose One to be sucked slowly in the mouth when hypertriglyceridaemia, hypokalaemia, tast
required. perversion.
Authorised Qty 20 lozenges. Contraindications (refer): Known
hypersensitivity to ingredients or related zole
compounds. Patients with a history of: serious
underlycing disease, breast feeding, pregnancy.
Dioralyte sachets (P; box of 20) Patients taking: anticoagulants, benzodiazepines,
endogenous steroids, sulphonylureas,
Indication: Correction of electrolyte loss in Hydrochlorothiazide, Phenytoin, oral
infants, children & adults associated with acute contraceptives, Rifampicin, Cyclosporin,
diarrhea, watery diarrhea and gastro-enteritis. Theophylline, Terfenadine, Cisapride, Zidovudine,
Rifabutin, Tacrolimus
Side effects Hypersensitivity to ingredients.
Counselling Consider treating regular sexual
Contraindications (refer) Patients with a history
partner for Candidal vaginitis or balanitis.
of intestinal obstruction requiring surgical
intervention, hypotension, hypertension, Dose Take one capsules immediately.
hyperkaleamia, hypokaleamia, intolerance to
Authorised Qty 1 capsule pack.
glucose absorption, diabetes, liver disease, kidney
disease, if patient has had symptoms for longer
than 48 hours.
Counselling Dissolve each sachet in 200ml Gavsicon Advance suspension (PO)
ofdrinking water. Use within 1 hour of
reconstitution, unless refrigerated which can be Indication Gastro-esophageal reflux such as
kept for up to 24 hours. acid regurgitation, heartburn, indigestion occurring
due to reflux of stomach contents, for instance,
Dose 200-400ml of solution after each loose
after gastric surgery, as a result of hiatus hernia,
motion.
during pregnancy or accompanying reflux
Authorised Qty 6 sachet pack. oesophagitis.
Side effects Patients sensitive to the ingredients
may develop allergic manifestations such as
urticaria or bronchospasm, anaphylactic or
E45 cream (GSL)
anaphylactoid reactions.
Indication Dry skin conditions Contraindications (refer) Hypersensitivity to any
of the ingredients, including esters of
Side effects Hypersensitivity reactions to
Hydroxybenzoates (parabens). Patients on a
ingredients, eczema,
highly restricted salt diet due to i.e. congestive
Contraindications (refer) Known cardiac failure, renal impairment. Avoid in
hypersensitivity reactions to ingredients patients with hypercalcaemia, nephrocalcinosis,
recurrent calcium containing renal calculi,
Counselling For external use only.
hyperkaelimia.
Dose To be applied to the affected area when Counselling: Do not use three months after
required.
opening. Do not refrigerate. Shake well before
Authorised Qty: 50g tube. use. After food & at bedtime.
Dose: One or two 5ml spoonfuls to be taken four
times a day after meals and at bedtime.
Fluconazole 150mg capsule (P) Authorised Qty: 150ml bottle.

Indication: Candidiasis of the mucosa, systemic

candidiasis, Crytococcosis, Genital candidiasis,
prevention of fungal infection in Gaviscon Advance tablets (PO)
immunocompromised patients, Dermatomycosis.
Indication Gastro-esophageal reflux such as
Side effects: Hypersensitivity reactions to acid regurgitation, heartburn, indigestion occurring
ingredients, headache, rash, abdominal pain, due to reflux of stomach contents, for instance,
diarrhea, flatulence, nausea, renal & hepatic after gastric surgery, as a result of hiatus hernia,
abnormalities, blood abnormalities, dizziness, during pregnancy or accompanying reflux
seizures, alopecia, Stevens-Johnson syndrome, oesophagitis.
toxic epidermal necrolysis, dyspepsia, vomiting,
leucopenia, anaphylaxis, hepatitis, hepatocellular Side effects Patients sensitive to the ingredients
necrosis, jaundice, hypercholesterolaemia, may develop allergic manifestations such as

E3 V1.0 97
urticaria or bronchospasm, anaphylactic or Mifepristone, Moxonidine, muscle relaxants,
anaphylactoid reactions. nitrates, Penicillamine, Pentoxifylline,
Drospirenone, Sibutramine, Tacrolimus, vaso-
Contraindications (refer) Hypersensitivity to any
dialator antihypertensives, other NSAID?s
of the ingredients. Patients on a highly restricted
salt diet due to i.e. congestive cardiac failure, Counselling Must be taken with or after a recent
renal impairment. Avoid in patients with meal. Swallow whole, do not chew.
hypercalcaemia, nephrocalcinosis, recurrent
Dose One tablet to be taken 3 times a day when
calcium containing renal calculi, hyperkaelimia,
required.
phenylketonuria.
Authorised Qty 24 tablets.
Counselling Chew or suck tablets only.
Dose: One to be chewed or sucked four times a
day after meals and at bedtime.
Lactulose solution (P)
Authorised Qty 60 tablet tub.
Indication Chronic constipation or chronic portal
systemic encephalopathy.
Ibuprofen 400mg tablets (P as pack of 24) Side effects Cramps, flatulence, nausea,
abdominal distension,
Indication: Analgesic & anti-inflammatory effects
Contra-indications (refer) Galactosaemia or
in rheumatoid arthritis, ankylosing spondylitis,
lactose intolerance, gastrointestinal obstruction
osteoarthritis, frozen shoulder, bursitis, tendonitis,
patients taking anti-coagulants, pregnancy.
tenosynovitis, lower back pain, soft tissue injuries
such as sprains & strains, dysmenorrhoea, dental, Counselling Must be taken with plenty of fluids.
post-operative pain, headache & migraine. Can be taken with or after food to minimize side-
effects.
Side effects: Gastro-intestinal discomfort,
nausea, diarrhoea, rashes, headache, dizziness, Dose Three 5ml spoonful’s to be taken twice a
nervousness, depression, drowsiness, insomnia, day. Adjust according too response.
vertigo, hearing disturbances such as tinnitus and
Authorised Qty 300ml.
photosensitivity, haematuria, blood disorders,
increased blood pressure, fluid retention,
thrombotic events, vomiting, dyspepsia,
abdominal pain, melaena, ulcerative stomatitis,
Loratadine 10mg tablets (POM as pack of
gastrointestinal haemorrhage, gastritis, duodenal
ulcer, gastric ulcer, gastrointestinal perforation, 7 or 30 tablets)
non-specificx allergic reaction & anaphylaxis,
asthma, aggravated asthma, bronchospasm, Indication Symptomatic relief allergy such as
dyspnoea, oedema, cardiac failure, nephrotoxitiy hay fever, chronic idiopathic urticaria.
including interstitial nephritis, nephritic syndrome Side effects Drowsiness, nausea, headache,
and renal failure, abnormal liver functions inc hair loss, hypersensitivity reactions to ingredients,
hepatitis and jaundice, visual disturbances, optic effects on the liver, disturbances in heart rhythm,
neuritis, paraesthesia, confusion, hallucinations, fainting, extrapyramidal effects, dizziness,
vertigo, malaise, fatigue. confusion, depression, sleep disturbances,
Contraindications (refer) Avoid in patients who tremor, convulsions, palpitations, arrhythmias,
have a history of hypersensitivity to aspirin or any blood disorders, angle-closure glaucoma,
other NSAID, which includes those in whom psychomotor impairment, antimuscarinic effects,
attacks of asthma, angioedema, urticaria or GI disturbances, hypotension.
rhinitis have been precipitated by Aspirin or any Contraindications (refer) Patients with a history
other NSAID. Patients with a history of: of urinary retention, glaucoma and pyloroduodenal
breastfeeding, pregnancy, coagulation defects, obstruction, prostatic hypertrophy, hepatic
renal or hepatic impairments, cardiac disease, epilepsy, porphyria, pregnancy or
impairments, severe heart failure, peptic breastfeeding. Patient taking the following
ulceration, gastrointestinal disease, hypertension. medication Erythromycin, Ketoconazole,
Patients taking: ACE inhibitors, antacids, Fluconazole, Quinadine, Cimetidine, anti-
anticoagulants, antidepressants, anti-diabetics, depressants, anti-muscarinics, Amprenavir,
anti-epileptics, anti-hypertensives, alpha-blockers, Ritonavir, anxiolytics & hypnotics, Betahistine.
adrenergic neurone blockers, angio-tensin-II
receptor antagonists, quinolone anti-biotics, anti- Not for use in Air crew and caution in those
glycosides, Ciclosporin, Clonidine, Clopidogrel, handling weapons.
corticosteroids, Methotrexate, Diazoxide,
diuretics, Iloprost, Lithium, Methyldopa,

E3 V1.0 98
Counselling May cause drowsiness which may Authorised Qty 2 x 50ml.
effect performance of skilled tasks such as
driving. If affected avoid driving or operating
heavy machinery. Avoid excessive alcohol.
3.24 Mebendazole 100mg chewable tablet
Dose One tablet to be taken daily.
(Vermox) (P - if using for thread worm,
Authorised Qty 30 tablets. POM - for all other conditions)

Indication Thread worm.

Malathion 0.5% aqueous liquid (Derbac-M) Side effects Abdominal pain, diarrhoea, rash,
(P) hypersensitivity to ingredients, convulsions in
infants, toxic epidermal necrolysis, Stevens-
Indication Treatment of head lice, pubic lice and Johnson syndrome, exanthema, angio-oedema,
scabies. urticaria, liver function disturbances, hepatitis,
glomerulonephritisand neutropenia.
Side effects Skin irritation, hypersensitivity
reactions such as anaphylaxis, angioedema, and Contraindications (refer) Known
swollen eyes, chemical burns. hypersensensitivity reactions to ingredients,
pregnancy, breast feeding. Patients taking:
Contraindications (refer) Known sensitivity to Cimetidine, Metronidazole.
any ingredients, pregnancy, breast-feeding
Counselling Chew or swallow whole.
Counselling External use only. Avoid contact
with eyes and ingestion. Do not use more than Dose For the treatment of threadworm - one
once a week and for more than 3 consecutive tablet to be taken at once, then repeat again in 2
weeks. weeks if necessary. Authorised Qty 6 tablets.

Dose
• Head lice: rub the liquid into the scalp until all Miconazole Nitrate 2% cream (Daktarin)
the hair and scalp is thoroughly moistened.
Leave hair to dry naturally in a warm but well
(POM ? 30g tube)
ventilated room. After 12 hours, or the next
day if preferred, shampoo the hair in the Indication Mycotic infections of skin and nails,
normal way. Rinse the hair and comb whilst Gram-positive bacterial infections.
wet to remove the dead lice and eggs using a Side effects Anaphylactic reaction,
nit comb. Treatment should be repeated in 7 hypersensitivity to ingredients, angioneurotic
days. oedema, skin & subcutaneous tissue disorders,
• Pubic lice: Apply liquid to the entire skin urticaria, contact dermatitis, rash, erythema,
surface. Pay particular attention to all hairy pruritus, skin burning sensation, application site
areas including beards and moustaches. irritation.
Avoid any other areas above the neck. Leave
Contraindications (refer) Known
on for at least one hour before washing but
hypersensitivity to the ingredients, patients taking
preferably the liquid should be left on
anti-coagulants, pregnancy, breast-feeding.
overnight. Wash off in the usual manner.
Treatment should be repeated in 7 days. Counselling External use only. Avoid contact
• Scabies: Apply the liquid to the entire skin with eyes & mucous membranes. Wash hands
surface. In adults it may not be necessary to before and after use unless treatment area is the
apply above the neck. Do not wash off or hands. To be used for 10 days after lesions have
bathe for 24 hours. If hands or any other disappeared.
parts must be washed during this period, the
Dose To be applied to the affected area twice a
treatment must be reapplied to thos areas
day.
immediately. Treatment should be repeated
in 7 days. Authorised Qty 30g tube.

NB: No special sterilization of clothing is

necessary: ordinary laundering or dry cleaning
with hot iron pressing are sufficient. The Migraleve tablets (CD Inv P)
infestation is cleared by the treatment. However,
the itching and rash may persist for up to 7 days. Ingredients Pink tablet each 500mg
An anti-irritant cream can be applied if necessary. Paracetamol, 8mg Codeine Phosphate, 6.25mg
Family members and close contacts should also Buclizine Hydrochloride. Yellow tablet each
be treated simultaneously. 500mg Paracetamol, 8mg Codeine Phosphate.

E3 V1.0 99
Indication Migraine attacks which can include Counselling Wash hands before and after use.
the symptoms of migraine headache, nausea and Wash and dry application area thoroughly before
vomiting. use.
Side effects Allergic reactions, constipation, Dose Apply to the affected area morning and
drowsiness, rashes, blood disorders, kidney & night.
liver damage, abdominal pain, seizures, malaise,
Authorised Qty 25g cream and/or 70g powder.
hypothermia, muscle fasciculation, anorexia,
pancreatitis, nausea, vomiting, dry mouth, biliary
spasm, muscle rigidity, hypotension, respiratory
depression, bradycardia, tachycardia, palpitation,
3.28 Olive Oil BP (GSL)
oedema, postural hypotension, hallucinations,
vertigo, euphoria, dysphoria, mood changes,
Indications Softens ear wax.
dependence, dizziness, confusion, sleep
disturbances, headache, sexual dysfunction, Side effects Local irritation and hypersensitivity
urinary retention, ureteric spasm, miosis, reactions to ingredients.
sweating, flushing, urticaria, pruritus.
Contraindications (refer): Know hypersensitivity
Contraindication Some individuals may be ultra- to ingredients, ear infections, previous/ongoing
rapid metabolisers due to a specific CYP2D6*2x2 ear problems, perforated ear drum.
genotype which can occur in 0.5% - 1% in
Chinese, Japanese & Hispanics, 1 to 10% in Counselling Wash hands before and after use.
Caucasians, 3% in African Americans, and 16 to Do no use cotton buds in ear canal. Patient
should lie with the affected ear uppermost for 5 to
28% in North Africans, Ethiopians and Arabs. At
labeled dosage regimes individuals who are ultra- ten minutes after a generous amount of the
rapid metabolisers may experience overdose softening remedy has been introduced into the
ear. Patient should expect some of the product to
symptoms such as extreme sleepiness, confusion
or shallow breathing. Patients should be informed come back out when head is righted. Allow to
warm to room temperature before use.
of the risks and signs of morphine overdose.
Avoid in patients with renal/ hepatic impairment, Dose Instil 3-4 drops into the affected ear(s)
breast-feeding, acute respiratory depression, risk twice a day for 5 days.
of paralytic ileus, raised intracranial pressure,
head injury, asthma, hypotension, shock, prostatic Authorised Qty 10ml dropper bottle.
hypertrophy, obstructive or inflammatory bowel
disorders, convulsive disorders, hypothyroidism,
adrenocortical insufficiency. Patients already
taking: metoclopramide, anticoagulants, Busulfan,
Paracetamol 500mg tablets
Colestyramine, antidepressants, antimuscarinics, (Acetaminophen outside of UK) (GSL)
Ritonavir, Anxiolytics & Hypnotics, Betahistine.
Indication: Mild to moderate pain, pyrexia.
Counselling Do not use for longer than 3
consecutive days. Contains Paracetamol. May Side effects: Rashes, blood disorders, kidney &
cause drowsiness, if affected do not drive or liver damage
operate machinery. Avoid alcohol. Contraindications (refer): Patients taking
Not for use in Air crew and caution in those Metoclopramide, anticoagulants, Colestyramine,
handling weapons. Busulfan, Patients with a history of kidney/ liver
damage, heavy drinking habits.
Dose 2 pink tablets at onset of attack, followed
by 2 yellow tablets every 4 hours if necessary; Counselling Maximum 8 tablets in 24 hours. Do
max. 2 pink and 6 yellow in 24 hours. Authorised not take any other Paracetamol containing
Qty 1 x 12 pack of Migraleve tablets. products.
Dose Two to be taken every 4 - 6 hours when
required (max 8 in 24 hours).
Mycota cream or powder (GSL) Authorised Qty 16 tablets.

Indications Treats and prevents athlete’s foot.

Side effects Local irritation and hypersensitivity Potassium Citrate effervescent tablets
reactions to ingredients including a mild burning (Effercitrate) (GSL)
sensation, erythema and itching.
Contraindications (refer) Know hypersensitivity Indication Cystitis.
to ingredients.

E3 V1.0 100
Side effects Upset stomach, mild diuresis, Presentation Paint.
hyperkalaemia, hypersensitivity reactions to
Action Local tissue destruction.
ingredients.
Indication The ingredients work together to break
Contraindications (refer) Patients with a history
down and remove warts, verrucas, corns and
of renal impairment, hypertension, heart disease.
calluses.
Patient taking Potassium sparing diuretics, ACE
inhibitors, Aliskiren, angio-II receptor antagonists, Side effects Skin irritation.
Methenamine, Ciclosporin, aldosterone
antagonists, Tacrolimus. Contraindications Diabetic patients, or people
who suffer with poor blood circulation to hands or
Counselling Dissolve into water, Take with of feet. Protect surrounding skin and avoid broken
after food skin; not suitable for application to face,
anogenital region, or large areas
Dose Dissolve two tablets into a glass of water
and drink the entire solution three times a day. Dose Apply once a day and apply occlusive
dressing the paint should be used in conjunction
Authorised Qty 12 tablets.
with filing of dead skin. Follow printed instructions.
Authorised Qty 10ml.

Salbutamol 100mcg cfc-free aerosol

inhaler (POM)
Sodium Bicarbonate 5% ear drops (GSL)
Only to be issued via protocol and authorised
by Medical Officer Indications: Ear wax softening

Indication Emergency intervention in significant Side effects: Local irritation and hypersensitivity
asthma attack. Not to be supplied to take away. reactions to ingredients, dryness of ear canal.

Side effects Tremor, nervous tension, headache, Contraindications (refer) Know hypersensitivity
muscle cramps, tachycardia, arrhythmias, to ingredients, ear infections, previous/ongoing
hypokalaemia, collapse, hypotension, peripheral ear problems, perforated ear drum.
vasodilation, myocardial ischarmia, disturbances Counselling Wash hands before and after use.
of sleep & behaviour, paradoxical bronchospasm, Do no use cotton buds in ear canal. Patient
urticaria, angioedema, metabolism & nutrition should lie with the affected ear uppermost for 5 to
disorders, hyperactivity, palpitations, ten minutes after a generous amount of the
gastrointestinal disorders, mouth & throat softening remedy has been introduced into the
irritation, ear. Patient should expect some of the product to
Contraindications (refer) Patients with a history come back out when head is righted. Allow to
of cardiovascular disease, diabetes mellitus, warm to room temperature before use.
hypothyroidism, arrhythmias, susceptibility to QT- Dose Instil 3-4 drops into the affected ear(s)
interva; prolongation, hypertension, pregnancy, twice a day.
breast-feeding, thyrotoxicosis. Patients taking
antidepressants, Theophylline, corticosteroids, Authorised Qty 10ml bottle.
diuretics, non-selective beta-blocking drugs,
Atomoxetine, Digoxin & Methyldopa. Sodium Cromoglycate 2% eye drops 10ml.
Counselling Shake well. Release a puff into the (POM - for 13.5ml)
air before giving to patient to prime inhaler.
Indication Allergic conjunctivitis, seasonal
NB. Single patient use ? return to pharmacy for keratoconjunctivitis.
destruction after use.
Side effects: Hypersensitivity reactions to
Dose Emergency Treatment; one puff to be used ingredients, burning, stinging sensation.
every 15 to 30 seconds for acute episodes or
exacerbations of asthma. 10-20 puffs. Use via Contraindications (refer) Known hypersensitivity
spacer device (use a coke bottle or a paper cup if to ingredients.
a spacer is not available). Counselling Do not use soft contact lenses
during treatment and discontinue use of contact
Authorised Qty To be administered on site only. lenses until 24 hours after finishing treatment.
Eyesight will be blurred for approx. 10 minutes
after application, during this time avoid driving or
hazardous activities i.e. weapon handling.
Salicylic Acid Lactic Acid (Salactol) (P)

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Dose Instil one drop into the affected eye(s) four direction of hair growth. If applied to the hands
times a day. take care when driving or operating machinery as
it will make hands slippery.
Authorised Qty 10ml bottle.
Dose: Apply to the affected area up to four times
a day as required.

Yellow soft paraffin ointment (GSL) Authorised Qty: 30g tube

Indication Relief of dry skin conditions

Side effects Hypersensitivity reactions to
ingredients, folliculitis.
Contraindications (refer): Known
hypersensitivity to ingredients.
Counselling Flammable, avoid naked flames or
smoking whilst product is in use. Apply in the

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