Internal Medicine Clinical Treatment Guidelines

Republic of Rwanda
Ministry of Health
P. O. Box 84 Kigali
www.moh.gov.rw
Internal Medicine
C l i n i c a l Tr e a t m e n t G u i d e l i n e s
September 2012
Internal Medicine Clinical treatment guidelines 1

Republic of Rwanda
Ministry of Health
P. O. Box 84 Kigali
www.moh.gov.rw
Internal Medicine
C l i n i c a l Tr e a t m e n t G u i d e l i n e s
September 2012
Table of Contents
Internal Medicine Clinical treatment guidelines iii

iv Internal Medicine Clinical treatment guidelines
Internal Medicine Clinical treatment guidelines v
vi Internal Medicine Clinical treatment guidelines
Acronyms
Internal Medicine Clinical treatment guidelines vii

viii Internal Medicine Clinical treatment guidelines
Internal Medicine Clinical treatment guidelines ix
x Internal Medicine Clinical treatment guidelines
Foreword
Internal Medicine Clinical treatment guidelines xi

1
1. Internal medicine emergencies
1.1. Cardio Respiratory Emergencies
1.1.1. Cardio Pulmonary Arrest
Causes
Signs and Symptoms
Management

Chapiter 1: Internal Medicine Emergencies
Recommendations
2 Internal Medicine Clinical treatment guidelines

1
1.1.2. Pulmonary oedema
Causes
Signs and Symptoms
Complications

Investigations
Management
Recommendation

1
1.1.3. Acute Pulmonary embolism
Causes/Risk factors
signs and Symptoms
Complications

Investigations
Management

Recommendation

1.1.4. Pneumothorax
Causes
Signs and Symptoms
Complication
Investigations
Management
1.1.5. Acute Asthma attack
Causes

1
Signs and Symptoms
Complications
Investigations
Management

Recommendations
1.2. Shock
Complications
1.2.1. Hypovolemic shock
Causes
Symptoms

1
Signs
Investigations
Management
Recommendations

1.2.2. Cardiogenic shock
Causes
Signs and Symptoms
Investigations
Management

Recommendation
1.2.3. Septic shock
Causes
Signs and Symptoms

Complications
Investigations
Management

Recommendation
1.2.4. Anaphylactic shock
Causes

Signs and Symptoms
Complication
Management

1
1.3. Neurological Emergencies
1.3.1. Coma and Depressed Conscious State
Causes
Signs and Symptoms

Investigations

Management

Recommendation
1.3.2. Status Epilepsy
Causes
Signs and Symptoms
Management


1.3.3. Spinal Cord Compression
Causes
Signs and Symptoms
Complications
Investigations

1
Management

1.4. Toxicology
1.4.1. Stings and Bites
Signs and Symptoms
Management

Signs and Symptoms
Complications of snake bites
Management of snake bites

Signs and Symptoms
Management
1.4.2. Poisoning
Causes


Investigations
Management



Recommendation

1.5. Metabolic and endocrine emergencies
1.5.1. Diabetic Keto-acidosis (DKA)
Causes
Signs and Symptoms
Complications

1
Investigations
Management


1
1.5.2. Hyperosmolar Hyperglycemic Syndrome (HHS)
Causes
Signs and Symptoms
Complication

Investigations
Management

1
1.5.3. Hypoglycemia
Causes
Signs and Symptoms
Management

Causes

1
Signs and Symptoms
Investigations
Managemenet

Recommendations
1.5.5. Hyper/Hypokalemia
Causes

Signs and Symptoms
Complications
Investigations
Management

Causes
Signs and Symptoms
Complications
Investigations
Management

1
1.5.6. Hyper/Hyponatremia
Causes
Signs and Symptoms

Investigations
Complications
Management

Causes

Signs and Symptoms
Complication
Investigations
Management

1
1.5.7. Hypercalcemia
Causes
Signs and Symptoms
Complications
Investigations
Management

Recommendations
1.6. Gastrointestinal emergencies
1.6.1. Upper GI bleeding (UGIB)
Causes
Signs and Symptoms
Complications

1
Investigations
Management
Recommendation

1.6.2. Lower GI Bleeding (LGIB)
Causes
Signs and Symptoms
Investigations
Management

1
1.6.3. Acute Pancreatitis
Causes
Signs and Symptoms
Complications

Investigations
Management

1
Recommendations
1.7. Cardiovascular Diseases
1.7.1. Cardiomyopathies
Signs and Symptoms

Causes
Investigations
Complications
Management

1
1.7.2. Heart Failure
Etiology/Causes
Signs and Symptoms

Investigations
Complications
Management

1.7.3. Cardiac Arrhythmias
Causes
Signs and Symptoms

Complications
Investigations
Management


Recommendations
1.7.4. Valvular Heart Disease
Causes/Etiology
Signs and Symptoms
Clinical presentation

1
Investigations
Management

* See Table 7 for definitions
Etiology/Causes

Signs and symptoms
Complications
Investigations
Management

* See Table 6 for definitions
** Surgery must also be

considered if significant
changes occur during
Etiology/Causes

1
Signs and symptoms
Complications
Investigations
Management

Etiologies/Causes
Signs and symptoms

1
Complications
Investigations
Management

Chronic Severe Mitral Regurgitation
Clinical evaluation + Echo

Re-evaluation
Symptoms?
No Yes
LV function? LV function?
Normal LV function LV dysfunction

EF 0.60 EF 0.30 EF 0.30 and/or
EF > 0.60 ESD 55 mm ESD 55 mm
ESD <40 mm and/or
ESD 40 mm
Class I Class I
New onset AF? Chordal preservation

Pulmonary HT? likely?
MV repair
Yes Yes
Class IIa If not possible, Class IIa
No MVR No
MV repair Medical therapy

likely?
Yes*
Class IIa MV repair
No
Clinical evaluation
every 6 months
Echo every
6 months
Recommendation

1
1.7.5. Acute Coronary Syndrome
Etiology/Causes

Signs and Symptoms
Investigations
Management

Recommendations
Etiology/Causes

Signs and symptoms
Investigations
Complications
Management

Recommendation
1.7.6. Pericardial Effusion and Cardiac Temponade
Etiology/Causes

Signs and symptoms
Investigations

Management

1.7.7. Hypertension
Causes
Signs and Symptoms
Complications
Investigations

Management

2. Central and peripheral nervous
system
2.1. Epilepsy and Seizure disorders

2
system
peripheral nervous
Central and
Causes

Chapiter 2: Central and peripheral nervous system
Signs and Symptoms
Investigations
Management

system
peripheral nervous
Central and


Recommendation
system
peripheral nervous
Central and
2.2. Stroke and Transient Ischemic Attack
Causes/Risk Factors

Signs and Symptoms
Complications

Investigations
system
peripheral nervous
Central and
Management


2.3. Sciatica
Causes
system
peripheral nervous
Central and
Signs and Symptoms
Complication
Investigations

Management
Recommendations

2.4. Facial Nerve Palsy
Signs and Symptoms 2
system
peripheral nervous
Central and
Investigations
Management

Recommendation
2.5. Parkinsons disease
Causes/Risk factors
Signs and Symptoms
Complication
Investigation
Management

system
peripheral nervous
Central and
Recommendation

3. Endocrine system
3.1. Diabetes Mellitus (Type I and Type II)
System
Endocrine

Chapiter 3: Endocrine System
Investigations
Management

System
Endocrine


System
Endocrine


System
Endocrine


3.1.1. Diabetes complications
General recommendations
Goals
System
Endocrine
Management

General principles
Management

System
Endocrine

3.2. Pituitary Disorders
3.2.1. Prolactinoma
Investigations
Management
Recommendations

3.2.2. Hypopituitarism
Causes
3
Signs and Symptoms
System
Endocrine

Invetigations
Management
Recommendation

3.3. Thyroid diseases
3.3.1. Hyperthyroidism/ Thyrotoxicosis
Causes
System
Endocrine
Signs and Symptoms
Investigations
Management

Complications
Recommendation
3.3.2. Hypothyroidism
Causes
Signs and Symptoms
Complication

Investigations
Management
System
Endocrine
3.3.3. Thyroiditis
Signs and Symptoms
Complications

Investigations
Management

4. Hepato-Gastrointestinal conditions
4.1. Gastro-Oesophageal Reflux Diseases (GORD)
Causes and risk factors
Conditions
Gastrointestinal
Signs and symptoms Hepato-
Complications

Chapiter 4: Hepato-Gastrointestinal Conditions
Investigations if complications
Management

Conditions
Gastrointestinal
Hepato-
Recommendation

4.2. Dyspepsia and Peptic Ulcer Diseases (PUD)
Causes
Risk factors
Signs and Symptoms
Complication

Investigations
Management
Conditions
Gastrointestinal
Hepato-


Recommendations
Conditions
Gastrointestinal
Hepato-
4.3. Viral hepatitis
Transmission

Clinical manifestations
Complications
Investigations

Conditions
Gastrointestinal
Hepato-

Management

Recommendation
4.4. Liver cirrhosis
4
Causes
Conditions
Gastrointestinal
Hepato-
Signs and Symptoms

Investigations
Complications
Management

Conditions
Gastrointestinal
Hepato-


Conditions
Gastrointestinal
Hepato-

4.5. Liver abscess
Causes
Risk Factors
Signs and Symptoms
Complications
Investigations

Management
Conditions
Gastrointestinal
Hepato-

4.6. Acute Cholecystitis
Aetiology
Clinical features
Investigations
Complications

Management
Conditions
Gastrointestinal
Hepato-

4.7. Diarrhoeal Diseases
Causes
Signs and Symptoms

Complications
Investigations
Conditions
Gastrointestinal
Hepato-
Management


5. Selected Infections and Related
Conditions
5.1. Sexually transmitted and Opportunistic

infections
Causes
5.1.1. Gonococcal urethritis 5

Conditions
and Related
Selected Infections
Cause
Signs and Symptoms

Chapiter 5: Selected Infections and Related Conditions
Complications
Investigations
Management

Recommendations
5.1.2. Non gonococcal urethritis

Conditions
and Related
Selected Infections
Complication
Investigations

Management
Recommendations
5.1.3. Chlamydia Infections
Cause
Signs and Symptoms
Complications

Investigations
Management
Recommendations
5.1.4. Syphilis
Cause

Conditions
and Related
Selected Infections

Complications
Investigations
Management

Recommendations
5.2. Genital ulcerations
5.2.1. Chancroid
5
Conditions
and Related
Selected Infections
Cause
Risk factors

Signs and Symptoms
Complications
Investigations
Management
Recommendations

5.2.2. Granuloma Inguinale/Donovanosis
Cause
Signs and Symptoms
Complications
Investigation
Management
5
Conditions
and Related
Selected Infections

5.2.3. LymphoGranuloma Venereum (LGV)
Cause
Signs and Symptoms
Complications
Investigations
Management

Recommendation
5.3. Malaria
Signs and Symptoms
5
Conditions
and Related
Selected Infections

Complications
Investigations
Management

5
Conditions
and Related
Selected Infections


5.4. Tuberculosis
Etiology
5
Conditions
and Related
Selected Infections
Signs and Symptoms

Investigations
Management

5
Conditions
and Related
Selected Infections

Management of patients co-infected

Causes
Investigations
Management
5
Conditions
and Related
Selected Infections


5.5. Leprosy
Cause
Signs and Symptoms
Investigations
Management
5
Conditions
and Related
Selected Infections

5.6. Meningitis
Causes
Signs and Symptoms
Complications

Investigations
5
Conditions
and Related
Selected Infections


Management
5
Conditions
and Related
Selected Infections

Recommendation
5.7. Typhoid Fever (Enteric Fever)
Cause
Signs and Symptoms
Symptoms

Signs
Complications
Investigations
5
Conditions
and Related
Selected Infections

Management
Recommendations

5.8. Tetanus
Predisposing factors
Signs and Symptoms
5
Conditions
and Related
Selected Infections
Management


5.9. Fever of unknown origin
Causes
5
Conditions
and Related
Selected Infections

Signs and Symptoms
Investigations
Management

Recommendation
5
Conditions
and Related
Selected Infections

6. Musculoskeletal and connective
tissues conditions
6.1. Osteoarthritis
Causes
Risk factors
6
Conditions
Connective Tissues
Musculoskeletal and

Chapiter 6: Musculoskeletal and Connective Tissues Conditions
Signs and Symptoms
Investigations

Management
6
Conditions
Connective Tissues
Musculoskeletal and

Recommendation
6.2. Septic arthritis
Causes/Risk factors
Signs and Symptoms
Complications

Investigations
Management
6
Conditions
Connective Tissues
Musculoskeletal and

6.3. Gout
Causes/Risk factors
Signs and Symptoms

Complications
Investigations
6
Conditions
Connective Tissues
Musculoskeletal and

Management

Recommendations
6
Conditions
Connective Tissues
Musculoskeletal and

6.4. Rheumatoid a

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Republic of Rwanda

Internal Medicine Clinical treatment guidelines 1

Internal Medicine Clinical treatment guidelines iii

Internal Medicine Clinical treatment guidelines vii

Internal Medicine Clinical treatment guidelines xi

1.1. Cardio Respiratory Emergencies

1.1.1. Cardio Pulmonary Arrest

Signs and Symptoms

Internal Medicine Clinical treatment guidelines 1

2 Internal Medicine Clinical treatment guidelines

Signs and Symptoms

Internal Medicine Clinical treatment guidelines 3

4 Internal Medicine Clinical treatment guidelines

signs and Symptoms

Internal Medicine Clinical treatment guidelines 5

6 Internal Medicine Clinical treatment guidelines

Internal Medicine Clinical treatment guidelines 7

Signs and Symptoms

1.1.5. Acute Asthma attack

8 Internal Medicine Clinical treatment guidelines

Internal Medicine Clinical treatment guidelines 9

1.2.1. Hypovolemic shock

10 Internal Medicine Clinical treatment guidelines

Internal Medicine Clinical treatment guidelines 11

1.2.2. Cardiogenic shock

Signs and Symptoms

12 Internal Medicine Clinical treatment guidelines

1.2.3. Septic shock

Signs and Symptoms

Internal Medicine Clinical treatment guidelines 13

14 Internal Medicine Clinical treatment guidelines

1.2.4. Anaphylactic shock

Internal Medicine Clinical treatment guidelines 15

Signs and Symptoms

16 Internal Medicine Clinical treatment guidelines

1.3.1. Coma and Depressed Conscious State

Signs and Symptoms

Internal Medicine Clinical treatment guidelines 17

18 Internal Medicine Clinical treatment guidelines

Internal Medicine Clinical treatment guidelines 19

1.3.2. Status Epilepsy

Signs and Symptoms

20 Internal Medicine Clinical treatment guidelines

Internal Medicine Clinical treatment guidelines 21

1.3.3. Spinal Cord Compression

Signs and Symptoms

22 Internal Medicine Clinical treatment guidelines

Internal Medicine Clinical treatment guidelines 23

1.4.1. Stings and Bites

Signs and Symptoms

24 Internal Medicine Clinical treatment guidelines

Signs and Symptoms

Complications of snake bites

Management of snake bites

Internal Medicine Clinical treatment guidelines 25

Signs and Symptoms

26 Internal Medicine Clinical treatment guidelines

Internal Medicine Clinical treatment guidelines 27

28 Internal Medicine Clinical treatment guidelines

Internal Medicine Clinical treatment guidelines 29

30 Internal Medicine Clinical treatment guidelines

Internal Medicine Clinical treatment guidelines 31

1.5. Metabolic and endocrine emergencies

1.5.1. Diabetic Keto-acidosis (DKA)