1. Initial triage and resuscitation
   ABCDE approach, vital signs, danger signs, shock, sepsis, referral and transport.
2. Common adult OPD conditions
   Fever syndromes, respiratory illness, diarrhoea, hypertension, diabetes, asthma/COPD, headache, urinary symptoms, skin disease, musculoskeletal pain, mental health, and common infections.
3. Maternal, newborn, and child care
   Antenatal/postnatal danger signs, neonatal sepsis/asphyxia, IMCI-style child assessment, dehydration, pneumonia, malnutrition, immunization-related issues.
4. Communicable and public-health problems in Nepal
   Dengue, enteric fever, tuberculosis, malaria in risk areas, kala-azar where endemic, rabies exposure, snakebite, leptospirosis, and outbreak notification.
5. Minor surgery and wound care
   Abscess, lacerations, burns, foreign bodies, tetanus prophylaxis, fracture immobilization, and safe antibiotic stewardship.
6. Medical emergencies
   Acute coronary syndrome, stroke, acute severe asthma, anaphylaxis, hypoglycaemia/DKA, hypertensive emergency, seizures, poisoning, heat illness, and altered consciousness.
7. Surgical emergencies
   Acute abdomen including appendicitis, bowel obstruction and perforation; ectopic pregnancy; testicular torsion; strangulated/obstructed hernia; trauma; acute limb ischemia; necrotizing soft-tissue infection; and severe burns. The PHC priority is recognition, resuscitation, analgesia, selected first doses of treatment, NPO status when appropriate, and urgent referral rather than definitive surgery.
8. Practical PHC systems
   Essential-drug lists, documentation, infection prevention, point-of-care tests, referral notes, follow-up, and safety-net instructions.

1. Initial triage and resuscitation
   ABCDE approach, vital signs, danger signs, shock, sepsis, referral and transport.
2. Common adult OPD conditions
   Fever syndromes, respiratory illness, diarrhoea, hypertension, diabetes, asthma/COPD, headache, urinary symptoms, skin disease, musculoskeletal pain, mental health, and common infections.
3. Maternal, newborn, and child care
   Antenatal/postnatal danger signs, neonatal sepsis/asphyxia, IMCI-style child assessment, dehydration, pneumonia, malnutrition, immunization-related issues.
4. Communicable and public-health problems in Nepal
   Dengue, enteric fever, tuberculosis, malaria in risk areas, kala-azar where endemic, rabies exposure, snakebite, leptospirosis, and outbreak notification.
5. Minor surgery and wound care
   Abscess, lacerations, burns, foreign bodies, tetanus prophylaxis, fracture immobilization, and safe antibiotic stewardship.
6. Medical emergencies
   Acute coronary syndrome, stroke, acute severe asthma, anaphylaxis, hypoglycaemia/DKA, hypertensive emergency, seizures, poisoning, heat illness, and altered consciousness.
7. Surgical emergencies
   Acute abdomen including appendicitis, bowel obstruction and perforation; ectopic pregnancy; testicular torsion; strangulated/obstructed hernia; trauma; acute limb ischemia; necrotizing soft-tissue infection; and severe burns. The PHC priority is recognition, resuscitation, analgesia, selected first doses of treatment, NPO status when appropriate, and urgent referral rather than definitive surgery.
8. Practical PHC systems
   Essential-drug lists, documentation, infection prevention, point-of-care tests, referral notes, follow-up, and safety-net instructions.

1. Triage, ABCDE resuscitation, shock, sepsis, and referral
2. Common adult OPD problems
3. Maternal, newborn, and child care
4. Common infections and public-health conditions in Nepal
5. Medical emergencies
6. Surgical emergencies, trauma, wounds, burns, and minor procedures
7. PHC systems: medicines, tests, infection prevention, documentation, and safety-netting

PHC Triage and ABCDE Emergency Module

For Nepal primary health care OPD, basic health service centres, health posts, and primary hospitals

1. Core rules for every emergency patient

1. Triage immediately on arrival. Do not wait for registration, payment, OPD queue, full history, laboratory tests, or a diagnosis.
2. Call for help early. Assign a team leader if possible.
3. Treat while assessing. If airway obstruction, severe respiratory distress, active major bleeding, shock, seizure, or hypoglycaemia is present, intervene immediately.
4. Start referral early. Stabilization and referral occur in parallel. Do not delay transfer for a test that will not change immediate management.
5. Reassess ABCDE repeatedly, after each intervention, after any clinical change, and before transfer.
6. Use a structured handover. Provide a written referral note and verbal SBAR or ATMIST handover.
7. Document time zero. Record arrival time, onset or injury time, vital signs, findings, treatments, response, and time of referral/ambulance call.

2. Set up an emergency-ready PHC area

Essential roles during a resuscitation

Minimum emergency equipment checklist

Airway and breathing

• Oxygen source with tubing, masks, nasal cannula
• Pulse oximeter
• Suction machine or manual suction with catheters
• Bag-valve-mask devices: adult, child, infant
• Oropharyngeal airways, various sizes
• Nasopharyngeal airways, if available
• Nebulizer or spacer
• Basic intubation equipment only where trained staff can use it safely
• PPE: gloves, eye protection, masks

Circulation and monitoring

• BP cuffs for adult, child, and infant
• Thermometer, glucometer, ECG if available
• IV cannulas, giving sets, three-way taps
• Intraosseous access kit if trained personnel are available
• Crystalloid fluids: Ringer’s lactate/Hartmann’s and/or 0.9% saline
• Tourniquets, pressure dressings, pelvic binder or improvised sheet
• AED/defibrillator where available

Emergency medicines

• Adrenaline/epinephrine
• Salbutamol
• Dextrose
• Glucagon if available
• Benzodiazepine for active seizures
• Magnesium sulfate for eclampsia
• Tranexamic acid for major trauma/postpartum haemorrhage where indicated
• Broad-spectrum antibiotics according to local protocol
• Naloxone where opioid overdose is possible
• Aspirin for suspected acute coronary syndrome when appropriate
• Paracetamol and suitable analgesics
• Tetanus vaccine and tetanus immunoglobulin where locally available

Safety supplies

• Warming blankets/sheets
• Clean delivery and neonatal-resuscitation equipment
• Sterile dressings, splints, cervical collars where available
• Documentation forms, referral forms, emergency drug chart

3. Triage at the entrance

The first 30 to 60 seconds

• Can the patient speak?
• Is there visible respiratory distress?
• Is there severe external bleeding?
• Is the patient awake and behaving normally?
• Is there a seizure?
• Is the patient pale, cold, clammy, confused, or collapsed?
• Is there major trauma, burn, poisoning, pregnancy-related bleeding, or altered consciousness?
• Obtain rapid vital signs: pulse, respiratory rate, oxygen saturation, blood pressure if possible, temperature, and capillary glucose when altered consciousness or severe illness is present.

Practical triage categories

RED: Resuscitation now

• Choking, stridor at rest, gurgling, inability to speak
• Facial/neck burns, swelling of tongue/lips, suspected inhalation injury
• Reduced consciousness unable to maintain airway
• Persistent vomiting with reduced consciousness

• Severe respiratory distress, exhaustion, cyanosis
• Very low oxygen saturation despite oxygen or no measurable saturation with severe illness
• Apnoea, gasping, markedly slow breathing
• Suspected tension pneumothorax
• Severe asthma not responding to initial bronchodilator

• Uncontrolled bleeding
• Shock: confusion, weak pulse, cold/clammy skin, prolonged capillary refill, reduced urine output, hypotension, or collapse
• Suspected major internal bleeding: ectopic pregnancy, ruptured abdomen, pelvic injury, gastrointestinal bleeding
• Chest pain with sweating, breathlessness, syncope, or unstable vital signs

• Unresponsive patient
• Ongoing or repeated convulsions
• Acute focal weakness, facial asymmetry, aphasia, sudden severe headache suggesting stroke
• Suspected hypoglycaemia with altered mental state
• Severe poisoning or overdose

• Major trauma
• Severe burn
• Obstetric haemorrhage, eclampsia, cord prolapse
• Neonate needing resuscitation
• Severe dehydration or severe acute malnutrition with danger signs
• Suspected sepsis with shock or altered mental status

YELLOW: Urgent assessment

• Moderate breathing difficulty but stable oxygenation
• High fever with concerning appearance
• Significant pain
• Moderate dehydration
• Suspected fracture with intact distal circulation
• Persistent vomiting
• New jaundice
• Severe headache without focal neurological deficit
• Pregnancy with pain, fever, hypertension, reduced fetal movement, or non-heavy bleeding
• Infant feeding poorly but awake and perfusing adequately

GREEN: Routine, but safety-net

BLACK/expectant category in mass-casualty situations

4. Initial approach before ABCDE

1. Ensure scene safety: traffic, violence, electricity, chemicals, fire, infection risk.
2. Use PPE, especially gloves and eye protection if bleeding/vomiting is likely.
3. Identify trauma. If trauma is possible, assume cervical-spine risk until assessed.
4. Call for ambulance/referral support early.
5. Place the patient on a firm surface or trolley.
6. Attach pulse oximeter and monitor, if available.
7. Keep the patient warm and preserve dignity.
8. For unstable patients, obtain only a focused history from relatives while resuscitation proceeds.

5. ABCDE primary survey

A: Airway with cervical-spine protection

Assess

• Can the patient speak in full sentences?
• Snoring, gurgling, stridor, hoarseness, wheeze
• Vomit, blood, secretions, foreign body
• Facial trauma, burns, swelling, expanding neck swelling
• Reduced consciousness, inability to cough or swallow
• In trauma: neck pain, neurological deficit, high-energy mechanism

Immediate actions

• Position upright if conscious and breathless.
• If unconscious but breathing normally, place in recovery position.
• Open airway using head-tilt/chin-lift.
• Suction visible secretions, blood, or vomit.
• Remove a visible foreign body only. Do not perform blind finger sweeps.
• Insert an oropharyngeal airway only in an unconscious patient without a gag reflex.
• Consider a nasopharyngeal airway only when no major facial or basal skull trauma is suspected.

• Maintain manual in-line cervical-spine stabilization.
• Use jaw thrust rather than head tilt where possible.
• Apply a cervical collar only if it does not delay airway management and is correctly sized.
• Suction aggressively when blood/vomit threatens the airway.

• Encourage coughing if effective.
• If ineffective cough or unable to speak: give back blows and abdominal thrusts according to age and pregnancy status.
• For pregnant patients or markedly obese adults, use chest thrusts rather than abdominal thrusts.
• If unconscious: start CPR, inspect mouth before breaths, remove only visible object.

Escalate/referral immediately if

• Stridor at rest
• Severe facial trauma or airway burn
• Rapidly expanding neck swelling
• Inability to protect airway
• Need for advanced airway/intubation beyond local capacity

B: Breathing

Assess

• Respiratory rate, pattern, work of breathing
• Ability to speak/feed
• Chest movement and symmetry
• Accessory muscle use, nasal flaring, grunting, head bobbing in infants
• Oxygen saturation
• Auscultation if this does not delay treatment
• Cyanosis, wheeze, crackles, absent breath sounds
• Signs of chest injury, open chest wound, flail chest

Immediate actions

• Give oxygen to patients with hypoxaemia, severe respiratory distress, shock, trauma, altered consciousness, seizures, or suspected carbon monoxide poisoning.
• Sit the conscious patient upright unless shock, spinal injury, or another contraindication exists.
• Suction secretions.
• Assist ventilation with a well-fitting bag-valve-mask if apnoeic, gasping, exhausted, or unable to maintain adequate ventilation.
• Use a spacer with salbutamol when possible for acute wheeze/asthma. Nebulization is appropriate where available and safe.
• Seal an open sucking chest wound with an occlusive dressing, ideally vented if available.
• In suspected tension pneumothorax with severe distress and shock, emergency needle decompression is required only by a trained provider, followed by urgent transfer.

Oxygen targets

• For most critically ill adults and children: aim for SpO2 94% to 98%.
• In known or strongly suspected chronic hypercapnic COPD: a target of 88% to 92% is reasonable, but do not withhold oxygen from a critically ill patient.
• If no oximeter is available, give oxygen for clinical hypoxaemia or severe respiratory distress and reassess frequently.

Immediate referral triggers

• Persistent SpO2 below target despite oxygen
• Severe asthma, silent chest, exhaustion, altered consciousness
• Suspected pneumonia with severe respiratory distress or sepsis
• Suspected pulmonary oedema, pulmonary embolism, tension pneumothorax, severe chest trauma
• Any patient requiring continuing bag-mask ventilation

C: Circulation and catastrophic haemorrhage

Assess

• Pulse rate, quality, and regularity
• Blood pressure, but remember shock may exist before hypotension
• Skin: cold, clammy, pale, mottled, cyanosed
• Capillary refill, especially in children
• Mental state
• Urine output if catheterized and within local capability
• External bleeding
• Abdominal tenderness/distension, pelvic instability, vaginal bleeding, melena/haematemesis
• Peripheral pulses and limb perfusion

Control bleeding first

1. Apply firm direct pressure with dressing.
2. Pack deep wounds if trained and suitable materials are available.
3. Apply a tourniquet for life-threatening limb bleeding that does not stop with direct pressure.
4. Record tourniquet time clearly.
5. Apply pelvic binder or tightly wrapped sheet at the level of the greater trochanters for suspected unstable pelvic fracture.
6. Keep patient warm.
7. Do not delay referral for wound suturing, X-ray, or routine laboratory tests.

Obtain access

• Insert two large-bore IV cannulas when possible in shock or major trauma.
• Draw blood for group/crossmatch or essential tests only if this does not delay transfer.
• If IV access fails in a critically ill child or adult and trained staff/equipment are available, use intraosseous access.

Fluid principles

Adult hypovolaemia/sepsis, without signs of fluid overload

• Give an isotonic crystalloid bolus, commonly 500 mL, then reassess.
• Larger boluses, including 1 L, may be appropriate in clear severe volume loss where local protocol supports this.
• Use Ringer’s lactate/Hartmann’s or 0.9% saline as locally available.
• Reassess pulse, mental status, blood pressure, capillary refill, lungs, oxygen saturation, and urine output after each bolus.

Major trauma with haemorrhage

• Control bleeding and transfer for definitive haemorrhage control.
• Avoid repeated large volumes of crystalloid where blood loss is ongoing and blood products are needed.
• In penetrating torso trauma without traumatic brain injury, avoid raising blood pressure aggressively before haemorrhage control.
• Patients with suspected traumatic brain injury require avoidance of hypoxia and hypotension.

Child with shock

• Use weight-based treatment and frequent reassessment.
• A cautious initial isotonic crystalloid bolus of 10 to 20 mL/kg may be used for clear shock, according to local paediatric protocol and facility capacity.
• Stop or slow fluids if crackles, hepatomegaly, rising respiratory distress, or poor oxygenation develops.
• Use extra caution in severe acute malnutrition, severe anaemia, cardiac disease, renal disease, and suspected dengue.
• In a child with fever but no signs of shock, do not give routine rapid fluid boluses.

Pregnancy/postpartum

• Think of haemorrhage first in a collapsed pregnant or recently delivered patient.
• Establish IV access, control visible bleeding, give uterotonics and tranexamic acid as indicated under obstetric protocol, and refer urgently.
• Do not delay referral while waiting for ultrasound.

Suspected sepsis

• Take cultures only if rapidly available and if they do not delay treatment.
• Give oxygen, establish access, assess glucose.
• Give cautious isotonic fluid resuscitation with frequent reassessment.
• Give the first dose of appropriate broad-spectrum antibiotic according to the Nepal/facility antibiogram and protocol.
• Identify likely source: lungs, urinary tract, abdomen, skin/soft tissue, uterus, meninges.
• Arrange urgent referral if shock, altered consciousness, hypoxaemia, need for vasopressors, or source control is required.

Immediate referral triggers

• Persistent shock after initial stabilization
• Any internal haemorrhage suspected
• Major trauma, pelvic fracture, ectopic pregnancy, gastrointestinal bleeding
• Acute coronary syndrome with instability
• Sepsis with organ dysfunction
• Anaphylaxis, severe dehydration, or shock needing repeated boluses/vasopressors

D: Disability, neurological status, glucose

Assess

• AVPU: Alert, responds to Voice, responds to Pain, Unresponsive
• Glasgow Coma Scale if trained and practical
• Pupils: size, symmetry, response
• Limb movement, focal weakness, facial asymmetry, speech
• Seizure activity
• Capillary blood glucose
• Temperature
• Consider poisoning, alcohol/drugs, hypoxia, hypercapnia, stroke, meningitis/encephalitis, head injury, eclampsia, metabolic illness

Immediate actions

Reduced consciousness

• Recheck airway and breathing.
• Place in recovery position if breathing independently and no spinal concern.
• Give oxygen if hypoxaemic or clinically unwell.
• Check blood glucose immediately.
• Avoid oral fluids or medicines.
• Protect from injury and maintain warmth.

Hypoglycaemia

• Adult: 25 g IV glucose, then recheck glucose after 10 to 15 minutes. Follow with oral carbohydrate once awake and safe to swallow, or a glucose infusion/meal when indicated.
• Child: use a local paediatric protocol. A commonly used option is 10% dextrose 2 mL/kg IV, then recheck glucose.
• If IV access is unavailable and the patient cannot swallow, give glucagon if available and arrange urgent transfer.
• Search for the cause: insulin/sulfonylurea, missed meals, sepsis, alcohol, liver disease, malaria, adrenal disease.

Active seizure

• Protect the patient from injury. Do not restrain limbs or put objects in the mouth.
• Position laterally where feasible.
• Check glucose and treat hypoglycaemia.
• Give oxygen and suction secretions.
• If seizure lasts 5 minutes or more, recurs without recovery, or is associated with pregnancy, treat as status epilepticus and arrange urgent referral.
• Use a benzodiazepine according to the age/weight-based local protocol and route available. Do not repeatedly dose without airway and breathing support.
• In pregnancy or up to the postpartum period, consider eclampsia and give magnesium sulfate according to the national obstetric emergency protocol.

Suspected stroke

• Record exact last-known-well time.
• Check glucose immediately.
• Assess airway and swallow safety.
• Do not give oral food, fluid, or antihypertensive drugs solely to normalize a high BP.
• Refer urgently to a stroke-capable centre. Time-sensitive imaging is needed to distinguish ischaemic from haemorrhagic stroke.

Immediate referral triggers

• GCS less than 13 or worsening mental status
• Recurrent or prolonged seizure
• Acute focal neurological deficit
• Suspected meningitis/encephalitis
• Head injury with deteriorating consciousness, repeated vomiting, seizure, or focal signs
• Poisoning/overdose with reduced consciousness or respiratory depression

E: Exposure and environment

Assess

• Fully expose as necessary to identify injuries, rashes, bleeding, burns, bites, swelling, needle marks, or infection source.
• Examine back and flanks with spinal precautions in trauma.
• Check temperature.
• Look for medical-alert bracelets, medication packets, pesticides, snakebite marks, or toxic exposures.
• In children, inspect for non-blanching rash, dehydration, malnutrition, and trauma.

Immediate actions

• Prevent hypothermia: dry wet clothes, cover patient, warm fluids if available, keep the room warm.
• Respect privacy and dignity.
• Do not delay transfer for complete head-to-toe examination in an unstable patient.
• In burns, stop the burning process, remove constricting items, cover with clean dry dressing or clean cloth, avoid ice and topical home remedies, and calculate burn area when stable.
• In chemical exposure, remove contaminated clothing and irrigate generously while protecting staff.

6. Reassessment, secondary survey, and focused history

Reassess

• Airway patency
• Respiratory rate, work of breathing, SpO2
• Pulse, BP, perfusion, urine output if measured
• AVPU/GCS, pupils, glucose
• Temperature and pain score
• Response to each treatment

Secondary survey

AMPLE history

• A: Allergies
• M: Medicines, including insulin, anticoagulants, antihypertensives, traditional medications
• P: Past illness, pregnancy, operations
• L: Last oral intake
• E: Events leading to illness/injury

• Time of onset
• Fever, cough, vomiting, diarrhoea, chest pain, bleeding
• Travel, animal/insect/snake exposure, toxic ingestion
• Pregnancy and last menstrual period
• Prior treatment and antibiotics

7. Immediate action patterns by presentation

A. Respiratory distress

B. Shock/collapse

C. Altered consciousness

D. Major trauma

E. Fever with danger signs

F. Anaphylaxis

G. Cardiac arrest

1. Confirm unresponsiveness and absent/abnormal breathing.
2. Call for help and AED/defibrillator.
3. Start high-quality CPR immediately.
4. Adult: compression rate 100 to 120/min, depth about 5 to 6 cm, allow full recoil, minimize interruptions.
5. Give 30 compressions to 2 breaths if trained and able to ventilate.
6. Use AED as soon as available and follow prompts.
7. Continue until return of spontaneous circulation, handover to advanced team, exhaustion, or applicable termination criteria.

8. Referral and transport

Before leaving

• Confirm referral facility acceptance where feasible.
• Inform the receiving facility of diagnosis/syndrome, instability, treatments, and estimated arrival time.
• Ensure a capable escort accompanies an unstable patient whenever possible.
• Continue oxygen, monitoring, warming, IV fluids/medicines, bleeding control, and airway positioning during transfer.
• Send relevant results, drug chart, imaging if available, and referral note.
• Give the family clear instructions on destination and urgency.

Minimum referral note

• Patient identity, age, weight if child
• Time of onset/injury and arrival
• Main problem and suspected diagnosis
• Initial and latest vital signs
• GCS/AVPU, SpO2, glucose
• ABCDE findings
• IV access, fluids including volume and time
• Medicines, dose, route, and time
• Allergies, comorbidities, pregnancy status
• Procedures: tourniquet, splint, airway adjunct, oxygen, CPR, seizure treatment
• Reason for referral and requested service
• Referring clinician name/contact

Handover formats

SBAR

• Situation: “A 32-year-old woman with suspected ruptured ectopic pregnancy, in shock.”
• Background: “Six weeks amenorrhoea, acute abdominal pain and collapse.”
• Assessment: “BP 80/50, pulse 126, pale, tender abdomen. Two IVs, oxygen, 1 L crystalloid started.”
• Recommendation: “Urgent surgical/obstetric assessment and blood.”

ATMIST for trauma

• Age
• Time/mechanism of injury
• Major injuries found
• Interventions given
• Signs: vital signs/GCS
• Treatment and response

9. Special considerations

Children

• Not feeding or drinking
• Lethargic, unconscious, or seizure
• Central cyanosis or severe chest indrawing
• Apnoea, grunting, stridor at rest
• Cold extremities, weak pulse, prolonged capillary refill
• Severe dehydration
• Severe acute malnutrition with danger signs

Pregnancy and postpartum

• Heavy vaginal bleeding
• Abdominal pain/collapse in early pregnancy
• Severe headache, visual symptoms, hypertension, seizure
• Fever after delivery/miscarriage
• Breathlessness, chest pain, syncope
• Cord prolapse or obstructed labour

Older adults and people with chronic illness

Suspected infection-control risk

• Place patient in a separate area where possible.
• Use appropriate PPE.
• Limit unnecessary staff exposure.
• Notify local public-health authorities according to Nepal reporting pathways.

10. PHC emergency documentation checklist

• Arrival time and triage category
• Presenting complaint and onset time
• Initial ABCDE findings
• Vital signs at baseline and repeated intervals
• Glucose and SpO2
• Diagnosis or working syndrome
• Treatments: dose, route, time, response
• Referral call time, ambulance departure time, receiving facility
• Name of clinician and escort
• Outcome at transfer

11. Practical “first five minutes” card

Any critically ill patient

1. Call for help and prepare referral.
2. Check scene safety/PPE.
3. Start ABCDE.
4. Open/suction airway.
5. Give oxygen if hypoxaemic or severely ill.
6. Support ventilation if inadequate.
7. Stop major bleeding.
8. Obtain IV/IO access in shock.
9. Check glucose in altered consciousness/seizure.
10. Treat seizure, hypoglycaemia, anaphylaxis, or cardiac arrest immediately.
11. Keep warm.
12. Reassess ABCDE and transfer.

Never delay emergency care for

• OPD registration
• A complete history
• Routine blood tests
• X-ray or ultrasound in an unstable patient
• Payment/administrative processes
• A definitive diagnosis

Key source documents

Common Adult OPD Problems in Nepal

Practical PHC assessment, treatment, follow-up, and referral

1. Standard adult OPD assessment

• Main complaint and duration
• Temperature, pulse, respiratory rate, BP, SpO2, weight/BMI where relevant
• Pregnancy possibility and last menstrual period in women of reproductive age
• Medicines, allergies, chronic diseases, alcohol/tobacco, TB contact, travel/exposure
• Targeted examination
• Point-of-care tests when indicated: capillary glucose, urine dipstick, pregnancy test, malaria/dengue test according to local epidemiology, HIV test with consent, sputum test/referral for TB, ECG where available

Ask these danger-screen questions every time

• Fever with confusion, breathlessness, bleeding, persistent vomiting, severe weakness, low urine output, or severe abdominal pain?
• Chest pain, syncope, new weakness, speech problem, severe headache, or seizure?
• Breathlessness at rest, haemoptysis, SpO2 low, cyanosis, or inability to speak full sentences?
• Pregnancy, postpartum state, vaginal bleeding, pelvic pain, or severe headache/visual symptoms?
• Weight loss, night sweats, prolonged cough, dysphagia, jaundice, blood in stool/urine/vomit?
• Suicidal thoughts, violence, intoxication, or severe withdrawal?

2. Fever in adults

Common causes relevant to Nepal

• Viral illness, including dengue
• Acute respiratory infection, pneumonia, COVID-like illness where circulating
• Enteric fever
• Malaria in risk areas or after travel
• Urinary infection/pyelonephritis
• Acute gastroenteritis/cholera
• Leptospirosis after floodwater/animal urine exposure
• Tuberculosis if prolonged fever, cough, weight loss, night sweats
• Skin/soft-tissue infection, abscess
• Meningitis, sepsis, acute abdomen
• Kala-azar in endemic exposure with prolonged fever and splenomegaly

Assess

• BP, pulse pressure, hydration, capillary refill, urine output
• Rash/petechiae, bleeding, hepatomegaly, abdominal tenderness
• Chest findings, CVA tenderness, meningism, focal neurological signs
• Splenomegaly, lymph nodes, skin infection

PHC management

• Paracetamol for fever/pain: 500-1,000 mg orally every 6-8 hours as needed, maximum 3 g/day routinely in adults. Use a lower maximum or avoid excess use in significant liver disease, malnutrition, or heavy alcohol use.
• Oral fluids and nutrition if able to drink.
• Test selectively. Do not order broad panels without a clinical question.
• Do not give empirical antibiotics for a short uncomplicated viral syndrome.

Refer urgently

• Hypotension, cold extremities, confusion, severe weakness, SpO2 low
• Severe headache, neck stiffness, seizure, focal deficit
• Respiratory distress
• Bleeding, persistent vomiting, severe abdominal pain
• Jaundice with systemic illness
• Oliguria/anuria
• Pregnancy with fever and abdominal/pelvic pain or bleeding
• Immunocompromised patient with fever
• Suspected sepsis, severe dengue, severe malaria, meningitis, or acute surgical abdomen

3. Dengue: practical outpatient approach

Ask specifically for warning signs

• Severe abdominal pain or tenderness
• Persistent vomiting
• Mucosal bleeding
• Lethargy, restlessness, fainting
• Clinical fluid accumulation, breathlessness
• Reduced urine output
• Enlarged tender liver
• Rising haematocrit with rapidly falling platelets, if tests are available

Management without warning signs

• Oral rehydration, frequent small amounts.
• Paracetamol only for pain/fever.
• Avoid aspirin, ibuprofen, diclofenac, mefenamic acid, and intramuscular injections because bleeding risk may increase.
• Give daily review during the critical period if possible. Advise immediate return for warning signs, inability to drink, bleeding, faintness, low urine output, or worsening abdominal pain.
• Do not admit or transfuse platelets based on platelet count alone in an otherwise stable patient.

Refer/admit

• Any warning sign
• Shock, significant bleeding, altered consciousness, organ involvement
• Pregnancy, major comorbidity, inability to maintain oral fluids, unreliable follow-up
• Severe thrombocytopenia with bleeding or clinical deterioration

4. Cough, sore throat, and respiratory symptoms

A. Acute upper respiratory infection or acute bronchitis

Manage

• Fluids, rest, smoking cessation.
• Paracetamol for fever/pain.
• Honey or warm fluids may help cough in adults.
• Avoid unnecessary cough syrups, particularly sedating multi-ingredient products.
• Avoid routine antibiotics. Textbook evidence supports no routine testing or treatment for uncomplicated acute bronchitis in immunocompetent adults.

Review or refer if

• Fever persists more than 3 days or returns after improvement
• Breathlessness, pleuritic pain, haemoptysis
• RR elevated, SpO2 low, confusion, hypotension
• Older/frail person, chronic lung disease, immunosuppression, or suspected TB

B. Suspected community-acquired pneumonia

PHC actions

• Measure RR, SpO2, BP, pulse, temperature, mental status.
• Give oxygen if hypoxaemic.
• If stable enough for outpatient treatment, select antibiotic based on local protocol, allergy, pregnancy, comorbidities, and recent antibiotic use.
• A common low-resource outpatient choice is amoxicillin, if bacterial pneumonia is clinically likely and no penicillin allergy exists. Use the facility’s current dose and duration protocol.
• Review within 48-72 hours if treated as outpatient.

Urgent referral

• SpO2 below target, RR 30/min or more, hypotension, confusion
• Inability to take oral medicine
• Sepsis, multilobar signs, pregnancy with significant illness
• Failure to improve after initial treatment
• Suspected aspiration, pleural effusion, TB, pulmonary oedema, pulmonary embolism, or pneumothorax

C. Tuberculosis screening

• Cough lasting 2 weeks or more, especially with weight loss, fever, night sweats, haemoptysis, or TB contact
• Unexplained fever/weight loss
• HIV, diabetes, silicosis, immunosuppression, or close contact with known TB

5. Asthma and COPD

A. Acute wheeze or asthma flare

Assess severity

• Can the patient speak complete sentences?
• RR, pulse, SpO2, accessory muscle use
• Peak flow if available
• Drowsiness, exhaustion, cyanosis, silent chest
• Trigger: infection, smoke, biomass exposure, missed inhalers, allergy

PHC management for mild to moderate exacerbation

• Salbutamol by metered-dose inhaler with spacer is preferred where feasible: 4-10 puffs, repeated according to severity and response.
• Nebulized salbutamol if spacer cannot be used or severe disease is present.
• Give systemic corticosteroid early for a significant exacerbation, for example prednisolone 40-50 mg orally daily for 5-7 days in most adults, unless contraindicated.
• Oxygen if hypoxaemic.
• Reassess after initial bronchodilator treatment.

Refer urgently

• Unable to speak, agitation, drowsiness, exhaustion, silent chest
• SpO2 remains low or worsening after oxygen/bronchodilator
• Poor response to initial repeated salbutamol
• Previous ICU/intubation, severe comorbidity, pregnancy with significant attack
• Suspected anaphylaxis or pneumonia

Long-term asthma care

• Confirm variable symptoms/wheeze and assess inhaler technique at every visit.
• Avoid SABA-only long-term asthma care when inhaled corticosteroid-containing treatment is available.
• Provide an inhaler plan, trigger reduction, tobacco cessation, and follow-up.

B. COPD

Stable COPD at PHC

• Smoking and biomass-smoke reduction
• Vaccination as locally available
• Check inhaler technique and adherence
• Short-acting bronchodilator for symptom relief
• Refer for spirometry/diagnostic confirmation and frequent exacerbations

COPD exacerbation

6. Diarrhoea, vomiting, and dyspepsia

A. Acute diarrhoea

Assess dehydration

• Thirst, dizziness, weakness
• Dry mouth, reduced urine, tachycardia, postural hypotension
• Confusion, cold extremities, shock
• Blood/mucus in stool, fever, severe abdominal pain
• Exposure to unsafe water, outbreak, recent antibiotic use, travel

Management

• ORS is first-line. Encourage frequent small sips, with extra after each loose stool.
• Continue feeding.
• In the absence of adequate monitoring, oral rehydration can be safer than IV therapy.
• Consider IV isotonic crystalloid only for severe dehydration/shock or failed oral rehydration, with regular reassessment.
• Paracetamol for fever/pain.
• Avoid loperamide when fever, bloody diarrhoea, suspected dysentery, severe colitis, or possible cholera complication is present.

Antibiotics

Refer

• Shock, inability to drink, altered consciousness
• Bloody diarrhoea with systemic toxicity
• Peritonism, distension, severe pain, suspected obstruction
• Persistent vomiting
• Severe dehydration, oliguria, elderly/frail patient
• Suspected cholera outbreak needing notification/organized management

B. Dyspepsia/GERD

Think of common causes

• GERD or functional dyspepsia
• Peptic ulcer disease or H. pylori
• NSAID-associated gastritis/ulcer
• Gallbladder disease, pancreatitis, cardiac ischaemia, malignancy

Ask about alarm symptoms

• Unintentional weight loss
• Dysphagia or odynophagia
• Persistent vomiting
• Haematemesis, melena, iron-deficiency anaemia
• Jaundice, palpable mass, persistent severe pain
• New symptoms in older age or strong family history of upper-GI cancer

PHC management if no alarm features

• Stop NSAIDs if possible; avoid tobacco/alcohol and late heavy meals.
• Trial a proton-pump inhibitor, for example omeprazole 20 mg once daily before food for 4-8 weeks.
• Test-and-treat H. pylori where a reliable test and protocol are available.
• Do not give empirical multi-antibiotic H. pylori therapy without a testing/treatment plan and follow-up.

Refer urgently

• GI bleeding, severe anaemia, persistent vomiting, obstruction symptoms
• Severe epigastric pain with shock or peritonism
• Chest pain or exertional epigastric discomfort suggesting acute coronary syndrome
• Alarm features or failure of appropriate initial treatment

7. Hypertension

Diagnosis approach

• Use a validated device, correct cuff size, seated rest for at least 5 minutes.
• Measure BP twice and average if practical.
• Confirm persistent hypertension on repeat visits unless BP is very high or there is acute target-organ damage.
• Screen for diabetes, kidney disease, tobacco use, obesity, prior stroke/MI, pregnancy, and medication causes.

Lifestyle advice for all

• Stop tobacco and reduce alcohol.
• Reduce salt, processed foods, and pickles.
• Increase fruit/vegetables where affordable.
• Aim for regular physical activity.
• Weight reduction if overweight.
• Improve sleep and medication adherence.

Drug treatment at PHC

• ACE inhibitor or ARB
• Calcium-channel blocker
• Thiazide/thiazide-like diuretic

Follow-up

• Review after about 1 month after starting or changing treatment, sooner if BP is very high or symptoms occur.
• Check adherence, adverse effects, BP, glucose/renal function/electrolytes if relevant and available.
• Continue long-term treatment once controlled.

Same-day referral or emergency management

• BP 180/120 mmHg or higher with symptoms/signs of acute organ injury: chest pain, breathlessness/pulmonary oedema, focal weakness, seizure, confusion, visual loss, acute kidney injury, aortic pain, pregnancy-related symptoms.
• Do not rapidly lower asymptomatic BP at an OPD visit using short-acting sublingual drugs.
• Markedly elevated BP without acute organ injury needs confirmation, medication initiation/intensification, and close follow-up rather than reflex emergency transfer in every case.

8. Type 2 diabetes and high blood glucose

Screen/test if

• Polyuria, polydipsia, weight loss, fatigue, recurrent infections, neuropathic symptoms
• Hypertension, obesity, family history, pregnancy history
• TB, recurrent candidiasis, non-healing wounds
• Adults with cardiovascular disease risk factors

Diagnose carefully

• HbA1c, fasting plasma glucose, 2-hour OGTT, or random plasma glucose with classic symptoms, depending on test availability.

At every diabetes visit

• BP, weight, tobacco status
• Medication adherence and hypoglycaemia history
• Foot inspection: pulses, ulcers, fissures, infection, sensation
• Ask visual symptoms, neuropathy, kidney symptoms
• Review glucose record/HbA1c where possible
• Assess cardiovascular risk

PHC management

• Nutrition counselling based on local foods: reduce refined carbohydrates/sugary drinks, avoid skipping meals, portion control, increase fibre and activity.
• Metformin is usual first-line therapy if no major contraindication and renal function permits.
• Start low, such as 500 mg once daily with food, then titrate as tolerated and as guided by local protocol.
• Do not use metformin in severe kidney impairment, severe acute illness/hypoxia/shock, significant hepatic failure, or conditions with high lactic-acidosis risk.
• Add or refer for other therapy according to glycaemic level, comorbid heart/kidney disease, pregnancy status, access, and local protocol.
• Teach recognition and immediate treatment of hypoglycaemia.

Urgent referral

• Suspected diabetic ketoacidosis/hyperosmolar state: vomiting, abdominal pain, deep breathing, dehydration, confusion, very high glucose, ketones if available
• Severe hypoglycaemia or recurrent unexplained hypoglycaemia
• Foot ulcer, cellulitis, gangrene, absent pulses, suspected osteomyelitis
• Pregnancy with diabetes
• Significant renal impairment, visual deterioration, or uncontrolled diabetes despite available therapy

9. Dysuria and suspected urinary tract infection

Assess carefully

• Dysuria, urgency, frequency, suprapubic pain
• Fever, flank pain, nausea/vomiting
• Vaginal discharge/itching, genital ulcers, STI risk
• Pregnancy
• Male sex, catheter, stones, diabetes, immunosuppression, recurrent infection
• Haematuria

Uncomplicated cystitis

Management

• Fluids and simple analgesia.
• Urine dipstick may support diagnosis, but is not always necessary in a classic low-risk presentation.
• Use a short-course antibiotic based on current local susceptibility and facility guideline.
• Send urine culture or refer if recurrent, treatment failure, pregnancy, complicated infection, male patient, suspected pyelonephritis, or resistant organism risk.

Pyelonephritis/complicated UTI: refer

• Fever, rigors, flank pain/CVA tenderness, vomiting
• Pregnancy
• Male UTI
• Sepsis, obstruction, urinary retention, renal impairment
• Diabetes/immunosuppression with systemic illness
• Persistent haematuria or suspected stones/malignancy

10. Headache, dizziness, and chronic pain

A. Headache

Red flags requiring urgent assessment/referral

• Sudden thunderclap onset
• New focal neurological deficit, altered consciousness, seizure
• Fever/neck stiffness/rash
• Papilloedema or persistent vomiting
• New headache in pregnancy/postpartum, especially with high BP or visual symptoms
• Head injury or anticoagulant use
• Cancer, immunosuppression, HIV, TB
• New onset after age 50
• Progressive worsening pattern or exertional/sexual trigger

Simple tension-type headache

• Sleep, hydration, stress and posture advice.
• Paracetamol or ibuprofen if no contraindication.
• Avoid analgesics on more than 2-3 days/week to prevent medication-overuse headache.

Migraine

• Early paracetamol or NSAID if safe.
• Antiemetic if needed.
• Consider migraine-specific therapy only within local scope/protocol.
• Keep a trigger and headache diary.

B. Musculoskeletal low-back pain

Red flags

• New urinary retention/incontinence, saddle numbness, progressive weakness
• Fever, weight loss, cancer/TB history, IV drug use
• Major trauma, osteoporosis/steroid use
• Night pain, severe unremitting pain
• Abdominal pulsatile mass or acute vascular symptoms

Management if uncomplicated mechanical pain

• Encourage remaining active; avoid prolonged bed rest.
• Heat, graded exercise, posture/workplace adjustment.
• Paracetamol or short course NSAID if renal function, ulcer risk, pregnancy status, and cardiovascular risk allow.
• Avoid routine imaging in nonspecific acute low-back pain without red flags.
• Review if worsening or not improving.

11. Common skin problems

A. Scabies

• Treat patient and close household contacts simultaneously.
• Permethrin 5% cream is commonly used from neck down overnight and repeated after 7 days, according to product directions/local protocol.
• Wash or isolate bedding/clothes used in recent days.
• Itch may persist for weeks after successful treatment.
• Refer if crusted scabies, extensive secondary bacterial infection, immunosuppression, or failure after correct contact treatment.

B. Tinea/fungal infection

• Annular scaly itchy lesions suggest tinea corporis.
• Use topical antifungal for localized disease and keep skin dry.
• Avoid steroid-antifungal combination creams because they can mask/worsen fungal infection.
• Refer for scalp/nail infection, widespread disease, recurrent disease, or diagnostic uncertainty.

C. Cellulitis/abscess

• Assess for fever, rapid progression, severe pain, crepitus, diabetes, immunosuppression.
• Abscess usually needs incision and drainage, not antibiotics alone.
• Urgent referral for facial/periorbital infection, systemic toxicity, suspected necrotizing infection, hand involvement, diabetic foot infection, or rapidly spreading disease.

12. Mental health and substance use

Depression/anxiety

• “Have you felt hopeless?”
• “Have you thought of harming yourself or ending your life?”
• “Do you feel safe at home?”

Urgent same-day referral/protection

• Suicidal plan/intent, recent attempt, psychosis, severe agitation, inability to care for self
• Intoxication with risk to self/others
• Severe alcohol withdrawal, delirium, seizures
• Domestic violence or safeguarding concern

Alcohol and tobacco

• Ask and document use at every chronic disease visit.
• Give brief clear advice: stopping smoking and reducing biomass exposure are among the highest-impact interventions for respiratory and cardiovascular health.
• Assess alcohol withdrawal risk before telling a dependent person to stop abruptly without support.

13. OPD safety-netting and follow-up

1. Working diagnosis and uncertainty
   “This looks most consistent with viral fever today, but dengue, pneumonia, or another infection can evolve.”
2. Exact return precautions
   Return immediately for breathlessness, fainting, confusion, persistent vomiting, severe abdominal pain, bleeding, reduced urine, new weakness, seizure, inability to drink/take medicine, or worsening symptoms.
3. A clear review date
   • 24 hours: borderline dehydration, early dengue, uncertain fever, frail/older patient
   • 48-72 hours: outpatient pneumonia, UTI, skin infection, asthma/COPD flare
   • 1-4 weeks: hypertension, diabetes medication initiation/adjustment, chronic disease review
4. Medication instructions
   Name, dose, route, frequency, duration, major adverse effects, what to do if missed.
5. Documentation
   Record vital signs, diagnosis/differentials, investigations, treatment, follow-up, and referral advice.

14. Common antibiotic stewardship rules for PHC

• No antibiotic for uncomplicated viral URTI, most sore throats, acute bronchitis, or non-bloody self-limited diarrhoea.
• Use the narrowest appropriate antibiotic and shortest guideline-supported course.
• Check allergy, pregnancy, kidney disease, liver disease, drug interactions, and prior antibiotic exposure.
• Culture before antibiotics only when it will change care and does not delay treatment in sepsis.
• Always document indication, dose, duration, and review date.
• Refer or seek advice for treatment failure rather than repeatedly changing empirical antibiotics.

Maternal, Newborn, and Child OPD Care in Nepal

PHC assessment, routine care, first-line treatment, danger signs, and referral

1. Antenatal care
2. Common pregnancy complaints and danger signs
3. Postnatal care and family planning
4. Newborn and young-infant care, age 0-59 days
5. Child OPD care, age 2 months to 5 years
6. Nutrition, growth, immunization, and safeguarding
7. Referral and follow-up

1. Respectful, safe maternal and child OPD care

• Ensure privacy, dignity, consent, and a female attendant/chaperone where desired.
• Ask about pregnancy status and last menstrual period in every woman of reproductive age with relevant symptoms.
• Measure and document vital signs. In pregnancy, include BP and urine protein where available.
• Ask about domestic violence, coercion, food insecurity, mental distress, tobacco/alcohol use, and medication use in a private, non-judgmental manner.
• Check whether mother and baby have an up-to-date Mother and Child Health Card.
• Use the local family planning, ANC, PNC, immunization, IMNCI, nutrition, TB, HIV, and referral registers.

2. Antenatal care

A. At the first ANC contact

• Gestational age by reliable LMP and/or ultrasound if available
• Previous pregnancies and outcomes
• Previous caesarean birth, postpartum haemorrhage, pre-eclampsia/eclampsia, stillbirth, preterm birth, ectopic pregnancy, or neonatal death
• Chronic hypertension, diabetes, kidney disease, heart disease, epilepsy, TB, HIV, anaemia, thyroid disease
• Current medicines, allergies, substance use
• Vaginal bleeding, lower abdominal pain, vomiting, fever, urinary symptoms
• Psychosocial risks, violence, and mental health concerns

Examination

• BP, pulse, temperature, weight, height at first visit if feasible
• Pallor, oedema, thyroid/heart/lung examination if indicated
• Abdominal and pelvic examination only when clinically appropriate and with consent
• Fetal heart rate and fundal height later in pregnancy

Basic tests, depending on availability

• Haemoglobin
• Blood group and Rh status
• Urine dipstick for protein and glucose
• Syphilis testing
• HIV testing with consent and linkage to care
• Hepatitis B testing where programme-supported
• Blood glucose screening according to local protocol
• Ultrasound where available for dating, location, viability, and placenta/fetal assessment

B. Routine preventive care

Iron and folic acid

• Elemental iron 30-60 mg daily
• Folic acid 400 micrograms daily

Tetanus/diphtheria-containing vaccination

Calcium supplementation

Nutrition and lifestyle

• Encourage diverse foods: pulses/beans, eggs, milk or alternatives, green vegetables, fruits, whole grains, and locally available protein.
• Avoid alcohol, tobacco, vaping, and non-prescribed drugs.
• Avoid raw/undercooked animal foods and unsafe water.
• Encourage safe physical activity unless contraindicated.
• Discuss sleep, dental care, handwashing, and use of insecticide-treated nets in malaria-risk settings.
• Do not restrict food unnecessarily in pregnancy.

3. Antenatal danger signs: same-day referral

• Vaginal bleeding at any gestation
• Severe abdominal pain, shoulder-tip pain, fainting, or collapse
• Severe headache, blurred vision, confusion, seizure
• BP 140/90 mmHg or higher after 20 weeks with concerning symptoms or proteinuria
• BP 160/110 mmHg or higher, even if asymptomatic
• Fever with chills, breathlessness, confusion, severe weakness, or abdominal/uterine tenderness
• Reduced or absent fetal movements after fetal movements have been established
• Gush or persistent leaking of fluid per vagina
• Preterm labour symptoms, regular painful contractions before term
• Severe vomiting with dehydration or weight loss
• Severe pallor, dyspnoea, chest pain, or syncope
• Jaundice
• Breathlessness at rest, cyanosis, or suspected heart failure
• Suspected ectopic pregnancy
• Any trauma, poisoning, snakebite, or sexual assault

4. Common pregnancy presentations in OPD

A. Nausea and vomiting

Assess

• Gestational age
• Ability to keep fluids down
• Urine output, dizziness, weight loss
• Abdominal pain, vaginal bleeding, fever, headache
• Signs of dehydration or ketosis if tests available

PHC care for mild symptoms

• Small frequent meals, dry food before getting out of bed
• Avoid triggers such as strong smells and oily food
• Oral rehydration
• Consider pyridoxine with or without doxylamine according to local protocol

Refer

• Unable to keep fluids down
• Weight loss, dehydration, ketonuria, electrolyte disturbance
• Severe abdominal pain, fever, headache, visual symptoms
• Vomiting beginning after the first trimester or another diagnosis suspected

B. Anaemia

Assess

• Pallor, fatigue, breathlessness, dizziness, pica
• Dietary intake, deworming history where relevant, malaria risk, TB, chronic disease
• Haemoglobin if available
• Bleeding: heavy menstruation before pregnancy, GI bleeding, vaginal bleeding

Management

• Continue or start iron-folic acid.
• Nutrition counselling.
• Investigate/refer for severe anaemia, failure to improve, haemoglobinopathy risk, malaria, TB, hookworm, or ongoing bleeding.

Urgent referral

• Severe pallor plus dyspnoea at rest, tachycardia, syncope, heart-failure signs, active bleeding, or late pregnancy with severe anaemia.

C. Hypertensive disorders of pregnancy

At PHC

• Repeat BP correctly after rest using correct cuff size.
• Test urine protein if available.
• Check symptoms, reflexes if magnesium sulfate is being used, fetal movement, and fetal heart rate if feasible.
• Place woman in left lateral position if symptomatic.
• Establish IV access, avoid fluid overload, and arrange urgent referral.

Eclampsia or severe pre-eclampsia

• ABCDE resuscitation.
• Protect airway, oxygen if needed, left lateral position.
• Treat seizures with magnesium sulfate under the national obstetric emergency protocol.
• A common Pritchard loading regimen is 4 g IV slowly plus 10 g IM, 5 g in each buttock, followed by 5 g IM every 4 hours. Use only if trained and local protocol permits.
• Before repeat maintenance doses, ensure respiratory rate is at least 16/min, patellar reflexes are present, and urine output is at least 30 mL/hour.
• Keep calcium gluconate available for magnesium toxicity.
• Refer immediately for definitive obstetric care.

D. Vaginal bleeding and pain in early pregnancy

• Threatened or incomplete miscarriage
• Ectopic pregnancy
• Molar pregnancy
• Cervicitis or non-pregnancy-related bleeding

Do immediately

• Check ABCDE, BP, pulse, perfusion, pain severity.
• Ask LMP, pregnancy test, amount of bleeding, passage of tissue, shoulder pain, fainting.
• Establish IV access if unstable.
• Group and crossmatch if available and transfer is planned.
• Do not perform digital vaginal examination in heavy bleeding without need or capability.
• Refer urgently if positive pregnancy test with pain/bleeding, particularly with syncope, shoulder pain, peritonism, or shock.

E. Suspected urinary infection in pregnancy

• Dysuria/frequency without fever may still require urine testing and treatment because pregnancy increases the risk of ascending infection.
• Fever, flank pain, vomiting, rigors, or CVA tenderness suggests pyelonephritis and needs urgent referral/admission.
• Use pregnancy-safe antibiotics based on current local guideline and culture when feasible. Avoid empiric fluoroquinolones in pregnancy.

F. Vaginal discharge or genital ulcer

• Itching, odour, colour of discharge
• Dysuria, pelvic/lower abdominal pain, fever
• Ulcers, vesicles, warts
• Sexual exposure, partner symptoms, violence
• Pregnancy

5. Postnatal care: mother

At every postnatal visit, ask about

• Heavy bleeding, foul-smelling lochia, fever/chills
• Abdominal or pelvic pain
• Headache, visual symptoms, seizures, breathlessness, chest pain
• Urination/bowel symptoms
• Breastfeeding pain, breast redness, cracked nipples
• Perineal wound or caesarean wound
• Mood, sleep, intrusive thoughts, suicidal thoughts
• Family planning needs and sexual safety
• Newborn feeding, urine/stool output, fever, jaundice, breathing

Normal postnatal findings

• Lochia gradually reduces and changes from red to brown/pink to pale.
• Mild uterine cramps can occur, especially during breastfeeding.
• Breast fullness commonly occurs early but should improve with frequent effective feeding.

Urgent maternal referral after birth

• Soaking pads rapidly, passing large clots, persistent heavy bleeding, syncope
• Fever, uterine tenderness, foul lochia, severe pelvic pain
• Severe headache, visual symptoms, seizure, high BP
• Chest pain, breathlessness, unilateral swollen painful leg
• Wound separation, pus, severe wound pain
• Severe depression, psychosis, suicidal thoughts, thoughts of harming baby
• Inability to breastfeed because of severe illness or pain

6. Postpartum haemorrhage

First actions

1. Call for help, start ABCDE.
2. Uterine massage.
3. Two wide-bore IV lines if possible.
4. Give oxygen if hypoxaemic or shocked.
5. Rapid crystalloid resuscitation while arranging blood and transfer.
6. Check for the “4 Ts”:
   • Tone: uterine atony
   • Trauma: tears/haematoma/rupture
   • Tissue: retained placenta/products
   • Thrombin: coagulopathy
7. Give uterotonic treatment according to national protocol.
8. Give tranexamic acid 1 g IV over 10 minutes within 3 hours of birth for clinically diagnosed postpartum haemorrhage, if available. A second 1 g dose can be given if bleeding continues after 30 minutes or restarts within 24 hours, according to protocol.
9. Urgent transfer for definitive obstetric care and blood products.

7. Postnatal family planning

• Lactational amenorrhoea method: only if baby is under 6 months, breastfeeding is exclusive or near-exclusive, and menstruation has not returned.
• Condoms
• Progestin-only pills, injectables, implants
• Copper IUD or postpartum IUD where trained providers are available
• Permanent methods by informed choice
• Combined hormonal methods are usually delayed postpartum because of venous-thromboembolism risk and breastfeeding considerations.

8. Immediate newborn care at birth

Essential newborn care

• Dry immediately and thoroughly.
• Provide skin-to-skin contact.
• Prevent heat loss: hat/cloth, warm room, delayed bathing.
• Assess breathing.
• Delay cord clamping where appropriate and where newborn condition allows.
• Start breastfeeding within 1 hour.
• Give vitamin K according to national newborn protocol.
• Clean cord care: keep clean and dry, no ash/oil/herbal products.
• Weigh baby, examine for congenital anomalies, counsel family.

If not breathing or gasping at birth

• Call for help.
• Warm, position head, dry and stimulate.
• Clear secretions only if visibly obstructing ventilation.
• Start effective bag-mask ventilation promptly if apnoeic/gasping or heart rate remains low.
• Reassess heart rate and chest movement.
• Refer after stabilization if prolonged resuscitation, persistent distress, seizures, hypoglycaemia, temperature instability, or suspected sepsis.

9. Newborn and young infant care, age 0-59 days

A. Check at every infant visit

• Feeding: breastfeeding frequency, latch, suck, swallowing
• Urine and stool output
• Weight and weight change
• Temperature
• RR and work of breathing
• Jaundice
• Cord, skin, eyes
• Activity and tone
• Maternal wellbeing and ability to care for infant

B. Danger signs requiring same-day emergency referral

• Not feeding well, weak suck, or unable to breastfeed
• Convulsions
• Movement only when stimulated, lethargy, unconsciousness
• Fever 37.5°C or higher, or low temperature below 35.5°C
• Fast breathing: 60/min or more
• Severe chest indrawing, grunting, apnoea, central cyanosis
• Bulging fontanelle
• Umbilical redness extending to surrounding skin, pus, or severe skin infection
• Jaundice in first 24 hours, jaundice reaching palms/soles, or persistent significant jaundice
• Persistent vomiting, abdominal distension
• Diarrhoea with dehydration
• Weight loss/poor weight gain, especially with illness signs

C. Possible serious bacterial infection/sepsis

PHC action

• ABCDE, glucose, temperature control, oxygen if hypoxaemic.
• Keep warm, preferably skin-to-skin if stable.
• Establish IV access if trained and feasible.
• Give first-dose antibiotics according to national young-infant protocol before referral if this does not delay transfer.
• Refer urgently for injectable antibiotic treatment and monitoring.

D. Neonatal jaundice

Urgent referral

• Onset in first 24 hours
• Yellow palms or soles
• Deepening jaundice, poor feeding, lethargy, abnormal cry, arching, seizures
• Prematurity/low birth weight, infection, haemolysis risk
• Jaundice persisting beyond 14 days, pale stool, or dark urine

E. Breastfeeding difficulties

Assess a feed directly

• Position: mother comfortable, baby facing breast, body close, head/neck aligned.
• Attachment: mouth wide open, chin touching breast, more areola visible above than below, slow deep sucks.
• Frequency: usually at least 8-12 feeds/24 hours in early newborn period.
• Output and weight trend.

Help at PHC

• Correct latch and position.
• Encourage responsive, frequent feeding.
• Avoid prelacteal feeds, water, formula, and bottles unless medically indicated.
• Assess mother for engorgement, cracked nipples, mastitis, depression, or domestic constraints.
• Refer if dehydration, hypoglycaemia, weight loss, poor suck, cleft palate, tongue-tie affecting feeding, or maternal illness prevents feeding.

10. Child OPD, age 2 months to 5 years

A. General danger signs

• Not able to drink or breastfeed
• Vomits everything
• Convulsions
• Lethargic or unconscious
• Stridor when calm
• Severe acute malnutrition
• Severe respiratory distress, central cyanosis, shock

B. Cough or difficult breathing

Count respiratory rate when calm

Classify

• No fast breathing, no chest indrawing, no danger signs.
• Home care, fluids/breastfeeding, saline nose drops if useful, return precautions.
• Do not give routine antibiotics.

• Fast breathing, without severe danger signs.
• Oral amoxicillin and home care according to Nepal IMNCI/facility protocol.
• Reassess in 48 hours or earlier if worsening.

• Chest indrawing, general danger sign, stridor in calm child, central cyanosis, severe distress, or hypoxaemia.
• Give oxygen where needed.
• Give first dose injectable antibiotic if trained and indicated under protocol.
• Urgent referral.

C. Wheezing

PHC actions

• Check SpO2, RR, feeding ability, chest indrawing.
• Trial inhaled salbutamol through spacer or nebulizer if wheeze/bronchospasm is likely.
• Reassess response.
• Do not routinely give antibiotics unless pneumonia or bacterial infection is suspected.
• Refer if first wheeze in a young infant, poor response, hypoxaemia, severe distress, suspected foreign body, or recurrent/severe episodes.

D. Diarrhoea and dehydration

Assess

• Duration and number of stools
• Blood in stool
• Vomiting, ability to drink/breastfeed
• Urine output
• Sunken eyes, thirst, skin pinch, mental state
• Weight if available

No dehydration

• Continue breastfeeding and normal feeding.
• Give ORS after each loose stool.
• Give zinc according to age:
  • Under 6 months: 10 mg daily for 10-14 days
  • 6 months or older: 20 mg daily for 10-14 days
• Counsel on return signs.

Some dehydration

• Give ORS in facility under observation, following IMNCI Plan B.
• A common approach is 75 mL/kg over 4 hours, then reassess.
• Continue breastfeeding.
• Refer if unable to drink, worsening, repeated vomiting, severe malnutrition, or inadequate response.

Severe dehydration

• Lethargy/unconsciousness, unable to drink/drinking poorly, very sunken eyes, skin pinch returns very slowly, shock.
• Start urgent resuscitation according to age and protocol.
• If IV therapy is needed, use isotonic crystalloid with careful paediatric reassessment.
• Refer urgently.

Dysentery

E. Fever and malaria/dengue risk

Refer urgently

• Any danger sign
• Neck stiffness, altered consciousness, seizure
• Severe pallor, respiratory distress, shock
• Bleeding, severe abdominal pain, persistent vomiting, oliguria
• Suspected severe malaria, meningitis, severe dengue, sepsis, or acute abdomen

F. Ear pain/discharge

Assess

• Ear pain, fever, discharge duration
• Mastoid tenderness/swelling
• Hearing concern, speech delay
• Foreign body or trauma

Management

• Pain control with paracetamol or ibuprofen if safe.
• Dry ear precautions.
• Treat acute otitis media or chronic suppurative disease according to IMNCI/local protocol.
• Refer for mastoid tenderness/swelling, facial weakness, severe systemic illness, persistent/recurrent discharge, suspected foreign body not easily removable, or hearing impairment.

11. Nutrition and growth

At every child encounter

• Plot weight on the correct growth chart.
• Assess feeding:
  • Exclusive breastfeeding for the first 6 months
  • Complementary feeding from 6 months while continuing breastfeeding to 2 years and beyond
• Ask about meal frequency, dietary diversity, food insecurity, diarrhoea, TB contact, and recurrent infection.
• Look for bilateral pitting oedema, visible severe wasting, pallor, hair/skin changes, mouth ulcers, developmental delay.

Severe acute malnutrition: emergency signs

• Bilateral pitting oedema
• Severe visible wasting
• MUAC below national severe-malnutrition threshold
• Poor appetite, lethargy, hypothermia, hypoglycaemia, dehydration, severe anaemia, or infection

Moderate malnutrition

• Nutrition counselling based on affordable local foods.
• Treat infections and deworm according to age/programme.
• Provide supplementary feeding or referral according to local nutrition programme.
• Schedule close growth follow-up.

12. Immunization and preventive child care

• Check vaccination card.
• Provide missed vaccines according to the national catch-up schedule if eligible and not acutely severely ill.
• Explain expected minor post-vaccination effects and danger signs.
• Counsel on handwashing, safe water, smoke-free home, injury prevention, oral hygiene, and age-appropriate stimulation/play.
• Screen for vision, hearing, developmental delay, disability, and safeguarding concerns.

13. Safeguarding, violence, and child protection

• Repeated injuries or inconsistent explanation
• Delayed presentation
• Burns, bruises in non-mobile child, genital injury
• Severe malnutrition without a clear medical explanation
• Caregiver intoxication, mental illness, or unsafe home
• Adolescent pregnancy, sexual assault, or coercion

14. Maternal and child follow-up schedule

15. Parent/caregiver return-now instructions

• Cannot drink/breastfeed or feeds much less
• Vomits everything
• Has convulsions
• Is unusually sleepy, limp, irritable, or unconscious
• Develops fast or difficult breathing, chest indrawing, blue lips, or grunting
• Has fever or feels cold to touch, especially a young infant
• Has blood in stool
• Has persistent vomiting, severe abdominal pain, or reduced urine
• Has worsening rash, bleeding, or severe pain
• Becomes sicker despite treatment

• Heavy bleeding, fever, foul discharge, severe abdominal pain
• Severe headache, visual symptoms, seizure, chest pain, breathlessness
• Painful red breast with fever or inability to breastfeed
• Severe sadness, confusion, suicidal thoughts, or thoughts of harming the baby

Maternal, Newborn, and Child OPD Care in Nepal

PHC assessment, routine care, danger signs, first actions, and referral

1. Universal maternal and child OPD principles

• Measure and record vital signs.
• Check weight in children and plot growth where available.
• Ask about nutrition, breastfeeding, immunization, developmental concerns, and safeguarding.
• Consider pregnancy in every woman of reproductive age with abdominal pain, vomiting, faintness, bleeding, or missed periods.
• Ask about domestic violence privately where safe and appropriate.
• Provide a written return plan and clear danger signs.
• Arrange follow-up actively for missed ANC/PNC, low birth weight, malnutrition, TB exposure, HIV exposure, and chronic illness.

Immediate red flags

Pregnant/postpartum woman

• Heavy vaginal bleeding, fainting, shock
• Severe headache, blurred vision, seizure, confusion
• BP very high, especially with symptoms
• Severe abdominal pain, shoulder pain, or early-pregnancy collapse
• Fever with uterine tenderness/foul discharge
• Breathlessness, chest pain, cyanosis
• Reduced or absent fetal movements in a previously moving fetus
• Labour with cord prolapse, obstructed labour, or fetal distress

Newborn, age 0-59 days

• Not feeding or feeding poorly
• Fever or feels cold
• Fast breathing, grunting, severe chest indrawing, apnoea
• Convulsions, lethargy, movement only when stimulated
• Central cyanosis
• Umbilical redness spreading to skin, many pustules, severe jaundice
• Persistent vomiting, abdominal distension
• Low weight or poor weight gain with illness

Child, age 2 months to 5 years

• Unable to drink/breastfeed
• Vomits everything
• Convulsions
• Lethargic or unconscious
• Stridor in a calm child
• Severe respiratory distress, central cyanosis, shock
• Severe dehydration
• Severe acute malnutrition with complication

2. Antenatal care at PHC

A. At the first ANC contact

• Pregnancy and estimated gestational age
• Gravida/parity, previous caesarean, postpartum haemorrhage, stillbirth, pre-eclampsia/eclampsia, preterm birth, ectopic pregnancy
• Medical conditions: hypertension, diabetes, epilepsy, heart/kidney disease, TB/HIV, anaemia
• Medicines, allergies, substance use
• Blood group/Rh status if locally available
• Pregnancy spacing and psychosocial safety

Examination and tests

• BP at every ANC contact
• Weight and nutritional assessment
• Urine protein and glucose where available
• Hb testing for anaemia
• HIV, syphilis, hepatitis B testing according to national protocol and consent
• Blood group/Rh typing where available
• Fetal heart rate and fundal height when gestation permits
• Ultrasound and obstetric review according to local referral pathway

Routine counselling

• Nutrition with locally available foods: adequate calories, protein, fruit/vegetables, iron-rich foods.
• Daily iron-folic acid prophylaxis according to Nepal ANC protocol.
• Calcium supplementation where indicated by local/national protocol.
• Avoid tobacco, alcohol, unprescribed medicines, and harmful traditional preparations.
• Birth preparedness: planned delivery facility, transport, blood donor/support person, funds, emergency contacts.
• Encourage skilled birth attendance and institutional delivery.
• Vaccination according to the Nepal immunization schedule.
• Discuss contraception after delivery.

B. ANC danger signs requiring same-day referral

• Vaginal bleeding at any gestation
• Severe abdominal pain, shoulder-tip pain, syncope in early pregnancy: suspect ectopic pregnancy
• Severe or persistent vomiting with dehydration
• BP 140/90 mmHg or more with headache, visual symptoms, upper abdominal pain, reduced urine, facial/hand swelling, or proteinuria
• Convulsion in pregnancy or postpartum: presume eclampsia until proven otherwise
• Fever, dysuria with fever/flank pain, foul vaginal discharge
• Reduced fetal movement after viability
• Preterm labour symptoms, leaking fluid, or regular painful contractions before term
• Breathlessness at rest, chest pain, cyanosis
• Severe anaemia symptoms: syncope, breathlessness, tachycardia, heart failure signs

3. Hypertensive disorders of pregnancy

Suspect pre-eclampsia

• Severe headache
• Visual disturbance
• Epigastric or right-upper-quadrant pain
• Nausea/vomiting
• Hyperreflexia/clonus
• Oliguria
• Pulmonary oedema or breathlessness
• Fetal growth concern/reduced movements

PHC management

1. ABCDE assessment.
2. Repeat BP correctly with an appropriate cuff.
3. Place woman in left lateral position if unwell.
4. Establish IV access if severe disease.
5. Monitor consciousness, RR, SpO2, urine output if feasible, and fetal heart rate.
6. Arrange urgent obstetric referral.

Eclampsia

• Protect airway, left lateral position, oxygen if needed.
• Do not attempt to restrain the patient or place anything in the mouth.
• Give magnesium sulfate according to the Nepal obstetric emergency protocol and staff competency.
• Monitor for magnesium toxicity: respiratory rate under 16/min, absent patellar reflexes, urine output below 30 mL/hour.
• Refer urgently with an escort and continued monitoring.

4. Anaemia in pregnancy

Assess

Management

• Give iron-folic acid prophylaxis or therapeutic treatment according to measured Hb and Nepal protocol.
• Counsel on iron-rich diet and adherence. Take iron away from tea/coffee if possible.
• Investigate/treat likely causes such as nutritional deficiency, malaria where relevant, helminths according to programme guidance, chronic infection, or bleeding.
• Recheck Hb according to protocol.

Refer urgently

• Severe symptomatic anaemia
• Heart failure, syncope, dyspnoea at rest
• Hb severely low or not improving despite treatment
• Bleeding, suspected haemoglobinopathy, or late pregnancy with severe anaemia

5. Common pregnancy complaints

6. Postnatal care of the mother

At every PNC contact

• Ask about bleeding, fever, abdominal pain, headache/visual symptoms, breathlessness, breast pain, urinary problems, constipation, sleep, mood, and safety.
• Check BP, pulse, temperature, pallor, wound/perineum, uterine involution as appropriate.
• Assess breastfeeding and newborn feeding/weight.
• Provide family-planning counselling and method access.
• Screen for depression, severe anxiety, psychosis, intimate-partner violence, and social support needs.

Postpartum danger signs

• Heavy bleeding, passage of large clots, faintness, shock
• Fever/chills, lower abdominal pain, foul-smelling lochia
• Severe headache, visual symptoms, seizure, BP elevation
• Chest pain, breathlessness, unilateral swollen/painful leg
• Severe breast redness/systemic illness or suspected abscess
• Suicidal thoughts, hallucinations, mania, confusion, or inability to care for self/baby

Postpartum haemorrhage

1. Call for help and initiate ABCDE.
2. Uterine massage if atony suspected.
3. Ensure IV access, fluids, keep warm, assess shock.
4. Give uterotonic treatment and tranexamic acid according to Nepal obstetric emergency protocol and scope of practice.
5. Rapidly refer for blood, surgical assessment, and definitive treatment.

7. Essential newborn care

Immediately after birth

• Dry thoroughly and keep warm.
• Skin-to-skin contact with mother if stable.
• Start breastfeeding within the first hour.
• Clean cord care. Keep it dry and clean.
• Give vitamin K and birth immunizations according to Nepal protocol.
• Weigh baby and document gestational age/risk factors.
• Assess breathing, tone, colour, temperature, feeding.

Breastfeeding counselling

• Exclusive breastfeeding for the first 6 months: no water, honey, animal milk, ghutti, or other feeds unless medically indicated.
• Feed on demand, including overnight.
• Ensure good attachment: baby close, mouth wide open, chin touching breast, more areola visible above than below.
• Refer for poor latch, maternal nipple trauma, inadequate milk transfer, poor infant weight gain, or maternal illness affecting feeding.

Newborn danger signs: urgent referral

• Not feeding or poor feeding
• Convulsions
• Fast breathing, grunting, severe chest indrawing, apnoea
• Fever or hypothermia
• Lethargy, reduced movement, weak cry
• Central cyanosis
• Severe jaundice: onset in first 24 hours, yellow palms/soles, lethargy, or poor feeding
• Umbilical redness spreading to abdominal skin, pus, severe skin pustules
• Persistent vomiting, abdominal distension
• Low birth weight/prematurity with illness

Suspected neonatal sepsis

• Maintain warmth, airway, oxygenation, glucose, and feeding support.
• Give first-dose injectable antibiotics only under Nepal sick-young-infant/FB-IMNCI protocol if referral is required or delayed.
• Refer urgently. Neonatal illness can deteriorate rapidly.

8. Care of the young infant, 0-59 days

Minimum assessment

• Feeding: breastfeeds effectively? frequency? vomiting?
• Temperature
• RR for a full minute, chest indrawing, grunting, apnoea
• Movement/activity and cry
• Umbilicus and skin
• Jaundice
• Weight and weight trend
• Urination and stools
• Maternal illness and breastfeeding difficulties

Common problems

A. Poor feeding

B. Jaundice

• Jaundice begins in first 24 hours
• Baby is ill, lethargic, feeding poorly
• Palms/soles are yellow
• Jaundice persists beyond expected period or is worsening

C. Umbilical infection

• Mild local redness without systemic illness may need hygiene advice and close review.
• Spreading redness, pus, fever/hypothermia, poor feeding, or lethargy indicates possible sepsis: urgent referral.

D. Low birth weight/preterm baby

• Emphasize warmth, skin-to-skin kangaroo mother care, frequent breastfeeds, infection prevention, and scheduled weight monitoring.
• Refer if feeding difficulty, temperature instability, respiratory distress, jaundice, or poor weight gain.

9. Child OPD assessment, age 2 months to 5 years

1. Check emergency/general danger signs.
2. Ask about cough/difficult breathing.
3. Ask about diarrhoea.
4. Ask about fever.
5. Ask about ear problems.
6. Assess nutrition, anaemia, immunization, development, feeding, and other concerns.
7. Give treatment, counselling, return precautions, and follow-up date.

General danger signs

• Unable to drink/breastfeed
• Vomits everything
• Convulsions
• Lethargic/unconscious

10. Cough or difficult breathing in children

Assess

• Count RR for one full minute when calm.
• Look for chest indrawing, nasal flaring, grunting, cyanosis, stridor, wheeze.
• Check feeding, hydration, fever, SpO2 if available.
• Ask about TB contact, aspiration/foreign body, smoke exposure, previous wheezing/asthma.

• 2-12 months: 50 breaths/min or more
• 12 months to 5 years: 40 breaths/min or more

Classification and action

Severe pneumonia/very severe disease

• ABCDE, oxygen if hypoxaemic/distressed.
• Give first dose antibiotic according to Nepal protocol.
• Treat wheeze if present.
• Urgent referral.

Pneumonia

• Oral amoxicillin according to the child’s weight and Nepal IMNCI protocol.
• Counsel caregiver on dosing, feeding, fluids, and return immediately for worsening.
• Review in about 48 hours, sooner if uncertain.

Cough/cold, no pneumonia

• Home care, fluids, breastfeeding/feeding, saline for nose if needed.
• No routine antibiotic.
• Return if fast or difficult breathing, poor drinking, fever persists, or child worsens.

11. Diarrhoea and dehydration in children

Assess

• Lethargy/unconsciousness
• Sunken eyes
• Unable to drink/drinks poorly, or drinks eagerly/thirsty
• Skin pinch return
• Weak pulse, cold hands, delayed capillary refill
• Weight loss where previous weight is known

Management

No dehydration

• Give extra fluids/ORS after each loose stool.
• Continue breastfeeding and food.
• Give zinc according to Nepal child-health protocol.
• Teach caregiver return signs.

Some dehydration

• Oral rehydration solution under observation using IMNCI Plan B style treatment, with reassessment.
• Continue breastfeeding.
• Refer if unable to drink, worsening, repeated vomiting, or unreliable follow-up.

Severe dehydration/shock

• ABCDE and urgent referral.
• Start IV isotonic fluid only according to trained-provider paediatric emergency protocol.
• If IV is not possible and the child can drink, begin ORS while transfer is arranged.
• Keep child warm and monitor glucose where possible.

Dysentery or persistent diarrhoea

• Blood in stool needs assessment and antibiotic treatment according to local dysentery protocol.
• Persistent diarrhoea, severe malnutrition, blood in stool, abdominal distension, high fever, or severe dehydration requires referral.

12. Fever in children

Assess urgently for

• General danger signs
• Neck stiffness, bulging fontanelle in infants
• Rash/petechiae, bleeding, severe abdominal pain
• Respiratory distress
• Dysuria/flank tenderness
• Severe malnutrition
• Dengue warning signs
• Travel/exposure to malaria or kala-azar endemic settings

Management

• Test selectively according to symptoms, local epidemiology, season, and programme pathways.
• Give paracetamol for discomfort/fever in weight-appropriate doses.
• Encourage fluids and feeding.
• Do not routinely give antibiotics for uncomplicated viral fever.
• Avoid aspirin in children and avoid NSAIDs when dengue is possible.

Refer

• Suspected meningitis, sepsis, severe dengue, severe malaria, pneumonia, dehydration, or acute abdomen.
• Fever in a young infant, especially with poor feeding, altered activity, or temperature instability.

13. Nutrition, growth, and anaemia

At every child visit

• Measure weight and plot on a growth chart.
• Measure MUAC in children 6-59 months where available.
• Look for bilateral pitting oedema.
• Ask about breastfeeding, complementary feeding, food insecurity, diarrhoea, TB exposure, recurrent infection, and developmental progress.

Severe acute malnutrition: urgent referral

• Bilateral pitting oedema
• MUAC below programme threshold
• Severe wasting with poor appetite
• Any medical complication: fever, hypothermia, lethargy, dehydration, pneumonia, severe anaemia, persistent vomiting

Moderate malnutrition or poor growth

• Feeding assessment and age-appropriate dietary counselling.
• Address breastfeeding/complementary feeding frequency and diversity.
• Deworming, micronutrients, immunization, TB/HIV assessment according to programme policy.
• Scheduled weight follow-up.

14. Ear problems, skin disease, and common outpatient conditions

Ear pain/discharge

• Ask duration, fever, mastoid swelling, hearing loss, foreign body/trauma.
• Examine ear only if equipment and training allow.
• Chronic discharge, mastoid tenderness/swelling, severe pain, facial weakness, or systemic illness requires referral.
• Avoid inserting objects or unprescribed drops into the ear.

Scabies

• Treat child and household contacts together.
• Explain washing/isolation of recently used clothes and bedding where feasible.
• Refer for crusted scabies, widespread bacterial infection, or failure after correct household treatment.

Skin infection

• Assess for cellulitis, abscess, fever, rapid spread, severe pain, malnutrition, diabetes, or immunosuppression.
• Drainage is needed for many abscesses. Antibiotics alone are often insufficient.
• Refer rapidly if severe pain out of proportion, crepitus, facial/periorbital infection, systemic toxicity, or suspected necrotizing infection.

15. Immunization and preventive care

• Check the Mother and Child Health Card.
• Identify missed vaccines and provide or refer for catch-up according to Nepal’s national schedule.
• Counsel on handwashing, safe water, sanitation, injury prevention, smoke-free homes, and mosquito protection.
• Encourage exclusive breastfeeding to 6 months and appropriate complementary feeding from 6 months.
• Promote responsive caregiving, talking/playing with the child, early learning, and school readiness.
• Screen for developmental concerns and refer if delayed milestones, hearing/vision concern, loss of skills, or suspected disability.

16. Child discharge advice: return immediately if

• Is unable to drink/breastfeed or drinks poorly
• Becomes sicker, unusually sleepy, or difficult to wake
• Has a seizure
• Develops fast/difficult breathing, chest indrawing, blue lips, or grunting
• Has fever in a young infant or feels cold
• Has blood in stool
• Has repeated vomiting
• Passes very little urine
• Develops rash with bleeding, severe abdominal pain, or persistent vomiting
• Has worsening swelling, pus, or spreading skin redness

Sources used