OHC Medical Officer - Clinical Protocol Guide

15 Common Presentations: History, Examination & Management

How to Use This Guide

1. Triage - identify what needs referral vs. what you can manage
2. Treat - provide effective first-line care
3. Return to work - assess fitness and advise accordingly
4. Document - maintain accurate occupational health records

General History Framework (SOCRATES + OHC-Specific)

• Site/Onset/Character/Radiation/Associated symptoms/Timing/Exacerbating-relieving/Severity
• Occupational context: Was onset at work? Related to work activity/exposure?
• Past medical history and current medications
• Drug allergies
• Last meal (relevant for medications, procedures)
• Fitness to work assessment after each encounter

1. HEADACHE

History

• Onset: sudden ("thunderclap") vs gradual
• Site: unilateral (migraine, cluster) vs bilateral (tension, raised ICP)
• Character: throbbing, pressure, stabbing
• Associated: nausea/vomiting, photophobia, phonophobia, aura, visual changes, neck stiffness, fever
• Triggers: stress, screen time, dehydration, skipped meals, fumes/chemicals at workplace
• Previous episodes, family history of migraine
• Medication history: analgesic overuse headache?
• Red flags (SNOOP): Systemic illness/fever, Neurological signs, Onset sudden/severe, Older age new headache, Postural/positional change, Prior headache history change

Examination

• Vitals: BP (hypertensive headache), Temperature, SpO2
• General: distress level, pallor
• Neurological: GCS, pupil size/reactivity, focal deficits, cranial nerve exam
• Meningeal signs: neck stiffness, Kernig's, Brudzinski's
• Fundoscopy if available (papilloedema)
• Eyes: redness, visual acuity (glaucoma)
• Sinuses: tenderness (sinusitis)
• Workplace: assess for CO exposure, chemical exposure, ergonomic factors (screen posture)

Management (OHC)

• Tension headache: Paracetamol 500-1000 mg or Ibuprofen 400 mg. Rest, hydration, correct ergonomics. Return to work advice.
• Migraine: Paracetamol/NSAIDs + antiemetic (Domperidone 10 mg or Ondansetron 4 mg). Dim room, rest. Sumatriptan if available and not contraindicated.
• Hypertensive headache: Treat BP, refer if severe.
• REFER IMMEDIATELY if: thunderclap onset, meningism, focal neurology, papilloedema, GCS change, fever + headache (exclude meningitis), BP >180/120.

2. FEVER / VIRAL ILLNESS

History

• Onset, duration, pattern (continuous/intermittent/remittent)
• Height of fever; chills/rigors
• Associated: headache, body aches, sore throat, cough, rash, joint pains, urinary symptoms
• Travel history (malaria, dengue, typhoid belt)
• Sick contacts at workplace/home
• Immunization status
• Recent procedures/surgeries

Examination

• Vitals: Temp (rectal/oral/tympanic), HR, BP, RR, SpO2
• General: toxicity, hydration status, pallor, icterus, lymphadenopathy
• ENT: pharyngeal congestion, tonsillar enlargement/exudate
• Chest: air entry, adventitial sounds (pneumonia)
• Abdomen: hepatosplenomegaly (malaria, typhoid), tenderness
• Skin: rash (viral exanthem, dengue petechiae)
• Joints: swelling/tenderness

Management (OHC)

• Antipyretics: Paracetamol 650 mg TDS/QID (preferred) or Ibuprofen 400 mg TDS if no contraindication
• Oral hydration: encourage fluids
• Dengue suspicion: CBC with platelet count; avoid NSAIDs/aspirin
• Symptomatic treatment for URTI features
• Sick leave: advise isolation if suspected infectious (influenza, COVID protocol per current guidelines)
• REFER if: Temp >103°F not settling, rigor/chills suggesting malaria, severe dehydration, SpO2 <94%, petechiae/bleeding (dengue), confusion, HR >120 with fever

3. UPPER RESPIRATORY TRACT INFECTION (URTI)

History

• Duration, onset
• Nasal: congestion, rhinorrhoea (clear/purulent), sneezing
• Throat: soreness, pain on swallowing, voice change
• Ear: pain, discharge, hearing change
• Cough: dry vs productive, sputum colour
• Fever, body ache
• Exposure history (sick contacts, dusty/chemical workplace)
• Allergic history (differentiating from allergic rhinitis)
• Smoking history

Examination

• Vitals: Temp, SpO2
• ENT: nasal mucosa (red/pale/swollen), nasal discharge, sinus tenderness, throat congestion, tonsillar enlargement, exudate (bacterial vs viral), anterior cervical lymphadenopathy
• Ear: tympanic membrane (otitis media)
• Chest: to rule out lower respiratory involvement

Management (OHC)

• Viral URTI (most cases): supportive only - reassurance, saline nasal rinse, steam inhalation
• Analgesics/antipyretics: Paracetamol 500 mg TDS
• Decongestant: Pseudoephedrine or Xylometazoline nasal drops (short course, max 3-5 days)
• Antihistamine if allergic component: Cetirizine 10 mg OD or Loratadine 10 mg
• Antibiotics ONLY if: bacterial signs - purulent discharge >7 days, high fever, tonsillar exudate, severe sinus tenderness - Amoxicillin 500 mg TDS x 5 days or Azithromycin 500 mg OD x 3 days
• Cough: Honey, steam. Dextromethorphan if dry cough disturbs sleep
• Refer if: stridor, SpO2 drop, peritonsillar abscess, severe odynophagia, suspected epiglottitis

4. GASTRITIS / ACIDITY (Dyspepsia)

History

• Location: epigastric, upper central abdomen
• Character: burning, gnawing, fullness, bloating
• Timing: before meals (PUD), after meals (gastritis, GERD), nocturnal
• Relieved by: food/antacids (PUD), worse with food (gastritis)
• Associated: nausea, vomiting, belching, heartburn, water brash
• Alarm features: dysphagia, unintentional weight loss, haematemesis, melaena, progressive symptoms, age >45 new onset
• Medications: NSAIDs, steroids, aspirin (iatrogenic gastritis)
• Stress/work stress (functional dyspepsia)
• Alcohol, smoking, spicy food, caffeine, meal timing (skipped meals common in industrial workers)
• H. pylori: previous treatment, family history of PUD/gastric cancer

Examination

• Vitals: BP (haemodynamic stability)
• Abdomen: Epigastric tenderness, guarding/rigidity (perforation), liver size, Murphy's sign (cholecystitis), PR if melaena suspected
• General: pallor (bleeding PUD), signs of weight loss

Management (OHC)

• Dietary advice: small frequent meals, avoid NSAIDs/spicy food/caffeine/alcohol, elevate head of bed (GERD)
• Antacid (acute relief): Aluminium hydroxide + Magnesium hydroxide suspension 15 mL TDS or Calcium carbonate chewable
• PPI: Omeprazole 20 mg OD before breakfast (or Pantoprazole 40 mg) x 2 weeks
• H2 blocker: Ranitidine/Famotidine if PPI unavailable
• Prokinetic if bloating/nausea: Domperidone 10 mg TDS before meals
• Refer if: alarm features, haematemesis, suspected perforation (rigid abdomen), no response to treatment, suspected H. pylori (for endoscopy/testing)

5. VOMITING / DIARRHEA (Acute Gastroenteritis)

History

• Onset, duration, frequency
• Vomiting: projectile? blood/bile? timing relative to meals
• Diarrhea: frequency, consistency, blood/mucus, nocturnal (suggests organic cause)
• Associated: fever, crampy abdominal pain, tenesmus
• Last oral intake, fluid intake
• Food history: shared meals, canteen food, last meal timing (food-borne outbreak in occupational setting - very important)
• Others affected (cluster cases - notify if outbreak)
• Travel history
• Medications: antibiotics (C. difficile), NSAIDs
• Dehydration assessment: thirst, urine output, dizziness

Examination

• Vitals: BP (orthostatic hypotension = significant dehydration), HR (tachycardia), Temp
• Hydration: skin turgor, dry mucous membranes, sunken eyes, urine color
• Abdomen: diffuse tenderness (gastroenteritis), rebound/guarding (surgical cause), bowel sounds (hyperactive vs absent), hepatosplenomegaly
• PR exam if blood in stool or older patient

Management (OHC)

• Oral Rehydration: ORS (WHO formula) 200-400 mL after each loose stool. Encourage sips. Avoid plain water alone.
• IV fluids: if unable to tolerate oral, severe dehydration - NS or Ringer's Lactate
• Antiemetic: Ondansetron 4-8 mg (preferred) or Domperidone 10 mg
• Antispasmodic: Hyoscine butylbromide (Buscopan) 10-20 mg if crampy pain
• Antidiarrheal: Loperamide 4 mg loading then 2 mg after each stool (max 16 mg/day) - avoid if fever/bloody diarrhea (dysentery)
• Antibiotics only if: fever + mucus/blood in stool (dysentery) - Ciprofloxacin 500 mg BD x 3-5 days; or Metronidazole 400 mg TDS if amoebic suspected
• Diet: BRAT diet (Banana, Rice, Applesauce, Toast) or bland diet. Resume normal food as tolerated.
• Notify OHC/Plant Management if multiple workers affected (food-borne outbreak protocol)
• REFER if: severe dehydration not responding to oral/IV, blood in stool with high fever, suspected surgical cause, elderly/comorbid

6. MUSCULOSKELETAL PAIN (Limbs/Joints)

History

• Site, onset (acute vs gradual/insidious - overuse), mechanism (trauma vs spontaneous)
• Character: aching, sharp, throbbing
• Joint involvement: swelling, redness, warmth, morning stiffness (inflammatory)
• Occupational link: repetitive movement, vibration exposure, heavy lifting, awkward postures, static loading - extremely important at OHC
• Recent change in work activity/tools
• Previous similar episodes
• Past history: gout (hyperuricemia), RA, OA, previous fracture
• Medication: steroids (avascular necrosis), fluoroquinolones (tendinopathy)
• Sleep disturbance due to pain (fibromyalgia pattern)

Examination

• Inspection: swelling, erythema, deformity, muscle wasting, posture
• Palpation: point tenderness, warmth, joint effusion (fluctuance), crepitus
• Range of Motion: active and passive (restriction pattern - capsular vs non-capsular)
• Special tests: as per joint - McMurray (knee), Finkelstein (De Quervain's), Phalen/Tinel (CTS), Speed/Hawkins (shoulder)
• Neurovascular: distal pulses, capillary refill, sensory-motor exam distally

Management (OHC)

• RICE protocol for acute: Rest, Ice (20 min QID x 48-72h), Compression, Elevation
• NSAIDs: Ibuprofen 400-600 mg TDS after food (if no contraindication) x 5-7 days. Topical Diclofenac gel if local.
• Paracetamol: 500-1000 mg TDS (safer profile, can combine with NSAIDs)
• Muscle relaxant if spasm: Cyclobenzaprine/Thiocolchicoside 4 mg BD
• Physiotherapy referral: for persistent or occupation-related conditions
• Work modification: temporary duty modification to avoid aggravating tasks - document in OHC records
• Occupational assessment: ergonomic review, tool modification, PPE (anti-vibration gloves)
• Refer if: suspected fracture (X-ray needed), joint effusion requiring aspiration, suspected inflammatory arthritis (hot swollen joint with fever - septic arthritis is emergency), neurovascular compromise

7. BACK / NECK PAIN

History

• Onset: acute (trauma/lifting) vs insidious (postural/degenerative)
• Location: cervical, thoracic, lumbar, sacral
• Radiation: leg (sciatica - L4/L5/S1), arm (cervical radiculopathy C5-C8), belt-like (T-spine)
• Character: mechanical (worse with movement, better rest) vs inflammatory (worse at rest, morning stiffness >1 hour)
• Associated: paraesthesia, weakness, bladder/bowel dysfunction (cauda equina - EMERGENCY)
• Occupational: lifting, bending, twisting, driving (vibration), prolonged sitting, monitor height
• Red flags: age <20 or >50 new onset, trauma, thoracic pain, weight loss, night pain, fever, past malignancy, steroid use, IV drug use, bladder/bowel symptoms

Examination

• Posture & Gait: antalgic gait, list, lordosis/kyphosis
• Palpation: spinous process tenderness (fracture/infection), paraspinal spasm
• Range of Motion: flexion, extension, lateral flexion, rotation
• Neurological (lumbar): SLR (Lasegue's) positive <60° = disc prolapse; crossed SLR; ankle/knee reflexes; L4 (knee reflex, medial leg sensation), L5 (big toe extension, dorsum sensation), S1 (ankle reflex, lateral foot sensation)
• Neurological (cervical): Spurling's test; upper limb reflexes; grip strength; Lhermitte's sign
• Perianal sensation and anal tone if cauda equina suspected

Management (OHC)

• Acute mechanical LBP: reassurance (>90% resolve within 6 weeks), avoid bed rest, continue activity as tolerated
• NSAIDs: Ibuprofen 400 mg TDS or Naproxen 500 mg BD x 5-10 days
• Muscle relaxant: Thiocolchicoside 8 mg BD or Baclofen 10 mg TDS (short course)
• Paracetamol adjunct
• Heat therapy: warm compress or heat pad for muscle spasm
• Physiotherapy: core strengthening, McKenzie exercises referral
• Ergonomic advice: lifting technique, workstation adjustment, lumbar support
• Work restriction: document and advise modified duties - avoid lifting >5-10 kg acutely
• REFER IMMEDIATELY: cauda equina symptoms (bladder/bowel dysfunction, saddle anaesthesia), progressive neurological deficit, suspected fracture/infection/malignancy (red flags), failure to improve after 4-6 weeks

8. MINOR WOUNDS

History

• Mechanism: laceration (sharp), abrasion, puncture (nail, metal), bite (animal/human), crush injury
• Time since injury (wound age determines primary vs secondary closure)
• Location and depth
• Contamination: clean/dirty/grossly contaminated (soil, grease, rust)
• Tetanus immunization status - ESSENTIAL in OHC
• Bleeding: controlled vs ongoing
• Sensation/movement distally (nerve/tendon injury)
• Medications: anticoagulants (warfarin, aspirin), diabetes (impaired healing), immunosuppression
• Occupational context: document mechanism for MLC/accident record

Examination

• Wound assessment: size, depth, edges (clean vs ragged), base (visible fat/fascia/bone/tendon/joint)
• Contamination: foreign body (glass, metal - may need X-ray)
• Bleeding: venous vs arterial
• Neurovascular: two-point discrimination, capillary refill, distal pulses
• Tendon/Nerve: active movement against resistance, sensory testing distal to wound
• Signs of infection (if presenting late): erythema, warmth, swelling, discharge, lymphangitis, fever

Management (OHC)

• Bleeding control: direct pressure 5-10 min, elevation; tourniquet only if life-threatening
• Wound cleaning: copious irrigation with normal saline or clean water under pressure; clean with Povidone-Iodine or Chlorhexidine
• Debridement: remove devitalised tissue, foreign material
• Closure:
  • Simple lacerations <6 hours (facial <24 hr): suture or steristrips/skin staples
  • Contaminated/bite wounds: secondary intention (do NOT close primarily)
  • Deep or >6 hours old: refer for formal debridement
• Dressing: non-adherent primary dressing; change daily or as needed
• Tetanus prophylaxis (CRITICAL in OHC):
  • Fully immunized + booster <5 yr: nothing
  • Fully immunized + booster 5-10 yr: Td booster
  • Unknown/incomplete + clean wound: Td toxoid
  • Unknown/incomplete + dirty wound: Td + Tetanus Immunoglobulin (TIG) 250 IU IM
• Antibiotics: prophylactic if contaminated/bite/immunocompromised/diabetic - Amoxicillin-Clavulanate 625 mg TDS x 5 days; or Co-trimoxazole for Penicillin allergy
• Analgesia: Paracetamol/NSAIDs
• Animal bite: Rabies PEP protocol (ARV + RIG if indicated, report to health department)
• Accident documentation: mandatory for occupational injuries (Form 16/employer register per Factories Act)
• Follow-up: wound review at 48-72 hours, suture removal at 7-14 days (location-dependent)

9. MINOR BURNS

History

• Mechanism: thermal (flame, hot liquid/steam), chemical, electrical, contact
• Time of injury
• Agent: hot water (scalds common in industry), steam, chemical name (acid/alkali)
• First aid already given?
• Estimated area involved (Rule of Nines or Palm method)
• Depth estimate: superficial (redness, no blisters), partial thickness (blisters), full thickness (white/charred, painless)
• Inhalation injury: enclosed space, facial burns, singed nasal hair, hoarse voice, soot in mouth
• Tetanus status
• Occupational context: document for accident reporting

Examination

• Vitals: BP, HR, SpO2 (CO exposure, inhalation injury)
• Burn assessment:
  • Area: Rule of Nines (Adults) - Head 9%, each arm 9%, each leg 18%, anterior trunk 18%, posterior trunk 18%, perineum 1%
  • Depth:
    • Superficial/Epidermal: red, painful, no blisters, blanches
    • Superficial Partial Thickness: red, moist, blisters, very painful, blanches
    • Deep Partial Thickness: pale, less sensation, does not blanch, blisters
    • Full Thickness: white/brown/black, leathery, painless, does not blanch
• Location: face, hands, feet, genitalia, joints, circumferential (all high-risk - REFER)
• Airway: stridor, hoarseness, carbonaceous sputum, facial burns, eyebrow/nasal hair singeing

Management (OHC)

• Immediate: remove from source, remove clothing/jewellery
• Cooling: cool running water 15-20 minutes within 3 hours of burn (DO NOT use ice)
• Airway: if any inhalation injury suspected - high-flow O2, immediate referral
• Minor burns (OHC manageable): superficial/superficial partial thickness, <10% BSA adults, <5% BSA children, not on face/hands/feet/genitalia/joints
  • Clean with saline/chlorhexidine
  • Blister management: intact blisters - leave; ruptured blisters - debride roof
  • Dressing: Silver Sulfadiazine cream 1% (SSD) or non-adherent dressings (Mepitel/paraffin gauze)
  • Change dressings every 2-3 days
• Analgesia: Paracetamol + Ibuprofen; IV morphine/pethidine if severe pain (refer)
• Fluid: oral hydration for minor; Parkland formula IV fluids for major burns (refer)
• Tetanus prophylaxis as per wound protocol
• Chemical burns: prolonged copious water irrigation (30-60 min); do NOT neutralize
• REFER IMMEDIATELY: >10% BSA, deep partial/full thickness, face/hands/feet/genitalia burns, circumferential burns, inhalation injury, chemical/electrical burns, age extremes

10. EYE IRRITATION / FOREIGN BODY SENSATION

History

• Onset: sudden (FB, chemical splash) vs gradual (dry eye, infection)
• Character: gritty/FB sensation, burning, itching, pain
• Redness: diffuse (conjunctivitis) vs circumcorneal (keratitis, iritis)
• Discharge: watery (viral, allergy), mucopurulent (bacterial), stringy (allergic)
• Vision change: blurring, photophobia, diplopia - ALARM
• History of trauma, chemical splash, welding (UV keratitis - "arc eye")
• Contact lens use
• Occupational exposure: dust, chemicals, metal grinding (high-velocity FB - REFER)
• Medications: topical steroid use (herpes, glaucoma risk)

Examination

• Visual acuity: Snellen chart or near vision card (document baseline)
• External: periorbital edema, eyelid position, lash debris
• Conjunctiva: injection pattern (bulbar/palpebral), follicles vs papillae (viral vs allergic/bacterial), chemosis, subconjunctival hemorrhage, discharge
• Cornea: clarity (fluorescein stain under cobalt blue light for abrasion/ulcer), corneal reflex
• Evert upper eyelid: to check for subtarsal FB
• Pupils: size, reactivity, RAPD (afferent papillary defect = serious pathology)
• Anterior chamber: hyphaema (blood), hypopyon (pus)

Management (OHC)

• Chemical splash (EMERGENCY):
  • Immediate copious irrigation with NS or water for at least 15-30 min
  • Litmus pH check after irrigation (aim pH 7-8)
  • Immediate ophthalmology referral even after irrigation
• Conjunctival Foreign Body: evert lid, remove with moist cotton-tip or irrigation; fluorescein to check corneal integrity
• Corneal FB: superficial - remove with moist swab under magnification; deep/embedded - REFER to ophthalmology
• Corneal abrasion: fluorescein to confirm, antibiotic drops (Moxifloxacin 0.5% or Tobramycin), cycloplegic if painful (Cyclopentolate 1%), patch or bandage contact lens, review 24 hours
• Bacterial conjunctivitis: Moxifloxacin/Ciprofloxacin eye drops QID x 5-7 days; hygiene counselling (contagious)
• Viral conjunctivitis: supportive (cool compresses, lubricant drops), very contagious - work restriction advice
• Allergic conjunctivitis: Olopatadine 0.1% drops BD; oral antihistamine; avoid allergen
• Welding arc eye (UV keratitis): presents 6-12 hours after exposure; intense pain, photophobia, watering; antibiotic drops, cycloplegic, oral analgesia, dark room rest, patching; usually resolves 24-48 hours; PPE counselling
• REFER: chemical burns, corneal ulcer/opacity, visual acuity change, hyphaema, hypopyon, suspected penetrating injury, RAPD, no improvement

11. EARACHE (Otalgia)

History

• Onset, duration, laterality
• Character: throbbing (otitis media), itching (otitis externa), sharp (FB)
• Associated: hearing loss, discharge (otorrhoea - type: watery, purulent, bloody), tinnitus, vertigo, facial weakness
• Fever, preceding URTI (otitis media)
• Recent water exposure (swimmer's ear - OE)
• FB insertion, cotton-bud use (OE)
• Referred pain: dental (lower molar), TMJ, tonsil, throat - check if ear exam is normal
• Occupational: noise exposure (NIHL - usually painless but note), barotrauma (flying/diving/pressure changes in industry)
• Immunocompromised status (malignant OE risk)

Examination

• Pinna/Tragus: tenderness (otitis externa - tragal tenderness is hallmark), vesicles (Ramsay Hunt syndrome - herpes zoster oticus)
• EAC (External Auditory Canal): edema, erythema, discharge (OE), wax, FB
• Tympanic Membrane: intact/perforated, colour (grey = normal; red/bulging = OM; amber = effusion), cone of light, mobility (if pneumatic otoscopy available)
• Lymph nodes: periauricular, cervical
• CN VII: facial nerve function (Bell's palsy, cholesteatoma, Ramsay Hunt)
• Hearing: crude assessment (whisper test, Rinne and Weber with tuning fork)
• Dental/TMJ: if ear exam normal

Management (OHC)

• Otitis Externa (OE): aural toilet (gentle swabbing), Ciprofloxacin/Dexamethasone otic drops (Ciprodex) TID-QID x 7 days or Ofloxacin drops; oral analgesia; keep ear dry; wick insertion if canal severely swollen for drops to reach
• Acute Otitis Media (AOM):
  • Mild-moderate: Watchful waiting 48-72 hr + analgesia (Paracetamol/Ibuprofen) - most resolve
  • Antibiotics if: severe pain, high fever, age <2, bilateral, perforation, no improvement 48-72 hr - Amoxicillin 500 mg TDS x 5-7 days; if Penicillin allergy: Azithromycin
• Wax impaction: Ceruminolytic drops (olive oil/Waxsol) x 3-5 days then syringe/microsuction; do NOT irrigate if perforation suspected
• Barotrauma: decongestants, Valsalva manoeuvre advice, analgesia
• REFER: suspected perforation needing ENT assessment, cholesteatoma signs (foul smelling discharge, attic crust), mastoiditis (post-auricular swelling/tenderness, pinna pushed forward), facial nerve palsy, Ramsay Hunt, malignant OE (diabetic/immunocompromised - urgent ENT)

12. ALLERGIC REACTIONS

History

• Identify trigger: food (nuts, shellfish, eggs, milk), drug (penicillin, NSAIDs, latex), insect sting/bite, chemical/occupational exposure (latex gloves, industrial chemicals, dyes, resins - very relevant in OHC)
• Onset after exposure (immediate <1 hr = IgE-mediated; delayed hours-days = cell-mediated)
• Symptoms: urticaria, angioedema, rhinorrhoea, wheezing, throat tightness, voice change, abdominal pain, vomiting, dizziness, syncope
• Anaphylaxis red flags: throat tightness, stridor, bronchospasm, hypotension, LOC after exposure
• Prior episodes, prior anaphylaxis
• Current medications: beta-blockers (worsen anaphylaxis, blunt Epi response), ACE inhibitors (angioedema risk), antihistamines already taken

Examination

• Vitals FIRST: BP, HR, SpO2, RR - classify severity
• Skin: urticaria (wheals), erythema, flushing, angioedema (periorbital, lip, tongue, laryngeal)
• Airway: voice quality, stridor, drooling, trismus
• Chest: wheeze, air entry, SpO2
• CVS: pulse character, CRT
• Abdomen: tenderness (GI involvement in anaphylaxis)

Management (OHC)

1. Adrenaline (Epinephrine) 0.5 mg IM (1:1000 solution) into anterolateral thigh - FIRST LINE, give immediately
2. Lay patient flat, legs elevated (if no respiratory distress)
3. High-flow O2 15 L/min via non-rebreather mask
4. IV access - 500-1000 mL NS bolus for hypotension
5. Adrenaline can repeat every 5-15 min if no improvement
6. Chlorphenamine 10 mg IV (H1 antihistamine - adjunct, NOT first line)
7. Hydrocortisone 200 mg IV (delayed action, prevents biphasic)
8. Salbutamol nebulisation if bronchospasm
9. CALL AMBULANCE/TRANSFER to hospital immediately
10. Monitor for biphasic reaction (4-12 hours)

• Remove/stop trigger
• Cetirizine 10 mg oral or Chlorphenamine 4 mg oral
• Calamine lotion topical for urticaria
• Hydrocortisone cream for local reaction
• Prednisolone 20-40 mg oral for 3-5 days if significant urticaria/angioedema
• Observe 30-60 min before discharge
• Advise allergen avoidance, prescribe EpiPen if high-risk, refer to allergist

13. DIZZINESS

History

• Characterize first:
  • True vertigo (room spinning, false sense of movement) - vestibular
  • Presyncope (lightheadedness, fading, about to faint) - cardiovascular
  • Disequilibrium (unsteadiness, imbalance) - cerebellar/neurological
  • Non-specific (vague, floating) - anxiety, anaemia, hypoglycaemia
• Onset: sudden (BPPV, stroke, Meniere's) vs gradual (anaemia, medication)
• Duration: seconds (BPPV - positional), minutes (TIA, BPPV), hours (Meniere's), days (vestibular neuritis)
• Triggers: position change (BPPV), standing (orthostatic hypotension), stress
• Associated: nausea/vomiting, hearing loss/tinnitus (Meniere's), headache, diplopia, dysarthria, ataxia (posterior circulation stroke/TIA - EMERGENCY)
• Occupational: height work? machinery operation? (fitness-to-work critical)
• Medications: antihypertensives, sedatives, aminoglycosides (ototoxic), metformin (B12 deficiency)
• Recent viral illness (vestibular neuritis)
• Cardiovascular: palpitations, chest pain (arrhythmia, ACS)

Examination

• Vitals: BP both arms, orthostatic BP (lying-standing drop >20 mmHg systolic = orthostatic hypotension), HR (arrhythmia), glucose (hypoglycaemia), Hb if available
• Eyes: nystagmus (direction, fixation suppression), visual acuity, extraocular movements
• HINTS exam (for suspected central vs peripheral vertigo):
  • Head Impulse Test: abnormal (catch-up saccade) = peripheral (reassuring); normal = central (danger)
  • Nystagmus: unidirectional horizontal = peripheral; direction-changing = central
  • Test of Skew: skew deviation = central
• Dix-Hallpike test: for BPPV (posterior canal) - positive if upbeat-torsional nystagmus with latency
• Cerebellar: finger-nose, dysdiadochokinesia, gait, Romberg
• CNs: especially V, VII, VIII, IX, X
• ECG if presyncope/cardiac suspected

Management (OHC)

• BPPV: Epley manoeuvre (canalith repositioning) - highly effective; Betahistine 8-16 mg TDS if persistent
• Vestibular neuritis: Prochlorperazine 5 mg TDS (buccal) or Dimenhydrinate; vestibular exercises; reassure
• Meniere's: low-salt diet advice, Betahistine 16 mg TDS, refer ENT
• Orthostatic hypotension: hydration, compression stockings, medication review, rise slowly
• Hypoglycaemia: oral glucose/dextrose (see Weakness section)
• Anaemia: investigate cause, iron supplementation, refer
• Fitness to work: restrict from heights/machinery until vertigo resolved - CRITICAL in OHC
• REFER IMMEDIATELY: HINTS exam central features, new neurological signs (ataxia, diplopia, dysarthria, dysphagia), first severe episode with headache, age >50 new onset, arrhythmia detected, palpitations + dizziness

14. WEAKNESS (Generalised / Focal)

History

• Characterize: generalised (fatigue, malaise) vs focal (limb weakness - upper/lower motor neuron)
• Onset: sudden focal (stroke - EMERGENCY) vs gradual (anaemia, hypothyroidism, depression, deconditioning)
• Duration and progression
• Associated: fever (infection), weight loss (malignancy, TB), chest pain/SOB (cardiac), palpitations (arrhythmia, anaemia), polydipsia/polyuria (diabetes), cold intolerance (hypothyroid), low mood (depression)
• Hypoglycaemia symptoms: sweating, tremor, palpitations, confusion, known diabetic on insulin/OHA
• Occupational: shift work, night duty (sleep deprivation), heavy physical labour (overexertion), heat exposure (heat exhaustion/stroke), chemical exposure (organophosphate poisoning - weakness + cholinergic signs)
• Medications: statins (myopathy), steroids, diuretics (hypokalaemia), sedatives
• Diet, alcohol use

Examination

• Vitals: BP, HR, Temp, SpO2, RR, blood glucose (must check immediately)
• General: pallor (anaemia), jaundice, thyroid enlargement, lymphadenopathy, nutritional status
• Neurological (if focal weakness):
  • UMN vs LMN pattern: tone, power (MRC grading 0-5), reflexes, plantar (Babinski), sensation
  • FAST screen: Face drooping, Arm drift, Speech slurred - stroke protocol
  • Distribution: monoplegia, hemiplegia, paraplegia, cranial nerve involvement
• CVS: pulse rate/rhythm, murmurs
• Musculoskeletal: proximal vs distal weakness (myopathy vs neuropathy)
• ECG if palpitations/arrhythmia suspected

Management (OHC)

• Hypoglycaemia:
  • Conscious: 15-20 g fast-acting glucose oral (3-4 glucose tablets, 150-200 mL fruit juice), recheck glucose 15 min, repeat if needed, follow with complex carbohydrate
  • Unconscious/unable to swallow: 25-50 mL 50% Dextrose IV or Glucagon 1 mg IM/SC (if available)
  • Identify and treat cause; monitor; adjust diabetes medications
• Heat exhaustion: move to cool area, oral/IV hydration, rest, monitor
• Heat stroke (temp >40°C + CNS change): EMERGENCY - rapid cooling (ice packs to groin/axilla/neck, fans, IV fluids), immediate transfer
• Anaemia: investigate (CBC, iron studies, B12/folate), iron supplementation if iron-deficiency, dietary advice, refer
• Generalised fatigue/malaise: investigate underlying cause (thyroid, diabetes, depression, sleep disorder); advise adequate rest, nutrition; address workplace stressors
• Organophosphate toxicity: remove from exposure, Atropine 2 mg IV/IM (every 5-10 min until secretions dry), Pralidoxime 1-2 g IV, immediate transfer - document as occupational emergency
• REFER IMMEDIATELY: acute focal weakness (stroke protocol - FAST positive), sudden bilateral leg weakness (spinal cord compression), severe hypoglycaemia not responding, heat stroke, suspected poisoning

15. MINOR TRAUMA

History

• Mechanism: fall, crush, blunt impact, MVA, struck by object, machinery
• Time since injury
• Location: head, spine, thorax, abdomen, limbs
• LOC: any loss of consciousness? Duration? Amnesia? (Head injury protocol)
• Symptoms since: headache, vomiting (head injury), chest pain/SOB (rib fracture/pneumothorax), abdominal pain (solid organ injury), limb deformity/inability to weight bear (fracture)
• Tetanus status
• Medications: anticoagulants (higher bleeding risk), bone health (osteoporosis - low energy fracture)
• Occupational context: document mechanism, PPE used, scene conditions (mandatory accident reporting)

Examination

• ABCDE assessment first if significant mechanism
• Vitals: BP, HR (haemodynamic stability), SpO2
• Head: scalp laceration, haematoma, skull tenderness, CSF otorrhoea/rhinorrhoea, Battle's sign, raccoon eyes (base of skull fracture - delayed signs)
• Neurological: GCS, pupils, AVPU, focal deficits
• Cervical spine: midline tenderness, restrict movement until cleared (use NEXUS criteria: midline tenderness, altered alertness, intoxication, distracting injury, neurological deficit - any positive = X-ray/CT needed)
• Chest: paradoxical movement (flail chest), tracheal deviation (tension pneumo), air entry, rib tenderness
• Abdomen: seat belt sign, tenderness, guarding (splenic/hepatic rupture)
• Limbs: deformity, crepitus, shortening/rotation (fracture), tenderness, neurovascular status distal to injury
• Joints: stability, effusion (haemarthrosis)

Management (OHC)

• Haemostasis: direct pressure for bleeding wounds
• Suspected fracture:
  • Immobilise in position found (traction splint for femoral, back-slab for ankle/wrist, sling for upper limb)
  • Do NOT attempt reduction in OHC
  • Refer for X-ray and orthopaedic assessment
• Head injury:
  • Minor (no LOC, GCS 15, no red flags): observe 2-4 hours, provide head injury advice card, escort home, no heavy machinery/heights for 24 hours
  • Any LOC, GCS <15, persistent headache, vomiting >2 episodes, amnesia, seizure, anticoagulant use: REFER immediately for CT head
  • NICE Head Injury guidelines: document and apply
• Soft tissue injury: RICE, NSAIDs, analgesia, physiotherapy referral
• Wound care: as per minor wounds protocol
• Tetanus prophylaxis: as per wound protocol
• Accident reporting: MANDATORY - First Aid register, accident book, Form 16 under Factories Act, notify factory management; if serious - notify DISH (Directorate of Industrial Safety and Health) / appropriate authority
• REFER IMMEDIATELY: GCS <15, haemodynamic instability, open fractures, suspected internal bleeding, neurovascular compromise, C-spine injury, pneumothorax, penetrating chest/abdominal trauma

OHC EMERGENCY DRUGS & EQUIPMENT CHECKLIST

OHC DOCUMENTATION ESSENTIALS

1. Date, time, employee ID, department, job designation
2. Chief complaint + SOCRATES history
3. Vital signs + examination findings
4. Diagnosis / differential diagnoses
5. Treatment given at OHC (drug name, dose, route, quantity dispensed)
6. Fitness certificate: Fit / Fit with restriction (specify) / Unfit (specify duration)
7. Referral details if referred (where, urgency, reason)
8. Follow-up plan
9. For occupational injuries: mechanism, PPE status, accident report number, notification status

REFERRAL THRESHOLD SUMMARY