Table 2 Vignette case definitions, essential questions and treatment as defined in National Standing Orders

Acute diarrhea with severe dehydration- 13 month old boy with diarrhea

Severe condition

Main symptoms: Frequent watery stool with weakness, with or without vomiting

Examination: Lethargic or unconsciousness, sunken eyes, drinks poorly or unable to drink, skin pinch goes back very slowly

Treatment: ORS by mouth if child can drink AND 100 ml/kg Ringer’s Lactate Solution, first 30 ml/kg in 30 min and then 70 ml/kg in 2.5 h. Reassess every 1–2 h.

Pneumonia- 5 year old girl with a cough

Moderate condition, suspect Pneumonia

Main symptoms: Cough with fast breathing

Examination: fast breathing (> 40 breath/min), no chest in-drawing, temp >37C, chest not clear, difficulty breathing (danger sign), inability to suck/drink (danger sign)

Treatment: Cotrimoxazole 1 Tab (480 mg) bd ×5/7 OR Amoxicillin 250 mg/10mls qds × 5. Give Paracetamol if temp is > 37.5C, ½ tab or 250 mg qds × 5 days. Ask parent to bring child back in 2 days.

Diabetes Type II - 48 year old man feeling weak, without energy and is often hungry

Severe condition, suspect Diabetes

Main symptoms: Passing a lot of urine, getting up more than 4 times at night to pass large quantities of urine but without pain, feel very thirsty and drinks a lot of water/fluid, loss of weight

Examination: General weakness, examine urine for increased sugar and blood

Treatment: Refer to hospital (in analysis, if Medical Officer: Oral Hypoglycemic or insulin when hypoglycemic are not effective)

Pulmonary Tuberculosis- 40 year old man suffering from fever and cough for some time

Moderate condition, suspect Pulmonary Tuberculosis

Main symptoms: Cough of more than 3 weeks duration with or without chest pain with weight loss and shortness of breadth

Examination: Coughing, sputum may or may not have blood, weight loss, breathlessness

Treatment: Request for 3 sputum examinations, if at least 2 of 3 are positive, treat for pulmonary TB. Expectations of treatment depend on the receipt of specific TB training, not on specific cadres: if trained on TB management and have necessary drugs: First 2 months daily supervised: combined tablet of RHZE (150 mg + 75 mg + 400 mg + 275 mg). Daily for 6 months: combined tablet of EH(400 mg + 150 mg) OR supervised for 4 months: combined tablet of RH (150 mg + 75 mg). If not trained, refer to the Clinic.

Malaria with Anemia - 4 year old boy with fever for some time that is now worse

Severe Condition

Main symptoms: Fever with any of the following: Vomiting, unable to feed, convulsions or history of convulsions

Examination: Temp 37.5 C or above with any of the following: neck stiffness, change in alertness, convulsions, bulging fontanelle, moderate dehydration, lethargic

Treatment: Continue feeding. Paracetamol 250 mg stat. Artemether-Lumefantrine 2 tablets twice daily for 3 days OR Artesunate+Amodiaquine 50 mg/135 mg one tablet once daily for 3 days. Oral Chloramphenicol 1.2 ml.