Acute care Medical tips

Rapid Neurological assessment of a patient with an altered mental state

Charts/tables/references Medical tips

GCS assessment

Introductions Medical tips

Making a Referral

As we have expanded and started to offer advice in Malawi and also take on more clinical officers in Zambia, we thought it would be helpful to do a quick post of what to include in your referral to the Virtual Doctors advisors.

The picture below highlights the most important information to include.

Observations are really important so that we can advise upon the urgency of a clinical decision and get an idea of how unwell your patient is.

Knowing their background- age, gender and whether they have known HIV is really helpful as we can then rule in or rule out certain diagnoses.

Understanding why they have come to see you and what their main complaint is, is probably the most important thing to know, but putting this in context, by knowing if they have any past medical history or take any medication is also very important. If they have no past history and take no medication, please say so!

As we reply upon what you tell us, sending us any relevant examination findings, including photos is really useful. You are our eyes in the field! Our advice can only be as good as the information we receive!

Part of the process is to help with learning and education. It is helpful for us to know what you are thinking. What do you think is going on with the patient? Most importantly, what are you worried about? what do you want help with?

Please try and be specific when possible. This will help us be able to offer you the best advice we can to benefit the patients and clinical officers using the service.

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Medical tips

Taking a Pain History

Medical tips

Sore throats and antibiotics

The majority of acute sore throats (including pharyngitis and tonsillitis) are self‑limiting and often triggered by a viral infection of the upper respiratory tract. The symptoms can last for around 1 week, but most people will get better within this time without antibiotics, regardless of cause (bacteria or virus).

If you are concerned it may be strep throat (and therefore benefit from antibiotics) use the FeverPAIN scoring system. This reduces antibiotic prescribing by 30%!

FeverPAIN criteria

  • Fever (during previous 24 hours)
  • Purulence (pus on tonsils)
  • Attend rapidly (within 3 days after onset of symptoms)
  • Severely Inflamed tonsils
  • No cough or coryza (inflammation of mucus membranes in the nose)

Each of the FeverPAIN criteria score 1 point (maximum score of 5). Higher scores suggest more severe symptoms and likely bacterial (streptococcal) cause.

0 or 1 =13 to 18% likelihood of isolating streptococcus.

2 or 3 = 34 to 40% likelihood of isolating streptococcus.

4 or 5 =62 to 65% likelihood of isolating streptococcus. Treat these with penicillin (unless allergic) for a 5 to 7 day course ONLY (new evidence). Consider giving the same dosage twice a day rather than 4 times a day to improve compliance.

Medical tips


There is new guidance from the UK’s Faculty of Sexual and Reproductive Health with regards to taking the COCP. Please note this is accepted practice but is ‘off licence’ meaning the drug has not been formally approved for use in this way.

Most errors in taking the cocp occur in the pill free week. This pill free week is not necessary and should be shortened to 4 days.

Patients can now

  1. Run 2 or 3 packets together. This will give them regularity and regular menses. Only a 4 day break is needed.
  2. Continue running packets together until they get spotting. Then stop for 4 days.
  3. Continue running packets together whether there is spotting or not (like the POP).

Consider discussing this with your patients. It gives them more control and flexibility with their menses and reduces risk of pregnancy.


Medical tips

Home made spacer for asthma

As requested by

Here is a photo of a spacer made from a bottle-500ml ideally. Please make one and keep it handy for when patients come with asthma attacks. 10 puffs through a spacer is equivalent to a nebuliser and is more effective if the patient is not too short of breath to manage it.

In the UK, all patients are encouraged to use a spacer with every dose of inhaler as it improves the drug delivery to the lungs (from 10% with no spacer to more than 30% with spacer)

  1. Assemble spacer (if necessary)
  2. Remove inhaler cap
  3. Hold inhaler upright and shake well
  4. Insert inhaler upright into spacer
  5. Put mouthpiece between teeth (without biting) and close lips to form good seal
  6. Breathe out gently, into the spacer
  7. Keep spacer horizontal and press down firmly on inhaler canister once
  8. Breathe in and out normally for 3 or 4 breaths
  9. Remove spacer from mouth
  10. Breathe out gently
  11. Remove inhaler from spacer
  12. If more than one dose is needed, repeat all steps starting from step 4
  13. Replace inhaler cap
Charts/tables/references Medical guidelines Medical tips

Atrial fibrillation extras

As discussed in the podcast, here is the stroke risk calculator and an ECG example

CHADS2 Scoring Scheme

Condition Points
C Congestive heart failure 1
H Hypertension 1
A Age > 75 years 1
D Diabetes Mellitus 1
S2 Prior Strokeor TIA 2

Annual Stroke Risk with Respect to CHADS 2 Score (1)

CHADS2 Score Stroke Risk % 95% confidence interval
0 1.9 1.2-3.0
1 2.8 2.0-3.8
2 4.0 3.1-5.1
3 5.9 4.6-7.3
4 8.5 6.3-11.1
5 12.5 8.2-17.5
6 18.2 10.5-27.4

AF rapid ventricular response


Medical tips

exercises for shoulder and back

Following a case, here are some exercises for back and shoulder pains



Back Pain exercises 2002 14-1 (1)


Medical tips

Assessing the Unconscious Patient

A recent case sent to the volunteers  involved an unconscious patient.  A great acronym was given to help assess such a patient:


AEIOU TIPS is used to assess patients with an altered mental status (AMS) or an altered level of consciousness (ALOC).
A    Alcohol
E     Epilepsy
I     Insulin
O    Overdose
U    Underdose

T   Trauma
I    Infection
P    Psychosis
S    Stroke

There are some other useful tips on this website too.