Myanmar MMLE cheat sheet

Acute coronary syndrome: STEMI requires ST elevation ≥1 mm in two contiguous limb leads or ≥2 mm in precordial leads; immediate reperfusion with primary PCI within 120 minutes or fibrinolysis within 30 minutes of presentation.

Community-acquired pneumonia: CURB-65 score (Confusion, Urea >7 mmol/L, Respiratory rate ≥30/min, Blood pressure systolic <90 or diastolic ≤60, Age ≥65) - 0-1 outpatient, 2 short inpatient, ≥3 severe, consider ICU.

Diabetic ketoacidosis: diagnostic triad of hyperglycaemia (>11 mmol/L), ketonaemia (β-hydroxybutyrate ≥3 mmol/L) and metabolic acidosis (pH <7.3 or bicarbonate <15 mmol/L); initial fluid is 0.9% sodium chloride, add potassium once K <5.5 mmol/L and urine output adequate.

Hypertension: stage 1 is 140-159/90-99 mmHg, stage 2 ≥160/100 mmHg; first-line agents in Myanmar include thiazide-like diuretics, calcium channel blockers (amlodipine), and ACE inhibitors/ARBs; combine two agents when BP ≥20/10 mmHg above target.

Tuberculosis: presumptive pulmonary TB is cough ≥2 weeks with any of fever, night sweats, weight loss, or haemoptysis; Xpert MTB/RIF Ultra is the initial diagnostic test; standard regimen 2HRZE/4HR for drug-susceptible TB.

Stroke: non-contrast CT excludes haemorrhage before thrombolysis; intravenous alteplase within 4.5 hours of onset for ischaemic stroke if no contraindication; blood pressure <185/110 mmHg before thrombolysis.

Chronic kidney disease: eGFR <60 mL/min/1.73 m² for ≥3 months or markers of kidney damage; stage G3a 45-59, G3b 30-44, G4 15-29, G5 <15; use Cockcroft-Gault for drug dosing.

Malaria: severe malaria features include impaired consciousness, prostration, multiple convulsions, acidosis, hypoglycaemia (<2.2 mmol/L), severe anaemia (Hb <5 g/dL), renal impairment, jaundice, pulmonary oedema; treat with intravenous artesunate.

Acute appendicitis: Alvarado score (MANTRELS) - migratory pain, anorexia, nausea/vomiting, tenderness RIF, rebound pain, elevated temperature, leukocytosis, shift to left; score ≥7 suggests appendicectomy.

Bowel obstruction: initial management is nil by mouth, intravenous fluids, nasogastric decompression, analgesia, and serial abdominal examination; urgent surgery for strangulation signs (fever, tachycardia, peritonism, rising lactate).

ATLS primary survey: A Airway with cervical spine protection, B Breathing and ventilation, C Circulation with haemorrhage control, D Disability (GCS, pupils), E Exposure with prevention of hypothermia.

Burns: Parkland formula for crystalloid in first 24 hours = 4 mL × body weight (kg) × %TBSA burned; give half in first 8 hours from injury, remainder over next 16 hours; rule of nines for adult TBSA.

Hernia: inguinal hernia repair is the most common general surgical procedure; strangulation risk is higher with femoral hernia; irreducible painful hernia requires urgent surgical referral.

Thyroid surgery: recurrent laryngeal nerve injury causes hoarseness; external branch of superior laryngeal nerve injury causes loss of high pitch; hypocalcaemia after total thyroidectomy from parathyroid injury.

Shock: haemorrhagic shock classes - class I <15% blood loss, class II 15-30% (tachycardia, narrowed pulse pressure), class III 30-40% (hypotension, confusion), class IV >40% (lethargy, negligible urine output).

Surgical site infection prevention: administer prophylactic antibiotics within 60 minutes before incision (within 120 minutes for vancomycin or fluoroquinolones); re-dose intraoperatively every two half-lives or after 1500 mL blood loss.

Pre-eclampsia: new hypertension ≥140/90 mmHg after 20 weeks with proteinuria ≥300 mg/24 h or end-organ dysfunction; severe features include BP ≥160/110, platelets <100,000/µL, elevated liver enzymes, pulmonary oedema, visual or cerebral symptoms.

Postpartum haemorrhage: primary PPH is blood loss ≥500 mL after vaginal birth or ≥1000 mL after caesarean within 24 hours; first-line uterotonic is oxytocin 10 IU IM; tranexamic acid 1 g IV within 3 hours of birth for PPH.

Ectopic pregnancy: risk factors include previous ectopic, tubal surgery, PID, and IUD in situ; diagnosis by transvaginal ultrasound (empty uterus with adnexal mass) and serial β-hCG; methotrexate for haemodynamically stable, unruptured, hCG <5000 IU/L.

Gestational diabetes: screen at 24-28 weeks with 75 g oral glucose tolerance test; diagnostic thresholds fasting ≥5.1 mmol/L, 1-hour ≥10.0 mmol/L, 2-hour ≥8.5 mmol/L (IADPSG).

Labour: first stage from onset to full dilatation (cervix 4-10 cm in active phase); second stage from full dilatation to birth; third stage from birth to delivery of placenta; active management of third stage reduces PPH.

Contraception: combined oral contraceptives are contraindicated in migraine with aura, smoking age ≥35, hypertension ≥160/100, and history of VTE; progestogen-only methods are safer in these groups.

Cervical cancer screening: start at age 30 (or 25) with HPV testing every 5 years or cytology every 3 years; HPV 16 and 18 cause about 70% of cervical cancers; vaccinate girls 9-14 years.

Ovarian cancer: CA-125 is elevated in many cases but is nonspecific; risk of malignancy index (RMI) = CA-125 × menopausal status × ultrasound score; refer to gynaecologic oncology if RMI >250.

Paediatric basic life support: compression-to-ventilation ratio 30:2 for single rescuer and 15:2 for two rescuers; compression depth at least one-third of chest AP diameter; rate 100-120/min.

Neonatal resuscitation: initial steps are warmth, drying, stimulation, and clearing airway if needed; assess tone, breathing, and heart rate; positive pressure ventilation if apnoeic or HR <100/min; chest compressions if HR <60/min after effective ventilation.

Dehydration in children: assess using WHO criteria - sunken eyes, slow skin pinch, lethargy, drinking poorly; severe dehydration requires IV Ringer's lactate 100 mL/kg over 3 hours (infants) or 30 mL/kg in first hour then 70 mL/kg over 2.5 hours (older children).

Growth: weight doubles by 5 months and triples by 12 months; birth length ~50 cm, increases 25 cm in first year; head circumference increases ~12 cm in first year.

Acute otitis media: common pathogens are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis; first-line antibiotic is high-dose amoxicillin; observe for 48-72 hours in selected children ≥2 years with mild disease.

Kawasaki disease: diagnostic criteria - fever ≥5 days plus 4 of 5: rash, cervical lymphadenopathy, conjunctivitis, oral mucositis, extremity changes; treat with IV immunoglobulin 2 g/kg and aspirin; risk of coronary artery aneurysms.

Malnutrition: WHO defines severe acute malnutrition as weight-for-height z-score < -3 or MUAC <115 mm or bilateral pitting oedema; treat with ready-to-use therapeutic food; watch for refeeding syndrome.

Immunisation: Myanmar EPI schedule includes BCG and OPV at birth; pentavalent (DTP-HepB-Hib) at 2, 4, 6 months; measles-rubella at 9 and 18 months; vitamin A supplementation at 6-month intervals for children 6-59 months.

Incidence measures new cases per population at risk per time; prevalence measures all existing cases at a point or period; incidence × duration ≈ prevalence for stable conditions.

Sensitivity = true positives / (true positives + false negatives); specificity = true negatives / (true negatives + false positives); positive predictive value depends on prevalence.

Outbreak investigation steps: verify diagnosis, confirm outbreak, define cases, describe by time/place/person, generate hypotheses, test hypotheses, implement control, communicate findings.

Study designs: cohort studies measure incidence and relative risk; case-control studies measure odds ratio; randomised controlled trials provide strongest evidence for causality; cross-sectional studies measure prevalence.

Screening criteria (WHO): important health problem, accepted treatment, facilities for diagnosis and treatment, latent stage, suitable test, test acceptable, natural history understood, agreed policy on whom to treat, cost-effective.

Cold chain: vaccine storage temperatures - most vaccines 2-8 °C; OPV and varicella may require -20 °C for long-term storage; avoid freezing of aluminium-adjuvanted vaccines (DTP, HepB).

DALY = years of life lost (YLL) + years lived with disability (YLD); used to quantify burden of disease; one DALY equals one lost year of healthy life.

Basic reproduction number R0 is the average number of secondary cases generated by one infectious case in a fully susceptible population; herd immunity threshold = 1 - 1/R0.