Family Medicine

Andrea Tonelli
MBChB (UCT)
Semester 4
2018

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HIV Counselling and Testing
• Needles stick injuries
o Post-exposure procedure ® needle-stick injury or contact with body/body fluids
§ General
• Occupational exposure ® must be treated as a medical
emergency
• PEP must be commenced as soon as possible + within 72 hours of
exposure

§ Process
• Clean exposed area/wound with soap & water immediately
o Contamination involves mouth or eyes ® rinse mouth +
irrigate eyes thoroughly with water
o Report to hospital unit dedicated to occupational exposure

• Counsel exposed HCW ® obtain consent for HIV test if unknown

or -ve
o If source person is present ® counsel + perform blood tests
as per

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• Counsel HCW
o PEP side effects ® advise to report immediately if such occur
o Provide emotional support + address anxiety
o Advise condom use for at least 4 months to protect partner
o Refer for ongoing counselling if necessary

• Administer PEP
o If source person Ä consent to test ® treat as if HIV +ve +
provide PEP
o Staff who Ä testing ® must still be offered PEP
o Ä Testing ® lose the right to compensation + may develop
resistance to ARVs

• Incident ® must be recorded appropriately + reported

immediately to relevant supervisor
o Ensures timely administration of PEP
o Ensure adequate occupational compensation in cases of
transmission

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• Ethical guidelines for good practice with regard to HIV
o Responsibilities of HCWs ® HIV +ve patients
§ Against all ethical + professional standard to refuse treatment
§ Ethically + legally mandatory ® informed consent
§ Imperative ® HCW continues counselling + conducts further
investigations after HIV diagnosis
§ Important ® HCW takes concern for other HCWs involved in the
management of the HIV patient (consented disclosure)
§ HCWs ® must support all measures aimed at preventing HIV infection

o Confidentiality
§ Test of HIV +ve result ® treated with ­est level of confidence possible
§ Confidentiality ® extends to other HCWs unless patient provides consent
• For treatment + care of to be in best interest of patient ® disclosure
of clinical data must be discussed with them

§ Decision to divulge information ® always done in best interest of patient

§ Report of HIV test results by lab ® also requires confidentiality \
requirement for policy to maintain such confidentiality

o HIV testing
§ May only take place ® voluntary + informed consent
§ HCWs ® must be aware of reliability + safety of HIV testing kits (abuse in
the market)
§ In order to obtain informed consent, patient should be given information
• Purpose of lab test
• Advantages/disadvantages of testing
• Why the HCW requires such information
• Influence of test result on treatment
• How medical protocol D with result
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 § Requirement, HIV test +ve ® post-test counselling must follow

o Knowledge of HIV status of patients in healthcare setting

§ Factors ® unrealistic to rely solely on HIV testing when dealing with
occupationally exposed individuals
§ HCWs must appreciate
• Significance of window period of infectivity
• Prevalence of HIV infection in the community
• Different tests available
• Time frames necessary to obtain a reliable HIV test result

§ Ä Evidence that knowledge of HIV status of patients ® ¯ risk of needle

stick injuries
§ Well-defined ­-risk or exposure-prone procedures to be performed ®
patient must be consulted + informed consent sook
§ Such situations ® should Ä be abused in order to obtain informed consent

o Refusal to have blood tested

§ Ä Justifiable to test for HIV Ä patient’s informed consent
• Except ® certain circumstances set out in National Policy of Testing
for HIV e.g. anonymous testing for epidemiological purposes

§ HCW exposed ® immediate PEP is beneficial to health of HCW \

information regarding HIV status be obtained by
• Testing existing blood specimen from source patient
o Should be done with patient’s consent, BUT ® consent
withheld, blood may be tested nonetheless only after
informing patient

• Ä Existing specimen + patient refuses ® patient treated as HIV

+ve + HCW initiated on PEP
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 • Patient unable to give consent and is unlikely to be able to do so for
an extended period of time ® proxy consent
o Proxy consent ® consent by person legally able to give such consent in
terms of the National Health Act
o Order of precedence ® spouse or partner ® parent ®
grandparent ® adult child or brother or sister of patient
o All absent clinical manager

o Partner disclosure
§ HCWs ® recommend HIV +ve patients to disclose status to sexual partner
s such that they may undergo testing + treatment
§ Patient Ä ® HCW uses discretion when deciding whether or not to divulge
information (take into account risks of HIV infection for partner + risks to patient)
§ HCW decides to disclose ® accept full responsibility, steps recommended
• Counsel patient on importance of disclosing
• Provide support to patient to make disclosure
• Patient Ä or Ä to take other precautions to Ä transmission ®
counsel patient on ethical obligation to disclose such information
• Patient still refuses ® disclose + assist partner in undergoing testing
+ accessing treatment
• Follow up to check for any adverse consequences

§ When HCW records diagnostic information for patients on medical

insurance for purposes of processing claims ® informed consent

o HCWs infect with HIV

§ HCWs ® Ä obliged to disclose HIV status to an employer
§ HCWs ® encouraged to be aware of benefits of testing & counselling +
treatment
§ Universal precautions always used in ­-risk procedures
§ Restrictions that are Ä scientifically justified ® Ä be imposed
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• ACTS ® Advise, consent, test & support
o Advise ® all patients to have HIV test today
§ If Ä ® respond to concerns + motivate with benefits of
testing
• HIV -ve ® patient can learn how to stay -ve
• HIV +ve ® patient can get vital treatment

§ If patient is HIV +ve ® ensure patient receiving treatment

§ As patient about questions + concerns ® determine
readiness for HIV test

o Consent
§ Explain consent ® may only perform test with signed
informed consent form
§ Explain confidentiality ® Ä outside the health team may
be told about test + result without permission
§ Form signed
§ Explain testing procedure
• Finger prick ® test drop of blood for HIV
• Result ® read in ±15mins
• Test +ve ® need for confirmatory test

o Test ® Perform rapid test or nurse ® patient for prick

o Support

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 § Give result ® pause ® respond to concerns/support
HIV -ve HIV +ve
• You tested HIV +ve ® HIV infection
• Coping
o Ask about + respond to concerns
o Reassure ® status knowledge can
save life

• Living positively
• You tested HIV -ve ® window period \
o Explain importance ® CD4+ + HIV
new or multiple sexual partners, or
stage
unprotected sex?
o Stress importance ® return for CD4+
o Yes ® return in 6 weeks for test
results, dictate treatment
o No ® does Ä have HIV

• Protect your + partner health

• Discuss prevention options
o Avoid re-infection by HIV or new
o Abstain
STIs
o Be faithful ® to 1 partner or ¯
o Use condoms ® every time you have
o Use condom correctly ® every time sex
you have sex o Encourage partner testing + condom
o Encourage partner testing + use of use
condoms
• Testing
o Screen for TB + STI symptoms
• Get tested every year or sooner if you have
o Cervical screening for women
® STI, a new partner, practice unsafe sex, fall
o Obtain blood ® CD4+ count, RPR,
pregnant or sick
creatinine + HIV staging
• Question?
o Obtain urine ® pregnancy testing in
women of reproductive age

• Closure
o Assess need for post-test counselling
o Verify 2+ contacts for support +
follow-up if default

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• Post-test counselling
o Result given in person + patient told immediately or ASAP
o Negative
§ Check understanding of result
§ Allow patient ® express own feelings
§ Discuss window period if applicable
§ Stress
• -ve Test Ä = immunity to HIV
• Prevention ® safe sex + healthy lifestyle

o Positive
§ Allow patient ® express feelings
• Identify immediate concerns
• Discuss implications of disclosure
• Ask patient who they will tell
• Discuss who patient will spend next few hours/days
• Access suicide risk

§ Determine way forward

• Identify foreseeable difficulties + support structures
• Encourage questions + health lifestyle
• Discuss infection control
• Refer to other resources + support
• Follow up in 2 days
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 § Discuss pregnancy risks
• 25-30% chance of infecting ® ¯ by 50% if ARVs
given during late pregnancy or labour
• Pregnancy in later stages of HIV ® accelerate course
of disease

o Follow up appointment
§ Encourage questions + ask ® experience since diagnosis
§ Medical care depends on stage + prophylaxis may be given
§ Asses psychosocial + spiritual support

o Ongoing care
§ Routine symptom + risk assessment
§ Help patient feel in control
§ Ensure meaning in life + healthy self-esteem
§ Encourage on going social support ® include family +
friends

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 Obtain informed consent
• Educate client about HIV, methods of HIV transmission. risk factors, treatment and benefits of knowing one's HIV status.
• Explain test procedure and that it is completely voluntary.
• Children < 12 years need parental/guardian consent. If consent Is granted. proceed to testing immediately.

Test
Do first rapid HIV test on finger-prick blocd.
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q _ _; x;- tn L -I
Positive

Do a confirmatory' rapid HIV test on finger-prick blood.

Negative
11 tM hi & SM-- -.«; .552te;H---w -d MF 4
Repeat both the first and the conlirmatory rapid HIV tests above.
J t ~
(C
Cl)
N
One positive and one negative
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, z.::AJ ! i"'AW!'=AA±:;;w e &, & tt ; ;:::- :- -: Htta

ELISA positive ELISA inconclusive ELISA negative

• HIV cannot be
confirmed or
excluded
• Advise client to
repeat rapid HIV
tests in 6 weeks.

• Cliem does not have HiV.

• Encourage client to remain negative and acivise when 10 re-test
-If sexually active: 6-12 monthly
- If pregnant: around 20 and 32 weeks ge,tai,on
- If breastfeeding: 3 monthly
• Offer referral for male circumcision m d1n11nbh risl.. ol HIV infection.
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•
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11
Childhood Diarrhoea
• IMCI ® integrated management of childhood illness
o Programme
§ Looks at commonest causes of death + disability in
children
§ Recognises they are often linked
§ Seeks to prevent + cure through integrated programmes

o 3 main aims
§ Improve case management skills of HCWs through
training
§ Improve health systems + ensure constant supply of
drugs
§ Train families + community members to prevent illness

o IMCI success ® how effectively HCWs recognise signs +

symptoms + treat correctly + refer in severe cases

• Diarrhoea + dehydration
o Importance of treating diarrhoea
§ Kills ±2 million children/year
§ Effective programmes ® 9/10 are preventable

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 § Negative effects
• Weakens children ® prone to infection
• Loss of weight + undermines nutrition
• May cause death by dehydration

o Different forms of diarrhoea

§ Diarrhoea ® passage of loose or watery stools at least 3 times in
the last 24 hours
§ Acute watery diarrhoea
• Lasting 14 days or <
• Starts suddenly + normally caused by infection

§ Persistent/chronic diarrhoea
• Lasting >14 days
• Often present owing to co-morbidities ® HIV/AIDS
+ malnutrition

§ Dysentery ® diarrhoea with blood, with or Ä fever

o Dangers of diarrhoea
§ Dangerous itself ® causes death by dehydration
• Prolonged ® malnutrition
• ­ Infectious ® spreads rapidly in communities

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 § Ä Treatment ® dangerous
• Many believe ® treated with medicines + injections
• However ® tends to be self-limiting
• Greatest danger ® delay they cause in receiving
appropriate treatment

§ Ä ORS use ® dangerous

• > Salt ® convulsions
• < ORS given ® failure to rapidly treat dehydration
• Feed too fast ® vomiting + refusal of child
• Water ® may be contaminated with pathogens

§ Serious forms may be present

• Dysentery caused by shigella ® requires antibiotics
• Epidemic forms e.g. cholerae + typhoid ® require
co-ordinated community approach

o Action
§ Aim + targets
• <ORS use ® 50% of parents to understand in 1st year
+ 90% by 2nd year
• >ORS use ® ­ proportion of families that use it at
first sign of diarrhoea

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§ Choose suitable approach
• Decide which overall method is best
o Consult people ® discover local foods +
availability of medication etc.
o Follow national guidelines

• Decide ® ORS vs. home-made

o Packets ® must be cheap + easy to obtain +
always available
o Home-made ® may be sugar-salt solution or
liquid food e.g. rice water + soups + gruels +
potato water + carrot juice + coconut milk (¯
volume of stool + provide food and fluid)

• Decide ® appropriate container

o Ö Container ® known by everyone + available
at home + same size
o Must be cleaned out before

• Decide ® appropriate measuring device

o Ö Device ® known + available + standard
o Examples
§ 5ml teaspoon
§ Fistful of sugar + 3-finger pinch of salt
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§ Appropriate preparation
• Home-made SSS
o Wash hands following WHO guidelines

o Boil 1L of clean water

o Add 8 teaspoons of sugar + ½ a teaspoon of
salt ® mix thoroughly
o Allow to cool
o Feed to child as guided

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• Home-prepared liquid foods ® Ä children <6m
o Example ® rice water
§ Wash hands as above
§ Grind any sort of rice into powder
§ Add 2®3 tablespoons (50®80g) + pour
into water
§ Add 2 pinches of salt
§ Boil + stir for 5®7 minutes
§ Cool + feed

o Ground dried wheat + sorghum + millet +

maize or potato may be prepared in similar way
o Coconut juice + 2 pinches of salt/L may also be
given

• Packeted ORS
o WHO standard recommendations (mmol/L)
§ Sodium ® 75
§ Chloride ® 65
§ Anhydrous glucose ® 75
§ Potassium ® 20
§ Citrate ® 10
§ Total ® 245

o Cheap + Ö proportions + language understood

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§ Ö Feeding of ORS
• When to give
o Start same time as diarrhoea begins
o Continue ® until diarrhoea stops + normal
amount of urine passed

• How to feed
o Young children ® 1 teaspoon every 1-2 minutes
o Older ® sips from cup
o Breastfed ® continue breastfeeding
o As soon as possible ® give soft foods e.g.
bananas + cereal
o Recovery ® extra food + small amount of
added vegetable oil

• How much to feed ® first assess

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§ Teach all to use ORS
• Aim ® every community member knows how to use
ORS + enters folklore
• Every member should
o Know how to make it
o Know how to use it
o Believe in it ® when diarrhoea occurs ORS
given at once

• Methods to encourage use

o Understand local beliefs
§ Communities tend to be reluctant
§ Integrate guidelines with local beliefs to ­
uptake
§ Examples
• Africa + SEA ® giving fluid makes
diarrhoea last longer \ use orange in
the sun analogy
• Easy access to practitioners ® only
effective treatment is antibiotics + IV
+ injections

o Demonstrate use in clinics ® child presents with

diarrhoea ® HCW must demonstrate ORS use
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 o Demonstrate ORS use in home
§ Work of CHW ® continue until families
confident
§ CHWs should encourage use in own home

o Help community members know about ORS

§ Should encourage them to use it themselves
§ Church leaders + teachers + shopkeepers
etc.

o Teach children + pre-school

§ Older siblings ® younger
§ ORS ® central part of school health
programmes

§ Use other treatment methods

• Antibiotics
o Dysentery as caused by Shigella
o Cholerae + typhoid
o Amoebiasis + giardiasis ® requires lab
confirmation
o Consult national guidelines on which antibiotic
+ dosage

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 • Use of zinc supplements
o ¯ Death rates from acute diarrhoea + dysentery
o Infants ® 10mg elemental zinc daily
o Children >1 year ® 20mg elemental zinc daily

• When to refer
o Utilize tables above
o Referral Ä possible ® consider using NG tube
to give ORS

o Prevention of diarrhoea

§ Promote breastfeeding
• Continue up to 2 years of age
• Ä Mixed feeding for 1st 6 months

§ Teach Ö personal hygiene

• Ö Hand-washing with soap ® ½ diarrhoea rates
• Appropriate + hygienic food preparation
• Teaching must be reinforced
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 • WHO 5 key strategies in preparing/consuming food
o Keep hands + cooking surfaces clean
o Separate raw + cooked foods
o Cook food thoroughly
o Keep stored food at Ö temperatures
o Use safe water

§ Use cleanest water available

• If possible ® ­ community water source
• Other methods ® e.g. place plastic bottles in sun for
±5 hours before use

§ Promote use of latrines + burial of faeces

§ Design + use fly traps
§ Setup school teaching programmes
• Stress hygiene + sanitation
• Teaching ® specific

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• Local beliefs about childhood diarrhoea ® Northern KZN
o A ® Diarrhoea of natural causation
§ Loose + frequent stools natural response to physical
change e.g. teething
§ Perceived to affect older infants
§ \ Ä Reported as illness
§ \ Treatment direct at alleviating underlying problems

o B ® Diarrhoea of supernatural causation

§ Green mucoid stools followed by bloody stools
§ > Commonly reported + considered part of spectrum
affecting young + vulnerable infants
§ Causes
• Stepping over ‘evil tracks’ left behind by
lightning/sorcery
• Breaching of social taboos + provoking displeasure
of ancestors

§ Perceived as fatal if Ä ritual healing methods utilized to

correct disharmony between mother + baby + spiritual
environment

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o C ® Diarrhoea caused by germs or D in diet
§ Cholerae + AIDS-diarrhoea considered to be caused by
germs
§ Diarrhoea + dehydration ® considered important
characteristics \ ORT provided + treatment sought at
clinic

o Implications
§ A ® may result in treatment Ä directed at fluid imbalance
+ ­ likelihood to utilize traditional remedies \ delayed
care may occur
§ B ® greatest challenge to receiving appropriate medical
care
§ C ® beliefs + practices considered appropriate

o Recommendations
§ Instructions to caregivers ® should contain analogies +
explanations of diarrhoea using existing vocab +
concepts + beliefs
§ Ä Contradict beliefs but complement + integrate
§ There is discrepancy between biomedical concepts +
traditional beliefs regarding nature of childhood diarrhoea
• \ Taking discrepancies into account ® vital for
programmatic success
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• Codes of ethics
o Overrulingly ® WHO humanist view requires ethical
framework to:
§ Respect individual choice
§ Respect personal autonomy
§ Ensure the avoidance of harm
§ Apply to both individual + social aspects of health care +
research

o Journal of Health Education ® ethics for health education

profession
§ Responsibility to the public
• Educate to promote + maintain + improve individual
+ family + community health

§ Responsibility to the profession

• Responsible for professional conduct + uphold
reputation of profession
• Ethical conduct among employees

§ Responsibility to employers
• Recognise boundaries of professional competence
• Accountable for professional activities + actions

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§ Responsibility in the delivery of health education
• Promote integrity in delivery
• Respect rights + dignity + confidentiality + worth of
all people
• Adapt strategies + methods ® cater for diverse
groupings

§ Responsibility in research + evaluation

• Contribute to health of population + profession
through research in accordance with the law +
authorities + standards

§ Responsibility in professional preparation

• Those responsible in teaching ® must afford same
respect + treatment to learners as other groups
• Achieved ® providing quality education

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• Approaches to health promotion
o The medical approach
§ Aim ® freedom from medically defined disease +
disability
§ Activity ® promotion of medical intervention to prevent
+ relieve illness
§ Values ® patient compliance with preventive medical
procedures

o Behaviour change
§ Aim ® individual behaviour adaptation conducive to the
relief of disease
§ Activity ® facilitation of attitude + behaviour D to
encourage healthy lifestyle
§ Values ® healthy lifestyle as defined by health promoter

o Educational
§ Aim ® equip individuals with knowledge + understanding
to allow well-informed decision to be made + acted upon
§ Activity
• Information regarding cause + consequences
• Exploration of values + attitude
• Develop skills required for healthy living

§ Values ® individual choice + Ö educational content

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o Client-centred
§ Aim ® work with clients to make their own decisions own
their own terms + values
§ Activity ® work with health issues + choices + actions
identified by client + empowering them
§ Values ® client are = + right to set agenda + involves self-
empowerment

o Societal-change
§ Aim ® physical + social environment that enables choice
of healthy lifestyle
§ Activity ® political/social action to D physical/social
environment
§ Values ® right + need to make environment health
enhancing

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• Models of behaviour change
o The health belief model
§ Use to predict promotive health behaviours
§ Essentially a balance of benefits vs. costs of any health
behaviour
§ 4 key triggers ® health behaviour change
• Perceived susceptibility to illness
• Perceived severity of illness
• Perceived benefits of preventive action
• Perceive barriers to taking preventive action

§ Yet ® many people continue behaviour that undermines

health despite perceived severity + susceptibility + benefits
e.g. smokers + belief of ¯ likelihood contracting AIDS
§ \ Recent modifications ® place model with social
environment + recognises need for specific cues to
action e.g. construction of sport facilities etc.

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 § Application of health beliefs model ® BASNEF model
• Beliefs + attitudes + subjective norms + enabling
factors
• Focuses on beliefs + influence of important others +
wider environmental and social enabling factors that
influence behaviour change
• Enabling factors in developing ® money + time +
equipment + skills + availability of services
• \ Acts as a checklist for programme planning

o Stages in behaviour change

§ General
• Model ® represents slow process of behaviour
change
• Ä Predict change but showcases gradual process ®
change

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§ Stages of D Model ® process at individual level

• Pre-contemplation ® person is unaware of health

risks \ Ä action considered \ identify
• Contemplation ® individual knows about benefits +
Ä ready to change + open to \ > information
• Determination ® benefits clear + change feels
possible \ facilitate through \ support
• Action ® made decision to change + in the process
of D \ action plan + further support + rewards
• Maintenance ® new behaviour adapted + maintained
\ follow-up to check
• Relapse ® takes 2®3 cycles before individual
permanently adapts

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§ Diffusion of Ideas Model ® process at the community
level

• Process ® low uptake of particular behaviour ®

rapid acceptance by majority ® final acceptance by
slower ¯ minority
• Early innovators ® ­ SES individuals not typical of
community they live in
o Such ® introduce to early adopters who are >
conservative + representative of wide population

• Early adopters ® tend to be opinion leaders \

institute > acceptable D
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o \ Individuals need to feel empowered
§ As health promotion practitioners ® 2 questions
• What is the nature of this personal empowerment?
• With limited resources ® how may these best be
utilized for maximum public health benefit

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• SA Diarrhoea guidelines

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• Careseeking for child illness in sub-Saharan Africa
o Factors influencing careseeking
§ Cultural beliefs + illness perception
§ Perceived illness severity + efficacy of treatment
§ Rural location + gender
§ Household income + cost of health services
§ Habit in shaping household choices

o Treatment decision making ® dynamic

§ Characterized by uncertainty + debate
§ Experimentation with multiple + simultaneous treatment
options
§ Sifting interpretations of illness + treatment
§ Influenced by social negotiations hinging on control over
financial resources

o Conceptual model of household decision making

§ Household responses generally moved from inside the
house ® outside over course of illness
§ Operated over 4 different modes
• Direct caregiver recognition + response
• Seeking advice + negotiating access in family
• Utilizing middle layer of community-based treatment
options e.g. private doctors + traditional healers
• Accessing formal medical services
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• Cerebral palsy (CP)
o Epidemiology
§ Affects ±1 in 400 children in SA \ ±1600 diagnoses/year
§ Affects people of all social + ethnic background

o Definition
§ Ä Clearly define disease ® group of disorder of various
causes
§ Disorder of movement + posture + co-ordination resulting from
permanent + non-progressive lesions of immature brain
§ Motor side of disorder often overemphasized ® Ä take
associated handicaps into account e.g. those affecting
speech + hearing + sight + intellect

o Types of cerebral palsy ® may be classified according to

§ Part of body affected
• One arm or leg ® monoplegia
• Both arms or both legs ® diplegia
• One arm + one leg on same side ® hemiplegia
• All four limbs ® quadriplegia

§ How muscles are affected

• ­ Muscle tone ® spastic, rigid
• ¯ Muscle tone ® hypotonia, flaccid
• Movement disorders ® tremor, athetosis, ataxia
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 § Combination of above ® caused by damage to cerebrum,
cerebellum + basal ganglia
§ Severity
• Mild
• Moderate
• Severe

o Other complications
§ > Susceptible
• Visual + hearing + speech + sleep + chewing +
swallowing + dental problems
• Epilepsy
• Squints

§ Other problems
• Constipation
• Difficulty understanding spoken word
• Difficulty distinguishing + comparing shapes
• Learning disabilities

§ Remember ® some severely affected may have average +

above-average intelligence

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o Causes ® usually caused lack of oxygen and/or blood to
developing brain
§ Antenatally
• Genetic ® rare + infections ® rubella + syphilis
• ­ Temperature + X-rays + hypertension
• Alcohol + smoking + drugs
• Any cause of prematurity

§ Perinatally
• Prolonged labour + vacuum + impacted shoulder
• Forceps + cord around neck + APH (antepartum
haemorrhage)
• Asphyxia + hypoglycaemia + jaundice

§ Postnatally
• Meningitis + encephalitis
• Trauma + lead poisoning
• Tumour
• Acute infantile hemiplegia

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o Diagnosis
§ Often difficult ® signs appear late + picked up by
observant teacher
§ Sometimes diagnosed antenatally
§ Occasionally noticed at birth
§ Signs
• Cyanotic attacks
• Feeding problems
• Convulsions
• ­ or ¯ Muscle tone
• Abnormal movements or posture
• Distinct preference ® one hand in early life

o Post-diagnosis
§ Initial shock
• Mother’s intuition suggest something wrong but still
comes as traumatic news
• Behaviour ® hear + retain + comprehend in part \
Ä realize full scope

§ Ä Communication + counselling ® mother begins to

‘shop-around’ for other doctors + professionals + non-
medical

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§ Guilt ® one of the first feelings
• Results in overprotection or rejection of disabled
child
• Natural reaction + vital to work through

§ Common fears + anxieties

• Social stigma ® child + family
• Schooling ® long waiting lists
• Behaviour
• Isolation
• Hindered social development
• Further pregnancies

§ Stages parents may go through

• Denial ® frustration ® anger ® disorganisation ®
self-accusation ® questioning
• Parents may go through some + not others + may
even return \ Ä fixed rule

§ To achieve stability
• Allow parents to voice feelings of guilt + anger +
frustration + loneliness
• Unhealth to ‘bottle-up’

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o The multidisciplinary team ® management of CP child
§ Doctors + nurses
§ Psychologists ® educational + general; + genetic
counsellors + social workers
§ Physiotherapists + occupational therapists + audiologists +
speech therapists + orthoptists

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Medical Ethics
• 4 Principles of medical ethics
o Autonomy
§ Right of every individual to make their own decisions
§ Healthcare ® patient makes own decision after given all relevant +
necessary information
§ 4 Aspects
• Informed consent
o Threshold elements ® competence to understand +
voluntariness in deciding
o Information element ® full disclosure of information +
recommendations + ensure understanding
o Consent elements ® decision + authorisation

• Confidentiality
o All information must remain confidential
o Exception ® patient consents + ordered by a court of law +
information places other’s in danger

• Truth telling
o Tell the truth + Ä deceive
o Healthcare must inform patient of their health status

• Communication
o Utilize patient-centred approach at all times
o Listen to patient + be cognisant of consent & confidentiality at
all times
o Take necessary steps to overcome language barriers

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o Beneficence
§ Refers to doing good
§ Must be able to provide services we profess we can provide
§ Involves ongoing education + training + empowerment of patient (to control
their health)

o Non-maleficence
§ Refers to doing no harm
§ Doctors must be clear about risk + probability in assessments
§ Must practice using evidence-based techniques

o Justice
§ Obligations include
• Respect for people’s rights ® rights-based justice
• Respect for morally acceptable laws ® legal justice
• Fair distribution of limited resources ® distributive justice

§ SA ® distributive justice of ­ importance

§ \ Crucial ® patients compete on equal basis for admission to facilities + Ä
advantage other than medical need

46
• Sick certificates
o Appropriate medical certificate

47
o General facts
§ Sick leave abuse ® costs SA R12®16 billion/year
§ On average ® 15% of all staff absent on any given day
§ Only 1:3 absent employees are genuinely ill

o Right + responsibilities of employees

§ Rights
• Acceptable medical certificate ® employee must be paid statutory
sick leave pay
• Patient has the right to confidentiality regarding condition

§ Responsibilities
• Must furnish a legitimate medical certificate if
o Absent from work for > than 2 consecutive days, OR
o Absent on > than 2 occasions in a 8 week period

• Medical certificate must be issued + signed by a medical practitioner or

any person (professional nurses + allied health professions) certified to
diagnose treat + is certified with a professional council
established by an act of parliament
• Must accept if practitioner refuses to issue sick certificate
• Medical certificate must be an original document

48
Batho Pele
• Patient’s right charter ® common standard for achieving the realisation of the right
of all to access health care services
o A healthy + safe environment
§ Must ensure physical + mental wellbeing
§ Includes ® adequate water & sanitation + waste disposal + protection etc.

o Participation in decision making

§ Every citizen ® right to participate in the development of health policies
§ Right to participate in decision-making regarding ones health

o Access to healthcare
§ Everyone has the right to access healthcare services, include:
• Timely emergency care regardless of ability to pay
• Treatment + rehabilitation ® information must be made known
• Provision for special needs
• Counselling Ä discrimination
• Palliative care ® affordable + effective
• Positive disposition displayed by HCWs
• Health information ® availability of services + how to use such

o Knowledge of one’s own health insurance

§ Entitled to information regarding own scheme
§ Right to challenge any decision made by the insurance company

o Choice of health service

§ Everyone ® right to choose a particular health care provider or facility
§ Provided ® such choice is Ä in violation of ethical standards applicable to
such providers/facilities

49
o Be treated by a named healthcare professional
§ Right to know the person that is treating them \ must be attended by
clearly identifiable individual

o Confidentiality + privacy
§ Information concerning one’s health + treatment thereof ® may only be
disclosed with consent, UNLESS ® law/order of court

o Informed consent
§ Everyone ® given full + accurate information regarding nature of illnesses
+ diagnostic procedures + proposed treatment + cost etc.

o Refusal of treatment
§ May refuse treatment + such refusal must be in verbal or written form
§ Provided ® such refusal Ä harm others

o Be referred for a 2nd opinion

§ Everyone ® right to be referred for 2nd opinion on request

o Continuity of care
§ Ä Shall be abandoned by healthcare provider/facility which initially took
responsibility for one’s care

o Complain about health services

§ Right to complain + have such complaints investigated + receive full
response

50
• Responsibilities of patient
o Advise HCWs on wishes regarding death
o Comply ® prescribed treatment or rehabilitation procedures
o Enquire ® related costs + arrange for payment
o Take care of health records
o Take care of their health
o Care for + protect environment
o Respect the rights of other patients
o Utilise healthcare system properly
o Know their local health services + what they offer
o Provide HCWs ® relevant + accurate information

• Batho pele principles

o Consultation
§ Communities ® consulted regarding levels + quality of public services they
receive
§ Where applicable ® right to chose

o Service standards
§ Citizens should know level + quality of services they receive
§ Should know what to expect

o Access ® all have equal access to the services they are entitled to
o Courtesy ® citizens should be treated with courtesy + consideration
o Information ® all should be given full + accurate information about public
services
o Openness + transparency
§ Citizens ® should know how national + provincial departments are run
§ Should know who is charge

51
o Redress
§ Promised standard of service Ä delivered ® should be offered apology +
explanation + effective remedy
§ Should receive a sympathetic response

o Value for money

§ Public services should be provided economically + efficiently
§ Such that ® communities + citizens given best value for money

o Implications for health staff

§ Services with ­ standard of professional ethics
§ Mission statement for service delivery
§ Services are measured + performance indicators are displayed
§ Services ® in partnership + complement other sectors
§ Services ® customer friendly + confidential
§ Opportunities for community consultation
§ Outreach ® reaches all communities + families in greatest need
§ Easily accessible + effective ways of dealing with complaints/suggestions
§ Current information ® services available + hours of service

52
Health Screening
• Health screening
o General
§ Definition ® process used to detect disorders or risk factors in healthy people, of which
they are unaware
§ Objectives ® reduced disease incidence + morbidity + mortality +
disability
§ Screening ® usually a form of 2nd prevention \ identity individuals with
asymptomatic disease + prevent progression

o Criteria for screening ® e.g. Ca of Cervix + BP + HIV

§ Condition
• Common + important
• Must have a asymptomatic/latent phases
• Natural history must be well understood
• Effective treatment must be available
• Outcome improved by early treatment
• Effective treatment available

§ Test
• Suitable + acceptable
• ­ Sensitivity + specificity
• Resources for further diagnosis + treatment
• Screening should be continuous + follow quality improvement cycle
• Cost effective

o Limitations + dangers of screening ® NB in SA as ¯ resources + screening saves

§ Difficult in SA
• Ä Many population screening programmes in place \ lack of
awareness

53
 • Poverty-related problems ® Ä fixed address + moving for job/housing +
Ä fixed phone number
• Ä Structures registration system of patients at health facilities/GPs
• Lack of public awareness
• Culture, beliefs + ideas ® won’t happen to me etc.

§ Potential for harm

• False +ves ® unnecessary distress + investigation + treatment
• False -ves ® false reassurance
• Costs to society ® actual cost of equipment + services + treatment
+ time off work
• Funds diverted from other healthcare services

o Sensitivity + specificity
§ Sensitivity ® probability of the test being positive if the disease is truly present
• ­ Sensitive ® ¯¯¯ false -ves
§ Specificity ® probability of the test being negative if the disease is truly absent
• ­ Specificity ® ¯¯¯ false +ves

§ Screening tests ® need to be ­­ sensitive + specificity is < important as

such may be dealt with in later tests

• Cervical screening in SA
o Facts
§ 2nd Commonest cancer in women
§ SA ® 3 free cervical cytology smears + taken at 10-year intervals + all
women aged 30 or older
• Follow up + treatment ® free of charge
• HIV +ve ® every 3 years

§ Private ® usually done every 2 years

54
o Screening criteria
§ Common ® 2nd > common cancer in women (1 in 41 women are at risk)
§ Important ® ­ morbidity + mortality
§ Latent phase ® yes, > long
§ Natural history understood ® Ö well
§ Suitable + acceptable test ® ±yes, may be ­ via HPV screening
§ Outcome Ö by early treatment ® yes, LLETZ (large loop excision of the
transformation zone) or hysterectomy
§ Effective treatment available ® Ö
§ Resources for further diagnosis + treatment ® yes, BUT ® poorly
managed + resourced
§ Screening continuous + includes QI ® clinical auditing tool

o Interpret + explain different results

§ Explaining cervical smears + helpfulness
• Cervical cancer ® cancer of the mouth of the womb + > common
• Smear ® early screening test to try and identify signs of
possible/early cancer
• Saves lives ® doctors find D before disease \ can intervene
• Recommendations
o Global ® done every 2 years from the age of 25
o SA ® 3 free smears every 10 years from the age of 30

• However! ® if money is available, attend private doctor

• Test ® utilizes wooden instrument to wipe the mouth of womb +
smear on slide
• Slide ® sent to lab + results take ±6 weeks to be released
• Smear is done in consulting room + takes ± a few minutes

55
 § Explanations of results
Result Meaning Explanation Outcome Action
Repeat smear
Atypical squamous Minor changes in cells Most cases
HIV +ve ® 6m
ASCUS cell of uncertain Ä Cancer regress
HIVE -ve ® 12m
significance Most improve within a year spontaneously

Wart virus Often resolves as

HPV present, BUT ® Ä the body clears
changes in cells virus
D in Cells ® very early changes
Atypical glandular
that may lead to cancer
cells of
AGUS May be treated in hospital by a Colposcopy
undetermined
simple day-case procedure that
significance
removes part of the cervix
Low grade Very early D in some cells Most cases Repeat smear
LSIL squamous Ä Cancer regress HIV +ve ® 6m
intraepithelial lesion Most improve after 1 year spontaneously HIV -ve ® 12m
D in Cells ® very early changes
High grade that may lead to cancer
HSIL squamous May be treated in hospital by a Do not regress Colposcopy
intraepithelial lesion simple day-case procedure that
removes part of the cervix
Early cancer
Adenocarcinoma in Needs to be investigated Urgent colposcopy
AIS
situ Treated ® ¯ procedure or appointment
operation

o New screening tests

§ CA ® caused by persistent ­-risk HPV types ® 16 + 18 + 31 + 45 + 42
§ Types of HPV testing
• Non-discriminatory ® give +ve or -ve result for any ­-risk HPV
• Discriminatory ® differentiate between a specific ­-risk HPV (usually
16 + 18) + other ­-risk HPV types \ may identify specific type

56
§ Current guidelines

57
 § Advantages and disadvantages
• Advantages of HPV testing
o ­ Recommended screening interval
§ ­ Sensitive + ­ NPV
§ ¯ Resource
• HIV +ve ® 5 yearly (vs 3)
• HIV -ve ® 10 yearly (vs 5)

§ ­ Resource
• HIV +ve ® 3 yearly (vs 1)
• HIV -ve ® 5 yearly (vs 3)

o May be cheaper in the long run owing to ­ efficacy

• Disadvantages of HPV testing ® > costly

• Clinical audit tool + quality improvement

58
o General
§ Quality improvement ® process by which clinical governance activities
result in visible + viable D
§ Audit ® basic instrument of quality improvement cycle

o Establishing an ethos of quality improvement

§ Be patient-centred + consider needs of community
§ Focus on systems + processes that Ä performing
§ Focus on what can be improved + what is working
§ Team approach + aim to be inclusive
§ Ensure effective communication + feedback
§ Be proactive ® identify future areas for improvement!
§ Use data ® may be measured before + after intervention implementation

o Process
§ Assess the current situation = AUDIT
• Compare current vs target standards ® a goal that quantifies a desirable
level of performance in a particular aspect using multiple sources of criteria
• Criteria ® normally based on evidence-based guidelines + set for
o Structure ® resources + infrastructure
o Process ® events that occur as patients arrive at facility
o Outcome ® result of Ö quality care

§ Identity gaps in current provision ® collect + capture + analyse data

regarding specific performance variables

§ Analyse causes + explore alternative methods of improvement

• Consider underlying causes + contributing factors
• Explore different idea on how to D

59
 § Planning + implementing D
• Agree on goals = SMART
o S ® specific
o M ® measurable
o A ® achievable
o R ® relevant
o T ® timed

• Agree on strategy of implementation

§ Sustain changes + evaluate

• Cycle continues until desired change achieved
• Process ® usually slow + incremental
• QI team ® consistently re-evaluate target standards
• When D successful ® steps taken to ensure sustained + escalated to
other area of organisation

o Alternative QI model ® PDSA

60
Substance Use and Intimate Partner Violence
• Substance use
o General
§ DSM-V ® Diagnostic and Statistical Manual of mental Disorders 5th edition
§ Test on names + symptoms + diagnostic features of every mental illness
§ Recognizes ® substance-related disorders resulting from the use of 10
separate classes of drug e.g. alcohol + caffeine + cannabis + hallucinogens + tobacco
+ inhalants + opioids + sedatives + hypnotics + anxiolytics + other unknown
§ Activation of brain’s reward system ® central to problems arising from
drug abuse
§ People ® Ä all people are automatically or equally vulnerable to developing
substance related disorders + some individuals have ¯ self-control vs.
others

o Definitions
§ Substance use disorder ® patterns of symptoms resulting from the use of a substance
which the individual continues to take, despite experiencing problems as a result
§ Substance induced disorders ® problems caused by the substance’s effect on the body
• Intoxication + withdrawal
• Substance-induced mental disorders
o Substance-induced psychosis
o Substance-induced bipolar + related disorders
o Substance-induced depressive disorders
o Substance-induced anxiety disorders
o Substance-induced obsessive-compulsive & other related
disorders
o Substance-induced sleep disorders
o Substance-induced neurocognitive disorders

61
o Substance use disorders ® 11 criteria
§ Take substance in > amounts + for longer than person is meant to
§ Wanting to cut down or stop using substance + Ä
§ Spending a lot of time acquiring + using substance
§ Cravings + urges to use substance
§ Ä Managing to meet role obligations work + home
§ Continuing use, even when it causes problems in relationships
§ Giving up important social + occupational activities owing to substance use
§ Use substance again & again even though it puts one in danger
§ Continuing use even with the knowledge of having a physical or
psychological problem caused by such use
§ Development of withdrawal symptoms ® relieved by taking > of that
substance
§ Outcome
• 2-3 ® mild substance use disorder
• 4-5 ® moderate substance use disorder
• 6 or > ® severe substance use disorders
• Further details
o In early remission
o In sustained remission
o On maintenance therapy
o In controlled environment

62
o Screening tests
§ CAGE

§ Brief MAST (Michigan alcohol screening test)

63
§ Trauma Scale ® useful for detecting abnormal drinking patterns
• Since your 18th birthday
o Have you had any fractures or dislocations to bones or joints?
o Have you been injured in a road traffic accident?
o Have you injured your head?
o Have you been injured in an assault or fight?
o Have you ever been injured after drinking alcohol?
o Outcome
§ 2 or > +ve Answers ® +ve for abnormal drinking

§ AUDIT (alcohol use disorders identification test)

64
 o Barriers to the recognition of alcohol problems
§ Lack of clinician confidence as to what exactly constitutes alcohol misuse
§ Inadequate training
§ Lack of contractual incentives
§ Lack of time
§ Fear of labelling owing to stigma associated to alcohol misuse
§ Belief ® patient’s Ä honestly disclose their drinking practices

o Most modifiable predictor ® willingness of clinicians to ask about alcohol

habits appropriately
o Alcohol misuse screening ® should be part of routine care

• Interpersonal violence
o Definition ® intimate partner violence is any behaviour within a current, ex or would-be
intimate relationship that causes physical, psychological or sexual harm to either partner
§ Examples
• Physical violence ® punching + kicking + burning etc.
• Emotional (psychological) abuse ® insults + humiliation +
intimidation + threats
• Sexual violence ® forced sexual intercourse etc.
• Controlling behaviour ® isolating one’s partner from friends &
family + limiting access to financial resources

o Recognizing abuse
§ Signs
• Vague + non-specific symptoms
• History of mental problems or psychiatric medication
• Fatigue + sleep problems + unexplained somatic complaints
• Symptoms of depression + anxiety
• Chronic pain syndromes

65
 • Repeated STIs
• Assault/trauma
• Suspected alcohol or substance abuse

§ Direct questions ® sensitively

• Are you unhappy in your relationship?
• Do you sometimes feel unsafe with your partner?
• Has your partner ever hurt you?

o Cycle of violence + risk factors for IPV

§ Risk factors ® why it’s hard to leave/disclose

• Demographic variables ® having minimal/Ä schooling
• Childhood variables
o Frequent physical punishments
o Witnessing familial violence

66
 • Behavioural variables
o Problematic drug and/or alcohol abuse
o Past criminal involvement
o Involvement in community fights
o Having > than 1 intimate partner
o Verbally abusive behaviour

• Social variables
o Income or educational disparities between partners
o Social norms + attitudes that condone violence
o Patriarchal notions of masculinity ® power + control
o Perceived challenges to male authority
o Economic inequality in context of poverty
o Intergenerational cycle of violence
o Culture of violence in community

§ Understanding IPV

67
o Findings of studies regarding male perpetrators
§ Men’s violence against intimate partners ® associated with witnessing
violence in the home + drug and/or alcohol abuse +involvement in
conflicts outside of the relationship
§ Men ® often socialized into violence
• Aggressive behaviour ® learned through family + peers +
community

§ Men who are violent ® tend to have adopted rigid stereotyped views
regarding gender roles
• Violence ® often enacted when partner ‘violates’ such perceived
roles

§ Feelings of powerlessness + Ä being able to meet social expectations of

manhood (owing to poverty + unemployment etc.) ® violence
§ Violence ® often contains emotional (loss of control) + instrumental ( having
control) components

o Prevention of intimate partner violence

§ Individual
• Programmes ® ¯ antisocial + aggressive behaviour in adolescents +
children
• Counselling + psychotherapy for perpetrators of violence
• Treatment + rehabilitation ® prevent re-victimisation

§ Psychological + relational
• Parent + family interventions ® Ä child maltreatment
• Home-visitation programmes
• School-based programmes ® D gender norms + attitudes
• Life-skills + mentoring programmes

68
 § Socio-cultural
• Community-based programmes ® D gender norms
• Rape prevention programmes
• Public awareness campaigns ® dispel myths + encourage
• Human rights advocacy to foster gender empowerment +
empowerment

o Management + plan
§ Clinical
• Check for sexually transmitted infections
• Care for injuries + ensure adequate forensic documentation using
J88 form
• Check for pregnancy, offer ® contraception + termination and/or
sterilisation as appropriate

§ Individual
• Listen attentively to patient’s story
• Screen for mental problems ® e.g. anxiety + depression +
substance abuse + PTSD + suicide-risk
• Offer ® follow-up counselling + support

§ Contextual
• Refer
o Family court for protection order
o Victim Empowerment Unit at a police station
o NPO sector for legal aid

69
 • Domestic Violence Act ® police obligations
o Police must find abused a safe place to stay + help access
medical care
o Must inform abused of legal options ® laying a charge +
applying for a protection order
o Explain ® temporary protection order will come into effect
once abuser has been served
o Order contravened ® abuser will be arrested

• Perform a risk assessment ® consider following factors

o ­ Severity + frequency of abuse
o Availability of a weapon
o Threats to kill patient + children + abuser
o Previous attempts to kill patient
o Suicide attempt by patient

§ Help patient ® plan for safety

• Organise accommodation + help abused plan to leave abuser
• Encourage patient to seek help + support
o Lifeline ® contact information of shelters
o NICRO ® group + individual counselling
o Spiritual leaders

o Domestic violence act

§ General ® provides individuals experiencing violence the best protection
the law can provide
§ Purpose
• Possible ® get a protection order against an abuser
• Protection order ® Ä abuser from committing > acts of violence
• Abuse commits acts ® may be arrested + taken to court

70
§ Definitions
• Protection order ® order of the court where a magistrate lists various things
that an abuser may/may not do, to stop the abuser from abusing
• Domestic relationship
o Currently live or lived in the past under the same roof with
that person in an intimate relationship or civil marriage or
customary marriage
o Ä Live with the person, BUT ® in an intimate relationship
with that person
o Simply currently live with that person
o Person is a family member or a family member of a
current/past partner
o You share the responsibilities of a child with that individual
o Person believes/thinks ® intimate relationship

• Domestic violence
o Physical + sexual + emotional + psychological + verbal +
economic abuse
o Intimidation
o Harassment
o Stalking
o Damage to property
o Person enters place of residence Ä permission
o Any behaviour that is abusive or harmful + bad effect on one’s
safety + health + wellbeing

§ Protection orders
• General
o Who ® anyone who is currently being abused + on behalf of
someone being abused (written information)
o Where ® domestic violence section of local magistrates court
71
• Process
o Step 1 ® application form
§ Full details ® name + ID & phone number + address
etc.
§ Details of person abusing individual
§ All reasons for urgency
§ Explanation of abuse + asking about form of protection

o Step 2 ® interim protection order

§ Form completed ® taken to magistrate ® facts
analysed
§ Magistrate decides whether to issue an interim
protection order or not, UNTIL ® both may attend
court
§ Interim protection order ® date to return to court +
appear in front of magistrate
§ Protection order ® may only be used once it has
been served on him

o Step 3 ® service of documents + notice to abuser

§ Ö Interim protection ® following document served on
abuser
• Copy of application documents
• Copy of interim protection order
• Copies of any recordings or information used in
decision
• Notice ® calling abuser to come to court

§ Ä Interim protection ® following documents

• Copy of application
• Copy of witness affidavit
• Notice ® calling individual to court
72
 § All documents to be served ® must be taken to
police/office of sheriff by individual themselves

o Step 4 ® the return date

§ Magistrate will hear story + decide on final protection
order
§ Abuser ® also will have a chance to defend themselves
+ may even ask accuser questions regarding evidence
§ Magistrate ® takes into consideration all
documentation + witness statements
§ Decision ® issue final protection order or postpone
date + serve another date

• Final protection order

o The court may Ä abuser from
§ Entering abused home or certain room within home
§ Enter workplace
§ Commit acts of domestic violence against individual
§ Arrange ® other people to commit violence against
individual

o Further
§ Ä Abuser from sharing home with you
§ Ask police to remove dangerous weapons
§ Police officer to attend individual collecting personal
items
§ Depending on financial situation® make abuser pay
rental/bond payments + cover expenses incurred
owing to violence
§ Ä Abuser from seeing individual’s children

73
• Contravening protection order
o Abuser does anything that protection order Ä him from doing
§ Contact police + provide sworn affidavit
§ Police will arrest abuser if
• Contravention of order was serious
• Abuser may abuse individual >
• Ä Much time has passed between contravention
+ reporting of such

§ Ä Arrest ® police will provide individual with notice

to appear in court

o Punishment Abuser will appear in court + may be sent to jail

for ­ to 5 years or ordered to pay a fine or both
o Every protection order ® comes with a ‘suspended’ warrant
of arrest

74
Rational Prescribing
• Rational drug prescribing
o General
§ Rational prescribing ® process of ensuring that the diagnosis + advice + treatment
are Ö + if medicine is used, it is the correct choice
§ Medicine ® must be the correct medicine + given at the correct dose +
over the right period of time + patient must know enough about
medication to know where and when to take it + side-effects

o Choosing ‘first choice’ treatment

§ 4 Approaches to treatment
• Information + advice
• Treatment without drugs
• Treatment with drugs
• Referral

§ Choosing ‘first choice’ ® chosen on basis of comparison of efficacy ®

safety ® suitability ® cost (in order of importance)
• SA ® choice limited to Essential Drug List
o Essential drugs ® medicine that are critically required for the
treatment + management of 90-95% of common + important conditions
o Such medicines ® must meet ­ standard of safety + quality +
efficacy

• Questions to ask before prescribing ® Do I need a drug at all?

o What is it for? ® indications + 1st vs 2nd line
o How effective is it? ® trial-based knowledge
o How safe is it? ® contra-indications + interactions +
adverse reactions
o Who should Ä receive it? ® ­-risk patients = children +
geriatric patients + pregnant + breast-feeding + liver/renal
disease + porphyria + DM (than cost?)
75
o Process of rational prescribing
§ Step 1 ® define the patients problem
• Diagnosis ® via the utilization of clinical skills such as questioning
+ listening + examining
• Presenting problems
o Disease or disorder
o Sign of underlying disease
o Psychological or social problems
o Side effects of drugs
o Refill request ® polypharmacy
o Non-adherence to treatment
o Request for preventative treatment
o Combinations of above

§ Step 2 ® specify therapeutic objectives

• Decide on specific goals ® avoids unnecessary drug use
o NB ® your goals + patient reason for visiting may be very D
\ vital to discuss all information with patient

• Patient demand
o Demand for drug ® often much > than a demand for a
chemical substance
o May be owing to
§ Underlying psycho-social problems ® dependence +
depression etc.
§ Personal characteristics + views ® influenced by past
experience with clinicians + by family + by
advertisements

o Ä Rules to deal with such except 1 ® talk with patient +

give careful explanations, patients are partners
o Only enemy ® time
76
§ Step 3 ® choosing a suitable treatment
• Effective + safe + suitable + cheap chosen for condition, NOW ®
is the treatment safe and effective for this specific patient
• Effective treatment?
o Effectiveness ® indication + convenience
§ Review ® active substance is likely to achieve
therapeutic objective + whether dosage is suitable
§ Convenience ® massive effect on patient adherence \
¯ doses + least amount of time + simplest form of
administration

o Safety ® contra-indications + interactions + ­-risk groups

§ Contraindications ® determined by mechanism of
action of drug + characteristics of patient
§ Interactions
• May occur between prescribed drug + nearly any
other substance taken by patient
• Most well-known ® interactions with other
prescribed drugs
• Interactions may occur with food + some
interactions ® Ä drug

§ ­-Risk groups
• Pregnancy + lactation
• Elderly + children
• Renal + hepatic failure
• Hx of drug allergy
• Other diseases + medications

77
§ Step 4 ® starting the treatment
• Provide advice + write prescription
• Prescription requirements
o Doctor ® Name + qualifications + address + telephone
number + practice number + HSPCA number
o Date of issue of prescription
o Patient ® name + age + sex + address + condition (consent) +
allergies
§ Child ® weight + height

o Rx
§ Generic name + strength (how many milligrams) + type
(tablet + suppository + mL for liquids)
§ Information for label ® amount + dosage form (by
mouth etc.) + frequency + any specific instructions
(warnings etc.)
§ Repeat?

o Signature of prescriber
o Rules ® Ä abbreviations + lay language

§ Step 5 ® give information +instructions + warnings

• Patient must have full understanding of why they are being
treated
• Improving patient compliance
o Prescribe a well-chosen treatment ® as few drugs as possible +
rapid action + few side-effects + appropriate & simple dose + shortest
duration
o Creat Ö clinician-patient relationship
o Take time to give information + instructions + warnings

78
 • Giving information + instructions
o Effects of drug ® symptoms disappearance + importance of
compliance + consequences of defaulting
o Side effects ® when they occur & how to recognize + how
long they will remain + seriousness
o Instructions ® when to take + how + storage + length of
treatment + what to do if problems arise
o Warnings ® what Ä to do + maximum dose + importance
of finishing antibiotics
o Next appointment ® when to come back + what to do with
leftovers
o Everything clear? ® everything understood + repeat
information

• Prime responsibility of prescriber ® patient understands

treatment

§ Step 6 ® monitor the treatment (stop?)

• Patient returns ® 3 possibilities
o Treatment Ä effective
o Treatment Ä safe ® unacceptable side effects
o Treatment ® Ä convenient

• After patient leaves

o Did I achieve my therapeutic goals?
o Keep in contact ® 2 methods
§ Passive monitoring ® explain to patient what to do if Ä
effective/safe/convenient before they leave
§ Active monitoring ® make an appointment for the
patient to see clinician again
79
 • Was the treatment effective?
o Yes + disease cured ® Ä treatment
o Yes, BUT ® Ä yet completed
§ Any serious side effects?
• Yes ® reconsider dosage + drug choice
• No ® treatment may be continued

o No + disease Ä cured ® check all steps

§ Diagnosis correct?
§ Therapeutic objective correct?
§ First-choice drug suitable for this patient?
§ Drug prescribed correctly?
§ Patient being instructed correctly?
§ Effect monitored correctly?

• Standard treatment guidelines

o Definition ® practical recommendations to help the prescriber based on consensus using all
available data
o Criteria for valid + safe + effective guidelines
§ Multidisciplinary origin
§ Based on review of literature of regarding each specific clinical situation
§ Reached via group consensus
§ Unbiased ® best interests of patient in mind
§ Regularly updated

o Advantages
§ Assist in clinical decision making
§ Synthesis of many people’s knowledge
§ Explicit guidelines ® shown to improve practice
§ Usually factually up-to-date

80
 o Disadvantages
§ May be too restrictive
§ May recommend treatment not locally available
§ May stop provider from viewing patient as an individual

o Prescriber > likely to use guidelines if

§ Involved in the creation of the guidelines (national guidelines often adapted to
local context)
§ Exposed to an educational campaign regarding a specific problem
§ Unsure about clinical problem
§ Guideline ® significantly ­ patient’s outcome

• Iron therapy
o Iron deficiency anaemia
§ General
• ­-Risk ® infants + adolescents + elderly
• Common causes
o Inadequate dietary intake
o Parasitic worm infections
o Vegetarians + vegans

• Factors affecting iron absorption

o Tea + cereals containing phytates or phosphates
o Gastrectomy
o Renal failure + coeliac disease + H. pylori infections

§ Prescriber points
• Hb ® typically rises 2g/dL every 3 weeks in patients treated for iron
deficiency
• Oral administration preferred ® parenteral administration in select
cases
81
• Regeneration of Hb ® Ä affected by formulation/method of iron
administration
• Failure to respond to iron therapy suggests
o Blood loss
o Incorrect diagnosis
o Non-adherence
o Malabsorption
o Concurrent folate and/or B12 deficiency

• Doses
o Most adults ® 100mg elemental iron daily = Ö response
o Prophylactic dose for Ä of anaemia of pregnancy ® 60mg
elemental iron daily

• Adverse effects ® initiate slowly + ­

o Gastrointestinal irritation
o Black discolouration of stools
o Iron salts in liquid form ® may discolour teeth
o Constipation

• Iron preparations
o Oral iron preparations
§ Ferrous salts
§ Iron with folic acid ® used in pregnancy to Ä iron + folic acid
deficiency

o Parenteral iron preparations

§ Indicated
• Iron therapy has failed ® absorption defects +
severe & persistent GIT intolerance +
ongoing blood loss + non-adherence
82
 • Patients on erythropoietin
• Patients on haemodialysis

§ Iron polymaltose
§ Ferric hydroxide-sucrose complex
§ Iron hydroxide-dextran complex

o Chronic iron overload

§ Iron-chelating agents
• Deferoxamine
• Deferasirox

o Megaloblastic anaemia
§ Folate deficiency
• Causes
o Usually ® inadequate intake or poor dietary quality (alcoholism)
o Malabsorption
o Thalassaemias + other haemolytic anaemias
o Chronic use of medications with anti-folate activity
o ­-Demand in pregnancy + lactation

• Ö Sources ® liver + spinach + broccoli + mushrooms + beef +

whole-wheat products
• Prescriber points
o Folate Ä given alone to patient with megaloblastic anaemia
where B12 is WÄ known
o Folate therapy ® should be continued for 3-4m after desired
haematological abnormality corrected
o Prophylaxis ® ­-demand states e.g. pregnancy + lactation

83
§ B12 deficiency
• Main manifestations ® megaloblastic anaemia + neurological
symptoms (sub-acute combined degeneration of the spine + peripheral
neuropathy + dementia)
• Causes
o Strict vegetarian diet
o Impaired absorption owing
§ Lack of gastric intrinsic factor (pernicious anaemia)
§ Post-gastrectomy
§ Post gastric bypass
§ Ileal disease or resection
§ Rare congenital conditions

o May precipitate 2nd folate deficiency owing to methyl-folate

trap

• Ö Sources ® organ meats + milk + fish + meat & poultry

§ Treatment
• Vitamin B12 (cyanocobalamin)
• Folic acid + derivatives
o Folic acid
o Folinic acid

84
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