Download Management of a patient with acute chest pain

Acute chest pain
Management of a patient with acute chest pain:
When being phoned by the sister in charge of the Emergency Unit reporting
admission of a patient with acute chest pain who needs your immediate attention,
it will help if you instruct her to execute the following steps immediately while you
make your way to the Unit.
Remember: "O M I M A N"
O = OXYGEN (mask)
M = MONITOR (ECG)
I = INFUSION (Saline 200ml, to ensure venous access)
M = MORPHINE (10mg in 9cc water slowly IV for pain)
A = ASPIRIN (½ or 1 tab stat sublingually, give it before any other drug!)
N = NITRATES (sublingually, if not contra-indicated as in case of Viagra)
Upon your arrival you must assess the patient fully!!
Your assessment and management must include:
 Airway: check patency, remove foreign bodies, e.g. dentures, mucus, etc. if applicable.
 Breathing: ensure that the patient is breathing well or assist / intubate if necessary.
 Circulation: check pulse rate, rhythm and volume by feeling the carotid pulse. CPR to be
done if and when necessary. (Control bleeding if appropriate.)
 Drip, drugs, defibrillation if appropriate.
 Evaluate frequently and act accordingly; do ECG, cardiac Enzymes or Trop-T if indicated,
etc.
Some people prefer to use MONA LISA in place of OMIMAN….. as follows:
MONA LISA greets the patient…. Lisa first!
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L = Leads on first (12 lead ECG).
I = IV access.
S = Systolic BP.
A = Allergies.
M = Morphine.
O = Oxygen.
N = Nitrates sublingually.
A = Aspirin (first! Of the drugs).
Body Mass Index.
The Formula:
Weight(kg)
Height(m)2
Interpretation of BMI:
< 18,5 = UNDERWEIGHT.
18,5 – 24,9 = NORMAL.
25 – 29,9 = OVERWEIGHT.
30 – 34,9 = OBESITY (CLASS 1)
35 – 39,9 = OBESITY (CLASS II)
> 40 = EXTREME OBESITY (CLASS III)
American Family Physician
1 Oct 2005, Vol 72, No 7; p1391-8
American Heart Association Guidelines for In-clinic BP Measurement.
(Using mercury sphygmomanometers)
RECOMMENDATION
COMMENTS
Patient should be seated comfortably, with
back supported, legs uncrossed and upper
arm bared.
Diastolic pressure is higher in the seated
position, whereas systolic pressure is higher
in the supine position.
(If possible, the patient should be seated for 5
minutes before the reading)
An unsupported back may increase diastolic
pressure; crossing the legs may increase
systolic pressure.
(The middle of the cuff on the upper arm
should be level with the right atrium, at the
midpoint of the sternum)
Patient’s arm should be supported at the
heart level.
If the upper arm is below the level of the right
atrium, the readings will be too high; if the
upper arm is above the heart level, the
readings will be too low.
If the arm is unsupported and held up by the
patient, pressure will be higher.
In the supine position, the arm should be
supported on a pillow to raise it above the
level of the heart, which is situated about
halfway between the bed and the sternum.
Cuff bladder should encircle 80% or more of
the patient’s arm circumference.
An undersized cuff increases errors in
measurement.
Mercury column should be deflated at 2-3
mm per second (or per pulse when the heart
rate is slow).
Deflation rates greater than 2 mm per second
can cause the systolic pressure to appear
lower and the diastolic pressure to appear
higher.
The first and last audible sounds should be
recorded as systolic and diastolic pressure,
respectively Measurements should be given
to the nearest 2mmHg.
Neither the patient nor the person taking the Talking during the procedure may cause
measurement should talk during the deviations in the measurement.
procedure.
Tubing between the device and the cuff should be 70cm or more in the office setting.
The system must be airtight, so the tubing and the release valve should be inspected
regularly.
In older patients, BP should be measured routinely in the standing and seated positions to
screen for postural hypotension.
In patients with an arm circumference greater than 50cm, the cuff should be wrapped around
the forearm, supported at the heart level, and the radial pulse felt at the wrist.
EAR SYRINGING.
Prepare the correct equipment.
(A 10 or 20 ml syringe and a Jelco catheter is as effective as a large metal ear syringe!)
Explain to the patient what is about to happen and what should not happen, e.g. pain / water
running down inside the throat.
Check that the plunger of the syringe moves freely in the barrel.
Fill the reservoir jug with luke warm tap water or a temperature of 370C maximum.
Draw water into the barrel of the syringe.
Method:
 Drape the patient’s shoulder and neck.
 Position the collection dish below the patient’s ear – let the patient hold it in
position.
 Advance the nozzle into the patient’s external auditory meatus while
simultaneously applying traction to the pinna in an upward and backward
direction (to straighten the canal).
 Advance the plunger aiming the nozzle at the roof of the canal, i.e. in a posterior
superior direction.
 When the syringe is empty, examine the canal for the persistence of wax / foreign
body or damage to the ear canal.
Continue this process until the wax or the foreign body has been removed.
Dry / clean the patient.
Contra-indications for syringing an ear:
 Previous middle ear surgery.
 Perforated TM.
 Discharge obscuring the TM.
 Recent insertion of Grommets.
ECG / EKG
WHAT IS AN ECG / EKG?
It represents a “picture” of the electrical activity of the heart.
We need to be able to interpret the picture!
Compare waves coming towards you and going away from you – and those you see side-on.
Different electrodes “look” at the heart from various places – therefore the pictures differ.
Grouped leads are used to interpret abnormal patterns rather than looking at one lead only.
We shall discuss the following aspects:
 The placing of the electrodes.
 The normal ECG pattern and what each deflection represents.
 Normal values / sizes of each deflection.
 The order of “reading” the ECG:
 Rate / Rhythm / Axis / p-wave / PR-interval / QRS-complex / ST Segment / Twave / Q-wave and the R-wave progression.
[= Ra/Ry/Ax/P/PR/QRS/ST/T/Q/R ]
The Leads:
Bipolar leads = I, II, III (no visible wires!).
Unipolar leads = aVR, aVL, aVF.
Precordial leads = V1 – V6.
Placement of the leads:
aVR = on the right wrist.
aVL = on the left wrist.
aVF = on the left ankle(foot).
V1 = on the 4th ICS right sternal margin.
V2 = on the 4th ICS left sternal margin.
V3 = midway between V2 and V4.
V4 = 5th ICS on the left, mid clavicular line.
V5 = same level as V4 left, anterior axillary line.
V6 = same level as V4 and V5 left, midaxillary line.
Grouped leads:
Anterior = V1 – V4 (some say V1 – V6)
Antero-septal = V1 – V3
Apical = V5 – V6
Lateral = aVL, I, V5 - V6
Antero-lateral = aVL, I, V1 - V6
High lateral = aVL, I
Inferior = II, III, aVF
Infero-lateral = aVL, I, V5 – V6, II, III, aVF.
Posterior = Nil (some say dominant R waves in V1).
aVR: looks into the ventricles.
Interpretation of the ECG:
P-wave: represents the spread of electrical activation through the atrial myocardium starting
from the SA node(= atrial depolarization).
PR interval: represents the time taken by atrial depolarisation (electrical activation) or
conduction of the impulse through the AV node. It is measured from the start of the P wave to
the start of the R wave.
QRS or ventricular complex: represents spread of electrical activation (depolarisation)
through the ventricular myocardium (=ventricular conduction / depolarization).
ST segment: pause in ventricular electrical activity before repolarization.
T-wave: represents electrical recovery of the ventricular myocardium (in both ventricles) =
ventricular repolarization.
U-wave: Uncertain – possibly: caused by after potentials at the beginning of diastole. Can be
normal. Could be due to hypokalaemia.
When present, most clearly seen in the anterior chest leads namely V2 – V4.
U waves point in the same direction as the preceding T waves and result from the same
clinical abnormality.
How to determine the following…
1. RATE:
(RR) Count number of large squares – divide number into 300 = ventricular rate.
(pp) Count number of large squares – divide number into 300 = atrial rate.
(Atrial fibrillation = Irregular RR; Atrial flutter = Regular RR)
2. RHYTHM:
Check for P waves and then check for a QRS complex to follow each P wave.
Regular P waves followed by a QRS complex = SINUS rhythm.
3. AXIS: (Correlates with STD lead II). (N = -15 to +90 degrees).
The electrical axis represents the direction of spread of depolarization through the heart. To
determine the axis, use leads I and aVF.
QRS positive in I and aVF = normal axis;
QRS in I (+) and aVF (-) = Left axis;
QRS in I (-) and AVF (+) = Right axis.
Extreme right axis: (+90 to +180 degrees) QRS negative in I and aVF.
Causes of a Left axis deviation = HT, IHD, AMI, LV hypertrophy.
Causes of a Right axis deviation = COPD, RV hypertrophy, Pulm HT, Pulm Emb)
4. P-wave: (2,5 small squares wide and <2,5 small squares high)
Tall peaked P-wave = Hypertrophy of the right atrium, e.g. Pulmonary HT (= p. pulmonalis)
Notched broad P-wave = Hypertrophy of the left atrium, e.g. mitral stenosis (= p. mitralis)
Check P wave in V1 for atrial hypertrophy.
5. PR-interval: (5 small squares wide)
Prolonged = ß-blocker, heart block, digitalis.
Shortened = tachycardia.
6.
QRS Complex: (2,5 small squares wide = same as the p-wave)
Look at the width and height of the complex:
Wide = Bundle branch block (BBB)
Tall R waves in V1 = RV hypertrophy
Tall R waves in V6 = LV hypertrophy
Transition point: R and S waves are equal in the chest lead over the interventricular septum,
normally V3 or V4.
7.
ST Segment:
Flat or depressed = ischaemia; digoxin
Elevated / raised = AMI
‘Saddle-shaped’ ST segment elevation with small complexes = pericarditis.
8.
T-wave:
(< 5 small squares wide and <3 small squares high)
Peaked: could be hyperkalaemia; LV•ª, (etc.)
Flat = hypokalaemia.
Inverted: could be ischaemia, AMI, pericarditis, LV hypertrophy, pulmonary embolism,
BBB, or normal in some leads.
Always (+) T-wave in L1 and L2 and V4-6 (varies in other leads)
Always (-) in aVR
If inverted in V1/V2, must then upright in V4-6.
9.
Q-wave: (<1 small square wide and <2 small squares deep)
They result from septal depolarization (therefore also known as ‘septal’ Q waves) and are
usually absent from most of the leads of a normal ECG. Small Q waves are normal in leads
that look at the heart from the left: I, II, aVL, V5 and V6.
10. R-wave progression: Enlarges gradually from V1 to V6
R-wave >25 mm (5 large blocks) in V5 or V6 = LV hypertrophy.
Tall R in V5 (or V6) PLUS deep S wave in V1 (or V2) >35mm means left ventricular
hypertrophy.
Tall R waves in V1 or deep S waves in V5 and V6 means RV hypertrophy.
ECG changes in some conditions:
Myocardial Infarction:
Sequence of ECG changes:
Normal ECG.
Raised ST segments.
Appearance of Q waves.
Normalization of ST segments.
Inversion of T waves.
Pulmonary embolism:
Possible ECG patterns include:
Right axis (= S waves in I), plus Q waves in III and inverted T waves in III. ( = SIQIIITIII
findings).
Normal ECG with sinus tachycardia.
Peaked P waves.
Right axis deviation.
Right BBB.
Deep S waves in lead V6, etc…..
References.
1. Making sense of the ECG by Andrew R.Houghton and David Gray.
2. Wartak Electrocardiogram Interpretation. Distributed by Roussel.
Emergency Medicine.
H H H ….. A B C…
Hazards …..
Hello …..
Help …..
A = airway
B = breathing
C = circulation
And then ……?
Think Alfabet….
D = drip, drugs, defibrillation
E = evaluation, ECG
F = fractures, fluids
G = (blood)glucose, Glasgow coma scale
H = Hb, Ht, headinjury
I = Insulin, infusion, injections
J = JVP
K = K+, and other electrolytes
L = LP
M = metabolic conditions, malaria
N = neurologic conditions, neck injuries, N/G tube
O = oxygen, observations
P = pulses, pupils, PEEP, poisoning
Q = quality control, Q waves on ECG
R = reflexes, respiration, re-evaluation
S = scan
T = temperature, tamponade
U = urine output (catheter?), urea, ultrasonography
V = vital signs monitor, ventilator
W = wounds, withdrawal syndrome
X = X rays
Y = Yawn …
Z = zzzzzzzzzzzzzzzzzzzzz
Epistaxis
Management of epistaxis:
Compress the nose between the thumb and index finger for about 10 minutes.
Or use a 14F Foley catheter with a 30ml balloon and an anterior nose pack to control the
bleeding.
Equipment needed:
A pair of latex or rubber gloves.
A plastic apron.
Surgical goggles / spectacles.
A headlamp.
14 F Foley catheter with a 30 ml balloon.
Cotton tape, ± 2 meters in length.
BIPP.
A Tilley’s forceps.
Xylocaine local spray.
10 cc water.
10 cc syringe.
A metal kidney dish.
A linen saver or a large piece of paper towel.
Elastoplast, 25mm width, to secure the catheter.
Method:
Don rubber gloves, an apron and goggles.
Start with ice (on the bridge of the nose and behind the neck) and pinch the nose for a while.
Calm the patient and let him/her sit on a bed.
Measure the blood pressure – if it is low or should the patient bleed a lot – then put up a
Ringer’s drip.
If the bleeding continues, then anaesthetise the side from which the patient bleeds with
Xylocaine local anaesthetic spray (not always available!!).
Place the catheter in the nostril that bleeds and push it in gently until the tip is visible in the
nasopharynx/throat.
Inflate the balloon with 10ml water -- pull back the catheter until it feels ‘locked’ and then
further inflate, if necessary, until it feels well secured.
Pack the nose with a long piece of cotton tape soaked in BIPP, using the Tilley forceps.
Start DEEP, from the floor, and pack upwards and forwards until you have filled the nose.
Leave a piece of tape outside the nostril for when you want to remove the pack.
Fasten the catheter correctly onto the cheek with the Elastoplast (prevent pressure on the
nostril which could cause necrosis).
Admit for about 24 hours for observation and treatment.
Deflate the catheter within 12 hours.
First check for any visible posterior or anterior bleeding ---if none, then gently pull out the
catheter and then remove the tape.
Fracture Diagnosis.
Diagnosing fractures of the long bones using conduction of sound is a simple clinical method
to diagnose fractures of various tubular bones based on sound transmission along the
bone.
The basic principle is to place a stethoscope on one end of a long bone and to percuss or
elicit sound by tapping a fingertip or fingernail against the opposite
end of the bone, or toenail or fingernail.
Auscultation of the elicited sounds and comparing it with the opposite bone will indicate a
much reduced transmission of sound on the fractured side.
In case of a suspected fractured femur, the stethoscope can be placed on the symphysis
pubis for auscultation and the patellae percussed on both sides.
The application of this sign, when indicated, will facilitate early diagnosis and appropriate
management at the scene of the accident or will avoid taking unnecessary X-rays of limbs in
patients suffering from multiple injuries.
Remember…
When the bony (and cartilaginous) continuum is physically broken, e.g.
by joint effusion, it is impossible to differentiate fractures from these
alterations.
The Barford test:
Another method to diagnose a fracture of the femur neck is the Barford Test.
EXPLANATION:
Place both legs in mirror-image positions.
A stethoscope is placed over the symphysis pubis, and a comparison is made between the
sound heard from a vibrating 128Hz tuning fork placed on each medial femoral condyle and
patella in turn.
The test is positive if reduced conduction of sound occurs on the injured side.
If (+) = fracture of the neck of the femur. The fracture disrupts conduction of sound from the
distal femur to the pelvis.
INJECTIONS
Usually intra-muscular, subcutaneous or intravenous
Ask the patient about any allergic reactions to medication.
Before drawing up the medication, confirm you have the correct ampule in your hand, the
correct strength as well as the correct volume.
The top of a glass ampule must be broken off, but some ampules have rubber tops through
which the needle must be inserted to draw the content into the syringe.
Use a sterile needle to draw up the contents of the ampule, discard the needle and use a new
sterile needle to inject the patient. Ensure that the needle is firmly attached to the syringe!
Where to inject:
1. Subcutaneously (sc)
The deltoid area is usually used, but the arm, buttock or abdominal wall can also be used.
Pinch the skin between your thumb and forefinger, lift up slightly and insert the needle
through the skin with a quick jab, approximately parallel to the skin. Aspirate to check that the
needle is not intravenously.
2. Intra-muscular (IM or IMI)
The only safe area for an intra-muscular injection is the antero-lateral aspect of the thigh.
Other areas used are the deltoid muscle in the shoulder or the upper outer aspect of the
buttock.
The “safe area” of the buttock is described as follows:
Place the tip of your thumb on the anterior superior iliac spina and let the thenar aspect of the
thumb rest on the iliac border. The outspread hand now indicates the safe area.
Method of injection:
The patient may lie down, sit or stand for the injection. The best position is when the patient
lies down and it is also the most comfortable for the doctor and safest for the patient.
Sterilise the area sufficiently.
Tighten the skin.
With a quick movement insert the needle deeply into the muscle.
Aspirate to make sure the needle is not in a vein.
Press the plunger at a tempo of ± 3 seconds per 3ml or 1ml per second to inject the
medication into the muscle.
After injection, pressure on the area / rubbing for about 5 seconds will prevent the medication
flowing back and will prevent bleeding.
Safely discard the needle into the special container for sharp objects.
MDI technique.
Step by step instructions…
Hold the MDI correctly (with canister on top).
Shake the MDI well.
Exhale slowly.
Place the MDI mouthpiece in the mouth.
Close the lips tightly around the mouthpiece.
Press the canister down once and simultaneously inhale deeply…..Continue inhaling.
Hold the breath for as long as comfortable (? 10 secs).
Remove the inhaler.
Breathe out slowly.
(Repeat if needed).
When a spacer is needed…
Assemble the spacer correctly where applicable.
Connect the MDI to the spacer.
Put the mouthpiece in the mouth with the lips tightly around it.
Activate the MDI once.
Inhale deep breaths as soon as possible after activating the MDI.
Repeat, depending on the prescription.
Wash spacer once a week with a mild detergent, but drip-dry only. Do not wipe it!
Indications for using a spacer…
Patients with a persistent poor technique.
Patients requiring high doses.
Patients prone to developing Candidiasis.
Children.
Nocturnal asthma.
In an acute asthma attack when multiple doses of a ß-agonist is needed.
Instructions for obtaining midstream urine.
Introduction:
Specimen collection must be done very carefully to prevent contamination and to avoid falsepositive results. This is especially important in female patients.
A midstream specimen of urine (MSU) is representative of the site of infection (cystitis).
The MSU should be subjected to dipstick testing in order to determine the presence of red
blood cells, protein, leucocyte esterase and nitrites.
Method:
Instructions to the female patient:
Separate the labia with the fingers. Take a sterile 10 x 10-cm gauze pad soaked in clean tap
water and wipe the area (vestibule and external urethral opening) from front to back.
Repeat the procedure with a clean swab and finally dry the area with a third swab.
Maintain separation of the labia and allow the initial stream of urine to pass into the toilet
bowl. Thereafter place the specimen container into the stream of urine thereby collecting a
MSU specimen.
Instructions to the male patient.
Men are usually instructed to pass some urine into the toilet bowl, then to arrest the urine
stream by compressing the urethra, place the specimen container in position and by releasing
the pressure on the urethra to then pass urine into the container.
Remarks….
This specimen collection is known as: “a midstream clean catch urine collection”
The midstream portion of the urine is collected in a sterile container.
NB: If the specimen is being sent to a laboratory, this ought to be within one hour, or
refrigerated at 40C if any delay is anticipated.
Otoscopy
The examination…
The ear canal should be straightened by gently lifting the pinna upwards and backwards.
Select the largest speculum that will comfortably fit into the ear canal, since this will give the
best view and admit the most light.
The otoscope is then gently inserted along the line of the ear canal.
Check for wax or foreign bodies in the ear canal.
Check for inflammation or discharge in the ear canal.
Check the ear drum, the light reflex, the pars tensa with the handle and lateral process of the
malleus, as well as the tympanic membrane.
Some otoscopes have a pneumatic bulb which can be attached and used to assess the
mobility of the eardrum.
PEFR = Peak expiratory flow rate.
Method to determine the PEFR.
Insert the mouthpiece into the meter, if not already fitted.
Ensure the pointer is set at Zero (l/min position)
Hold the Peak Flow Meter so that your fingers are clear of the scale and slot, and do not
obstruct the holes at the end of the Peak Flow Meter.
Stand up and take a deep breath.
Place the Peak Flow Meter in the mouth and hold it horizontally, closing the lips around the
mouthpiece.
Now blow as hard and as fast as you can.
Note the number on the scale indicated by the pointer.
Return the pointer to zero and repeat the procedure twice more to obtain three readings.
Mark the highest reading on the peak expiratory flow chart.
Prescriptions.
Some Latin abbreviations used when prescribing medicines:
a.c. = ante canem (before food)
p.c. = post canem (after food)
b.d. = bis die (twice daily)
b.i.d. = bis in die (twice daily)
t.i.d. = ter in die (three times a day)
t.d.s. = ter in summendum (thrice be taken daily)
q.i.d. = quarter in die (four times a day)
p.r.n. = pro re nata (should the need be born)
s.o.s. = si opus sit (should there be a need)
c = with
mane = in the morning
nocte = at night
p.o. = per os (per mouth)
stat = at once
p.r. = per rectum
p.v. = per vaginum
IV = intravenous or infusion
IM = intramuscular
SC = subcutaneous
ung = ointment
gutta/e = drop/s
Other abbreviations…
6 hrly or q6h ( q.i.d. = quarter in die = four times a day)
4 hrly or q4h ( q.h. = quaque hora or
q.q.h.= quaque quarta hora = every four hours )
8 hrly or q8h (= eight hourly)
Example of a prescription…
℞: 1) Brufen tabs 200mg t.d.s. p.o. p.c. 20.
2) Panado ii 6hrly p.o. p.r.n. for pain 20.
3) Amoxil 500mg t.d.s. p.o.
15.
4) Tryptanol 10mg nocte p.o.
10.
5) Dulcolax i P.R. nocte p.r.n.
5.
6) Maxolon i t.d.s. p.o. ½ hour a.c.
20.
7) Canesten cream apply nocte to affected area. 20g.
Ensure the following when writing a prescription…
Legibility.
Must be written in ink.
Prescriber’s name, address, telephone number and qualifications.
Date.
Patient’s name and address, age or date of birth.
Prescriber’s signature and qualifications.
[Retain a copy of your prescription (fraud)].
Schedule classification of drugs.
Legally all drugs fall into a certain “schedule”classification.
These schedules range from Schedule 0 to Schedule 8.
Scheduling basically depends on the actions/effects, side-effect profile and addiction potential
of the medication.
Specific requirements are expected for each Schedule of classification.
Schedules.
Schedule 0 – 1: may be advertised to the public and obtained as “OTC”(over the counter)
medications.
Schedule 2 – 6: may only be advertised to doctors, dentists, vets and pharmacists authorised
to prescribe; and only prices, names, pack sizes and strengths may be announced to the
public.
Schedules 3 and 4:
These are “prescription only” medicines!
Each prescription may be repeated for a limited number of times (≤ 6 months).
Emergency supplies may not exceed 30 days.
Advertising inaccessible to the public.
A permanent record of the prescription must be kept in a drug register.
Schedule 5:
These are “prescription only” medicines.
Not more than 30 days supply.
In emergencies, on verbal instruction, only 48 hours supply may be dispensed.
The prescriber must be known to the pharmacist and a written prescription must be supplied
to the pharmacist within 72 hours.
A permanent record must be kept.
All details must be inaccessible to the public.
Schedule 6:
Also “prescription only” medicines.
Not more than 30 days supply.
When used for anxiolytic, antidepressant or tranquillising properties for longer than 6 months,
the prescriber must consult with a psychiatrist and the psychiatrist must consult with a second
psychiatrist.
When used for longer than 6 months for other indications the prescriber must consult with a
Family Practitioner.
Schedule 7:
These are so-called addiction producing drugs.
Available on prescription only.
All prescribing requirements must be complied with, AND in addition:May only be prescribed for a maximum of one month.
No repeats.
Dosage must be indicated in numbers and figures, e.g. 20 (twenty) mg.
Quantity must be indicated in the same way e.g. 100 (one hundred) ml or tablets.
Prescription must be signed with the prescriber’s name and qualifications.
Schedule 8:
These are “banned” substances and may only be prescribed, if at all, under exceptional
circumstances.
E.g.: Amphetamines are all Schedule 8 and may not be prescribed under any circumstances.
Cocaine, however, is also a Schedule 8 but may be prescribed as “cocaine in adrenaline”
which is used topically intranasally in ENT procedures.
If a Schedule 8 drug is prescribed, all the requirements of a Schedule 7 drug apply.
SIAMSOA3P4
S = Stott and Davis Model
* Presenting problem(s)
* Ongoing problem(s)
* Help seeking behaviour
* Health promotion.
(= the tasks of a consultation)
“The anatomy of a consultation”
I = Introduce yourself
A = Agenda of the patient (How can I help you..)
M = Meet the patient (Who, what, where)
S = Subjective (history)
O = Objective (examination)
A = Assessment (3 components)
Clinical = Problem list
Individual = fears, feelings, expectations; frustrations
Contextual = home; work; environment or communiry.
P = Plan (= management plan) (4 components)
How to manage the clinical problems.
How to manage the individual problems.
How to manage the contextual problems.
What special investigations to do.
Follow up of chronic disease…
(Think of the complications and inquire about any symptoms.)
Remember the 4 C’s! Check the following …..
Complaints.
Control.
Complications.
Compliance.
Suturing of wounds.
SUTURING MATERIALS.
SPECIFICATIONS FOR SUTURE MATERIALS:
(Applicable to both non- and absorbable)
1. It must be sterile when placed in a tissue.
2. It must be predictably uniform in tensile strength by size and material.
3. It must be as small in diameter as is safe to use on each type or tissue.
4. Sizes ranges from heavy 7 to very fine 11-0; and ranges vary with materials.
5. It must have knot security, remain tied and give support to tissue during the healing
process.
6. It must cause as little foreign body tissue reaction as possible.
CHOICE OF SUTURE MATERIAL.

Surgical sutures are divided into two classifications, namely Absorbable and Nonabsorbable suturing materials.
1. Absorbable (‘temporary’): e.g. Plain catgut, Chromic catgut, Vicryl.
These are sterile strands prepared from collagen derived from healthy mammals (animals) or
synthetic polymer.
They are capable of being absorbed by living mammalian tissue, but may be treated to
modify resistance to absorption.
They may be coloured by a colour additive approved by the FDA, e.g. Chromic.
2. Non-absorbable (‘permanent’): e.g. Silk, Prolene, Nylon.
These are strands of natural or synthetic (plastic) material that effectively resist enzymatic
digestion or absorption in living tissue.
During the healing process, this suture mass becomes encapsulated (enclosed) and may
remain for years in tissues without producing any ill effects.
They may also be coloured, e.g. Nylon.
They may be modified with respect to body, texture or capillarity.
Capillarity.
This refers to a characteristic of non-absorbable suture that allows the passage
of tissue fluid along the strand, permitting infection (if present) to be drawn along
the suture line.
The two classifications of suture materials, are sub-divided into monofilament
and multi-filament strand.
1. Mono-filament
It is a strand of suture consisting of a single thread-like structure that is non-capillary, e.g.
nylon.
2. Multi-filament
Is a strand made of more than one thread-like structure held together by braiding or twisting,
e.g. Vicryl, silk.
Surgeons select the type of suture material best suited to promote healing.
Factors influencing the choice of suture material
i) Healing characteristics of a tissue:
Tissue that normally heal slowly such as skin, fascia and tendons usually are
closed with non-absorbable sutures, e.g. Nylon.
ii) Location and length of incision:
Cosmetic results desired may be an influencing factor.(No rough and tumble work).
iii) Patient problems:
Such as obesity, debility, advanced age and diseases which influence the rate of
healing and time desired for wound support.
iv) Physical characteristics:
Of the suture material such as ease of passage through tissue, know tying and
other personal preferences of the surgeon.
ABSORBABLE SUTURES: e.g. Plain catgut, Chromic catgut, Vicryl.
Often named as catgut, e.g. chromic suture, it is derived from the sub-mucosa of
sheep intestines or serosa of beef intestine.
Surgical gut is easily digested by body enzymes and absorbed by body tissue
so that no permanent foreign body remains.
Factors influencing absorption of this suture
1. Type of tissue -- It is absorbed much more rapidly in serous or mucous membrane, i.e. in
soft tissues.
2. Condition of tissue -- It can be used in the presence of infection, even knots are absorbed.
Absorption takes place much more rapidly in the presence of infection.
3. General health status of patient -- The more undernourished, the more rapid is the rate of
absorption. (Except in elderly or debilitated patients).
4. Type of surgical gut -- Plain gut is untreated, but chromic gut is treated to provide greater
resistance to absorption.
Handling characteristics of a surgical gut.
1. Most surgical gut and collagen sutures are sealed in packets that contain fluid to keep the
material pliable.
2. This fluid is chiefly alcohol and water, but may be irritating to ophthalmic tissues.
3. The sutures should be used immediately after removal from their packets to avoid drying
and easy breakage.
4. If the suture is dried out, the scrub sister may dip it in normal saline or water to soften it
slightly, (do not soak), hence excessive exposure to water will reduce tensile strength.
5. Unwind the strand carefully. Never jerk or stretch surgical gut, this weakens it.
6. Excessive handling of this suture by rubber gloves can cause fraying.
7. Grasp the ends and tug gently to straighten.
Some more examples of these sutures are:
a. PDS: Used in tissues in which slow healing is anticipated and or for extended wound
support, e.g. in elderly patients.
b. Monocryl: Indicated for use in all types of soft tissues, especially in general, gynaecologic
and plastic surgery.
c. Maxon: Indicated for approximation of soft tissues, except in cardiovascular, neuro- and
ophthalmic surgery.
d. Vicryl: Is available dyed violet in, sizes 9/0 and 10/0 for ophthalmic procedures. Can be
mono-filament or multi-filament.
e. Dexon: Is available dyed green, in sized 2 through 8/0 and undyed natural beige in sizes 2
through 7/0. It requires two to three extra throws in knot tying and the ends must be cut
longer than for uncoated material.
NON-ABSORBABLE SUTURES: e.g. Silk, Prolene, Nylon.

Derived by chemical synthesis from coal, air and water.

It produces minimal tissue reaction.



Has high tensile strength.
It may be used in all tissues where a non-absorbable suture is acceptable, except
when long term support is critical.
It is available in three forms: Mono-filament, un-coated multi-filament and coated
multi-filament.
1. Mono-filament nylon
Example – Ethilon and Dermalon.
Used frequently in ophthalmic surgery because it has the desirable degree of elasticity.
2. Uncoated multi-filament nylon
Example – Nurolon suture
It is very tightly braided and treated to prevent capillary action.
Usually used dyed black, but also available in white nylon. Looks, feels and handles similarly
to silk.
May be used in all tissues in which a multi-filament non-absorbable suture is acceptable.
3. Coated Multi-filament Nylon: Example – Surgilon suture.
It is a braided strand of nylon treated with silicone to enhance its passage through tissue.
Its characteristics are similar to silk and uncoated multi-filament nylon.
4. Some other examples of non-absorbable sutures
a. Mersilene and Dacron suture – it is especially useful in the respiratory tract and some
cardio-vascular procedures.
b. Prolene and surgilene – it can be left in place for prolonged healing.
It is frequently used for continuous abdominal fascia closure, as a sub-cuticular pull-out
suture and for retention suture.
5. Handling characteristics of non-absorbable suture material:
Handle all sutures and needles as little as possible to avoid physical damage that can occur
from the time the suture is removed from the packet.
Avoid pulling or stretching sutures with instruments except when grasping the free end
during an instrument tie.
Needle holders and forceps with serration used on strands can crush, cut and weaken
sutures.
Knot security of these sutures requires additional flat and square ties.
Suture sizes:
Size denotes the diameter of the material and is stated numerically or in metric gauge.
Numerically: Known as USP or BP, a system of 0 gauges (zeroes) is used. The more
zeroes (0’s) in the number, the smaller the size of the strand. As the number of 0’s
decreases, the size of the strand increases.
The 0’s are designated as 5-0, or 5/0 for example, meaning 00000, which is smaller than
2-0. The smaller the size, the less tensile strength it will have.
Metric gauges: Indicates the actual diameter of the suture in tenths of a millimeter.
USP / BP 7/0 6/0 5/0 4/0 3/0 2/0 0 1 2 ……………
Metric 0,5 0,7 1,0 1,5 2,0 3,0 3,5 4 5 ………..
Needle points/tips can be tapered, blunt, conventional cutting, etc.
REFERENCES:
OPERATING ROOM TECHNIQUE BY BERRY & KOHN 8TH EDITION
MINOR SURGERY. A text and atlas. Fourth Edition. 2000. John Stuart Brown.
Tying knots correctly…
To prevent the knots of the sutures you inserted from coming loose, the following technique is
important:
Having pushed the needle through both skin edges, pull the suturing material through until
about 2cm is left on the one side of the wound. On the other side there will then be a long
piece of suturing material.
This long piece of suturing material is now turned once or twice around a needle holder in the
direction of the short piece and held between you thumb and index finger. Now catch the
short piece of string with the needle holder and pull it towards the side of the long piece,
rectangular to the laceration, while at the same time the needle holder and the long piece of
string is pulled towards the side where the short piece was. Now pull the knot tight without it
cutting into the skin.
The knots will now be properly ‘locked’. The process is then repeated until 3 knots have been
tied onto one another.
THUS: Turn the suturing material around the needle holder towards the short piece and then
pull the short piece to the other side of the wound, while the long piece is pulled to where the
short piece was in order to ‘lock’ the knot correctly.
Temperature Taking…
Methods of taking a patient’s temperature:
Oral.
Rectal.
Axilla.
Ear (tympanic membrane).
Skin.
General instructions…
 First clean the thermometer properly!
 Now shake it until the reading is below 350 C. Take care not to break it!
 Measure the temperature as prescribed.
 Again clean the thermometer properly!
 Remember that infections may be transmitted by unsterile thermometers.
 Digital thermometers are preferred these days.
Oral temperature…
 Easiest.
 Relatively reliable.
 Keep under the tongue for 2 minutes before reading the result.
Contra-indications:
 Babies & young children.
 Unconscious patients (coma, epilepsy,etc.)
 Psychiatric patients.
**Wait ±10 minutes after taking a hot or a cold drink.
Rectal temperature…

Most reliable method.

Compulsary for hypothermic patients.

Preferred in babies and young children.

Hold buttocks pinched together and prevent patient from moving. Read after 1
minute.
Use the correct thermometer and carefully insert it, 1cm deep in children and 2,5cm in adults.
Danger of perforating the rectum if not careful.
Axillary temperature…

Not to be used in shocked or hypothermic patients.

Use only when oral or rectal routes are contra-indicated.

Most unreliable method of measuring a patient’s temperature.

Dry the axilla and place the thermometer bulb to touch the chest wall and the
inner aspect of the upper arm. Then hold the arm adducted against the chest for
3-5 minutes.

After reading the result, add 0,50 Celsius to the reading in order to compensate
for this poor method.
A BASIC APPROACH TO THE INTERPRETATION OF X-RAY PHOTO’s IN ADULTS.
Compiled by Dr. P.T. Kenny.
INTRODUCTION….
X-rays should never be taken routinely and are always evaluated with the patient’s history
and clinical findings in mind (examine the patient first).
Check if the name, patient number and date are correct.
Check if the side e.g. left/right is clearly indicated.
Some X-ray films are indicated as "PA".
The position is usually only indicated if the patient is lying down (supine).
Standing postero-anterior & lateral views are usually taken.
1. THORAX
A) Technique: (4 basic requirements)
• Penetration or Exposure: on a PA survey one should just be able to see the
disc spaces of the thoracic spine, through the heart.
• Rotation: the medial borders of the clavicles must be the same distance
from the spinous process of the relevant thoracic vertebra on a PA photo.
• Inspiration: 6 ribs anterior in midclavicular line (PA) must be visible, or 10
posterior ribs.
• Motion: The borders of the heart, diaphragm and pulmonary vessels must
be sharp.
B) The PA X-rays:
We can only comment on the heart size on a PA view (not on a AP or mobile
view – can appear to be enlarged on these views).
The cardiothoracic (C/T) ratio is not more than 50%.
"Read" X-rays as follows:
Step 1:
Look at the soft tissues, and bony elements, e.g. clavicles, ribs and scapulae.
Step 2:
Look at the pleura, the fissures, the diaphragm, the costophrenic angles as well
as the cardiophrenic angles. (= peripheral aspects)
Step 3:
Look at the trachea, the mediastinum and the hila. (= central aspects)
Step 4:
Look at the heart and the major blood vessels.
Step 5:
Compare the lung markings of the upper, middle and lower lung fields.
Step 1:
NB: Soft tissues appear grey, while black areas may be leakage of air into the
subcutaneous tissues (as in surgical emphysema).
Women’s breast shadows contribute to the lung markings behind them and therefore a
lateral view x-ray must also be examined. Nipples may be mistaken for tumours or
granulomas.
Also look for calcifications in the axillae.
Bony elements: The thorax should appear symmetrical and the ribs must be equal
distances apart. Follow the curvature of each rib and look for fractures or destructive
processes. Also turn the X-ray on its side and look for a step or interruption of the line,
which will indicate a fracture. Identify the shadows caused by the scapulae.
Also examine the vertebrae, including the neck and also look for the presence of cervical
ribs.
Examine the pedicles (for metastases), the disci (TB), the shoulders and the clavicles.
Step 2:
Pleura: The pleural cavity is normally not visible. Air rises to the highest point of the
hemithorax. In case of a pneumothorax the air will rise and be more visible in the superior-
lateral part of the chest if the patient is X-rayed in the erect position. Thus, inspect the
inner aspect of the thoracic cage for visible visceral pleura in the form of a thin white line.
Calcifications, e.g. due to asbestos plaques, are usually visible on the domes of the
diaphragm.
Fissure: The right horizontal fissure is visible from the centre of the right hilum (or the 4 th
costosternal joint) to the 6th rib on the mid-axillary line (seen in 60% of normal x-rays). The
fissure is sometimes more visible due to increased pleural fluid (e.g. in cardiac failure).
Diaphragm: It has a curved shape with a clear edge. Gas can be seen in the stomach
under the left hemi diaphragm. The diaphragm may be flattened e.g. due to COPD or
hyperinflation, unilaterally elevated due to a sub-phrenic abscess, hepatosplenomegaly, or
it may even be ruptured due to trauma.
Costophrenic angle: Should be sharp. Can be blunted due to pleural effusion or a
haemothorax.
Cardiophrenic angle: Should be sharp.
Step 3:
The trachea: Is situated centrally or slightly to the right side. Displacement can be due to
a mediastinal shift due to a pulling force, or a pushing force (mass). The diameter of the
trachea should be equal throughout. Sometimes an enlarged thyroid gland may cause
external compression of the trachea.
The mediastinum: Can be widened due to fluid or air, or due to an aorta aneurysm,
masses, lymph nodes, or trauma. We can only comment on whether or not it is widened,
on a PA view.
The hilum: The left hilum is slightly higher than the right and both should have concave
borders. Increased density may be due to a tumour or lymphadenopathy.
Step 4:
The heart shadow = cardiac silhouette: Is situated slightly more to the left (2/3 left of
midline, 1/3 right). The cardiothoracic ratio is less than 50%. It means that the diameter of
the heart is less than 50% of the trans-thoracic diameter.
The diameter of the heart is measured between vertical lines drawn at the furthest point on
the lateral borders. The trans-thoracic diameter is the maximal thoracic diameter at the
level of the diaphragm. Pericardial effusion and other heart conditions can increase the
C/T ratio.
The right heart border from top to bottom:
- Superior Vena Cava
- Right atrium
- Inferior Vena Cava
The left heart border from top to bottom:
- Aortic knob
- Left main bronchus (on a higher level than right)
- Left atrium (auricle)
- Left ventricle
(Enlarged left atrium: Causes a "Double Density"; left main bronchus is elevated).
Enlarged LV / RV:
The cardiothoracic ratios are then more than 50%.
Different occurrence of LV+ vs. RV+
Enlarged right atrium: View the right heart borders).
Unfolding Aorta = prominent aorta.
On a lateral x-ray view the posterior heart border is mainly represented by the left
atrium and the anterior border by the right ventricle.
Step 5:
Lung fields: The lung fields are divided by lines through the 2 nd and 4th rib cartilages in the
upper, middle and lower fields. Inspect these fields from the hila laterally as well from the
top to the bottom for conditions like consolidation, cavities or masses. Masses can be
single or multiple ("cannon balls").
Pulmonary oedema produces a 'butterfly wings' or a bat's wings image.
Atelectasis = lung collapse
Carina: look at the angle; if more than 90 degrees, think of glands and search for pathology
like TB, malignancy.
"Oversee" areas: (have a good look at the following areas!!)
- Apex of both lungs: look for fibrosis / cavities / masses, etc.
- Hila: glands / masses.
- Behind the heart: consolidation.
- Diaphragm and sub diaphragmatic: air under diaphragm / fundus of the stomach / splenic
flexure. ?Abscesses sub diaphragmatic, especially right.
C) The lateral image:
- Again it is important that the approach must be systematic, e.g. soft tissues, bony
elements (especially vertebrae and disc spaces) etc.
- The right ventricle is enlarged when it takes up more than one third of the lower part of the
sternum.
- The left ventricle is enlarged if it extends more than 1 cm posterior of the Inferior Vena
Cava.
- Look at the hila.
- Lung fields: NB: The posterior segment of the left lower lobe.
Hiatus hernia; posterior to heart.
- Look at the aortic arch.
- Diaphragmatic domes (right is higher than left due to the liver); fundus of the stomach,
costophrenic angles, etc.
- Scapulae, axillary skin folds.
2. ABDOMEN
 Technique
It is important that the diaphragmatic arch (air under diaphragm) and the pelvis (hernial
orifices) are enclosed in the photo.
 Standard x-ray views include: AP, lying or standing surveys; decubitus surveys
(patient lies on his/her side) in patients who are unable to stand up.
Gas:

Free gas or air is usually seen due to a perforated peptic ulcer or after surgery. Other
types of perforations of intra-abdominal hollow organs e.g. perforated appendix can also
lead to free gas in the abdomen, but it is not too common. After laparotomy most air is
absorbed in 4 to 7 days time. The most common place to see free air is under the
diaphragmatic arch on a standing x-ray photo. Remember that part of the duodenum as
well as part of the colon is retroperitoneal. With severe trauma and rupture of these
structures, air can appear retroperitoneal.
 Air can be found in the intestinal wall in neonates born prematurely e.g. due to
necrotisising enterocolitis or in adults where intraluminal organisms cause pathology in the
intestinal wall e.g. ulcerative colitis.
 Air can be present in the bile ducts due to surgical intervention e.g. ERCP or due to
cholangitis, or gallstone ileus.
 Gas or bubbles of air-liquid can be present in abscesses.
 To distinguish between the colon and the small intestines:
Think of the colon as the frame and the small intestines as the picture.
Small intestines: valvulae coniventes – the whole circumference of the lumen: mostly
jejenum.
Colon: taeniae coli – does not cover the whole lumen.
It is normal to have intraluminal gas mainly in the colon.
Obstruction: Distended intestinal loops with air-fluid levels proximal to the obstruction is
seen. Sometimes air does not extend into the rectum.
Fluid:
 With ascites: There is loss of the preperitoneal fat lines; and bowel loops are moved
farther apart by the fluid.
Other:



Look for liver and spleen shadows.
A colostomy.
IUCD


Pancreatitis: "sentinel loop" ; loss of the psoas shadow.
Psoas shadow normally fades with retroperitoneal pathology such as with
pancreatitis or appendicitis.
3. SPINAL COLUMN
 Surveys:
–AP: Look at the pedicles (for metastases); the outline (scoliosis) and
the
paravertebral joints.
–Lateral: Look at the height of the vertebral bodies, disc spaces, cyphosis/lordosis.
–Oblique: Look at the foraminae.
 Metastases:
–Are lytic (e.g. myeloma) or sclerotic (e.g. Ca prostate or breast).
–Carefully look at the pedicles on the AP x-ray.
 Disc spaces:
– become bigger from top to bottom, except L5/S1.
–Look at the disc spaces for infection e.g. TB.
–"Schmorl's nodules" – no clinical importance
 Osteoporosis, etc.
 Spondylolisthesis: due to degeneration – one vertebra shifts on top of another; there are
different degrees.
 Spondylosis: degenerative changes e.g. disc space narrowing and osteophyte formation.
 Trauma: It is a big field of study.
3-column theory of the spinal column: anterior, middle and posterior.
3 Basic views
 AP
 lateral +/- swimmers,
 peg views (open mouth)
4. AN APPROACH TO THE LONG BONES.
 The growth plates are very important in children.
 NB:
– Take x-rays of the joint above and below the pathology.
– 2 different x-rays are usually important e.g. PA and lateral.
– Sometimes it helps to compare to the other (healthy/normal) side.
– Repeat x-rays after a few days (especially in case of the scaphoid).
 There are various types of fractures.
 Osteoporosis and metabolic bone illnesses.
 Osteomyelitis: periosteal reaction, involucrum, sequestra.
 Other reasons for periosteal reaction:- tumour e.g. osteosarcoma or a healing fracture, etc.
 Metastases: can be lytic or sclerotic; and can lead to pathologic fractures.
** CD available in the Skills Lab (Valab); it is also for sale:
Interpretation of Adult Chest X-rays.
References:
 Chest X Rays made easy: Elizabeth Dick – SPR Northern Thames Deanery. Internet
publication
 Chest X Ray as Diagnostic Tool: Arcot J. Chandrasekhar, M.D. Internet publication
 Looking at the chest radiograph: Radiology museum – London South Bank University
Web Site.
 Atlas of Human Anatomy: Frank H. Netter, M.D. 1989
1. MALE URETHRITIS SYNDROME (code MUS)
Discharge or dysuria?
YES
Treat with:


Ciprofloxacin 500 mg stat
Doxycycline 100 mg 2 x daily for 7
days
Ask patient to return in 7 days
if symptoms persist



Symptoms
and signs
improved?
Re-infection ?
Poor
compliancd?
Treat with:
NO

Metronidazole 2 g stat*
YES
Ask patient to return in 7 days if
symptoms persist
Repeat treatment
Improved?
YES
NO
Treatment
failure:
Refer to
doctor!
*
Avoid alcohol for 24 hours
2. VAGINAL DISCHARGE SYNDROME (code VDS)
Abnormal discharge or
vulval itching / burning?
YES
Treat with:
Lower abdominal
tenderness?
YES
S
Use lower abdominal
pain flowchart
NO
 Ciprofloxacin
500 mg stat
 Doxycycline
100 mg 2 x daily for 7 days
 Metronidazole
2 g stat*
In pregnancy / during breast feeding:
 Ceftriaxone
125 mg imi stat
 Erythromycin
500mg 4 x daily for 7 days
 Metronidazole
2 g stat*, **
If vulval oedema/curd-like discharge,
erythema, excoriations present, add:
Clotrimazole vag pes 500 mg inserted stat
Ask patient to return in 7 days if symptoms persist



YES
Symptoms / signs
improved?
Re-infection (new
episode)?
Poor compliance /
adherence?
Repeat treatment
NO
Treatment
failure:
Refer to
doctor!
*
Avoid alcohol for 24 hours; in addition, alcohol during pregnancy is not
recommended
** Not in first trimester: use clotrimazole vaginal pessaries for symptomatic
relief in 1st trimester
3. LOWER ABDOMINAL PAIN (code LAP)
* Pregnancy
* Missed / overdue
period
* Recent delivery/
abortion
* Guarding /
rebound tenderness
* Abnormal vaginal
bleeding
* Abdominal mass
* Fever > 38 0 C
* Excitation
tenderness ?
* Adnexal
tenderness?
* Lower abd
tenderness with or
without vaginal
discharge?
NO
YES
Treat with:




Ciprofloxacin 500 mg stat
Doxycycline 100 mg 2 x daily for 7 days
Metronidazole* 400 mg 2 x daily for 7 days
Remove IUCD if present
Review in 3 days or earlier if worsening
Improved?
YES: Finalise treatment
* Avoid alcohol during treatment and 24 hours after last dose
NO
Complicated
case:
Refer to
doctor!
4. GENITAL ULCER SYNDROME (code GUS)
Blister, sore, ulcer or
bubo in the groin?
YES
Treat with*:




Benzathine Penicillin 2.4 MU imi stat
Erythromycin 500 mg 4 x daily for 7 days
Aspirate any fluctuant local lymph node
Pain relief if indicated
Review every patient after 7 days
Blister, sore, ulcer or
bubo healed?
NO
Blister, sore, ulcer or
bubo improving?
YES
NO
Treatment
failure:
Refer to
doctor!
YES
Repeat treatment with:


Erythromycin 500 mg 4 x daily for 7
days
Aspirate any fluctuant lymph node
Review in 7 days
Blister, sore, ulcer or
bubo healed?
Yes
* Penicillin-allergic patients treat with:
Erythromycin 500 mg 4 x daily for 14 days
NO
Treatment
failure:
Refer to
doctor!
5. SCROTAL SWELLING (code SSW)
Scrotal swelling / pain
YES
Treat with:
Testis rotated or
elevated, tumour,
hydrocele, history
of trauma, other
non-STI reason?
NO


Ciprofloxacin
500 mg stat
Doxycycline 100 mg 2 x daily for 7 days
Review after 2 days
Improved
YES: Finalise
treatment
NO
Complicated
case:
Refer to
doctor!
6. BALANITIS / BALANOPOSTHITIS (code BAL)
Soreness / itching of glans
Treat with:





Clotrimazole cream 2 x daily for 7 days
Wash daily with weak salt solution
Instruct on retraction of foreskin when washing
Avoid soaps while inflammation is present
If malodorous, add: amoxycillin 500 mg 3 x daily for 5
days and metronidazole* 400 mg 2 x daily for 5 days
Ask patient to return in 7 days if symptoms persist
* Symptoms / signs improved
* Re-infection (new episode)
* Poor compliance?
NO
Treatment
failure:
Refer to
Any other STI
doctor!
syndrome or illness?
YES
Repeat treatment
* Avoid alcohol during treatment and 24 hours after last dose
ALL PATIENTS:





Educate and counsel
Promote abstinence from penetrative sex while under treatment
Promote and demonstrate condom use, provide condoms
Stress the importance of partner treatment and issue one notification slip for each sexual
partner, follow up partner treatment during review visit
Promote HIV counselling and testing, repeat negative test result after 3 months
SYPHILIS SCREENING OF PREGNANT WOMEN
Take blood for RPR test (always), for HIV test (if consent), and for other ANC routines
Syphilis test positive
HIV test positive
YES
NO
S
YES
S
Post-test
counselling,
PMTCT when
available
Repeat HIV
test after 3
months
if any STI
syndrome
present
Treat pregnant woman with:

Benzathine Penicillin 2.4 MU
imi once weekly for 3 weeks
or in case of penicillin allergy:

Treat all asymptomatic newborns
of mothers with positive RPR test
during pregnancy with:
+

Erythromycin 500 mg 4 x daily
for one month
Benzathine Penicillin
50 000 IU / kg imi stat
Symptomatic newborns
(congenital syphilis):


Notify (Notification of Medical
Conditions Form GW17/5)
Refer to doctor!
ALL PREGNANT WOMEN:





Educate and counsel, promote couple-counselling if applicable
Explain the risk of vertical transmission
Promote abstinence from penetrative sex while under treatment
1. Promote consistent condom use particularly during pregnancy, demonstrate condom
use, provide condoms
Stress the importance of partner treatment, issue one notification slip for each sexual partner
Promote HIV counselling and testing of partner
7. NEONATAL CONJUNCTIVITIS
Purulent discharge / swollen eyelids
Treat baby with:


Ceftriaxone 50 mg/kg imi stat (maximum
125 mg)
Erythromycin syrup 50 mg/kg/day in four
divided doses for 14 days
Treat with:
Mother:
 Ceftriaxone 125 mg imi stat
 Erythromycin 400 mg 4 x daily for 7 days
Father/partner:
 Ciprofloxacin 500 mg stat
 Doxycyline 100 mg 2 x daily for 7 days
Review baby in 3 days (or earlier if
necessary)
Improved?
YES


NO
Complicated case:
 Refer to
doctor!
 Reassure
mother
Finalise
treatment
Reassure
mother
PARENTS OF BABY WITH CONFIRMED NEONATAL CONJUNCTIVITIS:





Educate and counsel, promote couple-counselling if applicable
Promote abstinence from penetrative sex while under treatment
Promote and demonstrate condom use, provide condoms
Stress the importance of partner treatment and issue one notification slip for each sexual
partner, follow up partner treatment during review visit
Promote HIV counselling and testing, repeat negative test result after 3 months
PARTNER NOTIFICATION SLIP
PARTNER NOTIFICATION SLIP
SLIP No.
DEPARTMENT OF HEALTH
CLINIC NAME:
FILE NUMBER:
Dear Madam/Sir,
Please go to a clinic as soon as possible. Although you might feel well, you need to be
treated. Treatment at public primary health care facilities is free of charge.
Take this slip with you.
Thank you for your cooperation!
This person’s partner was treated for:
MUS
GUS
GW
VDS
SSW
PL
LAP
BAL
MC
RPR
+
Please provide the appropriate syndromic management and confirm treatment to us by
citing the slip number. For any questions, please call telephone number below.
Staff name: _____________________________ Signature:
_______________________
Date: ___________
Clinic Stamp:
Tel:_________________Fax:__________________
LETTER FOR SEXUAL PARTNER
(only in combination with partner
notification slip)
DEPARTMENT OF HEALTH
Name and address of clinic
________________________________________________________
Dear Sir/Madam,
Your partner was seen at our clinic today with an infection that can be passed
on during sexual intercourse. It is important for you to come for a free
consultation and treatment even if you do not feel or notice anything wrong.
Some of these infections can be present without showing themselves, but
they can still cause problems.
They can spread in the genital organs, cause pain or infertility. Some of them
also spread in the blood affecting other parts of the body or affecting the baby
in a pregnancy.
Please go to your nearest clinic with the enclosed notification slip as soon as
possible. You will be treated confidentially and any questions you have can be
discussed. The code on the slip will indicate to the clinic staff what treatment
you should receive.
Thank you for your cooperation!
Name of the clinic staff_________________________________
Signature_______________________
Date ______________
Clinic stamp
HIV COUNSELLING AND TESTING
HIV Pre-test Protocol:
Preparation

Complete privacy.

Health care worker (HCW) must be knowledgeable about and be able to explain:

o
Basic facts about HIV infection, transmission and immune response to HIV.
o
Long-term effects of HIV infection.
o
Difference between HIV and Aids.
o
Known HIV risk activities.
o
Essential facts about HIV testing, including

Tests that will be used.

Incidence and causes of false-positive and false-negative results.

Follow-up for positive results.
The HCW should feel comfortable discussing HIV risk activities, be able to appear
non-judgemental and supportive, regardless of personal beliefs/values.
Procedure

Explain purpose of test is to detect presence of antibody to the virus that is
associated with Aids.

Explain why the test is being done:
o
Because the person has a medical condition that could be related to HIV
infection.
o
Because the person is a prospective organ recipient or candidate for dialysis.
o
Because the person requested the test.
o
Because a health care worker has had a significant exposure to the patient’s
body fluids.

Ensure that the patient is aware:
o
That this not a test for Aids, but a rest for the presence of antibodies to HIV.
o
That the test will be part of the medical record.
o
Anonymous testing is available to other sites.
o
That the person must come in person to obtain the result and receive posttest counselling.

Establish HIV risk activities by asking neutral questions.

Date of the most recent known risk activity for HIV infection. If <14 weeks, explain
about “window period” and test must be repeated later.

Explain the test procedure:
o
If Elisa screening is negative, no further testing is necessary.
o
If Elisa is positive, a confirmatory test (Western blot or two more Elisa tests)
will be done on the same specimen).

Explain when result will be available.
Pre-test Counselling Checklist:

Assure the client that both counselling and testing are confidential procedures.

Be sure that if more than one session is required it can be offered.

Provide information about HIV infection and transmission and its link to AIDS,
sexually transmitted infections and tuberculosis.

Provide information on the technical aspects of testing the ‘window period’ and its
implications and the meaning of the terms ‘positive’ and ‘negative’.

Discuss the implications of a positive and negative diagnosis.

Provide information about the client’s legal rights in terms of who to tell (sexual
partner/s) or not to tell (e.g. the employer third parties, etc). Clients are not obliged to
tell anyone apart from their sexual partners.

Evaluate risk behaviour, find out why the individual wants to be tested, and the nature
and extent of previous and present high-risk behaviour, and discuss the steps that
they should take to prevent future infection or transmission.

Determine the client’s coping resources and support systems in the event of a
positive result.

Contain the client’s emotions as they deal with issues about relationships.

Determine whether the client wishes to be tested that day or not, and whether they
would like to receive the result that day or not.

Assure the client that you respect their decision.

Provide a sense of support and hope for the client.
A person who has tested HIV-positive may never have the same quality of life again. HIV-positive
people who are properly and appropriately counselled not only feel better following the support, but
also are better able to talk about their fears and feelings, and to plan their future. With ongoing
emotional and psychological support the HIV-positive person can change his or her behaviour from
destructive living to positive living.
HIV Post-test Protocol
Giving a negative result

If the Elisa is negative, tell the person she/he probably does not have the HIV
infection. Result may not be accurate if she/he engaged in high risk activities within
past 14 weeks.

Equivocal results.

Reinforce HIV risk reduction/avoidance.
Giving a positive result

Simply say: “Your HIV test result came back positive. That means you have been
infected with HIV”. Give patient time to absorb news. Answer questions.

Explain the significance of the result and the difference between HIV and an Aidsdefining condition.

Emphasise the person is infectious and discuss risk reduction/elimination.

Ask again about personal support. Did she/he discuss the fact that she/he was being
tested with anyone? Will she/he be able to disclose to the result to them?

Advise the patient not to make any immediate decisions about personal/work
commitments.

Emphasise that HIV is a long-term condition. Prevention and treatment of
opportunistic infections and cancers.

Outline the next steps to be taken:
o
Complete physical assessment.
o
Follow-up HIV test.
o
Assessment of immune function.
o
Immunisations.

Contact details of social services / NGO’s.

The patient will probably not remember most of what she/he was being told. Ask the
person what she/he expects the result to be. If a negative result is expected, but you
consider a positive result to be possible, explain briefly, giving reasons.

If the person asks what you think the result will be, try to be honest and do not give
false reassurances.

Ask the patient how she/he would react if the result is positive.

Ask the patient what support systems she/he can turn to if result is positive.

Inform the patient that if necessary, you will refer him/her to a physician / clinic
knowledgeable in HIV.

Discuss risk reduction guidelines.

Ask whether you have been understood and if the patient has any questions.

Ask whether the patient will wishes to go ahead with the HIV test. Let him/her sign the
consent form.
Post-test Counselling (Summary)
Post-test counselling helps the client to work through the crisis and other issues that may
arise as a result of being told heir HIV status.
Giving the results:
 Give the results as soon as they are received. Do not prolong the suspense with
inane conversation.
 Give the results face to face, never telephonically and never through third parties.
 The person who conducted the pre-test counselling should wherever possible also
give the result and post-test counselling.
 Let die client choose whether they want the result that day or not. People may need
more time to consider the impact of a possible HIV-positive result on their lives before
they receive the result.
 If the result is positive, do not give it unless you or a back-up support can see the
client the following day.
If the HIV result is negative:



Discuss the window period.
Reinforce the message of prevention and safer sexual practices.
Pick up on any other issues that may have been raised in the pre-test counselling
session.

Discuss referral if necessary, especially if there are ongoing risk factors.
HIV positive result:
Initially:
 Concentrate on managing the resultant crisis and addressing the client’s immediate
concerns.
 Be careful of information overload in the first encounters.
Later (often at a follow-up appointment the next day, if possible):
 Continue to contain the client’s emotions.
 Answer any questions.
 Remind the client of the need for partner notification (though they may still need some
time and support for this).
 Introduce concepts such as:
o the need for medical assessment and where to get it.
o safer sex.
o the cost and availability of antiretroviral therapies (ART) and drug trials.
o the importance of a well-balanced diet, rest and exercise.
o the need to eliminate alcohol, smoking or drugs.
Both pre- and post-test counselling are very important. It is dangerous to compromise the
counselling process and take short cuts in the counselling room.
Ongoing counselling helps the client to deal with issues such as partner notification,
relationship difficulties, queries about health and treatment and disclosure to others. With
written permission, the counsellor may liaise with other caregivers. Develop a good working
relationship with them, as you may be able to share contacts and referral sources.