COUNSELLING:

QUIT SMOKING
Introduction Introduce yourself & ask pt’s name

Explore pt’s details Occupation

Marital status
Medical problem
Special habits of medical concern (smoking, alcohol)
Explore ICE

5A’s approach Ask about smoking:

Ask - are you currently smoking?
Advice - type of smoking
Assess - frequency – how many cigarettes per day?
Assist - do you smoke in the morning after 1H waking up from sleep?
Arrange - duration

12M – - quitting history (and cause of failure)

melengah-lengahkan ,
menahan diri, menarik nafas
Panjang, minum air,
menyibukkan diri,
melakukan senaman,
mengalihkan perhatian,
menjauhkan sesuatu, mandi,
megambil wudhu etc
5D –
delay , distract, drink water,
deep breath, discuss your
feeling
DEAD strategy –
Delay, Escape, Avoid,
Distract
Withdrawal symptoms
- irritability, change of sleep
pattern
- poor concentration, anger,
frustration
- mouth ulcer
- constipation
- weight gain 4-5kg
- tremor
- effect on quality of life – DM/ HPT/ IHD/ CVA
Assessment of nicotine dependence
- FAGERSTROM score
- CAGE questionnaire
Advice pt on quit smoking
- impact of smoking
- benefit of quitting
~ reduced risk of chronic disease
~ reduced risk of lung CA
~ reduced risk of stroke/ IHD
~ reduced perinatal complications
~ good example to your children
~ save money
Assess willingness to quit
- are you willing to quit now or within 6 months?
- are u thinking about quitting in the next 6 months or have tried quit last year?
- pre contemplation stage : no
- contemplation stage : yes but not willing to quit
- action stage : yes & ready to quit
Assist (STAR quit plan)
- S- set a quit date
~ within 2 weeks , reduce the number of cigarette before TCA
~ write reason to quit
~ self reward every time able to abstain from smoking
T- tell family member, friends, co-worker
~ for understanding and support
~ encourage them not to smoke in their presence
(minimize treatment failure and exposure to 2nd hand smoke)

A- anticipate challenge to upcoming quit attempt (in 1 st week)

~ problem solving skill
Behavioural methods : - smoking diary, deep breathing, regular exercise, find
alternative to oral and hand activity

Drwnafifah
 R- remove tobacco product

Arrange follow up plan or referral

~ follow up weekly for the 1st month
~ then 2 weekly for then 2nd and 3rd month
~ then monthly up till 6 months

5R’s approach R - Risks:

(pt not willing to quit) - Ask the patient to emphasize the negative consequences of smoking:
- Social (children, pregnant wife), religion, risk of fire
Short-term risks:
- Exacerbation of asthma
- Harm to pregnancy (Fetal smoking syndrome) / infant
- Dental problem /Stained teeth /Gum inflammation
- Impotence /infertility

Long term risk:

- atherosclerosis, heart attacks
- peripheral vascular disease
- stroke, COPD, cancer

environment risk:
- increased risk of lung cancer and heart disease in spouse
- asthma, resp infection in children
- higher smoking rates by children of tobacco user

R- reward
- improved health, improved sense of smell/ taste
- save money
- set a good example to kids
- reduced wrinkling and aging

R – relevancy
- why quitting is relevant to him
- tailor to clinical situation: - acute respi illness, pregnancy, chronic disease (DM,
HPT, MI, COPD)

R- roadblocks: identify barrier to quitting

- withdrawal symptoms – will resolve after 1 month
~ sweating
~ nausea/ abdominal cramping
~ insomnia, anxiety/ irritability/ depression
~ headache
- fear of failure
- depression/ lack of support
- cost of treatment

R- repetition
~ motivational intervention should be repeated every visit

Drwnafifah
 Management

Closing - Check understanding

Safety netting ~ follow up weekly for the 1st month

~ then 2 weekly for then 2nd and 3rd month
~ then monthly up till 6 months

TCA if unwell

Drwnafifah
Drwnafifah
 NOCTURNAL ENURESIS
Introduction WIPE
History Taking Hydration history
Daytime voiding pattern
Toilet training history
Number and timing of episodes of bedwetting
Sleep history – sleep disturbance
Nutrition history - timing, quantity, type of solid food, caffeinated drink
Family history of nocturnal enuresis
any concern → want short term improvement? going to campaign etc

- fever, pain during urination, any foul-smelling urine → UTI

- family history of DM, polyphagia/ polydipsia, weight loss, any concurrent / recurrent
infection – rule out DM
- polyphagia/ polydipsia → diabetes insipidus
- gait abnormalities/ back pain/ history of fall? – rule out neurogenic bladder
- constipation
- psychological, behavior, personality and emotional status
~ move to new school/ kindergarten/ bully?

rule out red flags!!!

Explained regarding - Involuntary urination that occurs during sleep in a child with 5 years and older (after
nocturnal enuresis the age when a person should be able to control his/her bladder (bedwetting)
- Bedwetting is common in children under the age of five and it will often resolve itself
in time.
15-20% 5 y/o
5% of 10 y/o
1-2% of 15 y/o

Causes of nocturnal - Due to the smaller size of their bladder, children are more likely to need to pass urine
enuresis during the night; particularly if their urine production is higher than it should be.
In some children the nerves attached to the bladder may not yet be fully developed, so
they don't generate a strong enough signal to send to the brain.

- Bedwetting can also run-in families. In about half of cases, one of the child’s parents
(usually the father) had a history of bedwetting as a child.
- more common in boys

- In some cases, bedwetting can be a sign that your child is upset or worried. Starting a
new school, being bullied or the arrival of a new baby in the family can all be very
stressful for a young child

Implication considerable psychological impact on their self-esteem and confidence, particularly in

older children.
- Reassuring your child that everything is okay is very important if they regularly wet
the bed.
- Your child should know that it’s not their fault, they are not alone and it will get
better over time.
- You should also never tell off or punish a child who wets the bed. Not only can this
cause distress, it's also likely to make the problem worse.
- Bedwetting usually only becomes a concern in children who are five years of age or
over and who are wetting the bed at least twice a week.

Tips to help family - do not scold or punish the child

to deal with enuresis - praise the child if achieving dryness
- use a night light to help child who wakes
- use absorbent pyjama pants or matress protectors which will reduce the stress of
parents and child, and will not contribute to the enuresis

Drwnafifah
 Management - restricting the amount of fluid in the evening/ before sleep
- avoid caffeine/ bicarbonate drink → encourage urine production
- enuresis diary

enuresis alarm:
will help to train child to wake up once their bladder is full, helping them to hold urine
during the night
~ enuresis > 2x/week
~ short term improvement is not priority
~ family not having difficulty coping with burden of bedwetting
~ lower relapse rate
~ require highly motivated child and family

Medication:
desmopressin acetate
~ want short term improvement
~ difficult to coping with bedwetting
~ nocturnal enuresis with normal daytime voided urine
~ enuresis < 2x/week
~ higher relapse rate

Safety netting TCA 3/12 with bladder diary

TCA STAT if unwell, distress

Drwnafifah
 PRE-PREGNANCY COUNSELLING: SLE
Introduction WIPE
introduce yourself, ask pt’s name

Brief history A) acute complaints – keen to get pregnant, but u/l SLE

Ask about concurrent illness?

- since when been diagnosed?
- what are the first symptoms when first diagnosed?
- where is she currently follow up?
- what is the latest medication?
- when was the last attack/ flare?
→ what symptoms when she gets the attack
→ how frequent the attack?
→ admission to the hospital during the attack?

Any complications:
- lupus nephritis
- cerebral lupus
- myocarditis

When was the last blood result? how is it?

Background Past medical surgical history

- any other medical illness

- any history with blood clotting?

→blood easily clotted? – antiphospholipid syndrome
→ are you taking blood thinning medications?

Menstrual history?
- LMP
- period: regular/ irregular
- contraception before

Obstetric history:
- any pregnancy/ miscarriage before
- any h/o recurrent miscarriage

Any complications during previous pregnancy?

- PIH/ PE
- premature delivery/ SGA/ LBW
- did u take blood thinning medications during previous pregnancy

Psychosocial history:
- how many children?
- husband’s occupation? how is relationship with husband? is he always available if
you need help?
- how did she come to clinic?
→ pregnancy is an exciting moment but at some point, can be stressful as you need to
come for regular follow up→ especially during the 3rd trimester. need good support
from husband and other family members
- any family members staying nearby?

ICE Idea → any idea relation between SLE and pregnancy

Concern → any worry regarding her illness if she gets pregnant

Drwnafifah
 Complications - carries higher maternal and fetal risk compared to other healthy women
- the best time to get pregnant is after > 6 months last flare

SLE → pregnancy
- flare during pregnancy can lead to higher rate of fetal morbidity and mortality
- active SLE at time of conception is a strong predictor to adverse maternal and
obstetrics outcomes
- lupus nephritis: need to defer pregnancy until disease well control at least 6 months

Risk of SLE to mother:

- hematological → anemia, thrombocytopenia
- hypertension, eclampsia
- venous thromboembolism
- worsening renal function
- risk of maternal mortality

Risk of SLE to baby:

- miscarriage
- IUGR/ LBW/ preterm delivery
- risk of heart block
- neonatal lupus syndrome

Pregnancy → SLE
- increase risk of getting flare of SLE

Management Antepartum / antenatal

- physical examination + vital signs + blood test
- start folic acid to reduce risk of neural tube defect
- low dose aspirin @12weeks (reduce risk of pre-eclampsia)
- advice UPT when missed miscarriage → early booking
- adjust medications
→ HCQ (can continue)
→ AZA (can substitute with MMF prior to pregnancy)
→ cyclophosphamide (can cause congenital malformation, should be avoided during
the first 10th week)
→ MTX (teratogenic, cannot be taken during pregnancy)

+ folic acid at least 3 months preconception

Detailed scan
Refer to combine clinic – to co-manage with O&G team, Rheumatology & MCH team

Closure Need to repeat the blood investigations, urine FEME

- to make sure no complications before conception

need to inform managing team – rheumatology regarding pt plan to get pregnant

-to get green light from managing team first

Ask about contraception too

# TCA 1/12 to review blood investigations

Drwnafifah