Family Medicine Posting in Klinik Kesihatan Merbok (Group A3) Part 1 [02/11/2008-06/11/2008]

Welcome back to this blog...
But i would like to apologize that we do not have any photographs to show this time.

Currently my friends and i from Group A3 are in our final year of MBBS and we are posted in Klinik Kesihatan Merbok for 2 weeks for Family Medicine.

We consists of:-
1) Charlotte Marie d/o Ambrose Alexander (ID No: 0400387)
2) Chai Zsi Yuan (ID No: 0400414)
3) Chan Hui Ling (ID No: 0400420)
4) E'rlene Low Li Ern (ID No: 0400429)
5) Gan Yuen Keat (ID No: 0400435)
6) Cheah Boon Eu (ID No: 0400405)

Our posting in KK Merbok started on the 2nd of November 2008 and will end on the 13th of November 2008.

Hereby, what we have learnt it mostly a repetition of what we had done when we were in Year 4 (where we were posted in Baling and Sik for our District Health Office Posting). However, there are some activities and knowledges that we failed to collect during our previous postings in Year 4. Thus, i shall share it here with you.


Day 1 (02/11/2008)
A briefing about Family Medicine by Dr. Jamilah Abdullah and Staff Nurse Hasnah


Day 2 (03/11/2008)
We were being briefed on how Pap Smear is being done in KK Merbok. According to Staff Nurse Zakiah, every year, they have a target of 550 patients for Pap Smear examination. Sometimes, they will do health campaign to make the community aware about Pap Smear. Previously they used to send the Pap Smear samples to Hospital Sultan Abdul Halim, Sungai Petani for further investigations but since November 2008, the Pathlab representatives will come and collect the sample.

Besides Pap Smear, we were also told about Breast Self Examination (BSE).

After the two sessions mentioned, we were being briefed by Staff Nurse Meriam about Immunisation. Even though again this time we did not get a chance to go to the school to give the immunisation, we did learn some new things. First of all, all vaccines are being stored in the fridge at 2-8 degree Celcius. If at all there is no electricity, they will be inform early. However, most of the time, the fridge can maintain the temperature if left unopened for 48-72 hours depending on the different fridges used. The position of the fridge and the surrounding (eg. the wall) should be at least 30cm apart. And the fridge is normally placed in a room which is not exposed to the sunlight so that the temperature canbe maintained.

The temperature is maintain by cold chain which a minimec termometer is used to measure the temperature. The temperature is being taken twice a day (once in the morning at 8am and once in the evening at 4pm) and it is then being recorded in a book. Every time when the temperature is taken, a button is to be pressed on the minimec termometer to get the current temperature (suhu semasa). 3 colours will be used to draw the graph in the book to record the temperature. The red colour indicates the maximum temperature, the blue indicates the minimum temperature and the green indicates the current temperature. On weekends and public holidays (when the KK is not opened), there will still be someone resposible to come and check the temperature. If at all the fridge is not working or the vaccines has been exposed to a higher temperature, all the vaccines will be sent to the lab to be tested for its potency.

In the fridge, the vaccines are arranged in such a way that the live vaccines are placed at the most top. Live vaccines such as BCG, PV, Measles, etc; when given, it must not be cleaned with a spirit swab. BCG vaccination is given at birth and if there is no scar at the age of 3 months, it is given again and to be check again at the age of 7 years old, 12 years old and in secondary school. BCG is use to protect tuberculosis and the vaccination can only protect a person for 15 years.

A type of vaccination which is called as Triantrix is currently given. It contains of DPT, Influenza or HiB and Hep B. Baby who are HIV positive or those who are under chemotherapy, OPV is not given to them due to low immune system.

Complication for mumps in a male is impotence and complications for measles are meningitis, pneumonia and etc.

For a pregnant lady, vaccinations such as Tetanus and Rubella are those commonly asked to them. If an antenatal lady is Gravida 1, then she will be given 2 doses of Tetanus and if the mother is more than Gravida 1, then she will only be given 1 dose of Tetanus. In Gravida 1, the first dose is normally given at the 18/52 POG. And the second dose is given after 1 month of the first dose. If mothers who are more than Gravida 1, the dose is given one month after quickening. Rubella on the other hand is given to mothers after one week of postnatal to those mothers who had never had Rubella vaccination before.

For ATT, Hep B, DPT and DA (Double Antigen), they are usually whitish grey in colour. If it get spoiled, the colour will changed to yellowish brown. Another way of knowing whether the vaccination is still potent is by looking at the sediment. If there is sediment present, try to shake the bottle. If the sediment is still there, this means that the vaccine is no longer potent. As for MMR, the normal colour is light pink.


Day 3 (04/11/2008)
We had a more concise discussion about Cardiovascular Diseases and Diabetes Mellitus with Dr. Jamilah in Klinik Kesihatan Bedong.

For Cardiovascular Diseases, the cut-off point for a screening is 45 years old for males and 55 years old for females. For hypertension, the most important investigations done is urine analysis. For lipid profile, the most important ones that they will look into are LDL follow by HDL and TGL.

As for the Diabetes Mellitus, the current prevalence in Malaysia is 12%.


Day 4 (05/11/2008)
For the morning sessions, we follow the clinic on NCDC (eg DM and HPT, mostly). We each clerk a case from the OPD in KK Merbok and presented them to Dr. Jamilah Abdullah.

In the afternoon, we had a briefing on CDC (eg. HIV). We were told that the prevalence of HIV in the world is about 80,000 and the incidence for HIV daily is 16 patients worldwide. In Kuala Muda, there are about 50 patients with HIV and in the whole of Kedah, there are about 500 patients diagnosed with HIV.

All tuberculosis and high-risk patients are subjected to HIV test. In a high-risk patients, ELISA is done and the samples are sent to the Hospital and it takes about 3-4 days for the results to be returned. If a low-risk patients (eg, pregnant mothers, marriage couples, etc) a rapid test is to be done in the KK.

HIV virus will die once expose to the air. HIV can be transmitted through a lot of ways. As for needle-prick injury, the chances of getting HIV is 0.14% and HIV can be spread through sexual intercourse by 0.9%.

In a pregnant lady with HIV positive, she will be started on STAT (short-term antiretroviral therapy). With the treatment, there is only 8% chances of the fetus developing HIV, but without the therapy the fetus is at a 30% rate of getting HIV. The therapy will be stopped after delivery. The objective of this therapy is to prevent the fetus from getting HIV from the mother. For all the HIV positive pregnant lady, the mode of delivery will be Caesarean Section as baby will have a higher chance (which is 60%) of getting HIV is the mother deliver through spontaneous vaginal delivery.

All the treatment for infectious diseases are free of charge in Malaysia. As for HIV, a 6 monthly CD4+ check-up is done to see whether the patient needs the treatment for HIV (HAART). HAART is also known as highly active antiretroviral therapy which is given to those HIV patients with CD4+ count less than 250. The first dose is normally given to the patients but the subsequent doses is not free of charge. Currently, Malaysia is importing the HAART medications (Cipla) from India.

If a HIV positive patient were to be diagnose with tuberculosis, the HAART therapy will be stopped for one month when they start with their anti-tuberculosis medications. In HIV positive patients, IV streptomycin will not be given as they are trying to reduce the risk of getting needle-prick injury. Unless the HIV positive patient has been on HAART therapy for a long time, then it is not stop as by stopping it can cause resistance.


Day 5 (06/11/2008)
We follow Sister Che Bunga and a Community Nurse for Home Visit programme. Before a home visit is done, the nurses in-charge must have a worksheet on the objectives of the "Rumah Lawat" programme and they must submit a report after that. A home visit is normally done to those who are postnatal, antenatal, child follow-up and HOSPICE follow-up.

For the postnatal, a home visit is done on day 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 20. The first 10 days is important to detect for any Jaundice. The infant is then being measured for his or her weight at the 10th and 20th day. For antenatal home visit, it is done in a routine schedule which is once in first trimester, once in second trimester and once in third trimester. Unless, the mother has other complications, then the home visit would be more frequent. In a antenatal follow-up, first a urine dipstick is used to detect any abnormalities like sugar or protein in the urine. Then, a thorough medical check-up will be done (eg. measuring the blood pressure, checking for the fundal height and other general examinations). For child follow-up, it is meant for disable child or child with inadequate nutrition.

The things which are being brought during a home visit are:-
1) Delivery set
2) Swabbing set
3) Sterile gloves
4) Swabs and swabs
5) Top and Tail set
6) Urine dipstick
7) IV line
8) Catheters
9) Hibitane cream
10) Hibitane spirit
11) Fetal scope
12) Needles and Syringe
13) IV saline
14) Disposable sucker
15) Chinese paper
16) Mask and drape
17) Filter paper (to detect for G6PD)
18) Blood pressure set (Sphingomanometer)
19) Termometer
20) Measuring tape
21) etc......

This conclude our first week of our Family Medicine posting in Klinik Kesihatan Merbok.
Hope you enjoy reading our experience.
i will be posting our second week soon.
Till then, thank you very much.