Family Medicine Posting in Klinik Kesihatan Merbok (Group A3) Part 2 [09/11/2008-12/11/2008]

Hello back....

So sorry for me to take some time to continue writing in this blog regarding our 2nd week experience in Klinik Kesihatan Merbok. We had a wonderful and fabulous time there.



Day 6 (09/11/2008)
We had a very short day wherewe just clerked elderly patient and did some assessment on them such as Elderly Cognitive Assessment Questionnaire (ECAQ), Mini Mental State Examination (MMSE), Psychiatry Depression Scale, Symptoms of Dementia Screener (SDS) and Modified Barthel Index. Those test are actually compulsory to be tested on every elderly patients. We then presented our patients to Dr. Jamilah. We were also told that there is something called as "Geriatric Giants" which includes Instability, Immobility and Incontinence.



Day 7 (10/11/2008)
First of all, we were being briefed on children with special needs programme. We were told that it is the most important to prevent handicap children here in Malaysia and that the MOH (Ministry of Health) had launch a pre-pregnancy clinic in year 2004 where these clinics are located in both Klinik Kesihatan and in the Hospital to have a pre-pregnancy care. In the pre-pregnancy care, a couple of things have been looked into such as:-
1) Early diagnosis of Diabetes Mellitus, Hypertension, and Thyrotoxicosis
2) Counselling for all patients <50>
3) Advise to pregnant mothers that:-

(a) If mother is diagnosis to have thyrotoxicosis, they can be pregnant after the treatment

(b) Thyrotoxicosis can cause abortion

(c) Mothers who are pregnant are advise to take folic acid to prevent teratogenicity

(d) Mothers who are pregnant with diabetes mellitus have to be taken good care of to prevent

anencephaly, spina bifida, etc

(e) Mothers who are pregnant with heart problem will eventually face more medical problems

compare to their child

(f) Mothers who are pregnant with diagnosis of epilepsy can have teratogenicity effects to the

child if the mother is on anti-epileptic drugs

(g) If the mother is pregnant and is diagnose to have rubella infection, 99% the fetus will get

teratogenisity effects and therefore abortion have to take place. In the first trimester if

the mother comes with fever and rash, must ask whether the mother concern has been

given immunisation towards rubella or not. Then a titer test must be done and if the test

turns out to be positive, then pregnancy must be terminated.

Normally after delivery, agross examination will be done during the follow-up. Any developmental milestone delay will be detected and a early stimulation programme or exercise is done during the infant period (in this category, different exercises are given based on the age of the patient). After the age of one, if there is still a gross delay, then the patient is referred to the Paediatric Department to confirm the diagnosis. Once the diagnosis is confirmed in the Hospital, the patients will then be follow-up in any Klinik Kesihatan nearby. The diagnosis is categorised into mild, moderate or severe and then the patient undergo the multidisciplinary approach (including Paediatricians, Health team, Teachers, Physiotherapists, Social welfare and Parents) in order to get optimal care.

For the mild disability, they are sent to the TASKA. The moderate disability children will still be trained by the occupational therapist on simple tasks like toilet train skills, self-care and basic occupational therapy. As for the sever disability, they will be sent to the Children Rehabilitation Centre (PDK) and will be taught basic living there.

For severe mental retardation (eg. imperforated anus, etc), it involves two care units which are:-

1) Health Care

(a) Nursing for nursing care

(b) Physiotherapist for physiotherapy care

(c) Specialist for medication treatment

(d) Medical Officer for medication treatment

(e) Paediatricians for further care

(f) Occupational therapy - refer to Hospital

(g) Speech therapy - refer to Hospital

2) Community Care

(a) Jabatan Kesihatan (Health Department)

(b) Jabatan Pelajaran (Education Department)

(c) Jabatan Kebajikan Masyarakat (Social Welfare Department)

(d) Jabatan NGOs (Non-Governement Organisation)

In the district of Kuala Muda, Kedah, there are some Child Rehabilitation Centre (PDK). They can be found in:-

1) Merbok

2) Bedong

3) Bukit Selambau

4) Kota Kuala Muda

We then follow Dr. Jamilah to a Child Rehabilitation Centre (PDK) in Merbok. Over there, they are taught according to the ages. For the young ones, they are given some toys to play with. For those schooling-aged, they will be taught simple words and pronouncation. For adolescents, they will be given some tasks to do like sewing, bakery, etc and the things that they had done will be sold off so that the disabled children can received some money in the end. The parents of each children will be paid some money to encourage them to send their child to the centre. Currently they are paid RM 150 per month.

We were then being left in the Muzium Arkeology Bujang when the day ends.

Day 8 (11/11/2008)
We were being briefed by Staff Nurse Meriam on nutrition control on antenatal mothers. A normal diet containing carbohydrate, protein and vitamins were being advised to those pregnant mothers.

Day 9 (12/11/2008)

Today is our last day in Klinik Kesihatan Merbok. In the morning, we were assigned a few patients to be clerked and then we headed to the Physiotherapy Department to follow-up a patient. Over there in the department, a short briefing were being told to us by a new physiotherapist. Besides observing her teaching a stroke patient on how to move her right upper limbs, she also brief us on regarding the physiotherapy unit. In the whole of Malaysia, there are more than 200 Klinik Kesihatan but only 18 Klinik Kesihatan has a Physiotherapy unit with equipments by its own. In Kedah, there are 3 Klinik Kesihatan which has the facilities. They are:-

1) KK Merbok

2) KK Bandar Alor Setar

3) KK Pendang

However, in Sungai Petani, there are 5 Klinik Kesihatan which has physiotherapy unit of which only one had equipments. The 5 are:-

1) KK Merbok

2) KK Bedong

3) KK Selambau

4) KK Bandar Sungai Petani

5) KK Kuala Muda

Out of the 5 mentioned above, the physiotherapist from KK Merbok will visit the rest of the Klinik Kesihatan once in a month with portable equipments.

We then have a brief closing up session with Dr. Jamilah discussing about the whole entire programme of ours in the 2 weeks.

In the afternoon, we had a briefing on Tuberculosis and Adolescent by Staff Nurse Norizah. In the tuberculosis briefing, we learnt that there is 2 types of treatment given which are known as PR1 (Pusat Rawatan 1) and PR 2 (Pusat Rawatan 2). In PR1, they can start with anti-tuberculous medcations. The places are such as chest clinic (seen in any KK with Family Medicine Specialist (FMS) - KK Merbok and KK Bandar). For PR2, they are not allowed to start any medications but can only give DOTS to the patients. Screening for tuberculosis is open to:-

1) Walk-in patient with symptoms

2) Any diabetes patient with symptoms

3) Any HIV patients

The screening for tuberculosis regardless of any type of the patients will have to fill up the TBIS form and sent to the District Health Office Kuala Muda within 1 week. The 'Pegawai Persekitaran' will go to the patient's house to get any family members who may be in contact with the patient. A notification form is also been filled up. The patient's contact will be ask to take sputum and chest X-ray (for child, Mantoux test is taken and no CXR is taken). Patient is clerked by the doctor (an envelope and a file will be given to the patient). Baseline investigations (eg. LFT, AST, Sputum C&S, HIV status, RBS, etc) were done. Then, treatment (dosage) is given to the patient depending upon the body weight of the patient. A small book will be given to the patient; either yellow (for PTB +ve) or white (PTB -ve). For PTB negative, sputum culture is not require.

There are 2 different phase for treatment. In Phase 1, 52 doses are given. Then, the chest X-ray and sputum culture is being repeated before proceeding to Phase 2 where 32 doses are given (every fortnightly). After that, follow-up will be the first 3 months, follow by 6 months, 9 months and 2 years respectively. If patient's contact or family members were to be found positive, treat them accordingly too. If there is a defaulter, the 'Pegawai Persekitaran' will be informed and they will track the patients down and treatment is tobe started all over again. Then, they will be given a red card.

A template or brochure is given to patients to let them realise the importance of DOTS, the food and diet and also to educate the patient on tuberculosis. If a patient were to be transferred, a 'Borang 10K' must be filled up and the receiving place must make sure that the patient turn up for regular follow-ups. If the patient has passed away, a 'Borang 10J' have to be filled up. All together, there are about 25 forms just for tuberculosis.

In KK Merbok which covers areas like Bedong, Selambau and Merbok, there are about 10 new patients of tuberculosis yearly.

As for the adolescent briefing, we got to know that the range for adolescent is 10-18 years old. Any walk-in patient for screening or any refer cases (normally from the school) will then be given a form to be filled up. Then, any problems will be detected (eg drug abusers, smoking, depression, molest, etc) and they will be counselled. In KK Merbok, all female adolescent are counsel by S/N Norizah. Even for any male adolescent who smokes will be counsel by her too. For other male adolescent, they will be counsel by medical assisstant. Unless there is cases which are very severe, then those adolescent will be refer to the medical officer or the family medicine specialist.

And this ends our 2 weeks of posting in KK Merbok. We did had a splendid time there...

i hope you did enjoy reading the article...

Thank you...