KUALA MUDA, 6.8.08, (DAY 8): SPECIFIC REPORT

We went to water treatment plant at 8.oo am.It was the Sungai Petani and Pinang Tunggal Water Treatment Plant. The activity was a surprise for us as Mr. Silva, the PPKP for KMAM told us that he had already take special permission for us to enter water treatment plant. We could see how the river water was processed and become the clean water that comes out from our house pipe.

Firstly the river water was passed through a screen to trap the branches and large objects. Then the deep seated water with sand are sucked up by a pipe and poured to a small drain-like-connections in order to protect the sucking pump that connects to the treatment pond. At the pond, the water undergone aeration in order to oxidized the ferum, magnesium, and other metals so that it will not dissolved into the water. Through this process, the carbon dioxide and hydrogen sulfate will be released into the air.

Then the water went into flocculation pond. Aluminium sulfate or Poly Aluminium Chloride (PAC) is used to coagulate the small suspension of solids and colloidal materials. This coagulated to form Floc.

Then the water that is free of floc will be channelled to sedimentation tank. The retention time is 2 hours. The water is then percolated through a bed of a fine sand to remove fine suspended solids and colloidal matter.

After filtration, the water is then neutralised with calcium hydroxide to increase the pH of the water as it was acidified before by the PAC. The water is then added with sodium silicoflouride for the purpose of producing healthy teeth among the drinker. Chlorination is the next step in which chlorine is added into the water to kill residual bacteria. The water then is stored in clear water tank and channelled out to the household and another pipe channeled back to them for their usage (mixing chemicals).

Sorry for the simplicity because the blogger of this post is busy like an ant. (If any questions please do ask in the communication box. thanks.)

KUALA MUDA, 6.8.08, (DAY 8): DAILY REPORT

At 8.00 am, we departed for water treatment plan. Further detail will be listed in specific report.

At 11.45 am, a briefing regarding primary health care including expended and extended scope( mental health, geriatric health and stop smoking) delivered by Mr.Yusof Hashim, penolong pegawai perubatan kanan. The briefing extended up to 1.30pm.

After explaining the vision and mission of Ministry of Health, he introduced all the 8 goals of primary health care. He also talked about the organization chart of this unit. We were informed that government has allocated 0.6billion for primary health care. Besides that, according to 9th Malaysian Plan, for the Management of Crisis and Disasters, our government has become a member of an international network called Government Integrated Regulation Network (GIRN). It comprises a system of signaling sign of danger if there is any natural disasters in any country, among the members of GIRN.

There are additional services in primary health care which includes 4 expanded scopes namely, geriatric health( programme warga emas), adolescent health ( programme remaja), mental health and stop smoking( klinik berhenti merokok).

At 1.30 we dispersed for lunch break. Then, at 2.30 , we reassemble again for briefing on non communicable diseases and Methadon replacement therapy.

Non-communicable disease (NCD) Unit
(Surveillance for diabetes mellitus and cardiovascular disorders cases)
This session suppose to be carry out in the morning from 11.30am to 1.00pm but have to postpone to afternoon from 2.30pm to 4.00pm due to Mr.Selva suddenly called in the early morning say want to bring us visit to the loji pembersih air Sungai Petani & Pinang Tunggal.
Sharp at 2.30pm, all of my group members are gather in the clinic waiting for Mr.chong (PPP)k but unfortunately he is not around here . Even he is not around but he got order the staff nurses to bring us visit around the clinic to see what activities and how the activities carry out. We start our activities around 3.00pm. According to the staff nurses this clinic working hours is start from 7.30am to 5.00pm and they only having break for 1 hour from 1.00pm to 2.00pm. Timetable will be attached later.
Today they going to have funduscopy and do screening for diabetes patients. Staff nurses also explained to us how the records of the patient stored according to the last 4 digit number of identity card, gender and race. All the patient records are stored in one room. Staff nurses also got shows us the small record book for diabetes and cardiovascular disorders patients. Green color one is for diabetes patient whereby blue color one is for cardiovascular disorders. Normally patients will come every 3-4 months for follow up but for those the disease is not well controlled need to come more frequently for follow up. In the clinic there is a register counter specifically prepared for DM and hypertension patients. There is also a corner prepared for them to check their blood pressure, blood glucose, weight and also height to ensure that the disease is well controlled or not.


(Methadone maintenance therapy )
Another unit we went during this session is the Methadone maintenance therapy (MMT) program which is conducted by Mr.khairul (MA). According to Mr.khairul, there are 48 clients in Kuala Muda district list who received the therapy. Anyway according to the research there are actually around 500 cases but only 48 come and get the free therapy from government. The objective of this program is to prevent increase HIV cases in the Kuala Muda district. Mr.khairul also informed us that there is a specialist name Dr. Nor Azah in this unit. He also got explained to us how the client get register for the free therapy. First they must get a letter from ADK (Anti Dadah Kebangsaan), after that they need to do blood test and urine test before they get registered. For blood test they need to repeat after 6months whereby urine test for the first 2 months they need to do urine test every weeks then once in a month after that. One step test (urine test) used to detect the abuse of morphine, cannabis and amphetamine. However there is a special urine stick used to detect morphine and amphetamine separately. Once morphine are detected they will stop the therapy for that particular day and they will ask the client come only on the next day, but if amphetamine and cannabis are detected the therapy still given because morphine won’t cause overdose. According to Mr.khairul methadone usually started provided from 5mg and slowly increased to maximum 70mg in this DHO Kuala Muda.

At 4pm, we went to family planning unit (LPPKN) which is situated just beside the KMDHO. All of us were welcomed by Sister Zuriana who also briefed us about LPPKN. During the briefing, all of us were eager to know about LPPKN as it was unfamiliar to us.

To our surprise, LPPKN is neither government agency nor a private company. We were informed that LPPKN is a semi-government organisation which is an agency of Ministry of Woman, Family, and Community Development. Currently, there are 4 functioning LPPKN clinics in several districts in Kedah, namely Baling, Kulim, Kota Star, and Kuala Muda. The core services provided by LPPKN clinic include: papsmear, breast examination, psychosexual counselling, women and men wellness, family counselling, and marriage counselling.

However, there are no identified clinic and menopausal clinic available in LPPKN Kuala Muda at the moment. These services are only provided in LPPKN kota Star.

After the briefing, we were brought by the sister to visit the counseling room. In the counseling room, we had the opportunity to have a look on several contraceptive devices such as Implanon, IUD, OCP. we were also taught on the function, effectiveness and some disadvantages of various method of contraception. By 5.30pm we were dismissed and each of us were given some pamplets.

Reported by Thana, Yew Chai, and Chia Leong

KUALA MUDA, 5.8.08, (DAY 7): SPECIFIC REPORT

Mission: Active case finding (Aedes Survey) in Taman Ria Jaya

Objective:

• To find active case of Aedes (Positive breeding of mosquito larvae)
• To take preventive measures by adding ABATE into water tank
• To give awareness to public regarding Dengue fever and Aedes via pamplet

Date/Time: 5.8.08, 10.30am-12.30pm

Team: 3 teams, each team consist of PKA and 4 AIMST medical students (+1 in a team)

Law Used: Destruction of Disease Bearing Insect 1975

Tools Used: Empty sterile bottle, seal, pipet (small and large), forms, notice, ID card, Vest

Description:

Total of 88 houses were in for checking by the officers. We were divided in 3 groups and each group followed 2 officers to the specific locations.
The officers went house by house. They always introduced themselves and showed their identity to the house owners before beginning with the surveillance. The house owners followed the officers during the surveillance, as required. They checked the flower pots at the veranda, and any other containers that may contain water. Inside the house, they checked the washrooms and the toilets. They also flushed the toilets in order to check its efficacy as the spoiled flushes can be place for the mosquito breeding. If there were no larvae found, the officers add about 10g of Abate in powder form to the water in the toilet flushes and in any water containing pots or containers as a precaution.
In total of 88 houses only 3 houses were found to have larvae. In these houses, after the breeding place of the larvae found, the officers will it to house owners. They then show the empty bottles to house owners before collecting the samples as evidence that there were no foul play present. Then the samples were collected by using pipette. In both the houses 5 bottles of samples were collected each. Then the bottles were sealed and labeled with information like the date of the sample taken, the location of the sample collected and who collected it. The house owners were needed to write their identification card number and sign the label. The Pembantu Kesihatan Awam and/or the Pekerja Am witnessed these procedures. The house owners were given compound under the Act of Destruction of Disease Bearing Insect 1975, section 13. They will be required to pay RM100 each in the District Health Office by 14 days. The offenders are also given extra 7 days notice if they are not able to pay the compound within 14 days.
While in the empty houses where the owners were not present at the time, one notice was sticked in the front door to notify that the surveillance will be done the next day

Procedure:

• Introduce ownself and show ID. Then explain the motive of survey.


• Enter the house only if allowed, if not allowed (or no one is at home), a notice is sticked to the wall telling that survey will be doen the next day. If resident still insist not to allow health officer to enter for checking, then the act plays an important part this time. DDBIA 1975 will be used for lawsuit
• Surrounding of the house is surveyed for potential breeding site for larvae
  
• If found, a sample of AT LEAST 5 LARVAEs ARE TAKEN.


• Resident will be explained that the bucket contains larvae and show the larvae to him/her


• Explain to the resident that he or she has againt the law of DDBIA 1975 and a compound will be given.


• Before sample is taken, the new sterile bottle is shown to the resident first to prove that there is no foul-play


• At least 5 larvaes are taken by pipet


• The bottle contain these larvaes are shown to the resident again and then the bottle is sealed


• Bottle is labeled and compound is written.


• ABATE (larvicides) are put in water tank or potential space of water collection (both positive and negative findings of larvae)


• Education is given to the resident both verbally and through written materials.


• Sample is sent to DHO lab to analyst the breed of mosquito

Discussion:

Have you ever wonder that if any larvae is found in a drain outside of a particular house, will that particular resident be compounded? If yes, how to prove that the larvae did not swim from the drain of the other house further up to that particular resident's drain?

The answer is that there no need for us to crack head. This mission is to detect any aedes larvae in a household. Aedes only breed in water holding container and not normally in the dirty stagnant drain like those of Culex.

Do you know that Dengue fever (DF) and Dengue Haemorrhagic fever (DHF) are beaten by different Aedes?

Aedes main species are Aedes Aegypti and Aedes Albopictus (Asian Tiger Mosquito). Aedes Aegypti cause DHF whereas Aedes Albopictus cause DF. Aedes Aegypti likes to breed in dark area and Aedes Albopictus can breed in clear and open space stagnant clean water. Thus, if a larvae is found in the pail just like the picture shown below, it is most likely to be Aedes Albopictus.

How to know whether it is Culcine (Aedes, Culex, Mansonia) and Anopheles by looking at the larvae sampled?

To differentiate the which is the most likely type of mosquito, there is a great explaination given in K.Park 17th ed. page 545. In this contex, we will just consider on larvae. The sampled larvae is closely observed for siphon tube. It will be whitish pale in colour which is quite similar to the colour of cartilage. The siphon is located at 8th segment of the larvae. If there is appearance of siphon, the species will be Culcine.

Besides, the way how the larvae rest just below the meniscus of water can also distinguish which type of mosquitoes. The larvae that rest inclined at an angle to water surface will be the Culcine but not anopheles. Anopheles rest parallel to the water surface.

Thumbs:






Introduction before entering the house.






Consent given. We entered the house.






Surrounding of the house is looked for potential breeding site.






Gan was hoping to see one larvae but none was found.






The 'Abate guy' entered the house.






Toilet was checked.






Water collection for bathing was checked.






Collecting plate under the refrigerator was checked.






Abate in powder form is put into water straight. The chemical effect can last for 3 months.






Health education is given via written form to make the public aware about Dengue and Aedes.






Potential breeding site.






Larvaes spotted! Many of them!






Larvae spotted by health officer.



Resident is shown the breeding site and explained the characteristic of the larvae and how to identify it in layman's term.





Sample is taken with pipet





Sample is put into sterile empty bottle.


Bigger pipet for easy sampling





At least 5 samples of larvae taken




The larvae of Aedes look like this and it is the same as those in the sample bottle.


Bottle is sealed.





Compound is written by PKA.







Video:






Reported by Gaaitheri and Gan

KUALA MUDA, 5.8.08, (DAY 7): DAILY REPORT

KMDHO starts with field work

The day started at 8am where we started to gather in the Vector Borne Diseases Unit. Our field work for this morning is Aedes Surveillance in Taman Ria Jaya. After the Officers of the Unit finished their meeting,we were told to follow them to the surveillance area. The meeting was told to be about internal auditing and also about the surveillance that was going to take place. We were not allowed to participate in the meeting.
The meeting finished about 10am and we started to drive to the initial location of the surveillance, that is the Sekolah Menengah Kebangsaan Taman Ria Jaya. About 10.30am in the morning, we entered the school. 3 officers were there to do the surveillance. All the places where Aedes mosquitos can breed were checked. Those places are like the small pond, nursery, back of the canteen, and the surroundings of the school.
The larvae were found in the school nursery. The samples were collected in 5 small bottles using pipette. The bottles were then sealed and labeled with information like the date of the sample taken, the location of the sample collected and who collected it. The headmaster signed the label. The Pembantu Kesihatan Awam and/or the Pekerja Am witnessed these procedures. The school will be compounded RM 150, under the Act of Destruction of Disease Bearing Insect 1975, section 13.
After finishing the surveillance in the school, we then proceeded to the housing area, Taman Serampang that was opposite the school. The detail will be described in specific report.

Aedes Survey at Taman Ria Jaya

The entire surveillance session extended up to 12pm. We then dispersed for lunch. At 1.30pm we meet again at the Meeting room in the main building as Dr. Sawari Rajan, Dr.Kay, Dr.Sapna, and Dr. Lily came to meet us. In this 30 minute session, they questioned us about the things we learned over the last and this week and gave us some feedback on topics that should be covered in detail. Thanks to their suggestion that lead us to apply family planning topic from LPPKN which was governed by different ministry.

Visits from the honourable lectures, from left to right: Dr. Sawri Rajan, Dr. Sapna, Dr. Kay, and Dr. Lily.

PPP(K) Mr.Berhan

The next session was at 2.30pm PPP(K) Mr.Berhan. He is in charge of HIV anonymous and HIV testing pre-marriage proceedings. The session started off with a slide show. The first few slides were about the history of HIV that covered the first cases in the world and also in Malaysia. The first case in Malaysia was found in the year 1986. He also covered the mode of spread of the virus, and characteristics of the virus. It is found that blood, semen and vaginal fluids have very high content of the virus compared to the least containing tears, saliva and milk. There were also slides about the opportunistic infections that are common in HIV/Aids patients, e.g like Genital Candidiasis, Oral hairy leukoplakia, Pneumocyctic carinii pneumonia and TB.
The up coming slides contained graphs that contained needed statistics about the disease. There were slides about the prevalence and incidence of HIV patients in the world (1998). Africa has the highest number of both the prevalence and incidence globally, that is about 22.5 million prevalence cases. Global estimation of AIDS patient in the year1998 is 33.4 million and number of death is 2.4 million.
While in Malaysia from the year 1989-1998 the amount of HIV patients were 28,541 and amount of AIDS patients were 2354. The most common age groups that are affected in Malaysia are from the age 30-39 and 20-29. In Kedah from 1989-1998 the most commonly affected race were Malays with 74%, next are Chinese with 14%, then Indian 6% and other races who are Malaysian contribute about 3% and foreigners are bout 3% also. Besides that another graph showed sharing IV drug needles as the highest mode of transmission (82%) in Kedah, next is the heterosexual intercourse(11%) and third largest is the homosexual intercourse(3%). The fishermen are the most affected people with HIV in Kedah, next are factory workers. While in females most of the affected ones were housewives.
Besides that, measures to prevent HIV/AIDS were also discussed. Preventive measures for HIV/AIDS are very important as there is no cure or vaccines for it. Everybody is advised to live a healthy, straight lifestyle. The public are advised not to share needles if they are IV drug users, and do not practice random or unprotected sex with multiple partners. Besides that mothers are advised to have early detection test.
After that, we also discussed the programmes that run for Muslims. These programmes involve those who are intent to tie the knot. It is compulsory for them to fill up the Borang Pemohonan Pemeriksaan Kesihatan which is from the National Islamic Department. They need to involve in Programme Ujian Saringan HIV Pra-perkahwinan. If one of the partner’s test is reactive, that person will be referred to Family Medical Specialist, however the positive result of the individual will not be told to the other partner. If the test is positive after referring to the Family Medicine Specialist, treatment will be started and these individuals will be referred to the Islamic Department for decisions to be made about the marriage.
Other forms that are needed to be filled in are Reten Bulanan saringan HIV Pra-perkahwinan, Reten Modified Syndromic approach. While for the non-muslim they have Programme Pengurusan HIV but this is not compulsory.

Reported by Gaaitheri

KUALA MUDA, 4.8.08, (DAY 6): SPECIFIC REPORT

Drinking Water Qualitity Control Unit (KMAM)

In the afternoon 2.30pm, we were briefed by PPKP Silva on water supply and drinking water control. After that, we followed him to a nearby auxilliary for water sampling.

Mission: Water sampling in District Kuala Muda

Objective: Monitoring of water supply in District Kuala Muda.

Description:
- Water flowed from its main source the river or lake to treatment plant outlet (TPO) and finally to services reservoir outlet (SRO) and auxiliary.
- Various treatments have done in TRO include the flocculation, oxidation,
sendimentation, filtration and chlorination.
- Water sampling usually done in SRO and auxiliary.
- There are 67 SRO (station) in District Kuala Muda.
- 7 treatment plants are available in District Kuala Muda.
- There are 4 parameter have to be measured in water sampling:
1. Parameter 1 includes the physical and microbiology test. It is done in weekly basis. For the physical test: PH (6.5-9), NTU (nephelometric turbidity units) < color="#33ffff">Location: Auxilliary nearby the old hospital (A012)

Date: 04.08.2008 4.15pm

Team: PPKP Silva together with a PKA and Group B members. (Water sampling is usually done by a PPKP and a PKA.)

Tool Used: water container, Whirl Pack, PH meter, Colorimeter, NTU meter, Soudogaz etc.



Procedure:
- Water from SRO or auxilliary was allowed to flow for 2-3 minutes.
- Water has been filled in three water containers. First water container for PH testing. A probe inserted in the 1st container and PH meter show the value in a short while.
- Second water container placed in NTU meter and it showed up the turbidity value.
- Third water container mixed with DPD (white powder reagent). The water changed its color into pink after the mixture occurred. It is then placed in the colorimeter and chlorine value shown on the monitor.
- Before the sample for bacteriology test was taken, tap water was heated by soudogaz in order to get ride of bacterial along the tap and pipe.
- Whirl pack has been used to collect bacteriology water sample. Technique of sterile opening and enclose the pack was applied. Water around 100ml has been filled in the Whirl pack.
- Detail of water sampling such as the date, time and location of water sampling was stated clearly on the whirl pack.
- Whirl pack has been kept in cool ice box with temperature of 4 to 10 Celsius in order to prevent microorganism from multiplication.
- Forms were filled and samples were sent to labs within 24 hours.

Reported by Helly Chai

THUMBS: (coming up)

KUALA MUDA, 4.8.08, (DAY 6): DAILY REPORT

Nutrition Unit



PZM En. Wan Mohd Nurussabah bin Hj Abd. Karim of KMDHO

The briefing about nutrition unit started at 9.00am provided by PZM En. Wan Mohd Nurussabah bin Hj Abd. Karim. (PZM- pegawai zat makanan). En Wan is a graduate of UKM after his 3 years studies in food science. We have been told that every district has only one nutritionist and he is the nutritionist in District Kuala Muda. Basically nutrition unit is covering all the matter which related to food.

The job scope of a nutritionist is the following:
- Give counseling to the patient who are malnutrition in the nutrition clinic.
- Received cases which are referred from Doctor in hospital or clinic especially like cases of diabetes mellitus or hypertension.
- Give advise to the antenatal mother who have gestational diabetes mellitus
- Give counseling to the antenatal mother whose body weight did not increased correspondent to her period of pregnancy and so on.

We have been told by En Wan that there are difference between nutritionist and dietitian. Dietitian is the one who usually worked in hospital. They treat uncontrolled cases while the patient is in the hospital. There is no followed up done by the dietitian. Meanwhile, Nutritionist worked in the district health office. They serve more on community, prevent people from getting sick and treat those who were discharged from hospital.

The patient will come to visit nutritionist every month. Details such as diet recall for 24 hours, the main meal time, quantity, quality and way of food processing have been asked by nutritionist. This has done in order to calculate the daily calorie of patient and make sure their food is good and suitable for them. Daily calorie for a healthy adult is 2000 to 2500 calorie while 1500 to 1800 calorie for child. According to their diet habit, advice and diet modification have been given to patient.

The main activities held by nutrition unit include:
- Survey IDD (iodine deficiency disorder)
- Program kekurangan zat makanan (KZM)
- Program Penyusuan susu ibu (PSI)

Survey IDD
It has been started for more than 20 years. This is a randomized survey which concentrated on school student. Sample of urine is taken to measure the value of iodine within the body. There was found in the survey that IDD was serious not only in the rural area which is far away from the sea such as Sabah and Sarawak, many cases of low iodine found in the student of Kuala Muda. Some steps have been taken by the government to control this problem such as provide the iodinated salt in the market and setting up the iodinator in the main pipe. Iodinator has been settled up in a few places which are far away from the sea such as Sik and Padang Serai.


Program Kekurangan Zat Makanan (KZM)
The program cover for children aged 6 months to 7 years old. It has been categorized into yellow and red color where yellow are child who lack of nutrition and red are the serious cases. Under the program, the family income per capita less than RM87 can apply for aid in the form of food basket.

Food basket contains:
- Carbohydrate: rice, noodle, biscuit, flour etc.
- Protein : Ikan bilis, bean
- Fat : full cream milk(1kg)
- Multivitamins
Each food basket contains of 180% of calorie. Food basket provided for a child at least 6 months dependent on their health condition. If it is necessary, the child will be received the aids until the age of 7 years old. So far, we have been told by En Wan that district Kuala Muda has 14 of such cases in year 2008. Staff from district will make the monthly visit to the house of those received food basket. Recipient is also obligate to join all the activities which are held by nutrition unit. Besides that, child with congenital problem can apply for the food basket.

Program Penyusuan Susu Ibu (PSI)
It is a program promoted by WHO and held in worldwide. It concentrates on exclusive breast feeding where only breast milk is feed to child until the age of 6 months. In order to enforce the program, baby friendly hospital initiative (BFHI) has been settled up. Under this policy:
- 80% of staff include the doctor and specialist are obligate to attend breast feeding
courses for 18 hours.
- No milk bottle or artificial nipple should be placed in the hospital.
- Staff should encourage and support postnatal mother to feed their child with breast milk.
- Postal and pamphlet related to breast feeding should provide to the mother.
- Talk about breast milk feeding is provided to antenatal mother.
- Staff nurse who made the 1st postnatal visit should educate and give practical to the mother about breast feeding.
- No advertisement for formulated milk is allowed in the hospital.

Besides this entire program, nutrition also held some program for obesity in adolescent and body weight management program. Activities such as jungle tracking, hiking were organized by them in order to promote healthy lifestyle among younger generation.

Reported by Helly Chai

KUALA MUDA, 3.8.08, (DAY 5): SPECIFIC REPORT

After delivery, home visit are done from the 1st to 10th day and on the 20th day. This is visit is for both maternal and child.

During the post natal visit, the neonate is assessed as below:

weight
head circumference
length
general well being
-weak
-irritable
-anemic
-cyanosis
-jaundice
-alter bowel habit
-problems related to micturation
-feeding problem
-skin problem
5. Vital signs
-respiratory rate (normal 40-60/min)
-heart rate (normal 120-160/min)
-temperature




6. Examination of the head
-shape
-fontanelle
-swelling
-caput
7. Examination of neck
-swelling
8. Examination of eye
-abnormal e.g. congenital ptosis, squint
-cataract
-abnormal conjunctiva
-discharge
9. Examination of mouth
-cleft palate
-cleft lip
-oral thrush
10. Examination of ears
-abnormalities
-discharge
11. Respiratory system
-abnormalities in the nose
-sub/intercoastal recessation
-shape of chest wall
-breath sound
12. Cardiovascular system
-murmur
-femoral pulse
13. Gastrointestinal system
-distension
-umbilicus
-mass
-patency of anus
14. Genitalia
-male: testis, penis, scrotum
-female: imperforated hymen, discharge
15. Musculoskeletal system
-spine
-fingers and toes
-clubfoot / CTEV
-hip dislocation
16. Neurological system
-fits
-reflex ( moro / grasp / rooting)
-tone


The mother is assessed for:
a) general well being
b) temperature
c) blood pressure
d) pulse rate
e) breast examination
f) SFH
g) Perineum
h) Lokia
i) Urine albumin/sugar
j) BO/PU
k) Signs and symptoms of pulmonary thromboembolism



We were also briefed about the colour coding system which includes:
White 1: Deliver in hospital
a) primigravida
b) age <18>40
c) gravida 6 and above
d) height <145>145
f) age >18 or <40>37 and <41>2 kg and <3.5kg>3)
g) unsure of LMp
h) Past obstetric history e.g caesarean, DM, eclampsia, hypertension, prenatal death, perineum tear of grade 3, postpartum hemorrhage, instrumental delivery, baby weight <2.5kg>4.0kg
i) High blood pressure (140/90 mmHg) with urine albumin negative
j) Hb <>2kg in a week)
n) Weight >80kg
o) SFH more or less than 4 cm compared to POA
p) Malposition with no signs of delivery in >34 week
q) Head not engaged
Yellow: Refer to family health specialist or O&G specialist clinic
a) HIV +ve
b) Hepatitis B+ve
c) DM
d) Reduce fetal movement when >32 weeks
e) Gestation more than 7 days than given EDD
f) More than 1 fetus

Red: Immediate admission to hospital
a) eclampsia
b) pre eclampsia or BP >160/110mmHg
c) chest pain with symptoms such as palpitation, shortness of breath
d) Shortness of breath noted while performing simple task e.g. Sweeping, washing dishes
e) Uncontrolled DM
f) Abnormal fetal heart rate
g) Anemia
h) Premature contraction
i) Leaking liquor without contraction
j) Sudden exacerbation of asthma
k) Antepartum hemorrhage

Reported by Rathna