Medical Internship in Tegal Regency

After obtaining the certificate of competence as a primary care physician, every medical graduate from Indonesia must be enrolled in medical internship program. This new program was established by the Ministry of Health Republic of Indonesia. This program is intended to improve the fluency of medical practice of newly graduated GP before practice on their own responsibilities.

Medical Internship Program consisted of 4 months working as a CHC GP and 8 months as GP in ER/General Ward/ICU. I obtained the program in Tegal Muhammadiyah Hospital and Slawi Community Health Center.

Tegal Muhammadiyah Hospital

During the 8 months of working as a GP, I was supervised by senior GP. Our job was almost the same with senior GP, like diagnosing patient, giving therapy/consulting to clinical specialist, managing emergency cases, resuscitate newborn, doing CPR etc

Slawi CHC

This short 4 months were spent by working in the community health by means general clinic, geriatric clinic, pediatric/maternal clinic, health education and promotion, preventive measures like school-age vaccination, healthy life promotion etc. We were also asked to create a community project, and my CHC topic is about dengue virus infectiona and people’s behavior/perception towards its prevention.

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Pengalaman Ujian TOEFL IBT

Salah satu akhir dari belajar bahasa Inggris adalah ikut Tes TOEFL IBT. Dengan berbekal minjem CC Kakak sepupu, saya memberanikan diri mendaftar via akun ETS, biayanya sekitar 3 juta kurang, dengan persiapan cuma sebulan dan bermodalkan buku official IBT TOEFL ETS yang saya beli 2 tahun yang lalu. Untuk lokasi ujian saya memilih International Testing Center Plaza Central Jalan Sudirman Jakarta.

Pukul setengah tujuh saya sudah tiba di tempat, jam 7.15 mulai registrasi ulang dan menunggu dipanggil satu persatu untuk difoto dan diverifikasi, kemudian masuk ke ruangan dan jam 8 tet semua dimulai, ujian menggunakan komputer.

Step pertama adalah reading, artikel berbagai topik dan menjawab inti paragraf dsb.

Step kedua ujian listening, mendengarkan percakapan/kuliah lalu memberikan intepretasinya.

Step Ketiga, Speaking, ini paling absurd, jadi ada yang sifatnya kita telling sesuatu ataupun menyarikan hasil listening kuliah/percakapan.

Step terakhir writing, ada dua tugas, meringkas kuliah dan memberikan pendapat tentang sesuatu hal yang ditulis dari 250-350 kata dalam waktu singkat.

Habis ujian cm bisa pasrah, dan Alhamdulillah hasilnya bisa membuat orang tua lega udah ngeluarin duit buat bayarin kursus Inggris dari SD sampe kuliah.

Tips

Indonesian Medical Licensing Examination (IMLE)

Well in Indonesian it is called Medical Doctor Competency National Examination or UKMPPD, but the purpose is the same to measure the competency of medical graduates before taking hippocratic oath.

There were 2 kinds of examinations, computer based test and objective structured clinical examination/OSCE. In CBT we have to finish 200 questions within 200 minutes. In OSCE we have to deal with 13 stations with each spend 10-15 minutes. In OSCE I had obesity, acute viral hepatitis, bladder stone, bipolar manic episode, carpal tunnel syndrome, anterior epistaxis, measles, pulmonary TB, mild neonatal asphyxia, hypertensive crisis with LVH, femoral fracture, and dengue hemorrhagic fever.

Praktek Kedokteran Pariwisata di PKM Karimunjawa

Fadel Muhammad Garishah

Kepaniteraan Komprehensif

Fakultas Kedokteran Undip/Puskesmas Karimun Jawa

Klinik Kedokteran Pariwisata merupakan salah satu bentuk pelayanan kesehatan di daerah wisatawan yang ditujukan untuk kegiatan promotif, preventif, kuratif dan rehabilitatif wisatawan lokal maupun asing. Sebagai dokter muda kepaniteraan klinik komprehensif di puskesmas karimun jawa, saya berkesempatan memberikan pelayanan kuratif termasuk pada pasien wisatawan internasional. Keluhan yang utamanya dihadapi adalah diare (traveler’s diarrhea), demam, infeksi saluran pernapasan dan berbagai macam kelainan kulit. Wisatawan yang sering dijumpai berasal dari jerman, belanda, swedia, serta wisatawan nasional dari seluruh Indonesia. Secara umum wisatawan asing dapat berbahasa inggris, sehingga komunikasi selama proses anamnesis dan diagnostik tetap dapat dilaksanakan dengan baik. Penatalaksanaan juga disesuaikan dengan standar operasional pelayanan yang berlaku. Secara umum wisatawan internasional cukup puas dengan pelayanan kesehatan sederhana yang dapat diberikan.

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Gambar 1. Pelayanan Kedokteran Pariwisata di PKM Karimunjawa

Dari sebuah penelitian yang dipublikasikan oleh NEJM pada tahun 2006, dari 2793 wisatawan asing ke Asia Tenggara, 248 menderita demam, 210 menderita diare akut, dan 212 menderita penyakit kulit. Ketiga penyakit tersebut menjadi primadona penyakit yang diderita oleh wisatawan asing sepulang dari Asia Tenggara.

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Gambar 2. Distribusi Tujuan Wisata Internasional dan Posentase Wisatawan

Demam pada wisatawan asing pada umumnya diakibatkan oleh infeksi bakterial, viral dan parasit. Penyebab tersering adalah infeksi saluran pernapasan atas yang disertai gejala batuk, pilek, dan nyeri telan. Penyebab demam lain termasuk diare (traveler’s diarrhea). Demam sistemik yang sering didapatkan di Indonesia dengan inkubasi < 14 hari antara lain malaria, infeksi virus dengue, demam tifoid, leptospirosis dan hepatitis akut. Sementara demam > 14 antara lain tuberkulosis, hepatitis kronik dan infeksi HIV. Untuk demam dapat diberikan acetaminophen 500mg 3-4 kali sehari, pengobatan spesifik diperlukan untuk setiap penyebab demam. Pengobatan malaria diperlukan artemisinin combination based therapy, infeksi dengue perlu resusitasi cairan, demam tifoid dapat diberikan kloramfenikol atau siprofloksasin, leptospirosis diberikan doksisiklin atau seftriakson, untuk tuberkulosis diberikan obat anti tuberkulosis, HIV dengan pemberian terapi antiretroviral dan hepatitis diberikan terapi konservatif sementara.

Diare akut wisatawan dikenal sebagai Traveler’s Diarrhea yang berlangsung singkat kurang dari 1 minggu hingga 2 minggu atau lebih pada 1-3% kasus. Penyebabnya 50-75 % akibat infeksi viral dan bakterial pada diare akut seperti rotavirus, norovirus dan enterovirus serta Escherichia coli, Campylobacter jejuni, Salmonella enterica, Shigella dysenteriae, Vibrio cholerae dan Clostridium difficille. Sementara pada diare kronik umumnya diakibatkan oleh parasit seperti Giardia lamblia, Cryptosporidium parvum, Entamoeba histolytica dan Cyclospora cayetanensis. Penyebab diare lainnya akibat keracunan makanan, intoleransi makanan asam/pedas, intoleransi laktosa. Diare dengan darah atau disenteri diakibatkan oleh Shigella dysenteriae, Entamoeba histolytica dan Enterohemorrhagic Escherichia coli. Pengobatan drug of choice pada Traveler’s Diarrhea adalah Ciprofloxacin 500 mg dua kali sehari selama 3-5 hari, TMP/SMX 160/100 mg 3 kali sehari selama 5-7 hari, metronidazole 500mg 3 kali sehari selama  5-7 hari. Antidiare yang dapat diberikan loperamide 2-4mg setiap kali BAB dengan dosis 8-16 mg/hari.

Kelainan kulit dapat berupa papul, makulopapul, nodul, ulkus dan lesi linier dengan keluhan utama gatal, nyeri dan dapat disertai demam. Kelainan kulit seperti seabather’s eruption merupakan pruritus dengan ruam papuler yang muncul setelah berenang di laur, diakibatkan oleh larva anemon dan ubur-ubur.  Urtikaria dapat muncul akibat alergi dengan makanan laut. Penyakit kulit lain seperti scabies, dan gigitan kutu kasur. Dapat diberikan salep kortikosteroid, dan antihistamin oral serta kortikosteroid oral bila perlu.

Vaksinasi yang disarankan sebelum bepergian ke Indonesia dapat disarankan hepatitis A, hepatitis B, demam tifoid, kolera, rabies, tuberkulosis, dan pneumokokkus. Untuk profilaksis malaria di Indonesia dapat digunakan doksisiklin 100 mg setiap hari selama di daerah endemis dan 2-4 minggu setelahnya. Obat-obatan lain seperti Mefloquin dan Atovaquon-Proguanil.

Pencegahan universal untuk turis asing antara lain menghindari makanan mentah yang tidak dimasak atau buah yang tidak dikupas, minum dari air mineral tertutup segel, menggunakan repellent atau obat nyamuk dll.

Referensi

Freedman DO et al. Spectrum of Disease and Relation to Place of Exposure among Ill returned Travelers. N Engl J Med. 2006(354):119-29

Ryan ET. Illness After International Travel. N Engl J Med. 2002(347):505-16

Ryan ET. Health Advice and Immunizations for Travelers. N Engl J Med.2002(342):23;1716-25

Comprehensive Clerkship in Rehatta Hospital and Donorojo Leprosy Center

Finishing my clerkship in Karimunjawa, I should pass the rubber forest to reached Kelet, a district of Jepara sharing border with Pati regency. There I should finish my other one month in Dr. Rehatta Hospital and Donorojo Leprosy Center.

Rehatta General Hospital

This hospital belongs to the province of central Java. In this clerkship I spent my time working in Emergency Department and General Medicine Ward. Working with senior physicians and also some intern physicians in managing patients and sometimes consulted it to specialist. I have unforgettable experiencing a cardiac arrest patient here, an old lady with irregular heartbeat coming with shortness of breath, and I heart irregular heart sound of auscultation. Patient immediately recorded for electrocardiogram, and during recording suddenly she was fainted, and had cardiac arrest. The team worked with all efforts. It was a very unforgettable experience to me.

Donorojo Leprosy Center

Leprosy is one of the 17 NTDs defined by PLOS. Built during the Dutch Era, this leprosy center has far developed in managing people with leprosy. In this clerkship I assisted physicians in managing leprosy patients and diabetic foot patients. The banyumanis village has an abundant diabetic patients, and most of them have diabetic foot. In leprosy clinic we served patients on MDT and those who has reversal reaction/erythema nodosum leprosum.

Comprehensive Clerkship in Karimunjawa Community Health Center

After finishing all my clerkships in general medicine, before finally joined the Indonesian Medical Licensing Examination, medical students of Diponegoro University must finished comprehensive clerkship in Community Health Center and General Hospital. After a long struggling to apply the clerkship, I finally ended it with choosing Karimunjawa.

Karimunjawa are small islands located at the north of Jepara Regency. It is a fisherman’s village with the future of “Maldives” like, not to overrate it but it is kind of a truth. The beaches are still unpolluted and clear, the fisherman’s community is very warm… and well I should start my story instead of talking about the greatness of karimunjawa tropical island.

I started this journey with my partner Addy Saputro. We should have sailed by the beginning week of the clerkship, but due to weather disturbance, we sailed on the 3 days end of the clerkship. We took ferry with the local physician Dr. Masta and Dr. Favo.

In this clerkship we were responsible in managing the clinic and ward under their supervisions. Everything is limited in this island, so we have to work efficiently. In clinic we have to deal with locals and tourists as patients. Most have common diseases like AURTI, gastroenteritis, dyspepsia, vertigo, the challenging fever, urinary tract infection, essential hypertension, type-2 DM, and others. For ward/inpatient, we managed fever, gastroenteritis with dehydration, stroke, hyperemesis of preganancy and so on.

Sometimes, the health officers are invited to visit Kura-kura island for mobile clinic purposes. I was given the chance to visit patient there. We took around 20 minutes by speedboad to the island. This experience is one thing that I can never forget. I really enjoy this clerkship, and totally missed it.

Clinical Rotation On General Internal

Following the other 14 rotations, finally I come to the end rotation, which is general internal medicine. The department of general internal medicine is the core of medical education itself. Treating various conditions in adult and geriatric patients, internal medicine ward covers 60% patients in the hospital besides pediatrics.

The internal medicine clerkship consists of junior and senior clerkship phases. Junior clerkship deals with internal medicine wards, assessing new inpatients with internal medicine residents. Student doctors performs various tests such as physical examination, electrocardiography recording and vital signs monitoring. We also assists residents to make sure various patients’ programs work, such as vital signs observation, nebulization, electrocardiograms etc.

Senior clerkship mostly focuses in emergency department, dealing acute disorders, and exacerbation of patients with chronic diseases. Sometimes attending physician comes and discuss diseases with the residents and clerkships.

In the morning, all senior and junior students gather with attending physician to have morning report. We discuss chosen case (mostly chosen by resident), from history-taking, physical examination, laboratory/ecg/radiology findings, and assessments. Assessments are the core of this morning report.

In the mid-day, students will have bedside teaching with each divisions

Cardiology: During this bedside teaching with cardiology fellow (a senior internist who undertakes cardiovascular medicine specialty), we discuss about cardiovascular examination in a patient with heart disorders. How to do an effective history-taking, and finding the appropriate disorder, choosing the right .

Pulmonology: Internist-pulmonologists introduced us to several kind of pulmonary patients such as COPS, pulmonary tuberculosis, pulmonary masses, and brought us to a discussion about how to diagnose a patient with pulmonary symptoms.

Gastroenterology and Hepatology: Internist-Gastroenterohepatologists explained to us about history taking of an icteric patient, how to do a physical examination to a chronic liver disease patient, and laboratory findings related to the liver function tests.

Nephrology: I was the only medical student in this bedside, I almost had 5 days in 3 weeks of bedside with a very senior nephrologists, she took me to all her patients and I was so touched to know this. At the end of the bedside, I asked her permission to have examination and she blessed me “good luck, and be a  good doctor!” she said.

Rheumatology This is also another interesting bedside, with discussion of arthritis, SLE, scleroderma and ended with a practical OSCE.

Hematology and Medical Oncology A big evening round in oncology ward

Tropical Medicine, Infectious Disease and Clinical Immunology I am assisting my professor to find Tetanus, HIV patient, due to an exchange medical student from Japan came. And we have a morning round together.

Geriatrics a case presentation with geriatric assessment

Endocrinology, Diabetic, and Metabolic  A day round about diabetic foot with a diabetic foot specialist. We were taught to measure ankle brachial index.

I am so happy to end this clerkship with all my passion, and continue to comprehensive clerkship in Karimunjawa Island and Donorojo Lepra Center/Kelet Hospital.