Norman Borlaug (1914-2009)

12th September was the 6th death anniversary of Norman Borlaug, the man who saved a billion lives.

Interpreting chest X-rays

Dear House Officers,
When interpreting chest X-rays please present with the following format:

1. What kind of X-ray? Indicate the direction of the beam and the part of the body.
2. Name?
3. Taken when?
4.  Number of a series of what number?
5. Satisfactory inspiration?
•  Left hemidiaphragm must be below the sixth rib anteriorly.
6.  Central? Rotated?
• The medial end of the clavicles should be equidistant to the spinous processes of T1 to T5.
7. Exposure good?
• Just make out the vertebra behind the heart.
8. Position of scapula good?
9. Cardiothoracic ratio of < 50%?
10. Outlines clearly defined and seen?
• Diaphragm
•  Heart.
• Hila
•  Left higher than right
• Same density
• Bones
11.  Hidden conundrums
• Apex
•  Behind the heart
•  Hila
• Below the diaphragm

Example

This is a posterior-anterior (PA) chest X-ray of Mr. Smith taken on the 13^th of September 2015. This is the 3^rd chest X-ray of a series of 3. The assessment of its quality showed that inspiration was satisfactory, the X-ray was central, exposure adequate and scapula is well positioned. The cardiothoracic ratio is less than 50%. The outlines of the diaphragm, heart and bones are clearly seen and well defined with the left hilum being higher than the right and of equal density.

Mnemonic: (N)ame, (D)ate, (I)nspiration, (R)otation, (E)xposure, (S)capula, (C)ardiothoracic ratio, (O)thers/outlines; NDIRESCO

Review of System in Dusun

Dusun is one of the commoner indigenous language in Sabah and therefore knowledge if it is required to communicate with patients. I would like to thank Madam Ann Gilong and her brother Ricky Gilong for the translation. It is still a rough copy but will have to do for the time being. All mistakes are mine alone and if you have corrections please put it in the comments. Thank you.
System Review in Dusun

Of morning rounds, and silicone and plastic tubes

Dear House Officers,
When you see a patient in the morning:

1. List the problems:
• underlying chronic and long-standing problems (1 list headlined as PM)
• current acute problems (1 list headlined as Pb)
2. Ask:
• about the presenting symptoms 
• e.g. if the patient came in fever, cough and greenish sputum then ask about the whether the fever and cough is reduced and the sputum has turn white.
• the 5 basic functions of humans:
• eat
• drink
• pass motion
• pass urine
• sleep
3. Look at the observation chart
• the staff nurse already took the effort to take the blood pressure, pulse rate, respiratory rate, SpO2, temperature, pain score; input and output; vomit, stool, haemetemesis chart the least you can do is look at it and write down the latest reading.
• If you are excellent don't just take one reading in isolation but see the trend (up-going, down-going, stable)
• If anything is abnormal FIND THE CAUSE and add to your problem list above.
4. Examine:
• the presenting signs
• if the patient came in with crepitations ask yourself has it been reduced?
• Cursory look at the other systems:
• cardiovascular
• respiratory
• abdominal
• bed-sore
• count the number of plastic and silicone tubes in the patient, then ask yourself
• When was it set?
• Has been more than 3 days?
• is it necessary? 
• What was the original intentions? Is it still fulfilling its task?
• can I remove it? 
• Is it needed for anything important? Is it the only line for for patient for whom setting lines is a headache?
• should I remove it? 
• So even if it is necessary and the line can't be removed because it is literally a life-line but if it is infected and oozing with pus it should be removed.
• Please get an alternative line first before removing it.
5. Investigations:
• Trace all the results.
• If it is abnormal trace the baseline which is the result when the patient was well which is not the same as the admission results.
• If a result should be there but your colleague didn't take bloods please rectify the problem.
• Again do no look at it in isolation but determine the trend (up-going, down-going, static)
• Fill up your charts.
• Use a red pen to mark the whether the result is normal, high or low.
• If anything is abnormal add to your problem list.
• Write down the findings for the:
• Electrocardiogram
• X-rays
• Computed tomography
• Ultrasound
6. Medication chart:
• Is the medication correct?
• to treat the condition
• the form and method is correct.
• Is the dose correct?
• renal or hepatic adjustment.
• side-effects?
• contraindications?
• Is the medication served?
7. Plan:
• Think modularly.
• This is where your problem lists come in handy. 
• e.g. If the patient had chronic diabetes mellitus make sure you order for:
• refer for eye care, foot care, dietician and diabetic nurse counselling.
• Glucose monitoring
• Diabetic diet
• Start medications.
• Make sure every problem on the list has a plan to a solution.

Downloadable list

Systems Review in Melanau and more

Dear All,
I would like to thank my dear friend Nycholas Andria Balau who through his busyness provided with a basic translation into Melanau. It is still a work in progress and we would appreciate corrections and clarifications.
System review in Melanau

If you like to help translate into a language not already available you can get the template here
Template

Other translation for systems review available are:
Iban with thanks to Mr Morris
Bidayuh Bukar-Sadong with thanks to SN Cressida Christy
Tamil with thanks to Father Eisu Das of the Anglican Church

As well as fever history for:
Bengali with thanks to Mr Fakrul of Radicare
Nepali with thanks to Pastor Ram formerly of FGA KD
Burmese with thanks to Pastor Oliver Joseph of the Anglican Church

Thank you all so much.

Cost to patients

Granted medical care in Malaysia is heavily subsidised but we must remember there is still cost to the patient which some cannot afford if we are to do unnecessary bloods. This is all found the Medical Fee Order of 1982 Amended in 1994 and 2003. The 2003 Amendment is the controversial New Charge for Foreigners. It has been the law of the land since 2003 but just not enforced so if anyone has a problem against it they should fight for repeal. Anyways the following cost are only applicable to the Third Class Ward. If you go into First Class the payment is higher. On another note it should be noted that the in the 1st paragraph and 2nd section of the 1982 Order it is maintained that it is only applicable in West Malaysia which means my friends in East Malaysia can credibly maintain that the law does not apply to them however on this I am not totally sure so you will need to consult the lawyers. The cost are as follows:

1. General Outpatient: RM1/visit
2. Specialist Clinic: RM5/visit
3. General Ward stay: RM3/day
4. Maximum charge of a 3rd class patient: RM500
5. Caesarean section: RM100
6. Vaginal delivery: RM10
7. Physiotherapy: RM5
8. CAPD: RM100/month
9. Haemodialysis: RM25 if new filter RM10 if reuse approximately RM150/month
10. Chest X-ray: RM10
11. CT brain: RM60
12. ECG: RM5
13. Echocardiography: RM20
14. EEG: RM5
15. Mastectomy: RM100
16. Hysterectomy: RM100
17. Appendicectomy: RM50
18. Circumcision: RM10
19. Blood investigations:
• Group A: RM25/test
• full genotyping of blood group
• Group B: RM 20/test
• HLA-B27
• Group C: RM12/test
• acid blood gas
• blood culture and sensitivity
• Group D: RM10/test
• lipid profile
• liver function test
• renal profile
• full blood picture
• Group E: RM7/test
• C-reactive protein
• T4
• TSH
• urine catecholamine
• ANA
• Group F: RM5/test
• UFEME
• CSF biochemistry
• tissue culture
• Rheaumatoid factor
• VDRL
• TPHA
• ferritin
• folate
• B12
• Group G: RM2/test
• serum calcium
• serum uric acid
• cross matching
• LDH
• amylase
• glucose
• magnesium
• calcium
• MCV
• MCH
• PCV
• total white and differential count
• Group H: RM1/test
• Coomb's test

In summary, a lot of cost can be incurred on a patient especially long-staying ones and though the cost is capped at RM500. The employment to population ratio is 58%, which means for a population 30 million 17.4 million are eligible to work. However only 1 million are eligible to pay income tax which means only these people earn more than RM3060/month. For the rest RM500 would represent up to 16% of monthly income which would be catastrophic for 90% of the population. Moral of the story: Do not order unnecessary bloods.

Fever clerking in Bengali and Burmese

Rather correcting old broken links I might as well repost them. The Bangladeshis speak Bengali. They are the Muslim cousins of the Hindu inhabitants of West Bengal. The first Asian to win the Nobel Prize for Literature was Rabindranath Tagore who is a Bengali who wrote in Bengali and English. Below are the links.
Fever Clerking in Bengali
Fever Clerking in Burmese

I would like to thank Fakrul the Radicare worker in ward G2 for his kind assistance in Bengali and Brother Oliver for his assistance in Burmese.

Practising for the Clinical Stations

Dear House Officers,
When a person merely practises by repeating an action many times without thinking and analysis one does not get better but instead will develop bad habits. In order to become better one must use deliberate practise. One of the ways to deliberately practise is to have a script which is checklist to make sure that you have gone through all the steps. As you deliberately practise you will get better, be more familiar, rely on the script less and soon it will be second nature.
Please find the Checklists for Clinical Examinations at the link which I based on Ryder and others.

Model Formal Referral Letter

Dear House Officers,
Due to the Heartbleed Bug some of the older Dropbox links are not useable and I am still in the process of modifying the old ones. Here is a Model Referral Letter
Basically you must have:

1.  A history of what happened to the patient and what treatment was given.
2. The latest list of medications.
3. The latest investigation results be it blood or imaging.
4. The reason why the patient is being referred to the centre.
5. Be polite and courteous.

Revised Fever Clerking in Nepali

Dear All,
This is the revised fever clerking. It is to my understanding that there are very many dialects of the Nepali language so this is by no means foolproof but that being said some history is better than none.
Nepali Fever Clerking.

Procedure protocol and clerking manual reformatted with table of content

Dear All,
Thank you for coming visiting my blog. Again I would like to reiterate everything here is a work in progress. I will greatly appreciate constructive criticism and please point out any mistakes for correction. All my mistakes and mine alone. Thank you.

1. Procedure protocol
2. Clerking manual

Management Guide with Table of Contents

As my limited skills with Word increases I am able to improve my material. Though I do not significant new material but this revision of the management guide with table of contents should be helpful.
Management Guide with Table of Contents

Review of Systems in Other Languages

In response to the request of some students, I would like to repost my systems review in other languages. Please be informed that there are many dialects and there maybe mistakes in my transcription. They are of two kinds. A full system review and clerking for fever.
Full system review:

1. Bahasa Bidayuh Bukar-Sadong courtesy of SN Cressida Christy
2. Mandarin courtesy of Dr Chua Ping Lik
3. Tamil courtesy of Father Eisu Das of the Anglican Diocese of West Malaysia

Fever clerking for migrant workers include the following:

1. Bangladeshi workers speaking Bengali courtesy of Mr Fakrul our Radicare worker in ward G2
2. Myanmar workers speaking Burmese courtesy of Mr Oliver Joseph of the Anglican Diocese of Myanmar
3. Nepali workers speaking Nepali courtesy of Pastor Ram formerly of FGA

If you do know other languages or know people who know other languages especially those of Sabah and Sarawak and common migrant worker languages such as Vietnamese or Khmer please dowload the following template and send to me.

1. Fever clerking template
2. Systems review template

All mistakes are mine and mine alone. The contents of this site does not negate the need to seek professional help. It is merely to facilitate history-taking especially among students, where some history is better than none.