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