Appendix Form No. 5 (See Rule 1) MEDICAL CERTIFICATE OF CAUSE OF DEATH (Hospital inpatients: not to be used for Still Birth) (To be sent to the Register along with Form No. 3 (Death Report) Name of the hospital .............................................................................................. I hereby certify that the person, whose particulars are given below, died in the hospital in Ward No ...................... O n ................................................................... a t . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (AM/PM) NAME OF DECEASED For use of statistical office S E X Age of Death 1 . Male 2 . Female If 1 year or more, age in years If less than 1 year, age in months If less than one month, age in days If less than one day, age in hours Interval between onset and death approx. Immediate Cause: a . ........................ ............................ State the disease, injury or complication due to (or as a which caused death, not the mode of consequence of) dying such as heart failure, asthenia, etc. Antecedent cause: b . ........................ ............................ Morbid conditions if any giving rise to due to (or as a the above cause, stating underlying consequence of) conditions last c . ........................ ............................ Other significant conditions contributing .......................... ............................ to the death, but not related to the disease or conditions causing it. .......................... ............................ CAUSE OF DEATH Manner of Death How did the injury occur 1 . Natural 2 . Accident 3 . Suicide 4 . Homocide 5 . Pending investigation If decreased was a female, was pregnancy associated with death 1 . Y e s 2 . N o If yes, was there a delivery 1 . Y e s 2 . N o Name and Signature of the Medical attendant certifying the cause of death Date of Verification ................................... SEE REVERSE FOR INSTRUCTIONS (To be detached and handed over to the relative of the decreased) Certified that Shri/Smt/Kum ......................................... S/W/D of .................................................. Shri ........................................................................................................................... .................... R / o .................................................................................................... was admitted to this hospital O n .................................................. and expired on ...................................................................... Doctor (Medical Supdt.) ........................... Name of the Hospital ............................... ................................................................

2 Common Mistakes in Clinical Medicine BASIC PRINCIPLES OF EDUCA TION Everyone should know that the three basic principles on which this world is moving are teaching, learning and procreation. Procreation is required because every living being is mortal and life is limited. If no body procreates one day the species will be extinct. The other two (teaching and learning) are required for continuous flow of know- ledge. Always somebody is teaching and somebody is lear ning, it may be far ming, weaving, potter y , construction work, cooking, the work of a black smith, or others including medicine. Ordinarily the parents teach their children. This has continued for thousands of generations. If the parents do not teach his child the knowledge they have acquired in their lifetime will come to an end after their death. So everyone should teach his children. With the progress of time some highly intelligent people became gurus (teachers) and they taught the students. They mostly taught the principles of living in a society in addition to few other subjects. Nowadays teaching has become more compartmentalized, but the basic objective of teaching has not changed. Every teacher should teach his students whatever he has learned in his lifetime for continuation of knowledge. T o teach well one has to lear n well; means before somebody becomes a good teacher he has to be a good student. A teacher cannot teach well if his knowledge is limited. Every teacher should introspect himself whether he has been able enough to explain his knowledge to his students, if not he should always try to adopt means by which he can do better .

32 Common Mistakes in Clinical Medicine GENERAL ERRORS REACHING A T A DIAGNOSIS Diagnosis pr ecedes tr eatment. T r eating without a diagnosis is simply beating at the bush, playing with life. Diagnosis is done with the help of history taking, general physical examination, examinations of different systems and investi- gations. In an individual case any one part may be more significant than the others to reach at the diagnosis. Out of all the most important is the history taking (The Art of Histor y T aking book by this author may be r efer r ed). However , in some cases even detail investigation may not reveal the diagnosis. There are several situations where the patient dies without a clear-cut diagnosis, necessitating a pathological autopsy to understand the disease process and advancement of knowledge. Unfortunately this has not been possible in India. After collecting all the infor- mation from different aspects of case evaluation, highlight all the major points from each part and basing on them come to a conclusion. It is better if evaluation is done after each par t of the case evaluation, i.e. histor y , general examination, systemic examination and investigation. This increases the power of judgment and limits the investi- gations; hence r educing the total cost of therapy . In a particular case one is not expected to get all the symptoms and signs of the disease. F or diagnosis the positives (what are there) is more important than the negatives (what are not ther e). However , it is the negatives, which brings the possibility of other differential diagnosis.

100 Common Mistakes in Clinical Medicine INVESTIGA TING WITHOUT PROPER PLANNING Every case should be properly planned for investigations. Investigating without planning is like searching for some- thing in darkness. F o r planning we need a good histor y , a thorough clinical examination from which we can predict the provisional diagnosis and differential diagnosis. The investigations should be done to establish the diagnosis and to exclude some others. Planning is also not enough unless one is not able to prioritize the investigations. The investigation that is likely to give maximum information should be done first, if it is cheaper still good. If it is costlier one should consider , is it wor th spending for it or not If more or less similar information can be obtained from a cheaper test that should be done. Proper planning can not only save time and money , but also it will improve our power of clinical judgment. It has been worth told that, no doctor should r equest any special investigation unless he knows what information relevant to the problem it is likely to provide and has some idea of its cost and of its possible dangers to the patient(Hutchison s clinical method, 18th edition, page 4). PRIORITIZING THE INVESTIGA TIONS Many types of investigations are available these days. In a particular case several tests may have to be done. Which investigation is to be done immediately and which can be done later should be known, in fact every doctor should develop this habit. I shall quote a few examples how it helps.

140 Common Mistakes in Clinical Medicine CHLOROMYCETIN THERAPY Chloromycetin is an important antibiotic and still it is the most effective antibiotic for the tr eatment of typhoid fever . It is considered as a broad-spectrum antibiotic because of its action against gram-positive, gram- negative, Chlamydia and Rickettsia group of organisms. It is also effective against anerobic organisms. This is a good drug in a sense that its bioavailability is almost 100 percent, so the oral and parenteral dose are almost same, it does not require dose modification in renal failure and its CSF penetration is very good and it is effective against anerobes. In spite of so many advantages it has got one major disadvantage, hypoplastic anemia, which has to be watched by every physician. This may be dose related or idiosyncratic type. T o pr event this complication one should follow cer tain principles while prescribing this drug. These are: i . Do not prescribe this drug if alternative drug is available for the same illness. Nowadays there are several drugs available for the treatment of typhoid fever , so one should not tr y with chloromycetin from the beginning. i i . The total dose in one course should not exceed 28 grams. iii. I f a patient has received a course of the drug within six months, it should not be prescribed again. i v . While on therapy time-to-time check up of DC and TLC (particularly DC) should be done and once the neutrophil count falls below 40 percent, chloro- mycetin should be stopped.

220 Common Mistakes in Clinical Medicine Several bedside interventions are required in many patients. Several mistakes are committed during these procedures. These mistakes increase the sufferings of the patient and at times can be life-threatening. I shall try to mention the mistakes being done at one time or other so that those will not be repeated. ADMINISTRA TION OF IV FLUID Ever y now and then we give intravenous fluid. However , it is not same in all cases. The mistakes done in adminis- tering intravenous (IV) fluid are: Not getting a vein Rate of flow Odd timing Choice of IV fluid Amount of IV fluid Thrombophlebitis. Not Getting A V ein If you want to give IV fluid one should get an intravenous line. These days maintenance of an IV line has become easier due to intravenous catheters like Intracath or V einflon. I r emember a child suffering from diar rhea and dehydration was taken to a doctor . He told that he cannot give IV fluid to a child and referred to the subdivisional hospital and the child died on the way . So whatever may be our scientific knowledge, to use these knowledge we often require practical experience like getting an IV line.

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