Introduction: A medical record is a systematic documentation of a patient’s medical history and care for legal and future use. A poor quality medical record can negatively affect patient care and safety. The study aims to assess the adequacy of medical records in Bir Hospital, a central hospital.Methods:A cross-sectional study was conducted by analyzing consecutive discharge summaries of patients admitted during a 6 month period in a single unit of a tertiary care center. The discharge summary format of the hospital was taken as the standard and evaluation for adequacy of data entered was assessed. Descriptive statistics were used to analyze various statistical discrepancies. Results: Patient’s condition at discharge was missing in 86 (66.15%). Patient’s address was missing in 21 (16.1%) cases. Almost all the discharge sheets lacked mailing address. Total 96 (73.8%) had use of abbreviations diagnosis. Age and sex were missing in 1 (0.76%). Doctor’s signature was illegible in 103 (79.3%) and missing in 2 (1.5%) summaries. Doctor’s name and their level/position were missing in 118 (90.76%) and 125 (96.1%) respectively. Total 126 patients (96.9%) were not given any instructions on discharge.Conclusions: The discharge summaries analyzed were seen to be inadequate especially in documenting course during the hospital stay, condition at discharge, appropriate instructions and the treating physician’s details. These can probably be addressed by introducing electronic medical records if feasible. Otherwise, the discharge summary should be standardized and doctors should be trained to write legible, complete discharge summaries.Key Words: discharge, hospital, records, summaries
Introduction: Cervical carcinoma is an important women’s health problem throughout the world.There are very few published data on this disease in Nepal. We wanted to study the pattern ofcervical carcinoma based on hospital data.Methods: A 10 years retrospective study of scenario of cervical carcinoma was conducted. The datahave been analyzed according to age, occurrence of other cancers, histological type, religion, riskfactors and district wise.Results: The number of cervical carcinoma showed a rising pattern over the 10 year period. Themedian age of the patients was 45 years and maximum frequency (33%) of cases were found in theage group 40 to 49 years. Squamous cell carcinoma comprised 40% of cases, Adenocarcinoma 4% and1.1% cases were of mixed variety. 92% of cases were Hindu by religion. 43% of patients were smokerin our study, 5% had positive family history. Chitwan with 7.35% had the maximum number of casesfollowed by Rupandehi with 6.40% and Nawalparasi with 5.41%.Conclusions: The cancer pattern revealed by the present study provides valuable leads to cervicalcancer epidemiology in Nepal. Routine cytological screening of the population for cervical cancer ishighly necessary for its early detection and treatment.Key Words: Cervical carcinoma, hospital based study, Nepal, pattern
INTRODUCTION: Breast Cancer is the second commonest cause of cancer death in women. Almost all women survive breast cancer if it is detected before it starts to spread. The aim of the study is to analyze the demographical profile, stage of presentation, histological type, and treatment modalities of breast cancer in a tertiary care setting. METHODS: Total 1141 cases of breast cancer had been followed retrospectively from 1999 to 2006 A.D. in a tertiary care center and their patterns were analyzed. RESULTS: The mean age of presentation of breast cancer was 47.30 +/- 11.57 years in female and 59.03 +/- 14.63 in male, 31 (2.1%) cases of breast cancer were male. There were 123 (10.78%) stage I, 281 (24.62%) stage II, 466 (40.84%) stage III, and 271 (23.75%) stage IV patients. Infiltrating ductal carcinoma was the commonest variety 610 (53.5%). Chemotherapy was the mainstay for treatment of breast cancer 341 (29.9%) followed by surgery 287 (25.2%). CONCLUSIONS: Breast cancer trend is rising with more in late and advanced stages, mostly due to lack of awareness. Infiltrating ductal carcinoma is the commonest variety. Chemotherapy is the most commonly used modality of treatment. Male breast cancer present late and is not so uncommon. Keywords: breast cancer; chemotherapy; infiltrating ductal carcinoma; staging.
Introduction: Trauma is a common worldwide problem which has detrimental effect in the public health. It is one of the several prevailing causes of morbidity and mortality. The aim of this study is to reveal the existing nature of orthopedic injuries as seen in the emergency department and to identify potential areas of improvement for the enhancement of trauma research. Method: This study has been conducted prospectively. All the physical trauma patients visiting the emergency department of a tertiary care hospital over the period of one year were included in study. The population of the study included patients with all kinds of orthopedic injuries. Data was entered in Statistical Package for the Social Sciences (SPSS 16) to analyze, and the result of is obtained in terms of mean (percentage), appropriate plots, and chart where appropriate. The cases with pathological fracture, patients with end stage chronic diseases, and post-operative state were excluded from the study. Results: Total of 2823 orthopedic injury patients visited the emergency in a year, which comprised 15.46% of total emergency Patients. The gender distribution was 68.4% males and 31.6% female. Only 9.8% of the patients arrived to hospital on ambulance. 34.4% of the cases arrived within one hour of trauma incident. Fall was the most common cause of injuries(40.1%) followed by road traffic accident (34.6%).The study revealed that the most common injury was fracture (33.7%), followed by sprain & strain (26.0%), laceration (19.2%), contusion with intact skin (10.0%) and dislocation (9.1%). Commonly associated visceral injury was the head injury in 12.4% cases, followed by thoracic injuries in 10.8%, abdominal injuries in 1.7 % cases. Emergency department team alone treated and discharged 54.1% patients, whereas the remaining 45.9 % patients required specialized evaluation and treatment by other departments. Total 18.2 % patients were referred to other centers for further specialized treatment like neurosurgery, CTVS consultation, for ICU facility, for vacant admission bed, and on their wish to go to other center for further treatment. Conclusion: Fall injury and road traffic accident were the most common cause of trauma. Younger adults in their active period of life were found to be involved more in physical trauma incident. In addition to the healthcare improvement, road safety regulations should also be strengthened and enforced, which can save more lives and reduce the severity and duration of the illness.
Accidental foreign body ingestion is commonly encountered in the pediatric population, with a peak incidence between the ages of six months and three years. Since the act may go unnoticed, the child may present late. Here, we report a case of an 11 year old boy who present at Lamjung District Hospital after 24 hours of ingestions of two rupee Indian coin. To the best of our knowledge this is the first time we describe a case report on coin removal at district hospital of Nepal. J-GMC-N | Volume 11 | Issue 01 | January-June 2018, Page: 58-60
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