Asian Journal of Case Reports in Medicine and Health
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The Prediction of Return Quality Medical Record Documents William Booth Hospital, Semarang
No full textObjective: Completeness of medical records and the accuracy of returning medical records to assembling units in hospitals is one indicator of service quality. This study aims to obtain an overview of the quality and speed of return of medical records from hospital ward service units to medical record units and to be the basis for improving quality in-hospital services.
Methods: This research was conducted from 6 February to 21 March 2020 in a qualitative descriptive method with observation, in-depth interviews with medical records officers.
Results: Based on the results of the study, the predicted percentage of achieving medical record return for all wards with a target of 100% will be achieved in the 54th month with a modeling trend of y = 0.2254 x + 84.887. While the modeling trends of each ward are as follows: a). Kasandra Ward y = 0.034 x + 0.6947 with 100% of the target will be achieved in the 93 rd month. b). Agatha ward y = 0.047 x + 0.972 with a target of 100% will be achieved in the 6th month, c). Benetha Ward y = 0.047 x + 0.967 with a target of 100%, to be achieved in the 8th month. d) Perinatology Ward y = 0.0037 x + 0.7776 with a target of 100% will be achieved in the 61st month.
Conclusion: Return of medical records at a bad intention booth house will meet the quality indicators according to the target of 100% between 6 months to 93 months starting from January 2019.
Suggestion: Improved socialization to medical personnel regarding deadlines for returning medical records including gifts and penalties for all workers medically responsible
Accumulation of Urine in the Peritoneal Cavity after Bladder Rupture Following Vaginal Delivery: A Case Report
No full textSpontaneous bladder rupture following vaginal delivery is very rare. Herein, we present a case report with the accumulation of urine in the peritoneal cavity after normal vaginal delivery. An 18-year-old primigravid woman referred to the aImamHosein Hospital hospital, Mashhad, Iran, with the accumulation of urine in the peritoneal cavity. The computed tomography scan and ultrasound were normal for structure of bladder. Probably, the bladder rupture led to making a small hole in the bladder and accumulation of urine in the abdominal cavity. The laboratory symptoms and clinical and radiological findings would help emergency physicians to appropriately manage these patients
Dual Cholesteatoma in a Non-operated Ear: A Rare Presentation
No full textObjective: We report an interesting case where two cholesteatomas were found simultaneously in a non-operated ear. The presentation, management and implications for other patients with cholesteatoma are discussed.
Case Report: A 49-year-old male with a unilateral mixed hearing loss was found to have two cholesteatomas. Only one was suspected clinically, in the anterior attic, the other a large congenital cholesteatoma in the mastoid tip as an incidental finding on non echo-planar diffusion weighted image (Non-EPI DWI) MRI scan. The radiological findings were confirmed at surgery (combined approach tympanoplasty).
Conclusion: Congenital cholesteatoma in the mastoid process is extremely rare and multiple cholesteatomas occurring simultaneously in a non-operated ear is also rare. Non-EPI DWI MRI is increasingly used as a non-invasive technique for detecting recurrent or residual cholesteatomas post-operatively. This case supports extending the role of non-EPI DWI MRI scanning pre-operatively in primary disease to exclude additional cholesteatomas and to assess the suitability of permeatal endoscopic surgery
Isolated XIITH Cranial Nerve Palsy Secondary to Diffuse Large B Cell Lymphoma – A Rare Occurrence
No full textIsolated XIITH Cranial Nerve Palsy is an uncommon presentation. When it presents in isolation, it can be diagnostically challenging. We report a 43 year old male presenting with Unilateral Hypoglossal Nerve palsy marking the beginning of ongoing metastasis. This case report focusses on the importance of a meticulous approach towards diagnosis and finding the underlying cause
Glucose-6-Phosphate Dehydrogenase (G6PD) Deficiency Co-incident with Autoimune Haemolytic Anemia in an Adolescent Female: A Case Report
No full textBackground: Glucose-6-Phosphate Dehydrogenase (G6PD) deficiency is a genetic disorder with a deficiency or absence of G6PD, an enzyme required for the proper function of red blood cells. The pattern of inheritance for G6PD gene mutation is sex-linked recessive. It thus affects males and either homozygous or heterozygous females whose unaffected X chromosome is inactivated (lyonized females). Autoimmune hemolytic anemia (AIHA) is a disorder characterized by premature destruction of red blood cells (RBC) by autologous RBC autoantibodies whose presence is demonstrated by a positive direct antiglobulin (Coombs) test (DAT). AIHA is classified into primary or idiopathic and secondary types based on the absence or presence of an underlying disease. In Nigeria AIHA is rare in children but secondary forms are common in teenagers. Chronic granulomatous disease (CGD) is a rare, genetic, immune disorder characterized by neutrophil dysfunction and deficiency or absence of G6PD in both neutrophils and RBC. CGD has both sex-linked recessive and autosomal recessive pattern of inheritance. Therefore CGD with G6PD could occur in a female with X chromosome anomaly in whom co-existence of an immune disorder and G6PD deficiency could worsen hemolysis.
Aim: To highlight the possible existence of the rare chronic granulomatous disease.
Case: To describe a case of acute hemolytic anaemia on a background of G6PD deficiency, positive direct Coombs test and a seeming neutrophil dysfunction in an adolescent female.
Case Report: We report a case of a G6PD deficient 14 year-old female with systemic inflammatory response syndrome, marked neutrophillia yet mild toxic granulation, steroid-responsive hemolytic anemia and positive direct Coombs test.
Conclusion: C6PD deficiency and AIHA may co-exist in an adolescent female possibly as part of CGD but a definitive diagnosis of CGD is required
Corticosteroid Treatment for Recurrent Henoch- Schönlein Purpura with Gastrointestinal Manifestation: A Case Report
No full textAims: Henoch-Schönlein Purpura (HSP) is the most common vasculitis during childhood yet sometimes is misdiagnosed. Gastrointestinal symptom in HSP is a frequent finding which causes patient to seek medical care. Recurrent episode of HSP occurs in 2.7–30% cases, most of which has predisposing factors. HSP is usually a self-limiting disease which is managed with supportive treatment. Limited evidence has been reported about the use of corticosteroid for HSP.
Presentation of Case: A 10-year-old girl came with chief complaints of abdominal pain, nausea and vomiting, and palpable purpura in lower extremities a day prior to admission, preceded by upper respiratory tract infection. Patient had history of similar symptoms before, she was diagnosed with recurrent HSP with skin and gastrointestinal manifestations. She was treated with corticosteroid for two weeks and showed clinical improvement during follow-up.
Discussion: Recurrent episode of HSP occurs more frequently in patients with predisposing factors. Although there is no specific recommendation about the use of corticosteroid for HSP, several studies reported benefits of corticosteroid for patients with organ involvement such as gastrointestinal to relieve the pain. We considered giving short-term corticosteroid and observed clinical improvement in our patient.
Conclusion: Identifying predisposing factors for HSP in each patient may help to prevent the recurrence. Despite limited evidence regarding the use of corticosteroid, short-term use of corticosteroid could be considered in HSP with gastrointestinal involvements to relieve the symptoms
Opioid Induced Rhabdomyolysis with Acute Sensorimotor Axonal Neuropathy: An Unusual Presentation
No full textRhabdomyolysis is a clinical condition of potentially life threatening destruction of skeletal muscles caused by diverse mechanisms including drug and toxins. Opioid is one of the encountered drug which cause rhabdomyolysis in association with renal failure. Paraparesis is one of the important feature of rhabdomyolysis which usually occur due to dyselectrolytemia (secondary hyperkalemic periodic paralysis) recovers completely on normalization of electrolyte, we are presenting a case of opioid induced rhabdomyolysis who develop paraparesis even with normal electrolyte which later on diagnosed as acute sensory motor axonal neuropathy
Esophageal Cancer Causing Severe Bronchial Airway Obstruction – A Case Presentation
No full textEsophageal cancer is one of the leading malignancies of the gastrointestinal tract with the commonest symptom being dysphagia to solids and liquids. This is a case of esophageal cancer who presented to us with loss of appetite, weight and bronchospasm not relieved by bronchodilators. Esophageal cancer can affect the upper part of the esophagus or lower part of the esophagus. When the mass lesions are supra bifurcal they have thirty percent tendency of involving the airways.
Here we describe a case of a middle aged male, chronic smoker who presented with wheezing on and off for 3 months along with loss of appetite and weight. This was followed by worsening symptoms of breathing difficulty and productive cough for 3 weeks prior to admission. He was initially treated with bronchodilators but never improved. On evaluation he was found to have esophageal cancer which had invaded the pericardium and the right and left main bronchus resulting in the respiratory symptoms which was thought to be due to chronic obstructive airway disease.
Conclusion: Thus in this case report it tells us that - airway disease is not only because of inflammation of the airways caused by chronic obstructive airway disease or bronchial asthma but can be cause by other obstructive pathologies which arise from the airways or from adjacent structures of the airways
Primary Squamous Cell Carcinoma of Parotid Gland- Case Report
No full textMalignant neoplasms of salivary glands are rare, accounting for 6% of all head and neck malignancy. Incidence of primary squamous cell carcinoma of parotid gland is 0.3% to 1.5%. Squamous cell carcinoma of parotid gland is an aggressive malignancy seen mostly in adults in their 5th or 6th decade of life. Here we report a case of primary squamous cell carcinoma of parotid gland in a 29 years old, male patient. He hadaninfra-auricular swelling on right side of face progressively increasing in size since the age of 6 years and he had facial nerve paralysis since 10 years of age. Patient was diagnosed with squamous cell carcinoma of parotid gland at the age of 29 years. He underwent total parotidectomy without neck dissection elsewhere. Recurrence of tumour was there at the primary site within five months of the treatment of primary tumour. Recurrent tumour was treated successfully by wide local excision with level I-V neck dissection. Reconstruction was done with pectoralis major myo-cutaneous flap and patient had post-operative radiotherapy and chemotherapy.  
Thoracoomphalopagus-the Twins Sharing Heart
No full textConjoined twin is one the rarest and most fascinating phenomena of twinning. The incidence ranges from 1 in 50 000 to 1 in 100 000 live births. Even though the degree and location of conjunction and the shared internal organs determine the prognosis of conjoined twins, they are associated with a high perinatal mortality rate. Early prenatal diagnosis and precise characterization of conjoined twins are essential for optimal obstetric, interventional and postnatal management as well as to reduce psychological trauma to the parents. Imaging by ultrasound and MRI plays a significant role in diagnosis and further management prediction. In this report, we present a case of multigravida pregnant woman who presented at 36+2 weeks gestation with thoraco-omphalopagus twins in advanced labour in a tertiary hospital. This case report not only reports a rare case but also emphasizes on the fact that even after so many advancements in the field of medicine, there still exists a gap in timely access to the healthcare facility, especially in developing countries