Chandramma

 35 YEARS OLD P3L2D1 TUBECTOMISED WITH COMPLAINTS OF LOWER ABDOMINAL PAIN, WHITE DISCHARGE AND BURNING MICTURITION SINCE 1 WEEK.

HISTORY OF PRESENTING ILLNESS- PATIENT WAS APPARENTLY ASYMPTOMATIC 1 WEEK BACK THEN SHE DEVELOPED PAIN IN THE LOWER ABDOMEN / DIFFUSE ABDOMINAL PAIN / LOWER - SUPRAPUBIC REGION, CONTINUOUS, NON PROGRESSIVE, PRICKING TYPE, NON RADIATING, NO AGGRAVATING OR RELIEVING FACTORS ASSOCIATED WITH NAUSEA AND BURNING MICTURITION. NOT ASSOCIATED WITH LOOSE STOOLS, VOMITINGS, CONSTIPATION, FEVER. 

NO HISTORY OF OUTSIDE FOOD INTAKE.

PATIENT HAD VISITED PRIVATE HOSPITAL IN MIRYALGUDA FOR SIMILAR COMPLAINTS. BUT PATIENT DID NOT GET TREATED THEN AND CAME TO KIMS NARKETPALLY.

HISTORY OF WHITE DISCHARGE SINCE 1 WEEK (CURDY WHITE) AS TOLD BY THE PATIENT AND ASSOCIATED WITH FOUL SMELL. NOT ASSOCIATED WITH ITCHING. COMPLAINTS OF BACK PAIN SINCE 1 WEEK, DRAGGING TYPE, NO AGGRAVATING / RELIEVING FACTORS.

HISTORY OF BURNING MICTURITION SINCE 1 WEEK. NO DYSURIA, NO INCREASED FREQUENCY OF MICTURITION.

HISTORY OF IRREGULAR CYCLE SINCE 1 YEAR THAT IS ABOUT FOR EVERY 60 DAYS CYCLE, INFREQUENT. BLEEDS FOR 3 DAYS. THAT IS AMENORRHOEA FOLLOWED BY HEAVY MENSTRUAL BLEEDING. CHANGING 2-3 CLOTHS / DAY AND ASSOCIATED WITH PAIN ON ALL 3 DAYS AND ASSOCIATED WITH PASSAGE OF CLOTS MEASURING 2 x 2 CMS, 3 x 3 CMS. NO HISTORY OF INTER MENSTRUAL SPOTTING / BLEEDING.

PREVIOUSLY ( 1 YEAR BEFORE) REGULAR CYCLES.

NO HISTORY OF FEVER,COLD, COUGH, VOMITINGS, OBSTIPATION

NO HISTORY OF HEAT OR COLD INTOLERANCE

NO HISTORY OF WEIGHT GAIN / LOSS

HISTORY OF HAIRFALL SINCE 1 YEAR

HISTORY OF GENERALISED WEAKNESS, PALPITATIONS, GIDDINESS SINCE 1 YEAR

NO HISTORY OF BLOOD IN STOOLS / WORMS IN STOOLS



PAST HISTORY

NOT A KNOWN CASE OF DIABETES, HYPERTENSION, EPILEPSY, TB, ASTHMA, CAD, THYROID DISORDERS

NO HISTORY OF BLOOD TRANSFUSIONS OR OROFER INFUSIONS.


SURGICAL HISTORY

MINILAPAROTOMY BILATERAL TUBECTOMY 16 YEARS AGO 


FAMILY HISTORY

SEPARATED FROM HUSBAND 3 YEARS AGO

FATHER PASSED AWAY DUE TO CARDIAC EVENT 


PERSONAL HISTORY

DECREASED APPETITE


MENSTRUAL HISTORY

LMP - ? 5/8/23

AOM - 14 YEARS

PAST- 5/30, REGULAR, 4 PADS/DAY

PAIN + ON DAY 1 OF CYCLE, CLOTS -

PRESENT- 3/60, 2-3 CLOTHS/ DAY

PAIN + ON ALL 3 DAYS, CLOTS + 2 x2 CMS


MARITAL HISTORY

MARRIED LIFE - 24 YEARS

3RD DEGREE CONSANGUINOUS MARRIAGE


OBS HISTORY

1ST PREGNANCY - CONCEIVED SPONTANEOUSLY 2 YEARS AFTER MARRIED LIFE. FULL TERM NORMAL VAGINAL DELIVERY, FEMALE, BIRTH WEIGHT- 2.5 KGS, 22 YEARS, ALIVE AND HEALTHY

2ND PREGNANCY - CONCEIVED SPONTANEOUSLY 3 YEARS AFTER LAST CHILD BIRTH. FULL TERM NORMAL VAGINAL DELIVERY,  MALE, BIRTH WEIGHT - 2.5 KGS, 17 YEARS, ALIVE AND HEALTHY

3RD PREGNANCY- CONCEIVED SPONTANEOUSLY AFTER 3 YEARS OF LAST CHILD BIRTH. MALE, FULL TERM NORMAL VAGINAL DELIVERY, BIRTH WEIGHT - 2.5KG, DIED @ 7 YEARS 


GENERAL EXAMINATON

PATIENT IS CONSCIOUS, COOPERATIVE AND COHERENT. 

HEIGHT - 

WEIGHT - 

BMI -

TEMPERATURE- 99.2F

HR - 86 / MIN

RR - 19 CYCLES/MIN

BP - 120/80

GRBS - 99


SYSTEMIC EXAMINATION

CVS - S1S2 + 

RS - BILATERAL AIR ENTRY + , NORMAL VESICULAR BREATH SOUNDS

CNS- HIGHER MENTAL FUNCTIONS INTACT

P/A - SOFT, TENDERNESS PRESENT ON DEEP PALPATION IN LEFT ILIAC FOSSA. 

TUBECTOMY SCAR +

NO ORGANOMEGALY

P/S - CERVIX- CIRCUMORAL EROSION +

         VAGINA - YELLOWISH DISCHARGE

BME - UTERUS - ANTEVERTED, NORMAL SIZE, NON TENDER, MOBILE

           BILATERAL FORNICES FREE, NON TENDER 




INVESTIGATIONS 

CBP ON 16/9/23

HB- 8.3

TLC - 6800

PLATELETS - 2.82

SMEAR - MICROCYTIC HYPOCHROMIC ANEMIA


PERIPHERAL SMEAR - MICROCYTIC HYPOCHROMIC ANEMIA WITH FEW PENCIL FORMS

WIDAL TEST - NEGATIVE

DENGUE- NEGATIVE


RETICULOCYTE COUNT- 1.3


BGT- 


T3- 

T4- 

TSH - 


CUE

ALBUMINS - NIL

SUGARS- NIL

PUS CELLS - 2-3


UPT - NEGATIVE


RBS - 


SEROLOGY - NEGATIVE


ULTRASOUND

FINDINGS -HYPER ECHOIC FOCI NOTED WITHIN THE ENDOMETRIAL CAVITY

LIKELY ENDOMETRIAL POLYP

APPENDIX VISUALISED MEASURING 2.5 CMS

IMPRESSION - ENDOMETRIAL POLYP



TREATMENT GIVEN

  1. INJ TAXIM 1 GM IV BD
  2. INJ METRONIDAZOLE 100 ML IV TID
  3. INJ PANTOP 40MG IV OD
  4. TAB PCM + ACECLOFENAC PO/SOS
  5. CLINGEN VAGINAL PESSARY PV/HS
  6. TAB MVT PO/OD
  7. TAB CALCIUM 500MG PO/ OD
  8. TAB VITAMIN C 1500MG PO /OD 

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