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
- INJ TAXIM 1 GM IV BD
- INJ METRONIDAZOLE 100 ML IV TID
- INJ PANTOP 40MG IV OD
- TAB PCM + ACECLOFENAC PO/SOS
- CLINGEN VAGINAL PESSARY PV/HS
- TAB MVT PO/OD
- TAB CALCIUM 500MG PO/ OD
- TAB VITAMIN C 1500MG PO /OD
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