Sumithra
24 YEARS OLD P2L2A1 WITH 2 PREVIOUS LSCS CAME FOR PERMANENT STERILIZATION.
HISTORY OF PRESENTING ILLNESS- PATIENT WAS APPARENTLY ASYMPTOMATIC
NO COMPLAINTS OF PAIN ABDOMEN, FEVER, COUGH, COLD
NO COMPLAINTS OF LOOSE STOOLS, CONSTIPATION , NAUSEA, VOMITING
NO COMPLAINTS OF MENSTRUAL IRREGULARITIES, HISTORY OF ABORTION IN THE MONTH OF JUNE, SPONTANEOUS ABORTION AT 1ST MONTH. D AND C NOT DONE. CHECK SCAN NOT DONE.
NO COMPLAINTS OF BURNING MICTURITION, INCREASED FREQUENCY OF MICTURITION, DYSURIA
NO COMPLAINTS OF DYSPAREUNIA, POST COITAL BLEEDING
LAST COITAL ACTIVITY 01/9/2023
NO COMPLAINTS OF COLD / HEAT INTOLERANCE, WEIGHT GAIN/LOSS
NO COMPLAINTS OF HAIRFALL. NO COMPLAINTS OF BLOOD IN STOOLS, WORMS IN STOOLS.
NO COMPLAINTS OF GENERALISED WEAKNESS, PALPITATIONS, SHORTNESS OF BREATH.
MENSTRUAL HISTORY
LMP - 5/9/23
AOM - 14 YEARS
5/30, REGULAR, 1 PAD/DAY
PAIN - , CLOTS + 1 x 1 CMS
MARITAL HISTORY
MARRIED LIFE - 7 YEARS
NCM
OBS HISTORY
1ST PREGNANCY - CONCEIVED SPONTANEOUSLY 1 YEAR AFTER MARRIED LIFE. UNEVENTFUL ANTENATALLY. FTLSCS (IN VIEW OF NON PROGRESSION OF LABOUR AND PREMATURE RUPTURE OF MEMBRANE) @ MIRYALGUDA PRIVATE HOSPITAL, MALE, BIRTH WEIGHT- 2.5 KGS, 6 YEARS, ALIVE AND HEALTHY, POST NATAL UNEVENTFUL
2ND PREGNANCY - CONCEIVED SPONTANEOUSLY 3 YEARS AFTER LAST CHILD BIRTH. NO HISTORY OF CONTRACEPTION USED. UNEVENTFUL ANTENATALLY. FTLSCS IN VIEW OF PREVIOUS LSCS @ MIRYALGUDA PRIVATE HOSPITAL. MALE, BIRTH WEIGHT - 2.5 KGS, 3 YEARS, ALIVE AND HEALTHY, POST NATAL UNEVENTFUL.
ABORTION 1 - IN THE MONTH OF JUNE 2023. CONCEIVED SPONTANEOUSLY AFTER 3 YEARS OF LAST CHILD BIRTH. ABORTED @ 1ST MONTH. SPONTANEOUS MTP DRUGS USED. D AND C DONE. CHECK SCAN NOT DONE.
PAST HISTORY
NOT A KNOWN CASE OF DIABETES, HYPERTENSION, EPILEPSY, TUBERCULOSIS , ASTHMA, CORONARY ARTERY DISEASE, THYROID DISORDERS
NO HISTORY OF BLOOD TRANSFUSIONS OR OROFER INFUSIONS.
SURGICAL HISTORY
HISTORY OF 2 PREVIOUS LSCS. NO OTHER MAJOR PELVIC SURGERIES
FAMILY HISTORY
INSIGNIFICANT
GENERAL EXAMINATON
HEIGHT - 146 CMS
WEIGHT - 45 KGS
BMI - 21.1KG/m2
TEMPERATURE- 97.1 F
HR - 72 / MIN
RR - 19 CYCLES/MIN
BP - 100/70mmhg
GRBS - 92
SYSTEMIC EXAMINATION
CVS - S1S2 +
RS - BILATERAL AIR ENTRY + , NORMAL VESICULAR BREATH SOUNDS
CNS- HIGHER MENTAL FUNCTIONS INTACT
P/A - SOFT, NON TENDER, SUBUMBILICAL VERTICAL SCAR +
P/S - CERVIX - MILD LOWER LIP EROSIONS +
VAGINA - HEALTHY
BME - UTERUS - ANTEVERTED, NORMAL SIZE, NON TENDER, MOBILE
BILATERAL FORNICES FREE, NON TENDER
UROLOGY REFERRAL WAS DONE ON 13/9/23 IN VIEW OF RIGHT RENAL CALCULI
ADVICED:
TAB.DROTIN P PO/SOS
MINILAPAROTOMY BILATERAL TUBECTOMY DONE ON 14/9/23
INTRA OPERATIVE FINDINGS
- BLADDER NORMAL IN POSITION
- UTERUS NORMAL IN POSITION, NORMAL IN SIZE
- BILATERAL TUBES IDENTIFIED AND BILATERAL TUBECTOMY DONE BY MODIFIED POMEROYS TECHNIQUE
- BILATERAL OVARIES NORMAL
INVESTIGATIONS
CBP ON 11/9/23
HB- 10.1
TLC - 8800
PLATELETS - 4.23
SMEAR - MICROCYTIC HYPOCHROMIC ANEMIA
POST OP HB ON 15/9/23 - 9.7
BGT - B POSITIVE
BT - 2 MIN 30 SEC
CT - 4 MIN 30 SEC
T3- 1.41
T4- 10.57
TSH - 2.34
CUE
ALBUMINS - TRACE
SUGARS- NIL
UPT - NEGATIVE
RBS - 80
RFT
BLOOD UREA - 16
SERUM CREATININE - 0.7
SODIUM - 137
POTASSIUM - 4.1
CHLORIDE - 105
CALCIUM IONIZED - 1.16
SEROLOGY - NEGATIVE
ULTRASOUND
FINDINGS - EVIDENCE OF FEW CALCULI NOTED IN RIGHT KIDNEY. LARGEST IS 4-5 MM IN LOWER POLE
IMPRESSION - RIGHT RENAL CALCULI
POST OP HB: 9.7
TREATMENT GIVEN
- INJ TAXIM 1 GM IV BD x 3days
- INJ METRONIDAZOLE 100 ML IV TID x5days
- INJ PANTOP 40MG IV ODx3days
- INJ NEOMOL 100 ML IV TID X2days
- Tab cefixime 2oomg 3days
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