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

1. BLADDER NORMAL IN POSITION
2. UTERUS NORMAL IN POSITION, NORMAL IN SIZE
3. BILATERAL TUBES IDENTIFIED AND BILATERAL TUBECTOMY DONE BY MODIFIED POMEROYS TECHNIQUE
4. 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

1. INJ TAXIM 1 GM IV BD x 3days
2. INJ METRONIDAZOLE 100 ML IV TID x5days
3. INJ PANTOP 40MG IV ODx3days
4. INJ NEOMOL 100 ML IV TID X2days
5. Tab cefixime 2oomg 3days