Swapna

27 YEAR OLD P3L3A1 TUBECTOMISED CAME WITH COMPLAINTS OF WHITE DISCHARGE SINCE 7 YEARS

LMP- 10/9/23

HISTORY OF PRESENTING ILLNESS- PATIENT WAS APPARENTLY ASYMPTOMATIC 7YEARS BACK THEN DEVELOPED WHITE DISCHARGE WHICH IS THICK, MUCOID, WHITE IN COLOUR, PROFUSE IN QUANTITY, NOT ASSOCIATED WITH ITCHING IT FOUL SMELLING.

HISTORY OF ABDOMINAL PAIN, SUDDEN IN ONSET, NON PROGRESSIVE IN THE EPIGASTRIC REGION, PRICKING TYPE OF PAIN, INTERMITTENT, AGGRAVATED ON EXERTION AND RELIEVED ON REST. 

NO HISTORY OF BACK PAIN.  

HISTORY OF DYSPAREUNIA SINCE 4 YEARS

NO HISTORY OF POST COITAL BLEEDING. NO HISTORY OF MENSTRUAL IRREGULARITIES OR COGNITIVE DYSMENORRHOEA. HISTORY OF BURNING MICTURITION SINCE 4-5 YEARS, USED MEDICATIONS. 

NO HISTORY OF URGENCY, FREQUENCY OR SUPRAPUBIC PAIN.

HISTORY OF SIMILAR COMPLAINTS IN THE PAST AND USED MEDICATIONS (INJECTIBLE ANTIBIOTICS AS TOLD BY THE PATIENT. DOCUMENTS NOT AVAILABLE) SYMPTOMS SUBSIDED ON USING MEDICATIONS AND RETURNED AFTER STOPPAGE OF MEDICATION. 

HISTORY OF EXCESS HAIRFALL SINCE 4-5 YEARS AND HISTORY OF  LOSS OF WEIGHT. (5KG IN 9 MONTHS) 

NO HISTORY OF GENERALISED WEAKNESS, SHORTNESS OF BREATH, PALPITATIONS, BLOOD OR WORMS IN STOOLS, PICA OR BLEEDING GUMS.

NO HISTORY OF FEVER.

PAST HISTORY

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

NO HISTORY OF BLOOD TRANSFUSIONS OR OROFER INFUSIONS.

HISTORY OF BILATERAL RENAL CALCULI 4 YEARS BACK (AS TOLD BY THE PATIENT)

SURGICAL HISTORY

HISTORY OF MINILAPAROTOMY BILATERAL TUBECTOMY 4 YEARS BACK

FAMILY HISTORY

MOTHER IS A KNOWN CASE OF HYPERTENSION AND IS ON MEDICATION.

MENSTRUAL HISTORY

PAST (2 YEARS BACK) - 5/30, REGULAR, 4-5 PADS/DAY

PAIN - , CLOTS - 

PRESENT - 2/30, REGULAR, 2 PADS/DAY

PAIN - , CLOTS -

MARITAL HISTORY

MARRIED LIFE - 10 YEARS

NCM

OBS HISTORY

1ST  - CONCEIVED SPONTANEOUSLY 1 YEAR AFTER MARRIED LIFE. UNEVENTFUL ANTENATALLY. FULL TERM NORMAL VAGINAL DELIVERY (, MALE, BIRTH WEIGHT- 2.5 KGS, 9 YEARS, ALIVE AND HEALTHY

2ND - SPONTANEOUS ABORTION @3RD MONTH. D AND C DONE. 

3RD - CONCEIVED SPOTANEOUSLY AFTER LAST CHILD BIRTH, FULL TERM NORMAL VAGINAL DELIVERY, MALE, BIRTH WEIGHT - 2.5 KGS,  8 YEARS, ALIVE AND HEALTHY

4TH - CONCEIVED SPONTANEOUSLY AFTER 1 YEAR AFTER LAST CHILD BIRTH. FULL TERM NORMAL VAGINAL DELIVERY, MALE, 2.75 KG, ALIVE AND HEALTHY.

GENERAL EXAMINATON

PATIENT IS CONSCIOUS, COOPERATIVE AND COHERENT. 

HEIGHT - 148 CMS

WEIGHT - 43 KGS

BMI - 19.6

TEMPERATURE- 95.2 F

HR - 72 / MIN

RR - 19 CYCLES/MIN

BP - 100/60

GRBS - 94

SYSTEMIC EXAMINATION

CVS - S1S2 + 

RS - BILATERAL AIR ENTRY + , NORMAL VESICULAR BREATH SOUNDS

CNS- HIGHER MENTAL FUNCTIONS INTACT

P/A - SOFT, NON TENDER, TUBECTOMY SCAR +

P/S - CERVIX - BLEEDING THROUGH OS + , CIRCUMORAL EROSIONS HYPERTROPHIED +

         VAGINA - HEALTHY

BME - UTERUS - RETROVERTED, NORMAL SIZE, NON TENDER,

           BILATERAL FORNICES FREE, MOBILE, NO CERVICAL MOTION TENDERNESS

INVESTIGATIONS 

CBP ON 11/9/23

HB- 12.9

TLC - 5800

PLATELETS - 3.00

SMEAR - NORMOCYTIC NORMOCHROMIC

 

BGT - B POSITIVE

BT - 2 MIN 30 SEC

CT - 4 MIN 30 SEC

T3- 1.12

T4- 10.08

TSH - 1.22

CUE

ALBUMINS - NIL

SUGARS- NIL

RBS - 80

SERUM CREATININE - 0.8

SEROLOGY - NEGATIVE

URINE CULTURE AND SENSITIVITY- NO GROWTH

ULTRASOUND

FINDINGS - EVIDENCE OF FEW CALCULI NOTED IN LEFT KIDNEY. LARGEST IS 4 MM INTER POLAR REGION

IMPRESSION - LEFT RENAL CALCULI

TREATMENT GIVEN

1. INJ TAXIM 1 GM IV BD x 7DAYS
2. INJ METRONIDAZOLE 100 ML IV TID X 7DAYS
3. INJ PANTOP 40MG IV OD
4. TAB. MVT PO/OD
5. TAB CALCIUM 500MG PO/OD
6. TAB. VITAMIN C 500MG PO/ OD
7. CLINGEN VAGINAL PESSARY PV/HS X 7 DAYS
8. BETADINE VAGINAL WASH.