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