202342769

 

 

 


Case History and Clinical Findings

PATIENT CAME WITH C/O HEAVY AND PROLONGED CYCLES SINCE 1 MONTH

PATIENT WAS APPARENTLY ASYMPTOMATIC 1 MONTH BACK THEN SHE DEVELOPED 1 MONTH AMENORRHEA FOLLOWED BY HEAVY AND PROLONGED CYCLE, CONTINUOUS BLEEDING FOR 11 DAYS ASSOSIATED WITH CLOTS OF SIZE 5X5 CM CHANGING 12 PADS/DAY NOT ASSOSIATED WIT PAIN THEN SHE CONSULTED PRIVATE CONSULTANT WHERE SHE PRESCRIBED T. TRANEXA 500 MG [USED FOR 3 WEEKS] AND MEORANTE 1 MG [USED FOR 8 DAYS] BLEEDING SUBSIDED AFTER USING MEDIACTION. 5 DAYS BACK PASSED CLOTS OF SIZE 3X3 CM. C/O BURNING MICTURITION SINCE 2DAYS

NO H/O WHITE DISCHARGE, ABDOMINAL PAIN, DYSPARUNIA, POST COITAL BLEEDING, NO H/O STRESS INCONTINENCE

NO H/O ABDOINAL DISTENSION, CONSTIPATION, DYSPEPSIA NO H/O FEVER,COUGH, COLD

H/O WEIGHT LOSS SINCE 1 YR, H/O LOSS OF APPEPTITE SINCE 1 MONTH, H/O DYSPNEA ON WALKING SINCE 1 WEEK, GENERALIZED WEKNESS SINCE 1 MONTH

NO H.O WHITE DISCHARGE, ABDOMINAL FAMILY HISTORY- NOT SIGNIFICANT

ON EXAMINATION

 

VITALS-

TEMP- 97.5 F F PR- 99 BPM

RR 19 CPM

BP-150/80 MM HG GRBS - 98 MG /DL

SYSTEMIC EXAMINATION CVS S1 S2 + NO MURMERS P/A SOFT NON TENDER CNS NFND

RS B/L AE + NVBS COURSE IN HOSPITAL

PATIENT WAS ADMITTED IN OBG DEPARTMENT ON 22/9/23 I/V/O HEAVY AND PROLONGED CYCLES SINCE 1 MONTH AND WAS PLANNED FOR ENDOMETRIAL BIOPSY ON 23/9/23 AT 7 PM, GM REFERRAL DONE I/V/O UNCONTROLLED SUGARS, HYPERTENSIVE URGENCY AND THE CASE HAS BEEN TAKEN OVER BY GM TEAM.

PATIENT WAS FURTHER INVESTIGATED AND MANAGED CONSERVATIVELY WITH ANTIHYPERTENSIVE ADN ANTIDIABETIC MEDICATIONS AND THE SUGARS ARE UNDER CONTROL. PATIENT IS BEING DISCHARED IN HAEMODYNAMICALLY STABLE CONDITION AND ISADVISED FOPR ENDOMETRIAL BIOPSY.

Investigation

 

NameValueRangeNameValueRangeCOMPLETE BLOOD PICTURE (CBP) 22-09-2023 06:46:PMHAEMOGLOBIN7.2 gm/dl15.0-12.0 gm/dlTOTAL COUNT14600 cells/cumm10000-4000 cells/cummNEUTROPHILS68 %80-40 %LYMPHOCYTES23 %40-20 %EOSINOPHILS02 %6-1

%MONOCYTES07 %10-2 %BASOPHILS00 %2-0 %PLATELET COUNT4.95SMEARmicrocytic

hypochromic anemia with leukocytosis and thrombocytosis.COMPLETE URINE EXAMINATION (CUE) 22-09-2023 06:46:PMCOLOURPale yellowAPPEARANCEClearREACTIONAcidicSP.GRAVITY1.010ALBUMIN++SUGAR++++BILE SALTSNilBILE PIGMENTSNilPUS CELLS5-6EPITHELIAL CELLS3-4RED BLOOD CELLSNilCRYSTALSNilCASTSNilAMORPHOUS DEPOSITSAbsentOTHERSNilPOST LUNCH BLOOD SUGAR22-09-2023 06:46:PM469 mg/dl140-0 mg/dlRFT 22-09-2023 06:46:PMUREA52

mg/dl42-12 mg/dlCREATININE1.9 mg/dl1.1-0.6 mg/dlURIC ACID7.2 mg/dl6-2.6 mg/dlCALCIUM9.6 mg/dl10.2-8.6 mg/dlPHOSPHOROUS2.6 mg/dl4.5-2.5 mg/dlSODIUM135 mEq/L145-136 mEq/LPOTASSIUM3.8 mEq/L5.1-3.5 mEq/LCHLORIDE98 mEq/L98-107 mEq/LLIVER FUNCTION

TEST (LFT) 22-09-2023 06:46:PMTotal Bilurubin0.86 mg/dl1-0 mg/dlDirect Bilurubin0.19 mg/dl0.2-

0.0 mg/dlSGOT(AST)49 IU/L31-0 IU/LSGPT(ALT)27 IU/L34-0 IU/LALKALINE PHOSPHATE314 IU/L98-42 IU/LTOTAL PROTEINS7.4 gm/dl8.3-6.4 gm/dlALBUMIN3.72 gm/dl5.2-3.5 gm/dlA/G RATIO1.01T3, T4, TSH 22-09-2023 06:46:PMT30.93 ng/ml1.87-0.87 ng/mlT418.25 micro g/dl12.23-

6.32 micro g/dlTSH1.37 micro Iu/ml5.36-0.34 micro Iu/mlHBsAg-RAPID22-09-2023 06:46:PMNegative Anti HCV Antibodies - RAPID22-09-2023 06:46:PMNon Reactive RFT 24-09-2023 04:49:AMUREA47 mg/dl42-12 mg/dlCREATININE1.7 mg/dl1.1-0.6 mg/dlURIC ACID6.3 mg/dl6-2.6 mg/dlCALCIUM9.4 mg/dl10.2-8.6 mg/dlPHOSPHOROUS1.7 mg/dl4.5-2.5 mg/dlSODIUM134 mEq/L145-136 mEq/LPOTASSIUM3.6 mEq/L5.1-3.5 mEq/LCHLORIDE98 mEq/L98-107 mEq/LRFT 25-09-2023 04:23:AMUREA62 mg/dl42-12 mg/dlCREATININE2.1 mg/dl1.1-0.6 mg/dlURIC ACID7.4 mg/dl6-2.6 mg/dlCALCIUM9.4 mg/dl10.2-8.6 mg/dlPHOSPHOROUS2.3 mg/dl4.5-2.5 mg/dlSODIUM139 mEq/L145-136 mEq/LPOTASSIUM3.5 mEq/L5.1-3.5 mEq/LCHLORIDE98 mEq/L98-107 mEq/LPOST LUNCH BLOOD SUGAR25-09-2023 04:23:

AM362 mg/dl140-0 mg/dlRFT 26-09-2023 04:46:AMUREA53 mg/dl42-12 mg/dlCREATININE1.9

mg/dl1.1-0.6 mg/dlURIC ACID7.9 mg/dl6-2.6 mg/dlCALCIUM9.9 mg/dl10.2-8.6 mg/dlPHOSPHOROUS3.0 mg/dl4.5-2.5 mg/dlSODIUM138 mEq/L145-136 mEq/LPOTASSIUM4.0 mEq/L5.1-3.5 mEq/LCHLORIDE99 mEq/L98-107 mEq/LRFT 26-09-2023 10:11:PMUREA38 mg/dl42-

12 mg/dlCREATININE1.6 mg/dl1.1-0.6 mg/dlURIC ACID6.8 mg/dl6-2.6 mg/dlCALCIUM9.7 mg/dl10.2-

8.6 mg/dlPHOSPHOROUS2.4 mg/dl4.5-2.5 mg/dlSODIUM138 mEq/L145-136 mEq/LPOTASSIUM4.1 mEq/L5.1-3.5 mEq/LCHLORIDE99 mEq/L98-107 mEq/LRFT 27-09-2023 11:22:PMUREA33 mg/dl42- 12 mg/dlCREATININE1.7 mg/dl1.1-0.6 mg/dlURIC ACID6.5 mg/dl6-2.6 mg/dlCALCIUM10.0 mg/dl10.2-8.6 mg/dlPHOSPHOROUS2.4 mg/dl4.5-2.5 mg/dlSODIUM137 mEq/L145-136 mEq/LPOTASSIUM4.0 mEq/L5.1-3.5 mEq/LCHLORIDE99 mEq/L98-107 mEq/L

 

ULTASOUND ABDOMEN IMPRESSION- GRADE 2 FATTY LIVER B/L RAISED ECHOGENICITY OF KIDNEYS, LEFT RENAL CORTICAL CYSTS

2D ECHO - MILD AR, TRIVIAL AR, TRIVIAL MR, NO RWMA, SCLEROTIC AV, GOOD LV SYSTOLIC FUNCTIONS, GRADE 1 DIASTOLIC DYSFUNCTION PRESENT

Treatment Given(Enter only Generic Name)

INJ HAI S/C TID, 20U --- 20U --- 18U

T. REGESTRON 10 MG PO/OD

T. CLINIDIPINE 10 MG PO/BD

T. OROFER XT PO/OD CAP NEXPROL PO/OD T.KINPRIDE 1 MG PO/OD

SYP CITRALKA10 ML IN1 GLASS OF WATER

T. AUGMENTIN 625 MG PO/BD IVF NS @50 ML/HR

Advice at Discharge

INJ HAI S/C TID, 20U --- 20U --- 18U

T. REGESTRON 10 MG PO/OD

T. CLINIDIPINE 10 MG PO/BD

T. OROFER XT PO/OD CAP NEXPROL PO/OD T.KINPRIDE 1 MG PO/OD

SYP CITRALKA10 ML IN 1 GLASS OF WATER


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