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

 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 WEAKNESS SINCE 1 MONTH NO H.O WHITE DISCHARGE, ABDOMINAL 

FAMILY HISTORY- NOT SIGNIFICANT ON EXAMINATION 

VITALSTEMP- 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

PROVISIONAL Diagnosis :-

 UNCONTROLLED SUGARS (RESOLVED) WITH HYPERTENSIVE URGENCY (RESOVED) WITH AUB UNDER EVALUATION WITH MODS ANEMIA SECONDARY TO BLOOD LOSS WITH K/C/O HTN SINCE 20 YRS AND K/C/O T2 DM SINCE 2 YRS


Investigation:-

COMPLETE BLOOD PICTURE (CBP) 22-09-2023 06:46:PM

HAEMOGLOBIN7.2 gm/dl15.0-12.0 gm/dl

TOTAL COUNT14600 cells/cumm10000-4000 cells/cumm

NEUTROPHILS68 %80-40 %

LYMPHOCYTES23 %40-20 %

EOSINOPHILS02 %6-1 %

MONOCYTES07 %10-2 %

BASOPHILS00 %2-0 %

PLATELET COUNT4.95

SMEAR microcytic hypochromic anemia with leukocytosis and thrombocytosis

.COMPLETE URINE EXAMINATION (CUE) 22-09-2023 06:46:PM

COLOUR Pale yellow

APPEARANCE Clear

REACTION Acidic

SP.GRAVITY1.010

ALBUMIN++

SUGAR++++

BILE SALTS  Nil

BILE PIGMENTS  Nil

PUS CELLS5-6

EPITHELIAL CELLS3-4

RED BLOOD CELLS Nil

CRYSTALS Nil

CASTS  Nil  

AMORPHOUS DEPOSITS Absent

OTHERS  Nil  

POST LUNCH BLOOD SUGAR   22-09-2023 06:46:PM   469 mg/dl   140-0 mg/dl

RFT 22-09-2023 06:46:PM

UREA52 mg/dl42-12 mg/d

lCREATININE1.9 mg/dl1.1-0.6 mg/dl

URIC ACID7.2 mg/dl6-2.6 mg/dl

CALCIUM9.6 mg/dl10.2-8.6 mg/dl

PHOSPHOROUS2.6 mg/dl4.5-2.5 mg/dl

SODIUM135 mEq/L145-136 mEq/L

POTASSIUM3.8 mEq/L5.1-3.5 mEq/L

CHLORIDE98 mEq/L98-107 mEq/L

LIVER FUNCTION TEST (LFT) 22-09-2023 06:46:PM

Total Bilurubin0.86 mg/dl1-0 mg/dl

Direct Bilurubin0.19 mg/dl0.2- 0.0 mg/dl

SGOT(AST)49 IU/L31-0 IU/L

SGPT(ALT)27 IU/L34-0 IU/L

ALKALINE PHOSPHATE314 IU/L98-42 IU/L

TOTAL PROTEINS7.4 gm/dl8.3-6.4 gm/dl

ALBUMIN3.72 gm/dl5.2-3.5 gm/dlA/G RATIO 1.01 T3, T4, TSH 22-09-2023 06:46:PM

T3  0.93 ng/ml1.87-0.87 ng/ml

T4  18.25 micro g/dl12.23- 6.32 micro g/dl

TSH1.37 micro Iu/ml5.36-0.34 micro Iu/ml

HBsAg-RAPID22-09-2023 06:46:PMNegative 

Anti HCV Antibodies - RAPID22-09-2023 06:46:PMNon Reactive

 RFT 24-09-2023 04:49:AM

UREA47 mg/dl42-12 mg/dl

CREATININE1.7 mg/dl1.1-0.6 mg/dl

URIC ACID6.3 mg/dl6-2.6 mg/dl

CALCIUM9.4 mg/dl10.2-8.6 mg/dl

PHOSPHOROUS1.7 mg/dl4.5-2.5 mg/dl

SODIUM134 mEq/L145-136 mEq/L

POTASSIUM3.6 mEq/L5.1-3.5 mEq/L

CHLORIDE98 mEq/L98-107 mEq/L

RFT 25-09-2023 04:23:AM

UREA62 mg/dl42-12 mg/dl

CREATININE2.1 mg/dl1.1-0.6 mg/dl

URIC ACID7.4 mg/dl6-2.6 mg/dl

CALCIUM9.4 mg/dl10.2-8.6 mg/dl

PHOSPHOROUS2.3 mg/dl4.5-2.5 mg/dl

SODIUM139 mEq/L145-136 mEq/L

POTASSIUM3.5 mEq/L5.1-3.5 mEq/L

CHLORIDE98 mEq/L98-107 mEq/L

POST LUNCH BLOOD SUGAR25-09-2023 04:23: AM362 mg/dl140-0 mg/dl

RFT 26-09-2023 04:46:AM

UREA53 mg/dl42-12 mg/dl

CREATININE1.9 mg/dl1.1-0.6 mg/dl

URIC ACID7.9 mg/dl6-2.6 mg/dl

CALCIUM9.9 mg/dl10.2-8.6 mg/dl

PHOSPHOROUS3.0 mg/dl4.5-2.5 mg/dl

SODIUM138 mEq/L145-136 mEq/L

POTASSIUM4.0 mEq/L5.1-3.5 mEq/L

CHLORIDE99 mEq/L98-107 mEq/L

RFT 26-09-2023 10:11:PM

UREA38 mg/dl42- 12 mg/dl

CREATININE1.6 mg/dl1.1-0.6 mg/dl

URIC ACID6.8 mg/dl6-2.6 mg/dl

CALCIUM9.7 mg/dl10.2- 8.6 mg/dl

PHOSPHOROUS2.4 mg/dl4.5-2.5 mg/dl

SODIUM138 mEq/L145-136 mEq/L

POTASSIUM4.1 mEq/L5.1-3.5 mEq/L

CHLORIDE99 mEq/L98-107 mEq/L

RFT 27-09-2023 11:22:PM

UREA33 mg/dl42- 12 mg/dl

CREATININE1.7 mg/dl1.1-0.6 mg/dl

URIC ACID6.5 mg/dl6-2.6 mg/dl

CALCIUM10.0 mg/dl10.2-8.6 mg/dl

PHOSPHOROUS2.4 mg/dl4.5-2.5 mg/dl

SODIUM137 mEq/L145-136 mEq/L

POTASSIUM4.0 mEq/L5.1-3.5 mEq/L

CHLORIDE99 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

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  

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