A 45 y/o female with complaint of excessive bleeding per vagina
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CHIEF COMPLIANT:
A 45 year old P2L2 who is a daily wage worker by profession was presented to the casualty with the chief compliant of:
- excessive bleeding per vagina 3 days back.
-difficulty in breathing since 3 days.
Daily Routine : She is a daily wage worker by profession . She wakes up at 6 AM, prepares breakfast and eat and leave for work till 8AM. She return back to home for cooking and eating lunch. Then again she leave for work till 4 PM and finishes her work and come back to home till 7PM. She eats chappati, dosa and rice usually.
History of present illness:
Patient was apparently asymptomatic 3 days back then she had start of menstrual cycle and had excessive bleeding per vagina for 3 days during the cycle and devoped palpitations and had difficulty in breathing.
The bleeding was associated with abdominal pain which was dragging type, aggravated during menstrual cycle and non radiating.
She had heavy bleeding on 1st two days of cycle, changing 10-12 pads/day, associated with clots of size 2×2 cm, dysmenorrhea positive on first 3 days.
Then onwards, changing 1-2 pads/day.
PAST HISTORY:
No h/o excessive bleeding in the past.
N/H/O major pelvic surgeries.
N/H/O burning micturition, white discharge, constipation and fever.
N/H/O blood transfusion.
N/K/C/O DM, CAD, CVA, TB, Epilepsy, Thyroid.
K/C/O hypertension since 2 months on medication (not known and not regular)
FAMILY HISTORY
There are no similar complaints seen in her family.
PERSONAL HISTORY:
Married
Occupation - Daily wage worker
Diet: Mixed
Appetite: normal
Bowels: regular
Micturition: normal
No known allergies
No known addictions.
MENSTRUAL HISTORY:
Age of menarche- not remembered
Menstrual cycle: 4-5 days
Past: 3/30, regular, normal flow, no history of clots and pain.
This month:5-6 days, heavy flow, changing 10-12 pads/day associated with clots (2×2cm) and pain.
Patient was married at 17 years of age. She conceived her first child at 18 years of age. She have 2 children. No history of abortions.
OBSTETRIC HISTORY:
P1L1- male FTND, 26yrs now
P2L2- female FTND 25yrs now
Tubectomy done 25 years back.
Martial History:
Married for 28 yrs now, Non consanguineous marriage.
GENERAL EXAMINATION :
The patient is examined in well light room. He is conscious, coherent and cooperative and well oriented to time, place and person and consent was taken to examine him.
Pallor - +
Icterus - Absent
Cyanosis - Absent
Clubbing - Absent
Lymphadenopathy - Absent
Pedal Edema - Absent
Dehydration- Absent
VITALS:
Temp: afebrile
PR: 104 beats/min
BP: 160/90mm hg
RR: 15 cycles/min
SPO2: 100% at RA
GRBS: 133 mg%
SYSTEMIC EXAMINATION :
CVS:
s1 and s2 sounds +
no thrills and no murmurs heard
RS:
Dyspnea: no
Wheeze: no
position of trachea: central
vesicular breath sounds heard
Abdomen:
shape of abdomen: scaphoid
soft and non tender
no organomegaly detected
CNS:
conscious
normal speech
cranial nerves are intact
sensory system normal
motor system normal
Gait- normal
REFLEXES: BICEPS TRICEPS SUPINATOR KNEE ANKLE
RIGHT : ++ + + +
+
LEFT : + + + +
+
Cerebellar signs:
-finger -nose -in- coordination: absent
-knee-heel-in-coordination: absent
INVESTIGATIONS:
Hemogram:
PROVISIONAL DIAGNOSIS:
Anemia Secondary to Menorrhagia.
TREATMENT PLAN :
Inj. Viticofol 1500mg+ 5mg IM/OD
Tab. Levogen 150mg PO/OD
Monitoring vitals 4rth hourly
1 PRBC transfusion on 27.11.22
Tab Telma H 20mg PO/OD
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