Name - Bhavya Ranjan

Roll - 17 

Batch - 2019 

A 50 year old housemaker, who is a resident of Nalgonda came to OPD with chief complaints of-

Heavy and prolonged menstrual bleeding since 1 month.

History of presenting illness 

Patient was apparently asymptomatic 1 month ago , then she developed 1 month amenorrhea, followed by heavy and prolonged cycle, continuous bleeding for 11 days, associated with clots of size 5×5cm. Bleeding subsided on medication.

5 days back she passed a clot of size 3×3 cm two times.

H/o generalized weakness since 1 month.

H/o weight loss since 1 year.

H/o loss of appetite since 1 month.

No h/o abdominal distension, post costal bleeding, fever , cough and cold.


History of past illness

K/c/o HTN since 20 years 

K/c/o DM since 2 years 

No TB, Asthma, CAD, Seizers.

Treatment history

On medication for HTN and diabetes

Personal history 

Appetite- decreased 

Diet - mixed 

Bowel and bladder - normal 

Micturition- burning 

Any known allergens - none

Addictions- none 

Family history 

No similar complaints 

General Examination 

Patient is moderately built and nourished.

He is conscious, cooperative,comfortable.

Physical Examination 

Height- 154cm

Weight - 91 kgs

Pallor - absent

Icterus - absent 

Clubbing - absent 

Cyanosis - absent 

Lymphadenopathy - absent

Oedema - absent

Temperature - 97.5°F

Pulse rate - 99/min

Respiratory rate- 19/min

Blood pressure 

5pm: 168/100 mmhg

6pm: 130/80 mmhg

7pm:130/90 mmhg 

8pm:130/70 mmhg 

9pm: 120/60mmhg 

10pm:120/70 mmhg 

11pm:130/90mmhg

12am: 130/80mmhg

1am:130/80mmhg

2am:130/80mmhg

3am:130/80mmhg

4am:130/80mmhg

5am:130/80mmhg

6am:130/80mmhg

7am:130/80mmhg

8am:130/90mmhg






Systemic Examination 

CVS -

S1 and S2 heard 

No thrills

No cardiac murmur 

No focal deficits


RESPIRATORY SYSTEM:

NVBS 

BAE+

No cripts


PER ABDOMEN:-

 Distended abdomen

Soft non tender abdominal wall 

shape of abdomen is Scaphoid

Tenderness not seen 

No palpable mass 

Bowel sounds are heard 

Liver and spleen are not palpable

No free fluid

No bruits

Normal hernial orifices 


CNS:-       

Patient is conscious. 

Speech is normal.

No signs of meningeal irritation. 

Reflexes are normal


Reproductive system :=

Cervix - hypertrophied and bleeds on touch

Uterus - bulky 







Investigations

CBP, CUE, BGT, CT, USG abdomen and pelvis, RFT, LFT, UPT, HIV, Fundoscopy, ECG, Chest X ray, Fasting lipid profile, 2Decho

Provisional Diagnosis 

54 year old P6L4D2 non tubectomised with AUB-M under evaluation with second degree uterine vault prolapse with mild cystocele and rectocele.

K/c/o htn, dm

Obesity (metabolic syndrome)

Risk factors - 

Not yet attained menopause 

HTN

DM

Obese







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