obg

Patient name  p laxmi
Op number:20201025657
55 yr old p3l3 came with complaints of lower back pain since 10 days
Pain from back radiating to groin dragging type of pain,associated with burning micturition and hematuria
H/o dysparunia +,white discharge +,vomitings +,constipation +
H/o myomectomy 3 yrs back
No h/o postcoital bleeding
Menstrual h/o:
Aom 12 yrs
5/30 regular
No clots 
No pain
Menopause   2 yrs back
Marietal h/o:
ML  31 yrs
2 nd degree consanguinous marriage 
Obs h/o
P1l1  male /30 yrs/ftnvd/3kgs
P2l2 male / 29 yrs /ftnvd/3 kgs
P3l3 female /28 yrs/Ftnvd/3kgs
General examination 
Ht 150 cms
Wt 60 kgs 
Bmi 26.7
Temp afebrile 
Pulse 86bpm
Bp 170/120 mm hg
Pallor + 
No signs of  icterus ,cyanosis,clubbing,lympadenopaty,pedal edema
P/A
Soft ,NT ,vertical scar +
P/S
Blood+, yellowish discharge +,bleed on touch+
P/V 
All walls of vagina is firm ,indurated,bleed on touch,opening felt?vault?cervical os
55 yr old  p3 l3 with stress urinary incontinence for evaluation 

H/o wt gain +,
Loose stools 5 days back
No h/o Facial hair ,blackish pigmentation around neck
No h/o fever,vomiting,burning micturition,white discharge 
No h/o HTN ,DM,BA ,CHD,CKD,THYROID diseases
Family h/o : Father is k/c/o DM since 2 yrs on OHA
Menstrual h/o:
 AOM  14 yrs 
LMP  27/8/2020
5 /30 Regular
Not associated with pain and clots
General examination 
No signs of pallor icterus cyanosis clubbing lympadenopaty pedal edema
Temp  afebrile 
Bp 120 /80 mm hg
Pulse 86 bpm
Ht 154 cms
Wt 49 kgs 
Bmi 20.7 
21 yr old unmarried with amenorrhea under evaluation?pcos
Investigations- 
Usg abdomen and pelvis 
Upt



Bleeding for 3 days in every 15 days cycles,changing 2 pads per day,associated with pain ,no clots
No h/o white discharge ,
No h/o burning micturition,
No h/o dysparunia,
No h/o vomitings,loose stools ,fever
Menstrual history:
Lmp :4/10/2020 and
 previous Lmp 16/9/2020
Previous menstrual h/o:3/30 days regular
Present  menstrual h/o: 3 /15 days since 2 to 3 months, pain +,clots -
Marietal history: 
19 yrs of married life 
Non consanguinous marriage
Obstetric history :
P1L1 female baby 
Present age of girl 17 yrs
LSCS
P2L2 male baby 
Present age of boy 16 yrs
LSCS
TUBECTOMIZED 3 yrs after Last child born
Past history: 
Not a k/c/o HTN,diabetes mellitus,epilepsy,tb,thyroid ,cad
Family  history 
H/o HTN +
General examination 
Pallor+
No signs of ictetus , cyanosis, clubbing,lympadenopaty,pedal edema
Thyroid,breast ,spine ,gait  : normal 
Ht :141 cms
Wt :49 kgs
Temperature  : Afebrile 
BP :120/80 mm Hg
Pulse: 84 bpm
P/A : 
Soft ,non tender, vertical scar present

Pt is on day 2 of cycle not cooperative for p/s and p/v examination 
40 yrs old P2L2 tubectomized with AUB under evaluation
Inestigations:
Usg abdomen and pelvis
TFT 
CBP
Patient name: divya
Op number:20200004690
16 yr old unmarried with AUB under evaluation with anemia came for follow up
Used T.femilon for 1 cycle
21 days of cycle day of start10/9/20   -day of stop 30/9/20
Menstrual history:
Lmp :4/10/2020 
           7/09/2020
           17/08/2020
Aom  :13 yrs
Previous menstrual h/o:5/30 days regular
Present  menstrual h/o: 5/15-30 days irregular cycles 3pads per day, no pain 
,clots + peanut sized
Past history: 
Not a k/c/o HTN,diabetes mellitus,epilepsy,tb,thyroid ,cad
K/C/O maxillary polyp 
Family  history Not significant 
No h/o blood transfusions 
H/o orofer infusion 2doses 1 month back

General examination 
Pallor+
No signs of ictetus , cyanosis, clubbing,lympadenopaty,pedal edema
Thyroid,breast ,spine ,gait  : normal 
Ht :155 cms
Wt :41kgs
BMI:17.06
Temperature  : Afebrile 
BP :100/80 mm Hg
Pulse: 74 bpm
P/A : 
Soft ,non tender
On 1/9/2020
Hb 6.1gm/dl
Platelets 6.1 lakhs
P/s : microcytic hypochromic anemia with thrombocytopenia
Retic count :0.2
Serum ferritin:1.9 ng/ml

16 yr old unmarried with AUB under evaluation with anemia with ?maxillary polyp with thrombocytopenia came for follow up
Inves 
CBP   hb 9.5gm/dl
          Platelets :4.91 lakhs
Rx
1 Tab meprate 10 mg OD from day 15 to day25
From october 18 to october 28
2 Tab ferrous ascorbate 100 mg PO/OD for 1 month
3 Tab vit c OD for 1 month
4 Tab b complex OD for 1 month 

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