A 51 year old woman with excessive menstrual bleeding.

April 09, 2022

 This is online E-blog, to discuss our patient de-identified health data shared after taking her guardian's signed informed consent.



Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.

I have been a case in order to make my skills better in understanding the "Patient's clinical data analysis". Making a note of all the necessary information like the history of patient's present illness, his medical history, his family history, diagnosis and treatment plan. 

A 51 year old peri menopausal woman went to the OP with a problem of excessive menstrual bleeding since 1-2 years

 History of present illness:
  The lady was asymptomatic 2 years back then. since 1-2 years she was suffering from excessive menstrual bleeding with no clots and abdominal pain. She is also  moderately anemic.

History of past illness:
 No diabetes
 No hypertension 
No dysmenorrhoea 
No urinary symptoms
 
Personal history:
 The patient is a home maker. She has two kids one through NVD and one through LSCS. And is tubectomised.

Vitals:
Temperature: 98.6F
Pulse: 80/min
BP : 120/80mmHg 
Respiratory rate: 20/min
spo2: 92%

Systemic examination:
RS: Bilateral air entry adequate
CVS : S1+, S2+

Investigations:
Heamoglobin - 9gm/dl

Diagnosis:
Fibroid Uterus.

Medication:
Tab. Taxim O - 200 mg
Tab. Pan - 40 mg
Tab. Dolo - 650 mg
Tab. Cilacar- 10 mg
Tab. Orofex XT
Tab. Surbex CT

 


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