CASE REPORT
A 43year old female, resident of Narketpalle came with the
chief complaints of:
Generalised weakness since 15days
Bilateral pedal edema since 15days
HOPI:
Patient was apparently asymptomatic 15days back then she noticed swelling in both the lower limb which was present till below knee- insidious in onset,gradually progressive and pitting type, relieved during night time while sleeping
Since 15days the edema was on and off type but since 2-3days it was not relieving on rest also for which she visited hospital and blood test were done the haemoglobin was 4.5g/dl, she was not willing to admit after which she had similar complaints following which she had blood transfusion.
The pedal edema is relieved now.
She also complains generalised weakness
No h/o SOB, orthopnea, PND, palpitations
She noted no history of decreased urine output, burning micturition
She had no history of abdominal distension, abdominal pain, itching,erythema
She had no history of vomiting, loose stools or constipation, fever
Sequence of events:
12years back she had lower back pain which was not relieved on rest also hence she went to a local hospital in nalgonda and was on medications- the pain was relieved
Also consulted to gynaecology due to itching in vaginal area where she was said she had a lesion in uterus.
4years back patient has similar complaint of generalised weakness for which she visited a hospital in nalgonda on doing blood test her haemoglobin was 6g/dl for which she took iron and folic supplements for 1month and stopped.
2-3years back she had increased blood flow (inter-menstrual bleeding ) for which she visited gynaecologist and was on
?medication And after a month of course she stopped using medication, the bleeding was controlled at that time
Later 2-3months she had increased blood flow on 1st day of her menses she used around 4pads/day, there was no inter-menstrual bleeding
Following which 15days back she had complains of generalised weakness and bilateral pedal edema for which she is being evaluated
Past history:
She had similar complaint of generalised weakness 4years back.
K/c/o diabetes since 3days
Not a k/c/o HTN,Asthma, epilepsy , thyroid disorders,TB, CAD
Menstrual history:
Menarche-At the age of 13years
She had regular periods of 5/28
She used 2-3pads/day before but since 3months she has increased blood flow on her 1st day of menses for which she used around 4pads/day(fully soaked).
Marital history:
She got married at the age of 15years
1st child- normal vaginal delivery but died after 3days.
2nd child- normal vaginal delivery but died at the age of 6.
3rd,4th and 5th child through normal vaginal delivery and their current age 23yrs,18yrs and 16yrs.
Personal history:
Previously she used to wake up at 8am and do household works-cleaning house, make breakfast etc, and has her lunch by 2pm and dinner by 10pm and sleep by 12 pm
Whenever she gets time she used to look after the general store which is connected to her house.
Since few months, She said that she used to not take food properly and she used to skip meals when she had her meals she used to take only a little amount. There were days when she ate nothing at all, for 2-3 days at a time. She stated that the main reason for this was that she was facing psychological distress from family problems, and was worried about making ends meet. Currently, the family's main source of income was the general store, which she was taking care of alone. Additionally, doing the household work as well as caring for the children was taking a toll on her. She sadly noted that even admission in the hospital meant more worry for the family.
Diet:mixed
Breakfast- dosa with chutney
Lunch- rice with bendi curry and dal
Dinner-rice and curry
Breakfast:
2Dosa-168x2cal
Chutney-331cal
Lunch:
Rice:130cal
Bhindi curry-160cal
Dal-116cal
Dinner:
Rice:130cal
Dal:116cal
Aloo curry-107cal
Total calorie intake- 1,426cal
Deficit- 574cal
Appetite: decreased
Sleep: adequate
Bowel and bladder habits: regular
No addictions
Family history:
No significant history
GENERAL EXAMINATION:
Patient is conscious, coherent and co-operative.
She is moderately built and moderately nourished.
Pallor - Present
Icterus - Absent
Cyanosis - Absent
Clubbing - Absent
Generalised lymphadenopathy- absent
edema -previously present now resolved
Vitals :
Temperature - 96.8 ° F
Blood Pressure -110/70 mmHg
Pulse Rate -89 bpm
Respiratory Rate - 16 cpm
SYSTEMIC EXAMINATION:
PER ABDOMEN:
Inspection:
Shape - Scaphoid, with no distention.
Umbilicus - Inverted
Equal symmetrical movements in all the quadrants with respiration.
No visible pulsation,peristalsis, dilated veins and localized swellings.
Palpation:
No lacal rise of temperature
Inspectory findings are confirmed
No hepatomegaly
Spleen not palpable
Percussion:
Normal liver span
Fluid thrill and shifting dullness absent
puddle sign absent
Auscultation:
Bowel sounds present.
CVS:
Inspection:
There are no chest wall abnormalities
The position of the trachea is central.
Apical impulse is not observed.
There are no other visible pulsations, dilated and engorged veins, surgical scars or sinuses.
Palpation:
Apex beat was localised in the 5th intercostal space 1cm medial to the mid clavicular line
Position of trachea was central
There we no parasternal heave , thrills, tender points.
Auscultation:
Loud S1 and S2
There were no added sounds / murmurs.
CNS:
HIGHER MENTAL FUNCTIONS-
Normal
Memory intact
CRANIAL NERVES :Normal
SENSORY EXAMINATION
Normal sensations felt in all dermatomes
MOTOR EXAMINATION
Normal tone in upper and lower limb
Normal power in upper and lower limb
Normal gait
REFLEXES
Normal, brisk reflexes elicited- biceps, triceps, knee and ankle reflexes elicited
CEREBELLAR FUNCTION
Normal function
No meningeal signs were elicited
RESPIRATORY EXAMINATION:
Shape of chest is elliptical, b/l symmetrical.
Trachea is central. Expansion of chest is symmetrical
Bilateral Airway Entry - positive
Normal vesicular breath sounds
Provisional diagnosis:
This is case of 43year old female having anemia secondary to ?heavy menstrual bleeding
Denovo DM 2
INVESTIGATIONS:
On 7/6/23:
Serum electrolytes:
ECG:
Tachycardia(100bpm)
Normal sinus rhythm
USG:
Evidence of few calculi 3-4mm noted in the lower pole of right kidney
Evidence of 5.8x4.8 cm fibroid in the posterior myometrium
Impression:
Borderline spleenomegaly
Right renal calculi
Posterior myometrial fibroid
On 13 June 2023
Hb- 5gm/dl
TLC - 5800
MCV - 61.7
MCHC - 23.1
MCH - 14.3
Platelet - 3.0
Serum iron - 31 micro gram / dl
Blood urea - 22 mg/dl
Serum creatinine - 0.6 mg/ dl
Blood grouping - B +ve
Serum ferritin - 2.2ng/ml
Liver function test:
On 14 June 2023
Fasting Blood sugar -285 mg/dl
Chest x-ray:
On 15/6/23:
2D echo:
Final diagnosis:
This is case of 43year old female having
Anemia-nutritional(iron deficiency anemia)secondary to ?heavy menstrual bleeding
Denovo DM 2
Right renal calculi
Course in our hospital :
OBG Referral on 13/6/23:
O/E:
43year old P5L3D2 tubectomised with AUB-L with severe anemia
Patient not willing for per speculum and bimanual examination
Advice :
No active gynaecological intervention needed
Blood transfusion of 1unit PRBC was done on 13/6/23
Treatment:
On 14/6/23
INJ.IRON SUCROSE 200MG IN 100ML NS IV/OD OVER 1 HOUR.
INJ.OPTINEURON 1 AMP IN 100 ML NS IV/OD
TAB.METFORMIN 500MG PO/BD
TAB.GLIMIPIRIDE 1MG PO/OD
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