Name MIS kokila GYNAECOLOGY CASE RECORD

Age 1
Sex: F OP IP No.

Address: KoyApuram Date of Admission

Date of discharge

Ward No.
Socio Economic Status:

Occupation :PoUx Diagnosis Education: 12

Aadhar No.

Mobile No,

CHIEF COMPLAINTS:
H/o hepwmens-wual beedina or the past 37onths

History of pres enting illness

HO exesstVe ood louoast 3 ronths- cames 8 pads/day full
soaked aSsocioted with pAin
H/o pain-ful menstbuatton
in the post
No H/O Smilar epfsodes
No HO 0menor he0 be-tpse peiods
Menstrual History: spotng
No H/o pre /p0s-t menstua
H/0 fa-tique gwelng Ot leys
NO R/O pl pitaton duspnea
oY, ddcreae h uetaht
NO H/o nCreae
NO R/o moSS Olbdomer MENSTRUAL HISTORY
MaritalHistory:
Attained menarche
0d 4 years
MorTed odt yeor ReaalaY c y d e s A / 3 0

Non onganguinous maboiage Coake pads/doy

NOt
iased with pain Jclbts
etric History: 2 2 peiod- une Vênt
fulBaby
Antcnata kg cate
14e0Y Y monia9e IO1Male
biby25

dvered bu LSCS fn lusively breactf c d f o 1 n b

brth exc pefacl-dnevehtful
ven-tftul
hmmediadtelu oltey peifal-ape
Antenctia
d Hrh 3 ha
femse
3eArS
rS QlHcr
LSCS In TOh
Bobyaelyesed bby
 ofed owdtobey OfE BYh excusvely cast ea tor 6
Past Medical & Surgical History
No Wo dtoeteshper tenston 16,thord disordeas
tronsfusion
No o dood

NoWo 9hqe
Family History
No danikant oy histoy

Personal History
Mixed dfe
Nomol bwelandu bodder habits
No odverse srdal rob ts

Treatment History
Not dantfcat

GENERAL PHYSICAL EXAMINATION:

Modewel4 buttt ord pouthed
Polov-present
No fc0S, CHonosts, Clubirg
No pedol edera
No goificant erttolze

Beo e throfd Spine unphodanopaifuy

examino-tBon-Nowna
OVS-S52 heosd No mumar Nonal
RS-Norol yestoulov pitoth sourds heoard odded
CNS to al
roo logi cal dotit
No odbtd Serds
VITALS
PULSE:
82/ob BP 120/8D m
RESP.RATE 15/tei
TEMP:
Afoe Ht:163 w:
65 BM
 SYSTEMIC EXAMINATION
ABDOMEN EXAMINATON PALPATO
Not un Not n d e r
No Oganomeao
INSPECTON
Abdomen 00t distended Sott
No rocS ble
equally
All quad Tants hmove
w i t h respiyobioo PERCUCSION
No Shfting duune

Om bilicus
in oidine
,
veins
No SoUSes dilatek AVSCOLTATION
LSCS S o in
Bowe SOunds heard

Heathy
Suprapubic i o n ExAMINATON

Ortcesfree EaYNAECOLOhCAL
Heantal Eytera genibo)ia
No oC esron

P o r evaluaon
evaluaon
DIAGNOSIS:

AbnOymal
0
4tee
n in
nee Bleedr fo
Bleecrg
A e ob

Adenomyasi's

DIFFERENTIAL DIAGNOSIS:
End ometnosr8

TbDTd
Ceryfcal poP ing
End omebial samp
FOaLtiora
INVESTIGATIONS CLrettag
tcsts
CBC functon

Toyo 7d T r a n s a b do m i n a

VS61 Tans vay

inal

ard
ded
PAP Smear Colposcop opy
VIA, VILI

TREATMENT

J UP ADVICE
DiSc