Obstetric & Gynecology
case presentation
[Link] Shahriar kabir Riad
MD-phase A, Forensic Medicine
Bangladesh Medical University
Particulars Of the Patient :-
• Name -Mrs Julekha
• Age – 38yrs
• Address – Azimpur, Dhaka
• Occupation – Housewife
• Marital status – Married
• Husband’s name – Mr. Samim Hasan
• Husband’s occupation – fruit vendor
• Socio economic status – lower middle class
• Religion – Muslim
• Date of admission – 5/5/25
• Date of examination – 5/5/25
Chief complaints With Duration –c/o
heavy menstrual bleeding since 6 months
History of present illness – Patient was apparently
alright 6 months back Later she developed heavy
menstrual bleeding since 6 months lasting for 8 days
in a cycle . Her cycles were regular 24-30 days cycle
and she changed 6 -8 pads per day ,she also gives
history of changing pads in the night ,passage of clots
measuring about a coin size , associated with
squeezing type of pain in the lower abdomen after
the onset of menstruation, this pain subsided after
few hours after the onset
This was associated with easy fatigability and
tiredness. .She was on medical line of management for
the above mentioned complaints but her symptoms did
not subside .No intrauterine device was inserted. Patient
was not investigated further . Now she has come to
DMCH for further management
No history of dyspareunia , white discharge per vagina ,
intermenstrual bleeding , post coital bleeding , mass per
abdomen , mass per vagina, amenorrhoea followed by
bleeding.
• No history suggestive of pressure symptoms like
increased frequency ,urgency of urination or bowel
symptoms ,hair loss ,weight gain , lethargy ,
palpitation , tremors , loss of appetite , weight loss ,
excessive facial hair , acne , intake of long-term
medications , bleeding gums , easy bruisability,
epistaxis ,swelling of knees.
• Menstrual history
Age of menarche – 14 years
Last menstrual period – 15/4/2025
Previous cycles – Regular cycles /24-25days
cycle/4-5 days / 3-4pads per day / no clots / dysmenorrhoea
+
Present cycles – Regular cycles /24-30 days cycle
/7-8days /6-8pads per day/clots + / dysmenorrhoea+
Obstetric history
Para 2 Living 2
Full term normal vaginal deliveries
Last child birth – 14 yrs back
•
• Past history
No history of diabetes mellitus ,hypertension ,
tuberculosis ,epilepsy , bronchial asthma
No history of surgeries in the past
No history of blood transfusion in the past
• Family history
No similar complaints in the family
No history of gynaecological malignancies in the family
Marital history / sexual history
Married for 16years , non consanguineous marriage
Sexually active
Personal history
Bowel – Regular Bladder – regular , no urinary
disturbances
Sleep – adequate Diet – mixed
Appetite – good ,No habits , not on any regular
medications like anti- epileptics,anti depressants , anti-
coagulants ,NSAIDs
• General physical examination
Patient is conscious, alert and co operative
Moderately built and nourished
Height – 167cms
Weight – 80kgs
BMI – 28.7kg/m2
Spine , thyroid and B/L breast appear normal
Pallor – (+)
Icterus – (-)
Cyanosis – (-)
Clubbing – (-)
Lymphadenopathy - (-)
Edema –(-)
• Pulse rate – 98beats per minute
• Blood pressure – 120/70mmHg
• Respiratory rate – 16cycles per minute
• Temperature – 37°c
Systemic examination
• Respiratory system – Bilateral normal vesicular breath
sounds heard
• Central nervous system – conscious, oriented ,higher
mental functions are normal
Per abdomen examination
Not Done
P/V/E : Not Done
Salient Feature :-
• Mrs Julekha aged 38yrs housewife coming from low
socio-economic status admitted with history of heavy
menstrual bleeding since 6months . Her last menstrual
period was 15/4 /25 ,periods are regular but persisting
for 8 days occuring in 21-25days interval .
• On examination vitals stable and she appears anaemic
Provisional diagnosis
Abnormal Uterine Bleeding
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