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analyse_media
Reading File
Here is a complete clinical summary of both documents for Mrs. Meenabai Wadkar, 53F:
OPD Casepaper - Gynaecology (15/07/2026)
Reg. No.: ACPMMC / 1181037 | Department: Gynaecology | Seen by: Dr. Prajakta
Chief Complaints
- Heavy PV (per vaginal) bleeding with clots
- Abdominal pain x 1 day
- Polymenorrhea
Menstrual History
| Past History | Present (Last 5-7 months) | |
|---|---|---|
| Bleeding duration | 4-5 days | 15-20 days |
| Cycle length | 28-30 days | 15-16 days |
| Flow | Regular, Adequate, Painless | Heavy with clotting |
LMP: 13/07/2026
Past Medical History
| Condition | Medications |
|---|---|
| Hypertension | Telmisartan 40 mg, Nifedipine |
| Diabetes Mellitus | Dapagliflozin 10 mg, Sitagliptin |
| Dyslipidemia / Cardiovascular | Atorvastatin, Clopidogrel, Aspirin |
| Post-PCA (Percutaneous Coronary Angioplasty) | ~10 months ago |
Examination Findings
- General: Afebrile, Pallor (+), No edema/cyanosis/clubbing/icterus/lymphadenopathy
- Pulse: 120 bpm
- BP: 130/90 mmHg
- RS / CNS / P/A: NAD (No Abnormality Detected)
Abdominal Sonography Report (15/07/2026)
Organ Findings
| Organ | Finding |
|---|---|
| Liver | Enlarged - span 16.7 cm; Fatty liver Grade I |
| GB / CBD / PV | Normal |
| Pancreas | Normal |
| Spleen | Normal |
| Right Kidney | 124 x 46 mm; B/L raised echogenicity of renal cortices |
| Left Kidney | 104 x 36 mm |
| Bladder | Normal |
| Uterus | 12.3 x 5.4 x 7.4 cm (bulky); anteverted; ET = 6 mm; Posterior wall intramural fibroid 2.7 x 2.1 cm (FIGO Type 5) |
| Right Ovary | 3.1 x 1.7 cm |
| Left Ovary | Not visualized (marked "X") |
| Ascites / Effusion | None |
USG Impression
- Fatty liver Grade I
- B/L MRD (Medical Renal Disease) Grade I - bilateral raised cortical echogenicity
- Bulky uterus with posterior wall intramural fibroid (2.7 x 2.1 cm, FIGO Type 5)
Clinical Interpretation
This 53-year-old perimenopausal woman presents with a classic picture of abnormal uterine bleeding (AUB) driven by a uterine fibroid (leiomyoma):
- Polymenorrhea + heavy bleeding with clots over 5-7 months corresponds directly to the intramural posterior wall fibroid (2.7 x 2.1 cm, FIGO Type 5) found on USG. The bulky uterus supports this.
- Endometrial thickness of 6 mm is within normal limits for her age but warrants monitoring given the bleeding.
- Pallor + tachycardia (P 120 bpm) suggest acute blood loss anemia - she needs hemoglobin check urgently.
Complicating factors for management:
- She is post-PCA (~10 months ago) and on Clopidogrel + Aspirin (dual antiplatelet therapy). This is critical - surgical options (myomectomy/hysterectomy) carry high bleeding risk and antiplatelet therapy likely cannot be safely stopped this soon after PCA. Cardiology input is essential before any procedure.
- Diabetes + Hypertension + Dyslipidemia increase surgical risk.
- B/L MRD Grade I - NSAIDs (like tranexamic acid consideration) and contrast dye should be used cautiously; renal function (creatinine, eGFR) should be checked.
- Fatty liver Grade I - hepatic drug metabolism may be mildly affected.
- Left ovary not visualized - needs follow-up to rule out adnexal pathology.
Immediate priorities:
- CBC (hemoglobin, platelets), coagulation profile, renal function, LFTs, HbA1c
- Endometrial biopsy to rule out hyperplasia/malignancy (given age and prolonged bleeding)
- Cardiology consultation before any invasive intervention
- Medical management of AUB (GnRH agonists, levonorgestrel IUS, or hormonal therapy) - keeping antiplatelet status in mind
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