Dr Witty Raina

MBBS, MD, MRCOG

1/2
(HMC: 3584)

1000000101976948 2024-02-26 10:56

Urmila Bansal Mal , Age: 49 Y 0 M 9729510112

Wt: 79.1 kg
VITALS BP: 130 / 86 mmHg

Prescription

First Visit
P3l3, prev NVD LCB 23 yrs
H/o POSTMENOPAUSAL bleeding
Heavy episode on 6/2/24 after 1 yr of menopause

ON T thyronorm 100 mcg od , tab methotrexate

RA factor +
H/o diagnostic hysteroscopy + polypectomy in 2023
Polyp removed 2x1.5 cm

Mri (8.2.24) s/o uterine polyp 5.4x2.1 x 1.6 cm and adenomyosis

USG- ( 26/2/24) UT RV , ANTERIOR WALL ADENOMYSOSIS, ECHOGENIC

THICKENED ENDOMETRIUM 11 MM, LFT OVARY DIFFICULT TO ASSESS, RT
OVARY - EASILY SEEN, NAD

ON EXAMINATION
Breast- SOFT , NO LUMP NOTED
P/a soft, lax
P/s CIRCUMORAL dirty d/s
P/v: uterus rt, MULTIPAROUS , b/l ff
Cervix congested
LBC taken

TREATMENT

VG- CMC INTRAVAGINALLY ONCE AT BEDTIME FOR 6 DAYS

TAB FLAGYL 400 MG TWICE DAILY AFTER MEALS FOR 5 DAYS
CAP FLORITA LL ORALLY TWICE DAILY AFTER MEALS

INVESTIGATIONS
MRI PELVIS
Pap smear

1/2
 Dr Witty Raina
MBBS, MD, MRCOG
2/2
(HMC: 3584)

1000000101976948 2024-02-26 10:56

Urmila Bansal Mal , Age: 49 Y 0 M 9729510112

B/l USG breast AND mammogram

CBC
APTT,PT-INR
HIV 1&II
HBSAG
VDRL
ANTI HCV
LFT
KFT
Lipid profile
Chest x ray pa view
ECG
FASTING BLOOD SUGAR
HBA1C
TSH,T4,ANTI TPO
S Vit B12
Urine r/m

FOLLOW UP WITH REPORTS

This is a digital prescription and does not need doctor's signature. In case of any issues, please contact Reception or drop an email us
appsupport@cloudninecare.com

2/2