MAY 28, 2020
THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HER SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
A 29 year old female was presented to our OPD in a wheelchair with complaints of chest pain and abdominal distension since 1 month.
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic one month back then she developed chest pain on the left side stabbing type non radiating since one month and abdominal distension gradual in onset progressive in nature since 1 month associated with shortness of breath grade 2 to 3
N/H/O pedal Edema, Palpitations, Orthopnea and PND
N/H/O Constipation, Nausea, Vomitings or Diarrhoea
N/H/O Fever, Weight loss, Cough
N/H/O Hematemesis, Melena, or Yellowish discoloration of eyes
PAST HISTORY:
She got married in 2015 and conceived in the month of ?May 2016.
Bleeding PV after two months of pregnancy for which she had been to hospital and was told about abortion for which Dilatation and Curratage was done.
In 2017 September she conceived again and her 1st and 2nd trimester were uneventful. EDD was in the month of June 2018.
She had been to doctor on 1st June and USG turned out be normal. Then she had been to doctor again on June 11th as she had tightening of abdomen for which USG was done and was told as IUD as there was no fetal heart rate. And then normal vaginal delivery was for bringing out IUD.
In 2019 February they had been to doctor in view of not conceiving for which she underwent investigations and her PLBS? 210 and was started on OHA. She was on OHA for 1 month.
2020 May: LMP: 17/05/2021 she conceived for 3rd time. And was again on OHA (for 20days) in the month of July and from August she was on Inj Equisilin (NPH (70)/regular (30)/sc.
And when she had been on 24th January to doctor for abdominal distension causing difficulty in sleeping and moving, she underwent USG showing Polyhydramnios. And she was operated (Cesaerean section) at 7 pm IVO fetal bradycardia. Baby cried immediately after birth.
Baby weight (boy) 3200 grams. And she was discharged on 28th January 2021. Her sugars were normal so after delivery she was not on any hypoglycemic agents.
Since March 2021 c/o left sided chest pain stabbing type with abdominal distension with loss of appetite.
Past History: Patient is a diabetic since 3 yrs.
No history of Hypertension, Tuberculosis, HIV, Malignancy, Thyroid Disorders.
Personal History: Patient takes mixed diet, bowel bladder normal.
Non alcoholic and smoker.
No significant family history.
Surgery referral was done in the view of need for peritoneal biopsy.
Advice: Plan for diagnostic laparoscopy+ proceed to peritoneal or omental biopsy.
Report: Multiple paracentesis was done with 500ml draining out each time.
IT WAS REFRACTORY ASCITES.
17/03/2020
One unit of PRBC was transfused in view of blood loss during operation and was started on antibiotics post operatively.
INJ. TAXIM/BD
INJ.METROGYL/TID
INJ.AMIKACIN/BD
INJ.PCM/TID
INJ.PAN/OD
PERITONEAL BIOPSY AND OMENTAL BIOPSY.
Microscopy-sections studied from peritoneal biopsy shows chronic inflammatory cell infiltrate in the fibrocollagenous tissue.
Sections studied shows lobules of mature adipocytes with area showing chronic inflammatory cell infiltrate comprising of lymphocytes, epithelioid cells and plasma cells. Occasional neutrophilic infiltrate seen. Few multinucleated gaint cells seen.
Impression-peritoneum-features suggestive of chronic peritonitis. Omentum-features suggestive of granulomatous omentitis.
A drain was placed for 5 days after surgery
20/03/2020
In the view of above biopsy report patient was initiated on ATT with 3 drugs FDC according to body weight on 20/03/2020 and tab- prednisolone 30mg OD
20/03/2020
Patient complains of left Hypochondric pain and a review ultrasound and chest Xray was done.
USG report - Mild to moderate ascites-echogenic fluid. Right kidney irregular calycial dilation noted.
Chest Xray report - Mild to moderate pleural effusion on left side for which Thoracocentasis was done.
Pleural fluid analysis: Sugar -246mg/dl
Protein: 6.1gm/dl
Pleural fluid analysis: Exudative
Ascitic fluid analysis: SAAG: 0.5
Non portal hypertensive gastropathy
Differentials:? TB
? Peritoneal carcinomatosis
?Pancreatitis
GENERAL EXAMINATION
Patient is conscious, coherent and cooperative
Built: Moderately
Nourishment: Moderate
Afebrile
Pallor present
No Icterus, Cyanosis, Clubbing, Pedal Edema and Lymphadenopathy
VITAL SIGNS
Pulse: 97 BP Regular
Blood Pressure: 100/70mmhg, supine position right arm
Respiratory Rate: 24cpm
Temperature: 98.4F measured in Axilla
SYSTEMIC EXAMINATION
ABDOMEN INSPECTION:
1. Shape - Distended - uniform
2. Flanks - Full
3. Umbilicus - Central in position, shape-everted (transverse slit)
4. Skin - Stretched, striae present
5. No Dilated veins.
PALPATION:
Soft, tenderness diffuse all over the abdomen. No Organomegaly
PERCUSSION:
Shifting dullness present.
AUSCULATION:
Bowel sounds heard
CARDIOVASCULAR SYSTEM: S1, S2 heard with no murmurs
EXAMINATION OF RESPIRATORY SYSTEM: NVBS heard.
EXAMINATION OF CNS: NFND
INVESTIGATIONS:
Ascitic fluid amylase - 15
Ascitic fluid protein - 4.1
Sugar - 147
Ascitic fluid LDH - 431
Serology - Negative
LFT - TB-0.82, DB-0.20, AST-31, ALT-59, ALP-228, TP-5.6, ALB-2.2, A/G Ratio-0.66
FBS-166, RBS-215, Serum Albumin-2.2, Ascitic albumin-1.7, SAAG-0.5
RFT: Urea-11, Creatinine-0.7, Uric acid-6.6, CA-8.4, P-5.2, Sodium-138, K-3.9, CL-100, Serum Protein-5.5.
CUE: Color Reddish, ALB-2+, Sugars-Nil, Pus-10-12, Epi cells-3-4, RBC-5-6, Others-Budding yeast cells present
USG ABDOMEN; Gross Ascites
HEMOGRAM:
HB-9.6, TLC-6700, PCV-28.6, PLT-4.38
03/04/2020
ESR 80mm/ 1st hour
HAEMOGLOBIN 10.0gm/dl
TOTAL COUNT 5,700cells/cumm, Neutrophills 80%, Lymphocytes 15%, Eosinophils 02%, Monocytes 03%, Basophils 00%, PCV 35.4vol%, MCV 72.7fl, MCH 20.5pg, MCHC 28.2%, RDW-CV 20.2%, RDW-SD 48.8fl
RBC COUNT 4.87 millions/cumm, Platelet count 4.6lakhs/cu.mm, SMEAR RBC Normocytic hypochromic anemia, Light Microscopy, WBC within normal limits light microscopy, Platelets adequate in number and distribution light microscopy, Hemoparasites - No hemoparasites seen light microscopy, Impression Normocytic hypochromic anemia
LFT
Total Bilurubin 0.62mg/dl, Direct bilurubin 0.22mg/dl, SGOT (AST) 20 IU/L, SGPT (ALT) 22 IU/L
Alkaline Phosphate 232 IU/L, Total Proteins 6.0gm/dl, Albumin 2.0gm/dl, A/G Ratio 0.52
04/04/2020
C-Reactive Protein -Negative mg/dl
09/04/2020
HEMOGRAM
HAEMOGLOBIN 10.5 gm/dl, Total Count 5,200 cells/cumm, Neutrophils 80%, Lymphocytes 16%, Eosinophils 02%, Monocytes 02%, Basophils 00%, PCV 35.1vol%, MCV72.9fl, MCH 21.8pg, MCHC 29.9%, RDW-CV 20.8%, RDW-SD 49.3fl
RBC COUNT 4.81millions/cumm, Platelet count 3.22 lakhs/cu.mm, SMEAR RBC Microcytic Hypochromic Light Microscopy, WBC within normal limits Light Microscopy, Platelets Adequate in number and distribution Light Microscopy. Impression Microcytic Hypochromic.
LFT
Total Bilurubin 0.56mg/dl, Direct Bilurubin 0.24mg/dl, SGOT (AST) 17 IU/L, SGPT (ALT) 13 IU/L Alkaline Phosphate 203 IU/L, Tortal Proteins 7.2gm/dl, Albumin 2.91gm/dl, A/G Ratio 0.68
RFT
Urea 10mg/dl, Creatinine 0.6mg/dl, Uric Acid 8.7mg/dl DHBS, Calcium 9.6mg/dl, Phosphorus 3.9mg/dl, Sodium 139mEq/L, Potassium 4.0mEq/L, Chloride 101mEq/L.
CELL COUNT PLEURAL FLUID
Volume 3 ML, Colour Pale Yellow, Appearance Turbid, Total Count 50 cells/cumm
DIFFERENTIAL COUNT
Neutrophils 0%, Lymphocytes 100%, RBC-Nil, Others- Nil.
LDH 269IU/L
PLEURAL (SUGAR< PROTEIN)
Sugar 246mg/dl, Protein 6.1g/dl
SERUM PROTEIN
Serum Protein 7.8g/dl.
TREATMENT GIVEN:
TAB.PCM 650mg QID
TAB.PAN 40mg OD
INJ>DICLOFENAC IM SOS
Due to course patient developed arthralgia due to pyrizinzmide (ATT) due to hyper uricemia so eventually allopurinol was added and subjectively patient is feeling better and now presently is arthralgia is it enthesitis due to the same etiology causing pleuritis serositis is not known.
After 6 months of ATT she was subjectively feeling better and objectively there was no ascites.
[12-07-2025 16:46] PA: Sir eta ki operation case
[12-07-2025 16:47] PPM 1: Arektu kichu somoi ebong abdominal X-ray dekhe jana jete pare
Toto din surgery te observation a thakai bhalo
@CR pasting today's updates to the May 2025 patient 👇
[12/07, 11:48] Pt Mb 29F Serositis Gestational: Sir আমার wife কে গতকালকে দুপুরে খাওয়ার পর হঠাৎ প্রচন্ড পেট ব্যাথা নিয়ে হাসপাতালে ভর্তি করাই ,নাভির উপরে ব্যাথাটা ছিল,আজকে তলপেটে ব্যাথা হচ্ছে আর সাথে বমি,ডাক্তার USG লিখেছে।এখন কি করব বুঝতে পারছি না
[12/07, 16:18]cm: Unar intestinal obstruction hoyeche mone hocche.
Uni ekhane jokhon bhorti chilen oi somoikar discharge summary ache? Ekhane ki 2019 a aeshechilen?
[12/07, 16:28]cm: Eta ki unar case report?👇
Unake ki ekhane May 2020 te niye aeshechilen?
[12/07, 16:37] Pt Mb 29F Serositis Gestational: Haa sir
[12/07, 16:37] Pt Mb 29F Serositis Gestational: 2020 may mase
[12/07, 16:38] Pt Mb 29F Serositis Gestational: Discharge summary ache sir
[12/07, 16:38]cm: Thakle share korun
[12/07, 16:39] Pt Mb 29F Serositis Gestational: Sir ami to hospital a ,ota barite ache.pdf ta nei,
[12/07, 16:41] Pt Mb 29F Serositis Gestational: Sir eta surgery case?
[12/07, 16:46]cm: Pore share korleo cholbe
[12/07, 16:46]cm: Arektu kichu somoi ebong abdominal X-ray dekhe jana jete pare
[12/07, 16:47] Pt Mb 29F Serositis Gestational: Ota ki korbo?
[12/07, 16:48]cm: Apnar local daktar decision neben
[12/07, 16:49] Pt Mb 29F Serositis Gestational: Hospital er doctor refer korechen Coochbehar hospital
[12/07, 16:49]cm: Okhane bodh hoi uni surgeon er observation a rakhte chan.
[12/07, 16:51] Pt Mb 29F Serositis Gestational: Haa sir ,uni bolechen aneksamoy 2 dine obstruction khuleo jete pare,tai ajke Mathabhanga hospital a thakbe,
[12/07, 16:53] Pt Mb 29F Serositis Gestational: Kalke coochbehar hospital a Surgeon er kache refer koreche .
[12/07, 17:03]cm: Thik bolechen
[12/07, 17:03]cm: Asha kora jaak tar aagei khule jabe
[12-07-2025 17:15] PPM 3: Now again she got admitted sir
Thanija khatum?
[12-07-2025 17:28] PA: Yes ma'am, Yesterday after finishing lunch, she felt pain in stomach. Then I admitted her nearby hospital.
[12-07-2025 18:37] PPM 1: Admitted in WB
[14-07-2025 16.54] PPM 1: Today's update:
Another USG done today shows moderate ascites
[14/07, 14:42] Pt Mb 29F Serositis Gestational: Sir eta ajker report
[14/07, 16:20]pm: Abar jol jomechhe mone hocche.
Jol ta bar kore dekha dorkar kichu test kore jemon joltar TLC, DLC ebong SAAG
[14/07, 16:42] Pt Mb 29F Serositis Gestational: কিন্তু গত শনিবারের রিপোর্ট এ তো obstruction বলেছিল,আর আজকের রিপোর্ট এ এটা। 2দিনেই জলটা কিভাবে জমলো?
[14/07, 16:48] Pt Mb 29F Serositis Gestational: এক্ষেত্রে কি আবার আগের মত করেই জল বের করার পর আবার জল জমবে?
[14/07, 16:50] pm: Hain sheta jol ta test korle bojha jabe ebong aro kichu test kora jete pare
Today's update:
[16/07, 11:45] Pt Mb 29F Serositis Gestational: Sir আমরা সম্ভবত 20 তারিখ যাচ্ছি,
[16/07, 19:23]pm: Unar aer aage biopsy chara pet a onyo kono operation hoyechilo?
[16/07, 19:25] Pt Mb 29F Serositis Gestational: Na sir,
[16/07, 19:33] Pt Mb 29F Serositis Gestational: Sir akhon ki korbo?
[16/07, 19:54]pm: Aekhon uni kemon achen?
[16/07, 20:05] Pt Mb 29F Serositis Gestational: Sir pet bathata ager theke komeche,kichu to khete dicche na,maje majhe bomi korche
[16/07, 20:06] Pt Mb 29F Serositis Gestational: Kintu pete o buke naki jol ache bolche.
[16/07, 20:08] pm: Samanyo
[16/07, 20:08] Pt Mb 29F Serositis Gestational: Ora to jol ber korche na,
[16/07, 20:09] Pt Mb 29F Serositis Gestational: Sir or picture ta Debo ki?
[16/07, 20:09]pm: Oto kom jol bar kora mushkil
[16/07, 20:10]pm: Hain side theke jate pet ebong haath ta dekha jai ebong mukh na dekha jai
[16/07, 20:12] Pt Mb 29F Serositis Gestational: Kintu hospital theke ovabe to chobi tulte debe na mone hoy
[17-07-2025 13.36] PPM 1: Didn't realise that this morning clinical meeting would be unexpectedly interesting as this gastric perforation appeared to have been associated with many other comorbidities providing not only clinical complexity to morning cognition but also helped provide useful ideas around another long distance patient who had visited us with unexplained ascites that remained unexplained after a peritoneal biopsy and is going to visit us again for her current problem of recent intestinal obstruction with CT abdomen showing peritoneal adhesions archived.
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