A 30 year old female with c/o burning micturition, gallbladder polyp

  NOTE: THIS IS AN ONLINE E LOGBOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT.

Chief complaint: The patient seeking advice for gallbladder polyp.

Past history: A 30-year-old housewife, mother of a girl child( 7 years old). The patient was alright 9 years back with no history of hypertension, diabetes, or any health issues. 8 - 9 years ago first complain of intense burning micturition with incomplete voiding of urine. After that episodes( used to last for one day only) of intense burning micturition with incomplete voiding of urine happens infrequently i.e can happen once in a year or sometimes at a gap of 1 - 2 years, never lasting for more than one day. The patient never visited any clinician for that and used to take a single tablet on the recommendation of a local pharmacy as soon as the episode of burning micturition, which use to resolve it. Later due to an unwillingness to swallow tablets, used to take Potrate SF syrup 1 tablespoon on the recommendation of a local pharmacy with water only during such episodes. The last such episode happened 1.5 years back. For the past 3 years, she is complaining that her menstrual flow varing from month to month and most months are simply lighter than it used to be earlier i.e very scant bleeding. Also, her menstrual cycle period is getting longer approx. 35 days or more. 8 months ago she started having an abnormal sensation throughout her abdomen which she described as if something seems to be moving in her abdomen and these episodes used to last for less than one second. The patient does not complain of any pain in her abdomen. 1.5 months ago visited a Physician for this abdomen issue, who recommended medication that did not resolve it. Then tests were done and GALLBLADDER POLYP was detected. Surgery was recommended but since her husband is a laborer and stays in Bangalore, she could not afford the surgery. 7 days ago she had roti and pakora for dinner and from the next day complains of acidic burps after waking up from sleep one episode daily and a burning sensation in her throat throughout the day, present till date.

HER EARLY TEST REPORTS:

ECG report: Normal



X- RAY chest: Normal

CHEMICAL PATHOLOGY:

                  Test                                                                                   Test Report                                         

  • Bilirubin (T)                                                                            0.50mg/dl
  • Bilirubin (D)                                                                           0.20mg/dl
  • Serum Bilirubin (ID)                                                              0.30mg/dl
  • Serum Total Protein                                                                8.10gm/dl
  • Albumin                                                                                  4.76gm/dl
  • Serum Globulin                                                                      3.34gm/dl
  • Serum AG ratio                                                                        1 : 0.70
  • SGOT                                                                                       20 IU/L
  • SGPT                                                                                        12 IU/L
  • Serum albumin phosphatase                                                     78 U/L
  • Serum urea                                                                                11mg/dl
  • Serum creatinine                                                                      0.61mg/dl
  • Plasma glucose (Fasting)                                                           91mg/dl

Blood examination report:

  • HbsAg - -ve
  • Antibody to HIV - non-reactive
  • Antibody to HCV - -ve

Haematology:

Test Result:

  • Hb - 12.10gm/dl
  • TBC - 8.27 * 10^3/cmm
  • ESR - 35.00 mm after 1 hr

Differential leucocyte count:

  • Neutrophil - 75%
  • Lymphocyte - 20%
  • Monocyte - 03%
  • Eosinophil - 02%
  • Basophil - 00%
Report of peripheral blood film:
  • RBC - Predominantly normocytic normochromic
  • WBC - No morphological abnormality seen
  • Platelet - Adequate on smear
USG Report:
  • Hepatomegaly
  • Gall bladder polyp
  • No ascites or lymphadenopathy
  • No definite focal collection or sizeable mass is seen in the right iliac fossa. However, the appendix could not be visualized

Family history: No one in her family suffers from any health issues.




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