during my internship in gastroenterology department i presented the case, chairperson was my beloved sir Prof AHM Rowshan. this is a case about a 20 year old female presented with abdominal pain, fever which was low grade, and weight loss with marked anorexia for few months. the diagnosis was a dilemma. patient was undergone laparoscopic biopsy from intrabdominal enlarged lymph nodes and ultimately the diagnosis was a case of Non-Hodgkin's lymphoma and treated by chemotherapy.

1. Case
Presentation
Dr. Md. Shahjalal Khan Shetu
Intern Doctor
Department of Gastroenterology
Shaheed Suhrawardy Medical college &
Hospital

2. Topic
A 20 years old female
presented with
abdominal pain, fever
and weight loss

3. Particulars of the patient
Name : Mrs. Shibani
Age : 20yrs
Sex : Female
Marital Status: Married
Religion : Hindu
Occupation: Housewife
Address :Vill- Upazilla: Dist-Gopalgonj
Mobile No.:

4. Chief Complaints
 Abdominal pain & vomiting for 3 years
 Irregular low grade fever for same duration
 Loose motion for 2 years
 Weight lose for 1 year.

5. History of Present Illness
According to the statement of the patient she
was reasonably well 3 years back.Then she
developed abdominal pain around the
umbilicus, dull aching in character, mild to
moderate in intensity; non radiating, no relation
with food taking, and last for 30 mins to 1 hour.

6. Cont.
She also complained of vomiting for same
duration.Vomiting was periodic and usually
occurred 3 to 4 times a day persisted for 2 to 3
days & recurs often at every 2 to 3 days. It was
non-projectile.Vomitus was moderate in
amount, contained undigested food particles
but no blood.

7. Cont.
She also complained of low grade irregular
fever, mostly occur in the afternoon, without
chills & rigor and subsided spontaneously. She
also complained of passage of loose stool for
last 2 years. She passed stool usually 7 to 8
motion per day, moderate in amount & contain
no fresh or altered blood. It is not associated
with lower abdominal pain. She also lost significant
amount of her weight for last 1 year.

8. Cont.
She did not give history of night sweats,
coughing out of blood, itching, jaundice,
palpitation, heat intolerance, proximal muscle
weakness, arthralgia & arthritis, skin rash, oral
ulceration. She gave no history of contact with
TB patient. Her sleep pattern is normal & she
did not become unconscious any time during
this illness.

9. History of Past Illness
She is not hypertensive, non-diabetic, bronchial
asthma, COPD, no history of blood transfusion
or surgical operations.

10. Drug History
She gave history of irregular intake of
antiulcerant & painkillers, but she
cannot mention the names.

11. Family history
She is a housewife and lives with her husband
and one children. No family member or
relatives are suffering from same type of illness.

12. Socio-economic history
She comes from middle socio-economic class.
She is non-smoker, non-alcoholic and has no
habits of chewing betel nuts.

13. Menstrual & obstetric
history
Obstetrics history-
Para: 3-2 (still birth)
ALC:
Menstrual history:
LMP:
Cycle: regular
Period: 3 to 5 days
Bleeding: average

14. General examination
Appearance: ill looking, cachexic
Body built: below average
Co-operation: co-operative
Decubitus: on choice
Nutritional status: poor
Anemia: mild
Jaundice: absent
Cyanosis: absent
Clubbing: absent
Koilonychia: absent
Leuconychia: absent
Onycholysis: absent
Edema: absent
Dehydration: absent
Neck vein: not engorged
Thyroid: not enlarged
Lymph node: not palpable
Pulse: 84 b/min
BP: 100/70 mm Hg
Temp: normal
R/R: 18 breaths/min
Skin condition: normal

15. Systemic Examination

16. Alimentary system
Mouth & oral cavity: normal findings, NAD
Abdomen:
Inspection:
Shape: distended
Flanks: normal
Umbilicus: central, inverted
Skin condition: normal, presence of striae gravidarum.
Hair distribution: normal
Visible peristalsis: absent
Visible pulsation: absent
Visible engorged veins: absent
Groins: normal

17. Cont.
Palpation-
Superficial palpation-
Temperature: normal
Tenderness: mild tenderness present in right iliac,
right lumbar, left iliac region
Muscle guard: absent
Deep palpation:
No organomegaly
Fluid thrill: absent

18. Cont.
A palpable mass measuring about 4x3cm
found in the right iliac fossa. It is firm in
consistency, smooth surfaced, fixed with
underlying structure free from overlying skin ,
mildly tender, with no discharging sinus.
Another mass of similar nature measuring
about 6x4cm is found in the left iliac fossa &
left lumbar region

19. Cont.
Percussion:
Percussion note: tympanitic all over the
Abdomen.
Upper border of liver dullness: in 5th ICS on right
MCL
Shifting dullness: absent
Auscultation:
Bowel sound: present
Hepatic bruit: absent

20. Other systems
Respiratory system-
Inspection: chest is normal in size & shape.
Palpation: trachea central, apex beat in the left
5th ICS, expansion is normal.
Percussion: percussion note is resonant in all
lung fields.
Auscultation: Breath sound is vesicular, no
added sound.

21. Cont.
Cardiovascular system:
Inspection: precordium normal in size & shape, no
bulging, no engorged vein, no visible vein.
Palpation:
- apex beat in the left 5th ICS
- fluid thrill: absent
- left parasternal heave,
- palpable P2- absent
Auscultation: Heart sound is normal in all four
areas with no added sound and murmur.

22. Cont.
Nervous system:
Higher psychic function: normal
Speech: normal
Cranial nerves: intact
Motor function: intact
Sensory function: intact
Other systems:
No abnormality detected.

23. Salient feature
Mrs. Shibani, 22 years old, hindu, married,
housewife, normotensive , nondiabetic lady hailing
from Gopalgonj admitted in this hospital through
OPD with the complaints of abdominal pain,
vomiting & irregular fever for 3 years, loose motion
for 2 years & weight loss for 1 year. Abdominal pain
was around the umbilicus, dull aching in character,
mild to moderate in intensity; non radiating, no
relation with food taking, and last for 30 mins to 1
hour.

24. Cont.
She also complained of vomiting for same
duration.Vomiting was periodic and usually
occurred 3 to 4 times a day persisted for 2 to 3
days & recurs often at every 2 to 3 days. It was
non-projectile.Vomitus was moderate in
amount, contained undigested food particles
but no blood.

25. Cont.
She also complained of low grade irregular
fever, mostly occur in the afternoon, without
chills & rigor and subsided spontaneously. She
also complained of passage of loose stool for
last 2 years. She passed stool usually 7 to 8
motion per day, moderate in amount & contain
no fresh or altered blood. It is not associated
with lower abdominal pain. She also lost significant
amount of her weight for last 1 year.

26. Cont.
She did not give history of night sweats,
coughing out of blood, itching, jaundice,
palpitation, heat intolerance, proximal muscle
weakness, arthralgia & arthritis, skin rash, oral
ulceration. She gave no history of contact with
TB patient. Her sleep pattern is normal & she
did not become unconscious any time during
this illness.

27. Cont.
On examination she is ill looking, cachectic,
moderately anemic. Her pulse is 84/min, BP is
100/70 mm Hg, RR 18/min, temperature normal.
On abdominal examination mild tenderness
Present in right iliac fossa, right lumbar, & left
Iliac fossa . A palpable mass measuring about
4x3cm found in the right iliac fossa. It is firm in
consistency, smooth surfaced, fixed with
underlying structure free from overlying skin ,
mildly tender, with no discharging sinus.

28. Cont.
Another mass of similar nature measuring
about 6x4cm is found in the left iliac fossa &
left lumbar region.
There is no ascites, no organomegaly

29. Provisional Diagnosis
?

30. Provisional diagnosis
AbdominalTuberculosis

31. Differential diagnoses
1. Abdominal Lymphoma
2. Inflammatory bowel disease
3. Intra-abdominal malignancy

32. Investigations
 Complete blood count
Hb%: 11.4 gm/dl
ESR: 05 mm in 1st hour
TC: 8,800 /cu mm
DC: N- 70%, L- 25%, M- 2%, E- 3%
 S. creatinine: 0.4 mg/dl
 S. bilirubin: 1.0 mg/dl
 SGPT: 26.0 U/L
 RBS: 75 mg/dl

33. Cont.
 Blood grouping & Rh-typing: O “+ve”
 ANA: 17.00 IU/ml
 Blood C/S: normal
 Urine- R/E: normal study
 CXR-P/A view: normal study
 ECG: normal study
 Tuberculin test: 02 mm ( negative)

34. Cont.
 USG ofW/A:
- Extensive intra-abdominal
lymphadenopathy
- Hyperdynamic peristalsis with mildly
dilated small bowel loops.
- Features of cystitis.

35. Cont.
 Endoscopy: DUD in remission with narrowed
bulb.
 Biopsy: ( Duodenal mucosa)- Non-specific
ulcer.
 Short colonoscopy: Normal study

36. Treatment plan
 Tab. P/C
 Cap. Omeprazole
 Tab. Frenxit
 Tab. B/C

37. Further
Further investigation:
Laparoscopic biopsy for histopathology.