1801006025 short case

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41 year old male who works as ward boy in the hospital came with the complaints of 

-fever since 15 days

-body pains and generalised weakness since 10 days 

-loss of appetite since 1week 

History of illness-

 Patient was apparently asymptomatic 15 days back then developed

 -fever since 15 days ,low grade , not associated with chills and rigors , fever more during nights  and relieved with medications. Patient went to local doctor and took medications and 2 injections.Body pains and generalised weakness since 10 days

Loss of appetite present since 1week

No history of vomitings ,loose stools,giddiness,cough ,cold,SOB,

H/O greenish color/black colored stools 

H/o easy fatiguability present

No h/o pain abdomen

Past history-

N/K/C/O  HTN,DM,CAD, thyroid , seizure disorder 

H/O umbilical hernia surgery 2years back 

H/o leucorrhea of left eye since childhood

Personal history-

Diet -vegetrain eats egg occasionally (as it may be the cause of vit -b12 deficiency)

Appetite -decreased since 1week

Bowels- regular 

Micturition-normal

No allergies

Occasional alcoholic -drinks once/twice monthly-1quarter

On General Physical Examination-

Pallor present

No icterus, cyanosis,clubbing, lymph nodes not palpable 

Edema -present -pitting type extending upto knee

Vitals -

Temp-96.8 F

PR- 80 bpm

RR-18 cpm

Sp02-98 % on RA

GRBS-103 mg/dl

Systemic examination- -S1,S2 heard , no murmurs

RS- BAE present ,Normal Vesicular breath sounds

CNS- No abnormality detected

P/A- soft , nontender ,bowel sounds present

investigation

CBp-hb -7.3 gm/dl 

Total count -3,060cells/cumm

Platelet count -35,000/cumm

Smear -macrocytes with few microcytes

Complete urine examination -normal 

BGT- O POSITIVE

Reticulocyte count- 0.8

PT-22 sec

INR-1.6

Aptt- 43 sec

BT- 2mins

CT-5mins

LDH-2158

S electrolytes-

- 141

K-4.7

Cl-106

Ca2 - 1.08

B. UREA-12

S creatinine-0.8

Rbs- 105

Serology - negative 

LFT- total bilirubin level-1.67(normal-0-1mg/dl)

Direct bilirubin -0.3mg/dl(normal0-0.2mg/dl)

Sgot -75iu/l

Chest x ray pA veiw

Usg abdomen - mild spleenomegaly

Widal test -negative

Dengue -NS1antigen negative

Blood parasites -malaria -negative

8/3/23

Hb-6.4gm/dl

Total count -2000cells/cumm

Platelet -90000/cumm

9/3/23

Hb -6.9gm/dl

Total count-3,520cell/cumm

Platelet -98000/cumm

LFT- total bilirubin -1.62 mg/dl

Direct bilirubin -0.46mg/dl

Sgot-43iu/l

Provisional diagnosis-

PANCYTOPENIA

DIMORPHIC ANAEMIA

?VIT B 12 DEFICIENCY 

Treatment-

-Tab dolo 650mg Po/sos

-INJ VITCOFOL 1000mg /IM / alternate day (next dose -10/3/23)

-monitor vitals and inform sos

Follow up :

On 14/3/23

Hb -7.4gm/dl and diagnosed as dimorphic anemia 

And on told continue medication sryp .folic acid and 

Inj.vitcofol 1000mg/im/alt days

 And patient feel better and his generalized weakness has reduced , appetite improved.