GM prefinal case presentation :-Roll 10

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20years old male  presented to the OPD with chief complaints of 

1, Vomitings-1/2episodes/day since 2months

2,shortness of breath since 2months

3, generalised weekends since-2months

4,low grade fever since 40days

History Of Present Illnesses 

Patient was apparently asymptomatic 2months back den he had onset of vomiting:-1/2episode per day since then he felt week 

Then he had grade 4 SOB

  he also has low grade fever associated with neck pain

Then he observed pale yellowish discoloration of  hands,eyes 

Then he had edema in lower limbs on which pt visited near by lab in Nampally (near to NALGONDA)

Where he diagnosed as having Jaundice and low blood cell count(RBC/WBC/PLATELETS)

then he went to near by doctor  where he was given no medication to treat and suggested to cure jaundice by ayurvedic medicine instead 

 and he also told unless jaundice is cured he will not treat of his low blood cell count

Aftr using ayurvedic powder for 1.5month he got tested again and he was told that severity of Jaundice is decreased by lab technician and now to get treatement fo low blood count,he went to local doctor in Halia where he was suggested to visit KIMS

 

 HISTORY OF PAST ILLNESS

No relevant past history

No known Diabetes

No known Hypertension

No Asthma

No T.B

No sugeries

Treatment for Jaundice

He used ayurvedic powder for 1 and half month then he stopped

PERSONAL HISTORY:

UnMarried

Occupation: stays at home

Appetite: decreased since 2months

Bowels: normal

Micturition: burning

No known drug allergies 

 ADDICTION:-

Pt was alcoholic since 6/7years then he stopped  for 1.5year in between then again had alcohol for 4 months and the stopped 1year back

Smoking:-since 6/7years he used smoke 

1-2cigarette/day and stopped 1year back

FAMILIAL HISTORY:

Diabetes : no

HTN: no

Heart disease: no

Stroke: no

Cancer: no

TB : no

Asthma:no

No other hereditary diseases.

PHYSICAL EXAMINATION:

GENERAL EXAMINATION:

Pt was c/c/c

Pt oriented to time,place, person

Pallor: yes

Icterus: yes

Cyanosis:no

Clubbingof fingers /toes:no

Lymphedenopathy: no

Edema of feet : yes(not prominent)

Malnutrition : no

Dehydration :no

VITALS:

Temperature: 103° F

Pulse rate: 85

RR : 24 breaths per minute 

BP : 126/80

SpO2:-98%

SYSTEMIC EXAMINATION:

GIT:-

No hepatomegaly

Inguinal lymphnodes:-not palpable

CVS:

Cardiac sounds S1 & S2 are present. 

CNS : conscious

PROVISIONAL DIAGNOSIS:-

PANCYTOPENIA

B12 DEFICIENCY

FOLIATE DEFICIENCY

Investigations

18/12/2021

HEMOGRAM:-

Hb-3gm/dl

TLC-3000

N/L/E/M:-63/34/1/2

PCV-8.8

MCV-117

MCH:-40

MCHC:-34

RDW-CV-27.3

RBC-0.75

PLATELETS-70,000

Smear:-ANISOPOIKILOCYTOSIS

RBC:-HYPOCHROMIC,MICROCYTIC,PENSIL FORMS,Macrocytes,macroovalocytes

WBC:-DECREASE ON SMEAR

PLATELETS:-DECREASE ON SMEAR(PANCYTOPENIA)

BGT:-B positive

COMPLETE URINE EXAMINATION

Albumin:-Traces

Sugar:-Nil

PUS CELLS:-2-4

Serology:-NEGATIVE

UREA:-23

CREATININE:-0.7

Na+:-146

K+:-3.8

Cl-:-96

LIVER FUNCTION TEST:-

T B:-2.75

DB:-0.6

AST:-52

ALT:-10

ALP:-91

TP:-6.6

ALB:-3.3

A/G:-1.03

Ultrasound

Clinical images

          

Diagnosis

PANCYTOPENIA

B12 deficiency

Treatment

Tab.B12

Tab.OROF.R-XT-1tab po/OD

Tab.MVT.1tab  po/OD

B.P/PULSE RATE/TEM Monitering 4th hourly