General medicine case -2

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Date of admission  : 18/12/2021

A 20 year old male patient presented to the OPD with the chief complaints of  low grade fever ,vomitings and weakness since 3 months 

HISTORY OF PRESENT ILLNESS:

patient was apparently normal  3 months back then he developed low grade fever and  vomitings 2- 3 episodes per day  and  he visited local hospital 2 months ago they suggested for a blood test  and was told that there is increase in bilirubin levels and decreased in haemoglobin  and there he got  admitted for a day and went back to  his home and referred to an ayurvedic doctor to control his bilirubin levels they gave  herbal medicine which he continued for a month. And went for routine check up for every 15 days  there is fall in haemoglobin levels where they suggested  for blood transfusion and then he visited our hospital  

PAST HISTORY:

no similar complaints in the past 

Patient is not a k/c/o  diabetes , hypertension,asthma , tuberculosis, epilepsy

No surgeries in the past

PERSONAL HISTORY: 

appetite : lost since 3 months 

Bowel : irregular (alternate days )

Micturition: normal 

Diet : mixed 

Habits : alocholic since 6 - 7 years back ( one beer daily) and stopped a year back 

Smoking since 6-7 years back (1-2 ciggerates per day ) and stopped an year back 

Sleep : adequate 

FAMILY HISTORY: 

no similar complaints in the family

GENERAL EXAMINATION:

patient is conscious , coherent, cooperative 

Pallor - present

Cyanosis- absent

Icterus- present

No lymphadenopathy

Malnutrition: absent 

Clubbing - absent 

BP : 120/70 mmHg 

Pulse rate : 92 beats per min 

Respiratory rate : 18 cycles/min 

Spo2 at room temperature: 98%

Systemic examination: 

CNS : 

Patient is Conscious 

Speech normal 

Cranial nerves : intact 

CVS :

S1 , S2 sounds heart 

No murmers 

RESPIRATORY SYSTEM:

Position of trachea-  central

No vesicular breath sounds heard

PER ABDOMEN:

No tenderness, palpable mass 

Liver and spleen not palpable 

INVESTIGATIONS  :

PROVISIONAL DIAGNOSIS :

Hemolytic Anemia with jaundice

DIFFERENTIAL DIAGNOSIS: 

Megaloblastic anemia ,

FINAL DIAGNOSIS: 

Pancytopenia 

TREATMENT: 

-INJ vitamin b12 (NERVIGEN ) 100MG IN 100ML NS /IV STAT 

- TAB OROFER -XT PO/OD 

- TAB MVT PO /OD

-BP , TEMPERATURE, PULSE RATE MONITORING EVERY 4 HOURLY