42/M ANEMIA SECONDARY TO VITAMIN B12 DEFICIENCY WITH PANCYTOPAENIA

I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan. is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome

Case History and Clinical Findings 

PATIENT CAME WITH COMPLAINTS OF-FEVER SINCE 15 DAYS-BODY PAINS AND GENERALISED WEAKNESS SINCE 10 DAYS-LOSS OF APPETITE SINCE 1 WEEK 

HISTORY OF PRESENTING 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 . BODY PAINS AND GENERALISED WEAKNESS SINCE 10 DAYS LOSS OF APPETITE PRESENT SINCE 1 WEEK

NO H/O VOMITINGS, LOOSE STOOLS, GIDDINESS, COUGH, COLD, SOB,

 H/O GREENISH COLOR /BLACK COLORED STOOLS NO H/O PAIN ABDOMEN 

PAST HISTORY 

N/K/C/O HTN, DM, CAD, THYROID , SEIZURE DISORDERS

 H/O UMBILICAL HERNIA SURGERY 2 YEARS BACK 

PERSONAL HISTORY

OCCUPATION- WARD BOY 

APPETITE-DECREASED SINCE 1 WEEK

 BOWEL AND BLADDER- REGULAR

 NO ALLERGIES

 OCCASIONAL ALCHOLIC - DRINKS ONCE /TWICE MONTHLY- 1 QUARTERON 

GENERAL PHYSICAL EXAMINATION

PT IS CONSCIOUS ,COHERENT, COOPERATIVE

TEMP : 96.8F PR : 80 BPM BP : 110/70 MM HG RR : 18 /MIN SPO2: 98% AT ROOM AIR GRBS : 103 MG /DL 

PALLOR PRESENT NO ICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY,PITTING TYPE OF EDEMA EXTENDING UPTO KNEE

CVS : S1 S2 HEARD NO MURMURS

RS: TRACHEA CENTRAL NORMAL VESICULAR BREATH SOUNDS PRESENT

P/A : SOFT , NON TENDER BOWEL SOUNDS PRESENT

CNS: NAD

COURSE IN HOSPITAL PATIENT PRESENTED WITH THE ABOVE MENTIONED COMPLAINTS EVALUATED CLINICALLY APPROPRIATE INVESTIGATIONS WERE DONE .ON EVALUATION PATIENT WAS FOUND TO HAVE DIMORPHIC ANEMIA WITH DECREASED VITAMIN B12 LEVELS.VITAMIN B12 SUPPLEMENTATION WAS DONE PATIENT RECOVERED SYMPTOMATICALLY AND DISCHARGED IN STABLE CONDITION. Investigation 

USG : IMPRESSION :MILD SPLENOMEGALY 

2D ECHO: NO RWMA , EF:60% ,TRIVIAL TR,AR PRESENT , MILD LVH

 URINE CULTURE SENSITIVITY: NO PUS CELLS SEEN 

CULTURE REPORT: NO GROWTH

 BLOOD CULTURE SENSITIVITY: CULTURE REPORT: NO GROWTH AFTER 24HRS OF AEROBIC INCUBATION REPORTS :

HB = 7.3--6.4--6.9--7.1--8.3 PCV= 23--20.3--21.5--21.8---26.1 TLC=3060---2000--3520--5500---5900 PLATELET COUNT=35000---90000---98000---120000---203000 VIT B12 =100 PG/ML SERUM FOLIC ACID= 6.2NG/ML IRON =234micro grams/dl Treatment Given(Enter only Generic Name) INJ VITCOFOL 1000MCG IM/ONCE DAILY ON ALTERNATE DAYS TAB DOLO 650MG/PER ORAL/SOS MONITOR VITALS AND INFORM SOS 

Advice at Discharge TAB MVT PO/ONCE DAILY AT 2PM INJ VITCOFOL 1000MCG IM ONCE WEEKLY [NEXT DOSE 14/3/23].

Follow up:No limitation in physical activity

Diagnosis

ANEMIA SECONDARY TO VITAMIN B12 DEFICIENCY WITH PANCYTOPAENIA