A 20 year old male with? Haemolytic Anemia? Pancytopenia secondary to ? B12 deficiency.

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box is welcome."I've 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 a diagnosis and treatment plan




CHIEF COMPLAINTS

A 20 year old male patient came to OPD with C/o Generalised weakness since 3 months
C/o recurrent vomitings 1-2 episodes / day since 2 months.
C/o paleness of skin since 2 months.
C/o SOB on exertion since 3 months.


HOPI: Patient was apparently asymptomatic 3 months back then he developed generalised weakness, recurrent vomiting since 3 months 1-2 episodes /day greenish yellow in colour,a/w low grade fever.
C/o dragging type of pain ,tingling sensation in B/L Lower limb and left half of the face.
C/o constipation since 1 month.
H/o jaundice 2 months back.
No H/o haemoptysis
No H/o Malena.


PAST HISTORY: Not a K/c/o DM,HTN,TB,CAD Epilepsy,Asthma.

PERSONAL HISTORY: 
DIET- Mixed
APPETITE- Normal
B&B- Constipation since 2 months
ADDICTIONS: Patient is alcoholic since 6 years,then stopped for 1 and half year and in between,he took alcohol for 4 months and stopped about an year back.

Patient is a smoker since 6 years ,then stopped smoking for 1 and half year and in between,he started smoking for 4 months and stopped about an year ago ( 1-2 ciggerates/ day).


FAMILY HISTORY: Not significant.


GENERAL EXAMINATION

PALLOR +
No icterus
No clubbing
No edema 
No lymphadenopathy

Vitals: TEMP: 97.6 F
            PR: 79 BPM
            RR: 18 CPM
            BP: 120/70 mm HG
            SpO2: 98 %@ RA

Systemic examination

CVS: S1 S2 +, NO MURMURS
RS: BAE+, NVBS
CNS: INTACT
P/A: SOFT, NON TENDER, BS+


INVESTIGATIONS

            



















PLAN OF TREATMENT

Inj. VIT B12 (NERVIGEN 100 mg in 100 ml NS/IV/STAT)
Tab.OROFER XT PO/OD
Tab.MVT PO/OD
1 Bag PRBC transfused

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