A 27 year old male with decreased appetite and generalised weakness

 A 27 year old male who is a student and resident of Choutupally came to hospital on 15/9/22 with 

 CHIEF COMPLAINTS

Decreased appetite and fever  and generalised weakness since 1 month. He has bitterness in mouth since 5 days. No H/O pain or vomitings. He has breathlessness since 5 days . 

HISTORY OF PRESENT ILLNESS 

The patient was apparently assymptomatic 1 month ago. Then he had decreased appetite and generalised weaknesses. He didn't consult any physician. Then he developed a low grade fever which is not associated with chills and rigor and he had bitterness in mouth since 5 days. He has no complaints of vomitings or any .

HISTORY OF PAST ILLNESSES  

No history of DM and HTN . 

No H/O asthma or CAD or TB 

No past surgeries 

PERSONAL HISTORY 

A student

Unmarried

Mixed diet 

Adequate sleep 

Inadequate appetite

Normal bowel movement

Normal micturition

Non alcoholic

Non smoker

No drug allergies 

No known allergies  

FAMILY HISTORY 

No H/O DM or HTN  

No H/O asthma or TB or CAD 

GENERAL EXAMINATION

Conscious and coherent

Moderately built and moderately nourished

Pallor-- present 



No icterus 

No cyanosis,  clubbing of fingers,  lymphadenopathy,  pedal oedema  

VITALS 

Temperature -101C

Pulse rate- 110 beats/min 

Respiratory rate-18 /min 

BP - 120/80 

SpO2- 98%

GRBS-128mg% 

SYSTEMIC EXAMINATION  

CVS 

No thrills

S1 S2+ 

No cardiac murmurs 

 RESPIRATORY SYSTEM 

Dyspnea - present

No wheezing 

Centrally located trachea

ABDOMEN

Scaphoid shaped abdomen 

No tenderness

No palpable mass

Mild hepatomegaly 

No splenomegaly 

No free fluid 

CNS 

Conscious and coherent

Normal speech 

 INVESTIGATIONS 


TREATMENT 

1. Tab. DOLO 650mg PO TID 

2. Inj. NEOMOL 1gm IV 

3. Inj. METHYLCOBALAMINE 1000mcg + 100ml NS  IV OD 


PROVISIONAL DIAGNOSIS 

Pancytopenia secondary to vitamin B12 deficiency.




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