1702102021 LONG CASE

 CASE : 


A 30 year old man,lorry driver by occupation,
resident of tangapally Choutupal came to the OPD with chief complaints of
- blood in stools,pain while excretion since 2 months
- fever since 1 week

HISTORY OF PRESENT ILLNESS:


Patient was apparently asymptomatic 2 months back and since 2 months he had complains of loose stools( 3 to 4 episodes ) which are watery occasionally black stools associated with pain abdomen
- Decreased urine output, and burning micturition since 2 months
- Yellowish discoloration of eyes since 20 days associated with generalized weakness 
- H/o fever - intermittent, low grade and associated with chills since 1 week

No history of vomitings, pedal edema 
No h/o cold , cough , sob

No other complaints

PAST HISTORY:

No h/o DM/HTN/Asthma/Epilepsy/CAD/TB

PERSONAL HISTORY:

Diet - mixed
Appetite - decreased 
Sleep - adequate
Bowel & Bladder - Loose stools and burning micturition
Chronic alcoholic since 16 years

 

GENERAL EXAMINATION:

Pt is conscious, coherent,cooperative
Pallor +,icterus +,
No signs of cyanosis ,clubbing, lymphadenopathy,edema 
Signs of dehydration +
Blackish discoloration of hands bilateral since 1 year
Tongue -dry and blackish discoloration +
Knuckle hyperpigmentation +







Vitals : 

Temp : 98.7°F 
PR: 120 bpm regular normal volume 
RR: 18
Bp: 100/60 
Spo2 : 98 % 


Systemic examination : 
CVS : S1,S2 Heard ,ESM +Aortic area and pulmonary area 
RS : BAE +,NVBS Heard 
P/A : Scaphoid abdomen , soft , NT
CNS : No FND 

Provisional diagnosis : 
Anemia under evaluation ?IDA/?B12 deficiency
Fever under evaluation
?osmotic /? infective diarrohea


Investigations :

ECG:

Chest x-ray:


HEMOGRAM : 

Peripheral smear:
Anisopoikilocytosis with hypochromasia microcytes , normocytes , tear drop cells & pencil forms

PT - 17 sec 
INR - 1.2 sec
APTT - 35sec
BT - 2min 30 sec 
CT - 5 min 00 sec 

BLOOD GROUPING AND RH TYPING : O POSITIVE 

Stool for occult blood : positive 


CUE : 
Albumin - trace 
Sugar nil 


Reticulocyte count : 0.4 %


Serology : negative 
 

RFT 
urea -27

Creat - 0.8

Na -138
K - 4.1
Cl - 98


LFT : 

TB - 3.42
Db - 0.60
AST -12
ALT - 10
ALP - 139
TP - 5.7
Alb -3.4
A/G -1.5 

LDH - 884

 
RBS - 146 

Vit b 12 levels  - 377 

Serum Iron : 70

USG Abdomen


Diagnosis:

Pancytopenia (secondary to ?B12 
?Bonemarrow suppresion)
-chronic diarrhoea under evaluation 
-Indirect hyperbilirubenemia


Treatment:

1)Inj.vitcofol 1 amp (1000microgram)/IM/daily for 1 week 
2)Inj.THIAMINE 2 amp in 100 ml NS /IV/TID
3)Inj.PAN 40 mg/iv/od
4)Inj.ZOFER 4 mg /iv/sos 
5)Tab.PCM 650 mg /PO/Sos
6)Inj.CEFTRIAXONE 1 gm/iv/bd 
7)Monitor vitals 
8)GRBS charting 

PRBC TRANSFUSION WAS PLANNED .

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