23 yr old male came with complaints of fever

 A 23 year old male patient who is driver by occupation came with chief complaints of fever since 15 days.

HOPI 

Patient was apparently asymptomatic 3 yrs back.

Then he developed fever and went to the hospital and there he was done blood investigation and his hb level was 4g%for which he was given red blood cell transfusion.Then again after 3 yrs ,i.e since 15 days developed fever which was high grade. He also had yellowish discoloration of eyes.The fever was associated with chills and rigor was intermittent and subsided with medication.There is also history of stomach pain and blood in stools.

Past history

There was similar complaint in the past which was 3 years ago and he was diagnosed with anemia and got treated.

No history of HTN ,DM ,Asthma, epilepsy ,CKD.

Treatment history: blood transfusion for Anemia

Family history No significant family history

Personal history

Diet:veg.

Appetite: decreased

Sleep: adequate

Bowel and bladder: regular (1 episode of blood in stools)

Addictions: occasionally alcoholic 

General examination

Patient was conscious, coherent and cooperative

Moderately built and nourished

Pallor: present

No icterus, cyanosis, clubbing, generalised lymphadenopathy and edema.

Vitals 

Temperature : Afebrile

PR 68 bpm

RR 18 cpm

BP 100/60 mm Hg

Systemic examination

CVS s1 s2 heard no murmurs 

Respiratory system  BAE normal vesicular breath sounds heard

GIT  soft and non tender 

CNS no focal neurological deficit 

INVESTIGATIONS






Biopsy



Provisional diagnosis 

Pancytopenia secondary to Megaloblastic anemia

Treatment


Inj methyl cobalamine 

Inj PANTOP 

T.Zofer 

T.PCM

High fibre diet






















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