27 yr old student with fever and generalized weakness

27 years old Student with fever and generalized weakness.

27 years old male patient who is preparing for govt. job is also an agriculture worker , came to the opd on 15.9.22  with the complaints of 

•fever since 15 days 

•generalized weakness since 1 month.

HOPI.

patient was apparently asymptomatic 1 month back,then he developed generalized weakness and dizziness.

He visited some MBBS doctor for the same complaints,was given some medications and was advised to visit a hospital.

• h/o fever since 15 days.

On and off. 

Low grade.

Not a/w chills, rigor.

No h/o muscle pain.

H/o loss of weight of 10 kgs in 6 months 

He does agricultural work for 6 hours in a day and then he prepares for govt. job at night.

H/o decreased intake of food and inadequate sleep since 1 month.

No h/o abdominal problem.

No h/o  cold and cough.

No h/o   burning micturition.

No h/o numbness,tingling sensation

• past history.

No similar complaints in past.

Not a k/c/o TB,asthma,htn,DM,CAD,epilepsy.

Personal history:

Appetite : less

Sleep: inadequate

Diet: mixed

B/b : regular

Addiction: no 

Diet history:

He takes 3 meals per day and each meal contains rice and vegetables.

He takes chicken only 1-2 times a month and 

dal,egg 1-2 times a week.

Family history:

Not significant.

GENERAL EXAMINATION:

pallor: present

No cyanosis, icterus, clubbing, lymphadenopathy, edema

Vitals- BP- 110/70 mm hg

           PR- 100 BPM

           TEMP- 101°F

           RR-21 CPM

CVS- S1S2 (+) 

R/S- BAE(+) 

P/A- soft, non tender

CNS-NFND

CLINICAL IMAGES:

 

INVESTIGATIONS:

DIAGNOSIS: PANCYTOPENIA SECONDARY TO VIT-B12 DEFICIENCY. 

TREATMENT:

1) INJ. METHYLCOBALAMINE 1500 mcg + 100ml NS IV OD

2) TAB. FOLIC ACID 5mg PO OD

3) TAB. DOLO 650mg PO SOS

4) INJ. NEOMOL 1 GM IV SOS(IF TEMP. >101°F) 

5) TEMPERATURE CHARTING 4RTH HOURLY

6) BP/PR CHARTING 6TH HOURLY