45YEAR OLD MAKE WITH SOB,TINGLING AND NUMBNESS

 FINAL PRACTICAL- SHORT CASE

 "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 available 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-centered online learning portfolio and your valuable inputs on the comment

January 12,2022

____

SHIVANI THOTA, 1701006181

A 45 year old male, who is a food contractor in railways  came to the OPD with chief complaints of:

• Shortness of breath on exertion since 2 months
• Tingling and numbness of the limbs since 2 months

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 2 months back then he developed then he developed shortness of breath which was insidious in onset, initially grade 2 (NYHA) then progressed to grade 3.

Patient complains of tingling and numbness of both the limbs since 2 months. Initially it was confined to lower limbs then later involved upper limbs as well. 

Patient also complains of passing dark coloured stools 3 days back.

PAST HISTORY: 

No similar complains in the past

Patient had an episode of involuntary tonic clonic movements with uprolling of eyes and drooling of saliva 20 years back. Then he went to the hospital and was diagnosed with epilepsy. He took medication , later after 15 days he experienced 2-3 episodes of seizures.

Not a known case of hypertension, diabetes mellitus,  asthma, TB

PERSONAL HISTORY:

• Diet: Mixed
• Appetite: Normal
• Sleep:Adequate 
• Bowel and bladder:Regular , passage of dark coloured stools 3 days back , one episode per day
• addictions : consumes more than quarter(whiskey) since 20 years but stopped taking alcohol since 2 months ,ghutkha chewing since 10 years
• No known allergies

FAMILY HISTORY: Insignificant 

GENERAL EXAMINATION:

The patient was examined in a well lit room,with informed consent.

Patient is conscious,coherent,Cooperative and is moderately built and malnourished 

Pallor: Present 

Icterus: Absent

Cyanosis: Absent

Clubbing: Absent

Lymphadenopathy: Absent

Edema: Absent 

VITALS :

Pulse rate : 75 bpm

Respiratory rate : 15 cpm 

Blood pressure : 120/70 mm of Hg 

Temperature : afebrile

GRBS: 108 

RESPIRATORY EXAMINATION:

Bilateral air entry present 

Normal vesicular breath sounds heard 

CVS EXAMINATION:

S1 and S2 heard 

No murmurs 

ABDOMINAL EXAMINATION:

Soft, non tender abdomen 

No organomegaly 

CNS EXAMINATION:

Intact

INVESTIGATIONS

10/6/22:

CBP:

Hb : 3.2 g/dl

TLC: 3,400 cells/cumm 

Neutrophils: 42

Lymphocytes: 56

Eosinophils: 0

Monocytes: 02

Basophils: 0

PCV : 9.2

MCV: 117.9

MCH: 42

MCHC: 34.8

RDW-CV: 24.2

RBC: 0.78 

Platelets: 68,000

ESR: 40

Reticulocyte count: 0.5

LFT:

TB: 2.69

DB: 0.70

ALT: 14

AST:51

ALP: 115

TP: 5.8

Albumin: 3.6

A/G: 1.69

RFT:

Blood urea: 16

Sr. Creatinine: 0.8

Sr. Uric acid: 7.8

Sr. Electrolytes:

Sr. Calcium: 8.9

Sr. Phosphorus: 3.9

Na+: 133

Cl: 107

K+: 3.8

RBS: 104

LIPID PROFILE:

Total cholesterol: 90

Triglycerides: 116

HDL: 24

LDL: 49

VLDL: 23

12/6/22:

Hb: 2.8 g%

TLC: 2380

Neutrophils : 36

Lymphocytes: 60

Eosinophils:0

Monocytes: 4

Basophils: 0

PCV: 8

MCV: 115.8

MCH: 39.8

MCHC: 34.3

RDW-CV: 33.5

RBC: 0.69

PLT: 72,000

PS: Anisopoikilocytosis with hypochromia with microcytes, macrocytes and pencil cells. 

PROVISIONAL DIAGNOSIS:

Pancytopenia 2° to vitamin B12 deficiency

TREATMENT

INJ. VITCOFOL 1000mcg/IM/OD × 7 days

INJ. OPTINEURON 1AMP IN 100ml

TAB. PANTOP 40mg/PO/OD