A 27 yr old Male with fever and Weakness

A 27 years old male patient who is preparing for govt. job is also an agriculture worker , came to the opd 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

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