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

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