45/M with Pancytopenia secondary to B 12 deficiency.

FINAL MBBS PRATICAL EXAMINATION: SHORTCASE


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N. Raveela

Hall ticket no: 1701006123

I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.  

CONSENT AND DE-IDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.

Case Report:

45/m resident of bibi nagar came to the casuality

Cheif complaints :

Sob on exertion: 2months
Tingling sensation of limbs: 2 month's
Dark coloured stool :3 days back

HOPI:

Patient was apparently asymptomatic 2 months back den he development sob on exertion which was insidious in onset and gradual in progression. 
Not associated with orthopnea and PND, wheeze
Not associated with edema

Tingling sensation in the limbs in both the lowe limbs 
Since 2months

Dark colored stool 3 days back. 

History of fever and oral ulcers 

No history of weight loss ,no loss of appetite

No history of pain abdomen or abdominal distension , vomitings ,loose stools .

No history of burning micturition.

Past History:

No History of similar complaints in the past. 


No history of Diabetes , Hypertension , Tuberculosis ,Bronchial asthma ,COPD , coronary artery disease , Cerebrovascular accident ,thyroid disease.

Family History:

No H/o of similar complaints in the family

Personal history : 

Diet : mixed 
Appetite: decreased
Sleep : adequate
Bowl and bladder : regular
Addiction: Chews pan. 

General examination:

Patient is conscious, coherant and cooperative
Moderately built and moderatly nourished

Pallor  :++
No  icterus, cyanosis, clubbing, lymphadenopathy, generalised edema. 

















Vitals


Patient is afebrile .

Pulse - 90 beats / min ,normal voulme ,regular rhythm,normal character ,no radiofemoral delay,radioradial delay.

BP - 110/80 mmhg ,measured in supine position in both arms .

Respiratory rate -16breaths / min. 

Systemic examination


Respiratory system:
Inspection:
No tracheal deviation 
Chest bilaterally symmetrical
Type of respiration: thoraco abdominal.
No dilated veins,pulsations,scars, sinuses.
No drooping of shoulder.

Palpation:
No tracheal deviation
Apex beat- 5th intercoastal space,medial to midclavicular line.
Tenderness over chestwall- absent.
Vocal fremitus- normal on both sides.

Percussion:                   
Supraclavicular            
Infraclavicular.         
Mammary
Axillary
Infraaxillary
Suprascapular
Infrascapular
Interscapular

Right side and left side- resonant in above areas.

Auscultation:
 Normal Vesicular breath sounds. 
Bilateral Airway entry - present.

Cardiovascular system:
Inspection : no visible pulsation , no visible apex beat , no visible scars.

Palpation: all pulses felt , apex beat felt.
Percussion: heart borders normal.
Auscultation: 
Mitral area, tricuspid area, pulmonary area, aortic area- S1,S2 heard.


GIT

INSPECTION :

Abdomen - distended 
Umbilicus - transverse slit like
Movements - all quadrants are equally moving with respiration
No scars and sinuses 
No visible peristalsis
No engorged veins.

PALPATION:

No local rise in temperature and no tenderness in all quadrants 
LIVER: no hepatomegly
SPLEEN- not enlarged 
KIDNEYS - bimanual palpable kidneys 

PERCUSSION :

no shifting dullness

AUSCULTATION :

Bowel sounds are heard and are normal
No bruit.

CNS: 

Higher motor functions- Normal

Speech: Normal

Cranial nerve functions - Intact. 

Sensory system- sensitive to pain, touch , vibration and temperature.

Motor system Right                 Left    
                    Power- UL    5/5    5/5
                                      LL 5/5    5/5 
                         Neck Normal 
                 Trunk muscles Normal  

          Tone- UL   Normal
                         LL   Normal

          Reflexes- 
Superficial reflexes - Intact 
                             Plantar flexion flexion
Deep tendon reflexes -
                           Biceps ++ ++
                           Triceps ++ ++
                         Supinator ++ ++
                                Knee ++ ++ 
                             Ankle ++ ++ 
               
                               Gait- Normal

                Cerebellar system - intact  

Investigation:






























Provisional Diagnosis: pancytopenia 2 to B 12 defici
ency. 



Treatment:

1)  Inj. vitocofol. 1000mcg
2) Tab.Pain D
3) Inj. Optineuron. 







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