FINAL PRACTICAL SHORT CASE: Case of a 45 year old male with sob on exertion and tingling and numbness of the limbs

GENERAL MEDICINE - FINAL PRACTICAL EXAM

SHORT CASE

Hallticket no: 1701006158

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.

CASE PRESENTATION:

A 45 year old male, who works in a parcel company came to the OPD with

CHIEF COMPLAINTS:

•  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 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 as epilepsy. He took medication , later after 15 days he experienced 2-3 episodes of seizures. After that he had seizure free period. 

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

PERSONAL HISTORY:

Diet: Mixed

Appetite: Decreased

Sleep: Adequate

Bowel and bladder habits: passage of dark coloured stools 3 days back , one episode per day

Addictions: Used to consume alcohol daily since 12 years about 90 ml everyday

Alcohol abstinence since 2 months

FAMILY HISTORY : Insignificant

GENERAL EXAMINATION:

Patient is examined in a well lit room after obtaining informed consent. 

Patient is conscious, coherent and cooperative. 

Patient is moderately built and moderately nourished. 

Pallor - present

No signs of cyanosis, clubbing, lymphadenopathy and edema. 

VITALS :

Temp: 98.6°F

BP: 110/80 mmHg

Resp rate: 16 cpm

Pulse rate: 80 bpm

SpO2: 98%

GRBS: 108 

SYSTEMIC EXAMINATION:

CVS : S1S2 heard, no murmurs

RS: NVBS heard

Per Abdomen: soft, non tender, no organomegaly

CNS : Normal

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