Case history 4
CASE HISTORY 4
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A 30 year old Male patient presented to OPD with a chief complaint of :
1. pedal edema since 1 month .
2. shortness of breath since 1 month .
HISTORY OF PRESENT ILLNESS :
Patient was apparently asymptomatic 1 month before
And then developed pedal edema and shortness of breath .
Pedal edema is of pitting type .
There is presence of abdominal distension
And presence of abdominal pain since 1 month and the pain is relieved by taking medication .
Patient complains of cough with sputum since 1 month
And also complains about high grade fever and chills since 2 days .
PAST HISTORY :
Patient had a similar complaint 10 years back and he is a known case of anemia
And he got blood transfusion once
He has no history of hypertension, asthma,epilepsy and diabetes.
PERSONAL HISTORY :
Diet - mixed
Appetite - decreased
Sleep is adequate
Bowel and bladder movements are normal
No history of alcohol and smoking habits .
GENERAL EXAMINATION :
Patient consent was taken and he is conscious, coherent and cooperative and examined in well lit room .
Pallor - positive
Icterus - present
Bilateral pitting edema is seen and it is pitting type
No cyanosis and clubbing is seen
Abdominal distension is seen .
SYSTEMIC EXAMINATION:
CVS : S1 and S2 heart sounds are normal
Respiratory : Bilateral air entry is normal
Soft , non tender , mild hepatomegaly are seen with percussion/ auscultation
CNS : Normal
INVESTIGATIONS :
ECG :
ULTRASOUND:
CHEST X - RAY :
OTHER INVESTIGATIONS :
PROVISIONAL DIAGNOSIS :
Anemia secondary to vitamin B - 12 deficiency with thrombocytopenia.
TREATMENT :
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