A 23 Year Old Male With Megaloblastic Anaemia Secondary to Vitamin B 12 Deficiency ? Asymptomatic Celiac disease, fissure in ano.

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A 23 year old male studied up to intermediate, currently working as driver came to OPD with 

C/O yellowishdiscoloration of eyes since 15 days. 

C /O fever since 1 week 

SOB on extertion since 1 week

abdominal discomfort and pain since 1week 

blood in stools 1 episode ,2 days back. 

HOPI: patient was apparently asymptomatic 3 years back, history of fever went to hospital ,on examination  PALLOR +, investigations :Hb-4 gm%,-3 PRBC  transfusions done 3 years back, attenders  said that his anaemia is secondary to B12 deficiency, patient received the B12 injections ,his  Hb improved from 4 gm%to 12 gm%  and also planned for bone marrow biopsy, but they didn't perform  as he was improved with B12 injections. 

After this episode, no similar complaints until 15 days back ,suddenly developed  yellowish discoloration of eyes 15 days back, he was taken to a local RMP said to have jaundice, patient took herbal medication for 1 week. 

Fever: high grade, associated with chills and rigor,SOB  on exertion (Grade 2 )

SOB insidious inonset, gradually progressive from GRADE I  to GRADE 2 in 1 week. 

Orthopnea +, No PND. 

PAIN ABDOMEN:squeezing type, intermittent associated with nausea.

Blood in stools 

1 episode 2 days back, normal consistency. No vomitings,hemoptysis, ,hematemesis ,melena .  

He is also complaining of burning sensation while passing stools since 2 days. 

PAST H/0: H/o blood transfusion 3 yrs back. 

PERSONAL H/O :Diet-mixed

                             Appetite -normal                                                       Sleep-adequate

      Bowel &bladder movements-regular

ALCOHOL H/O: 1-2 beers for every 3 weeks.

          O/E     : Pt is c/c/c

Bp- 100/60 mm Hg

PR-80 bpm

RR-20 cpm

Spo2-100%@ RA

Grbs-92 mg/dl

Pallor-++

Icterus-+ mild

No cyanosis, clubbing, no lymphadenopathy. 

Oedema of feet -+ , upto B/L ankles. 

Hyperpigmentation of knuckles:+

SE:CVS- S1, S2+, JVP raised

                Flow murmur +,   

                Venous hump +

       Apex beat :at 5th IC space. 

RS: BAE+

P/A:  mild hepatomegaly+

           mild splenomegaly +

           BS +

CNS :NAD 

 

PROVISIONAL DIAGNOSIS: PANCYTOPENIA UNDER EVALUATION? Secondary to Vitamin B12 deficiency. 



CHEST X- RAY DONE ON :10/2/22



USG DONE OUTSIDE ON :7/2/22

2D ECHO DONE ON :10/2/22

ECG done on :10/2/22

USG DONE ON 10/2/22

Review USG done on 12-2-22



INVESTIGATIONS

Surgery opinion :done on 14/2/22

Investigations done on :15/2/22  &18/2/22.

ICU BED-3 

DAY-1

S: sob subsided,pain abdomen subsided

O: BP:100/80 mmHg

PR:120 bpm

RR:18 cpm 

SPO2: 99% at RA

GRBS: 93mg/dl

Stools: not passed

RS:BAE+

CVS: S1S2 +

P/A:Soft,non tender,bs+

CNS:NAD

I/O:500/200ml

A: Pancytopenia under evaluation secondary to ?B12 deficiency 

P: Inj. Methylcobalamine 1500mcg in 100ml NS IV/OD

Inj. Lasix 20mg BD(8am—4pm—x)if SBP >110mmHg

Inj. Pantop 40mg IV/SOS 

Inj. Zofer 4mg IV/SOS

Tab. Ultracet 1/2  PO/SOS

Tab. PCM 500mg PO/SOS

Monitor vitals 4th hourly 

I/O,Temp charting 

GRBS 12th hourly

1 unit of PRBC transfusion done on 10/2/22 , started at 11:30 PM, ended on 5AM 11/2/22.

ICU BED-3 

DAY-2

S: No sob,pain abdomen,fever,bleeding manifestations

O: BP:100/50 mmHg

PR:108 bpm

RR:20 cpm 

SPO2: 99% at RA

GRBS: 79mg/dl 

RS:BAE+

CVS: S1S2 +

P/A:Soft,non tender,bs+

CNS:NAD

I/O:1200/950ml

Stools passed

A: Pancytopenia under evaluation secondary to ?B12 deficiency 

P: Inj. Methylcobalamine 1500mcg in 100ml NS IV/OD(Day-2)

Inj. Pantop 40mg IV/SOS 

Inj. Zofer 4mg IV/SOS

Tab. Ultracet 1/2  PO/SOS

Tab. PCM 500mg PO/SOS

Monitor vitals 4th hourly 

I/O,Temp charting 

GRBS 12th hourly

AMC BED-3 

DAY-3

S: No sob,pain abdomen,fever,bleeding manifestations

O: BP:110/70 mmHg

PR:93 bpm

RR:20 cpm 

SPO2: 99% at RA

GRBS: 75mg/dl 

RS:BAE+

CVS: S1S2 +

P/A:Soft,bs +,Splenomegaly + 1cm below left coastal margin 

CNS:NAD

I/O:700/1250ml

Stools passed

A: Pancytopenia under evaluation secondary to ?B12 deficiency 

P: Inj. Methylcobalamine 1500mcg in 100ml NS IV/OD(Day-3) 

Inj. Pantop 40mg IV/SOS 

Inj. Zofer 4mg IV/SOS

Tab. Ultracet 1/2  PO/SOS

Tab. PCM 500mg PO/SOS

Monitor vitals 4th hourly 

I/O,Temp charting 

GRBS 12th hourly

AMC 

BED NO :3

DAY-4

S: No sob,pain abdomen,fever

   1 episode of blood in stools yesterday

O: BP:110/60 mmHg

PR:92 bpm

RR:20 cpm 

SPO2: 99% at RA

GRBS: 78mg/dl 

RS:BAE+

CVS: S1S2 +

P/A:Soft,bs +

CNS:NAD

I/O:850/1600ml

Stools passed

A: Pancytopenia under evaluation secondary to ?B12 deficiency 

P: Inj. Methylcobalamine 1500mcg in 100ml NS IV/OD(Day-4) 

Tab. PCM 500mg PO/SOS

Monitor vitals 8thhourly 

I/O,Temp charting 

GRBS 12th hourly

Ward updates:23yr/M
DAY-5
S: No sob,pain abdomen,fever, no blood in stools, thrombophlebitis present, edema of eyelids present, and face present

O: BP:100/80 mmHg
PR:85 bpm
RR:20 cpm
SPO2: 99% at RA
GRBS: 78mg/dl
RS:BAE+
CVS: S1S2 +
P/A:Soft,bs +,
CNS:NAD

Stools passed

A: Pancytopenia under evaluation secondary to ?B12 deficiency

P: Inj. Methylcobalamine 1000mcg in 100ml NS IV/OD+0.75 mg FA(Day-5)
Tab. PCM 500mg PO/SOS
High fibre diet +adequate hydration
Sitz bath for 20 min /TID
ointment lignocaine for LA/BD
Tab. OXERUTE OD X 2 days

Monitor vitals 4th hourly
I/O,Temp charting
GRBS 12th hourly

Haemogram :13/2/22
Hb-3. 2 g/dl
TLC-4, 400
N/L/E/M/B:35/55/03/07/00
PCV-8. 9
MCH-35. 1
MCHC-35. 3
RDW-32. 6
PLT-35, 000
RBC-0. 90 millions/cumm

General medicineward case 

DAY-6

S: No sob,pain abdomen, 1 episode of fever spike at 8 AM. 

No  episode of blood in stool yesterday,no thrombophlebitis , edema of  right side of face present

O: BP:100/60 mmHg

PR:88bpm

RR:20 cpm 

SPO2: 99% at RA

GRBS: 78mg/dl 

RS:BAE+

CVS: S1S2 +

P/A:Soft,bs +, 

CNS:NAD

Stools passed yesterday 

A:  megaloblastic anemia secondary to B12 defiecency 

P: Inj. Methylcobalamine 1500mcg in 100ml NS IV/OD + 0.75 mg FA(Day-6) 

Tab pcm 500 mg po/soa

High fiber diet + adequate hydration 

Sitz bath for 20 min/ tid 

Ointment lignocaine for LA /BD 

Tab OXERUTE X 2 DAYS

Ward case :Day 7 updates:

S: No fever spikes, edema of  right side of face decreased. 

O: BP:100/70 mmHg

PR:88bpm

RR:19cpm 

SPO2: 99% at RA

GRBS: 78mg/dl 

RS:BAE+

CVS: S1S2 +

P/A:Soft,bs +, 

CNS:NAD 

Stools passed 

A: Megaloblastic anemia secondary to VitB12 deficiency  ? Asymptomatic celiac disease 

P: Inj.  Vitcofol 1500microgm im/od.

   Tab pcm 500 mg po/sos.

   Tab Pantop 40mg po/od

   High fiber diet + adequate hydration  with gluten free diet

Sitz bath for 20 min/ tid 

Ointment lignocaine for LA /BD

General medicineward case 

DAY-8

S: No fever spikes, edema of  right side of face decreased. 

O: BP:100/70 mmHg

PR:82bpm

RR:19cpm 

SPO2: 98% at RA

GRBS: 86mg/dl 

RS:BAE+

CVS: S1S2 +

P/A:Soft,bs +, 

CNS:NAD 

Stools passed 

A: Megaloblastic anemia secondary to VitB12 deficiency  ? Asymptomatic celiac disease fissure in ano

P: Inj.  Vitcofol 1500microgm im/od.(weekly once)

   Tab pcm 500 mg po/sos.

   Tab Pantop 40mg po/od

   High fiber diet + adequate hydration  with gluten free diet

Sitz bath for 20 min/ tid (after defecation)

Ointment lignocaine for LA /BD (before defecation).  

Bone marrow aspiration and biopsy done reports awiated