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A 50-year-old male presented with generalized weakness

Dr. Nasrin Akhter

MD Resident (Phase-B)

Haematology

BSMMU

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Particulars of the patient

Name: Mr. Adhir Chakrabarty
Age: 55 years
Sex: Male
Religion: Hindu
Occupation: Machine operator in jute mill
Address: Rupgonj, Narayangonj
Date of Examination: 4^th November, 2020

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Chief complaints

Generalized weakness and tiredness for 2 months

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H/O present illness:

According to the statement of the patient, he was reasonably well 2 months back, then he has noticed that he is gradually becoming weak and pale. Initially he could perform all activities with little discomfort but now he becomes tired while he does usual daily activities. Along with weakness he occasionally experience vertigo and palpitation specially during strenuous activities. His apetite is good and dietary habit is normal. His bladder and bowel habit is regular.

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Negative History: No history of

fever, sore throat, cough, sputum
Bleeding manifestations, skin rash
Nodular swelling, itching
Night sweat
Wight loss
Joint pain
jaundice
Increased frequency of micturition
Limb weakness

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Continued. . .

With these complaints, when he visited to physician, he was advised some investigations and treated with 3 unit of red cell concentration transfusion along with some medications.

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History of past illness

No previous history of jaundice, radiation therapy or other significant chronic illness.

Family history

He is married and have two son and one daughter.

All her family members are in good health.

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Personal History: He is non smoker, non alcoholic. He worked in a jute mill as a machine operator.

Drug history: no significant drug history

Treatment History: No significant past treatment history other then received 3 unit of Red blood cell transfusion in this period of illness in last month.

Socioeconomic condition: He belongs to middle socioeconomic condition.

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Physical examination

General examination:
Appearance: Normal
Built: Well built
Height:163cm
Weight:66 kg
BMI:24.84
Anaemia: Moderate
Jaundice: Absent
Oedema: Absent
Lymphadenopathy: Absent
Bony tenderness: Absent

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Contd:

Generalized skin condition: pink to red annular patches with raised scaly border that expand peripherally and tend to clear centrally all over the skin resembling Tinea corposris.
Temp: 98.4F
Pulse:88 b/min
Resp. rate: 18 b/min
BP: 110/70 mmHg

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Systemic examination:

Gastro-intestinal system

Cardio-Vascular system

Respiratory system NAD

Nervous system

Musculoskeletal system

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Salient features

A 52 years old male, machine operator in jute mill, nondiabetic, normotensive, resident in Narayangonj came to us in BSMMU with complaints of generalized weakness and tiredness for 2months. He states that he was reasonably well 2 months back, then he has noticed that he is gradually becoming weak and pale. Initially he could perform all activities with little discomfort but now he becomes tired while he does usual daily activities. Along with weakness he occasionally experience vertigo and palpitation specially during strenuous activities. His appetite is good and dietary habit is normal. His bladder and bowel habit is normal .

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He had no history of fever, sore throat, cough, sputum, joint pain, oral ulcer, skin rash, nodular swelling, itching, night sweat, weight loss, polyuria. He had no significant past, family, personal, drug or treatment history. On examination patient is mildly anemic, t. corporis all over the skin. There is no lymphadenopathy, bony tenderness, purpura, petechiae. vitals are normal. Systemic examination revealed no abnormality.