35 year old man with Chronic pancreatitis, severe Anemia and heart failure

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A 35 year old man, working at a store for printing wedding cards, from Suryapet presented to the casualty at 8pm with the  complaints of 

Fever since 2 months
Generalized weakness since 2 months 
Dyspnea on exertion since 2 months 
Pain abdomen since 20 days
Right sided chest pain since 20 days
Vomiting since 20 days 
Dark coloured stools since 20 days

He works at a store that prints wedding cards at Suryapet. He has 2 daughters. Since the past 15 years he has been consuming alcohol everyday, he consumes around 360ml of whiskey per day and his last alcohol intake was yesterday.
Since 15 years he has been smoking, he says he only smokes occasionally. 
Since the past 2 years he started to experience  loss of appetite. He also tells us that he started consuming less food and started to consume larger amounts of alcohol. He also tells us that he started to experience recurrent episodes of pain abdomen along with recurrent episodes of vomiting every alternate day and he has visited hospitals 5-6 times over the past 2 years. 
Since the past 2 months he has been experiencing dyspnea on exertion, he says he started to feel dyspneic on walking short distances of less than 100m and also started to experience generalized  weakness so much so that he stopped going for work.
He also tells us that over the past 2 months he has been experiencing low grade fever along with loss of around 12kgs.

20 days back he complains of  one episode of blood tinged vomitus and has been experiencing increased pain abdomen in his epigastric and right hypochondriac region along with right sided chest pain.
He also complains of black tarry stools since 20 days.


On examination- 


He is a thin built man 
PR - 84bpm, regular - Hyperdynamic pulse
BP - 120/80mmhg
RR - 18cpm
Temp - 98.4 F
Spo2 - 98% on Room Air
Grbs - 102 mg/dl
Pallor +
2 Hypopigmented patches over his abdomen- he has been having them since childhood, pain sensation +

Per Abdomen- 
Diffuse tenderness  +
Guarding +
Bowel sounds +

Cvs - 
Palpable P2 +
Apex beat in 6th ICS at MCL 
S1,S2 +
ESM +

Lungs - 
BAE +
Clear


Provisional diagnosis-

Chronic pancreatitis with 
Pyrexia of unknown origin 
Anemia under evaluation ( -  Secondary to GI blood loss and Nutritional)  
 Heart failure secondary to ? Beri beri and severe Anemia 





















Hb- 3.8 
TLC - 13,500
Plt - 4.8

Peripheral smear - Anisopoikilocytosis with hypochromasia, microcytes with tear drop cells, pencil cells with target cells and few normocytes

LDH - 363

Retic count - 1.8
Serology negative

LFT - 
Tb - 0.47
Db - 0.18
Ast - 23
Alt - 10
Alp - 161
TP - 5.4
Alb - 2.9
A/G - 1.19




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