38yr old female with viral fever and herpes labialis

E-LOGS GENERAL MEDICINE


 
Roll no 04 
Hi, i am lasya, 5th Sem Medical Student. This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent. This also reflects patients centered care and online learning portfolio. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. Hope this will be informative!
CHIEF COMPLAINT: 

A 38 year old female came to opd with the chief complaints of 

Fever since 2 months associated with chills 
Difficulty during deglutition for 3 days 


HISTORY OF PRESENT ILLNESS: 
Patient was apparently asymptomatic 2 months back , then she developed fever ( intermittent in nature) associated with chills for which she went to a local hospital and it was relieved on medication ( temperature rise was usually in the evenings around 4pm). Rise of temperature was present once for every 3 days. 

4 days back, patient again developed fever associated with chills and also had complaints of difficulty in deglutition for about 3 days. 

She also had complaints of painful lesions around the mouth since 4 days. 

No h/o vomitings, loose stools, constipation, chronic cough, abdominal pain 

HISTORY OF PAST ILLNESS: 

Not a k/c/o DM, HTN, TB, CAD, Asthma, epilepsy 

TREATMENT HISTORY: 

No relevant treatment history 

PERSONAL HISTORY: 
Married 
Appetite- normal 
Having mixed diet( Non vegetarian) 
Bowels- regular
Micturition- normal
Alcohol intake- teetotaler 
No habit of smoking 
No other habits/ addictions 
GENERAL EXAMINATION:
Patient is moderately built and nourished 
Presence of lymphadenopathy 
Absence of pallor,Icterus, Clubbing, Cyanosis, Pedal edema

 VITALS:

1.Temperature: Afebrile 

2.Pulse rate: 80 beats per min

3.Respiratory rate: 16 cycles per min 

4.BP: 110/70 mm Hg

5.SpO2: 98%@Room air 

6.GRBS: 114mg % 

SYSTEMIC EXAMINATION:

*CARDIOVASCULAR SYSTEM:

S1, S2 heard
No thrills, No murmurs


*RESPIRATORY SYSTEM:

Normal vesicular breath sounds
Position of trachea is central
Dyspnea is absent 
No wheeze


*EXAMINATION OF ABDOMEN:

Shape- scaphoid
tenderness- absent 
No palpable pass
Normal hernial orifices 
No free fluid
No Bruits
Liver is not palpable
spleen is not palpable
Bowel sounds heard

*CENTRAL NERVOUS SYSTEM:

Patient was consious 
Speech is normal
No focal neurological defect

PROVISIONAL DIAGNOSIS:
VIRAL FEVER WITH HERPES LABIALIS 



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