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