A 28 yrs old female with viral fever

June 30, 2022

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Date of admission: 27/06/22

CHIEF COMPLAINT:

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

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

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 2 months back , then she developed fever 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.

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

Painful lesions around the mouth

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

INVESTIGATIONS:

Fever chart

Chest X-ray

USG neck

USG Report

ECG

TREATMENT:

Treatment on 27/06/22:

1. Inj. MONOCEF 1gm IV/BD

2. IVF 10 NS@50ml/hr with 1amp optineuron

3. Temp monitoring every 3 hrs