GM Case

This is an online e-log platform to discuss case scenario of a patient with their guardians permission. 

I have been given this case to solve in an attempt to understand the topic of patient clinical data analysis to develop my competency in reading and comprehending clinical data including histoty, clinical findings, investigations and come up with a diagnosis and treatment plan.

Case:
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 cervical 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 mass.
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: 






Treatment:
1. Inj. MONOCEF 1gm IV/BD 
2. IVF 10 NS@50ml/hr with 1amp optineuron 
3. Temp monitoring every 3 hrs 
4. Vitals monitoring every 4th hrly 


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