A 38 year old lady with fever

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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 history, clinical findings, investigations and come up with diagnosis and treatment plan.

 My case was a 38 year old female  who is a daily wage labourer by occupation and resident of suryapet has come on 27/06/22 with

CHIEF COMPLAINTS:

Fever since 2 months
Throat pain since 2 days

HISTORY OF PRESENT ILLNESS :

Patient was apparently asymptomatic 2 months back and then she developed fever which was intermittent in nature. Temperature rises once every 3 days ,more in the evening(after 4 pm) than morning .
Everytime she had fever she took medications prescribed by local practitioner and it subsided.
Fever was also associated with chills and rigors since 15 days.

She also complains of throat pain since 2 days .she has difficulty swallowing and for which she took medication Azithromycin prescribed by local practitioner.

She stopped going to work since 2 months.

No history of cough, weight loss, vomiting,oose stools, abdominal pain.

Since the fever was not subsiding she went to a local hospital ,and the doctor suggested some tests and the test reports are :

HISTORY OF PAST ILLNESS:

Patient is not a known case of diabetes, hypertension, epilepsy, asthma, tuberculosis.

Daily routine- 

Patient wakes up at 6 AM , does the household work ,haves her breakfast and leaves to work by 9 AM.

Lunch at 1 PM and she comes back home from work at 5 PM .She then does household work and then dinner at 8 PM and sleeps at 9 PM. 

She is not going to work since 2 months 

PERSONAL HISTORY:

Diet : mixed

Appetite: normal

Sleep : adequate

Bowel and bladder movements :regular

Addictions :none

FAMILY HISTORY:

Not significant. 

GENERAL EXAMINATION:

Patient is conscious, coherent and cooperative.

Moderately built and moderately nourished.

Well oriented to time, place and person.

No pallor ,icterus, cyanosis, clubbing, edema.

Lymphadenopathy present

VITALS:

BP: 110/70 mmHg

RR: 18 cpm

PR : 80 bpm

TEMP: Afebrile

GRBS: 114 mg%

SP02: 98%

SYSTEMIC EXAMINATION :

Respiratory system: 

         Bilateral air entry present

         Normal vesicular breath sounds 

Cardiovascular system : 

         S1 S2 heard, no murmurs

Central nervous system : 

        No focal neurological deficits

Abdominal examination:

     Inspection:

         Shape- scaphoid

         Umbilicus inverted

         Movements - moves with respiration 

     Palpation:

         No local rise of temperature 

         No tenderness of abdomen

         Hernial orifices normal 

         Liver is not palpable

         Spleen is not palpable

     Auscultation:

         Bowel sounds heard 

         No bruits

Clinical pictures:

Fever chart updated at July 2nd 2022

PROVISIONAL DIAGNOSIS :
Fever under evaluation with Herpes labialis.

TREATMENT: 

Inj. Monocef 1gm IV BD

IVF 10 NS @ 50ml/hr with 1amp Optineurin

Vitals monitoring every 4th hourly

Temperature monitoring every 3 hourly.