18 year male student by occupation

Patient came with c/o :
Fever since 1 day
Headache since 1 day
Fever - high grade , intermittent , relieves on taking medication , not associated with chills and rigors.
Headache - present in the frontal region, no aggreavating or relieving factors , not associated with any postural variation .
HOPI :
15 days back pt has c/o nasal congestion as pt symptoms of nose blockage increased since 4 days for which pt was using nasal decongestion tablets . Pt is having excessive anger since 2 days which he was attributing that occur after taking the medications .
At age of 12 yrs pt was admitted in KIMS ( 14/10/2016 ) with c/o fever , vomitins , seizures ( 4 episodes ) and headache diagnosed as hypertensive encephalopathy secondary ? PSGN , discharges on ( 28/10/2016 ) and used tab phenytoin for 7 months and stopped on advise of doctors .

N/K/C/O DM , HTN , TB , ASTHMA , EPILEPSY

PERSONAL HISTORY :
Diet- mixed
Appetite- normal
Sleep- adequate
Bowel and bladder movements- regular
No known allergies

FAMILY HISTORY: 
Not significant

GENERAL EXAMINATION:
No Pallor 
No icterus, cyanosis, clubbing, koilonychia, lymphadenopathy, edema
No neck stiffness
Kernig and Brudzinski sign negative
VITALS AT ADMISSION :
Temp - 103 F
PR- 120 bpm
RR- 22 cpm
BP- 130/80 mmHg
SpO2- 98 %
GRBS- 105 mg/dl

SYSTEMIC EXAMINATION:
CVS: S1S2 heard, no murmurs
RS: R/s- B/LAE+
P/A: Soft, Non-tender
CNS: NAD

PROV DIAGNOSIS : 

Viral Pyrexia with Dengue NS1 positive .

TREATMENT : 
1. Inj PAN 40 mg iv od
2. Inj MONOCEF 1 gm IV bd 
3. Inj ZOFER 4 mg iv sos
4. IVF NS RL @ 100 ml/hr
5. Tab DOLO 650 mg po tid
6. Inj NEOMOL 1 gm IV sos
7. Temp charting hourly
8. Strict I/O charting
 
S.O.A.P 
26/3/22

S 
Fever , headache
O
PATIENT IS CONCIOUS , COHERENT COOPERATIVE
NO PALLOR, ICTERUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA
VITALS - 
TEMPERATURE - 101.1
PULSE RATE - 83 bpm
BLOOD PRESSURE - 120/70 MM HG 
RESPIRATORY RATE - 17 cpm
SPO2 - 98 %
HB - 14.3 26/3/22
Plt - 1.75 lakh 26/3/22
SYSTEMIC EXAMINATION - 
PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY
CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : 
 B/LAE+
CENTRAL NERVOUS SYSTEM : NAD
A
Viral Pyrexia with Dengue NS1 positive .
P
 IVF NS RL @ 100 ml/hr
Tab DOLO 650 mg po tid
Inj NEOMOL 1 gm IV sos
Temp charting hourly
Strict I/O charting





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