13 year old boy with fever

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable comments on comment box is welcome

 13 year old boy who is studying 6 th class came with chief complaints of Fever ( since 1 day ).

Patient was apparently alright till one day back he had high grade fever, which relieved on taking medication, not associated with any vomitings , loose stools , pain abdomen, not associated with any night sweats , cough , no h/o any ear pain / ear discharge .
5 months back patient got admitted in our hospital for c/o SOB ( treated conservatively for 5 days and discharged ) .

PAST HISTORY :
Not known case of DM2 , Hypertension , Asthma , TB , Epilepsy .
PERSONAL HISTORY :
Diet- mixed
Appetite- normal
Sleep- adequate
Bowel and bladder movements- regular
Occasional alcohol intake +
No known allergies
FAMILY HISTORY: 
Not significant
GENERAL EXAMINATION:
No Pallor 
No icterus, cyanosis, clubbing, koilonychia, lymphadenopathy, edema.

VITALS AT ADMISSION :
Temp - 99 F
PR- 72 bpm
RR- 22 cpm
BP- 110/70 mmHg
SpO2- 98% RA
GRBS- 126 mg/dl
SYSTEMIC EXAMINATION:
CVS: S1S2 heard, no murmurs
RS: BAE+ NVBS+
P/A: Soft, Non-tender
CNS: NAD







PROV DIAGNOSIS : 
Viral Pyrexia

TREATMENT : 
1. Inj MONOCEF 1gm IV BD
2. Tab Dolo 650 mg PO BD 
3. IVF NS with OPTINEURON @ 75 ml/hr
4. Inj Neomol 1 gm IV SOS
5. Vitals monitoring every hourly
6. Strict I/O charting.

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