A 13 yr old boy with fever and swelling over the neck

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A 13 year old boy presented to casuality with complaints of swellings over the neck and Fever since 10 days. 

  Patient was apparently asymptomatic 20 days back.  Then,  12 Days back patient noticed swelling over right side of neck initially very small which progressed to present size. Since 10 days patient developed fever, high grade, continuous type associated with body pains and malaise.
No vomitings,
no loose stools, 
no burning micturition ,
no cough,
no sore throat.
  
Past history:
Not a K/C/O DM/HTN/TB/Epilepsy/Asthma
No H/O similar complaints in the past.

Personal History:
Diet - mixed
Appetite - normal
Sleep - normal
Bowel habits - regular
Micturition - normal

Family History - Not significant

GENERAL EXAMINATION:
Pallor present
No icterus, cyanosis, clubbing, edema
Temp. - 103 degrees F
PR - 122 bpm
RR - 20 cpm
BP - 130/70 mmHg
SpO2 - 99% at RA

SYSTEMIC EXAMINATION:
CVS - S1, S2 heard , No murmurs
RS - B/L Air Entry +
P/A - Soft, Non tender
CNS - NAD+

PROVISIONAL DIAGNOSIS:
Fever with cervical lymphadenopathy

?cat scratch disease??

                              
                                  
                                                   Swelling over the neck region.
                           
   
                                                    
                                                           Cat scratch mark over the abdomen
                         
   
    Investigations:
                               
                                          USG shows enlarged lymph nodes

                            
                                                                                                  Chest X-Ray

                             
                                                                                                         ECG

                            
                                                                                                                     Fever chart 
                                 
                                                                                                         2D Echo

                                
  
 Ophthalmology opinion was taken to rule out neuroretinitis and retinal exudates

SOAP NOTES 12/12/2021

                                    
                                                             

S :
Patient subjectively feels better.
C/ O Fever yesterday night - 99 degreee F
1 episode of vomiting

O:
Pt is conscious, coherent and cooperative 
BP : 110/70 mm Hg
PR : 98 bpm
Temp : 98.6 degrees F
SpO2 : 99% @ RA
CVS : S1S2 + , No murmurs
RS : BAE + 
P/A : Soft , Non tender
CNS : NAD+

A :
Fever with cervical lymphadenopathy (?Cat scratch disease/Viral pyrexia with cervical lymphadenopathy)

P:
1.Inj PCM 450 mg /IV in 100 ml NS /IV/SOS if temp > 102 degree F
2.IV Fluids - NS and RL @ 100ml/hr
3. Tab . Doxycycline 100mg PO/BD
4. Tab. Azithromycin 500 mg PO/OD
5. Tab. Dolo 500 mg PO / TID
6. Tab. PAN 20 mg PO / OD
7. Plenty of oral fluids
8. BP/PR/Temp charting
9. Tepid sponging SOS
10. Strict I/O monitoring

                                                        SOAP NOTES 13/12/2021
                                   
                                                   

S :
Patient subjectively feels better and is active.
No fever, vomitings.

O:
Pt is conscious, coherent and cooperative 
BP : 100/70 mm Hg
PR : 88 bpm
Temp : 97.6 degrees F
SpO2 : 99% @ RA
CVS : S1S2 + , No murmurs
RS : BAE + 
P/A : Soft , Non tender
CNS : NAD

A :
Fever with cervical lymphadenopathy (?Cat scratch disease/Viral pyrexia with cervical lymphadenopathy)

P:
1.Inj PCM 450 mg /IV in 100 ml NS /IV/SOS if temp > 102 degree F
2.IV Fluids - NS and RL @ 100ml/hr
3. Tab . Doxycycline 100mg PO/BD
4. Tab. Azithromycin 500 mg PO/OD
5. Tab. Dolo 500 mg PO / TID
6. Tab. PAN 20 mg PO / OD
7. Plenty of oral fluids
8. BP/PR/Temp charting
9. Tepid sponging SOS
10. Strict I/O monitoring

                                                                 SOAP NOTES 14/12/2021

S :
Patient is active and has no complaints and is feeling better.
No fever, vomitings.

O:
Pt is conscious, coherent and cooperative 
BP : 100/70 mm Hg
PR : 92 bpm
Temp : 97.6 degrees F
SpO2 : 99% @ RA
CVS : S1S2 + , No murmurs
RS : BAE + 
P/A : Soft , Non tender
CNS : NAD

A :
Fever with cervical lymphadenopathy (?Cat scratch disease/Viral pyrexia with cervical lymphadenopathy)

P:
1. Tab . Doxycycline 100mg PO/BD
2. Tab. Azithromycin 500 mg PO/OD
3. Tab. Dolo 500 mg PO / SOS
4. Tab. PAN 20 mg PO / OD
5. Plenty of oral fluids
6. BP/PR/Temp charting
7. Tepid sponging SOS
8. Strict I/O monitoring

Note : This is still an ongoing case and the further details will be uploaded.

Any reviews ,comments, inputs, advices about the content presented is absolutely welcome !!!

Thanks & Regards,

Nomika Alli

3rd SEM