Blood Pressure: 107/57

Pulse: 104

Weight: 46.8

Temperature: 36.7

Glucose:

History
16 year old female, LMNP:24/08/22. complains of coughing, started in 1/12 ago ,treated at local clinic, but has 3/7 now with coughing, productive cough with greenish sputum, no hemoptysis, with rigors, fever, also with dyspnea, associated with exertion, no loss of weight, loss of appetite, no night sweats. family history of atopy on examination comfortable in room air,normal breath sounds bilateral, no inspiratory creps, no wheezes, no increased vocal fremitus,no dullness on percussion

Diagnosis
manage as CAP

Medication
ceftriaxone 250mg imi stat tto purmycin 250mg tds po paracetamol 1g tds po cough mixture 10ml tds or prn rhineton 1tb prn multivitamin 1tab daily

Sick Leave
0