病历_6_20_67
{"visitSummary":"Kelvin Corsami presented with headaches, neck pain, and fever lasting for three days. The patient's symptoms suggest a viral infection with no immediate signs of a more serious condition. A flu vaccine has been recommended for the patient's father, Carlo, and Kelvin is advised to get vaccinated later.","subjective":"Kelvin Corsami reports experiencing severe headaches, neck stiffness, and eye movement-related brain pressure starting three days ago. He also had a fluctuating fever, peaking at 101°F, without respiratory symptoms. Kelvin describes a light cough and phlegm onset today, along with neck muscle aches. He denies feeling generally tired.","objective":"Physical examination reveals no signs of meningitis. Neck examination does not show any significant issues. Neurological examination of the eyes and mouth is normal. Respiration is clear without any chest complications. Range of movement tests for the neck show discomfort in certain positions but no extreme pain.","assessmentAndPlan":"Diagnosis points to a viral infection, given the presentation of fever, headaches, and muscle pain. Meningitis and other serious conditions have been ruled out. The treatment plan includes symptomatic relief with acetaminophen for fever and pain. Kelvin should remain hydrated and rest. No antibiotics are prescribed as this is a viral, not bacterial, infection.","patientInstructions":"Kelvin is advised to continue taking acetaminophen for headache and fever and to ensure adequate hydration and rest. He should monitor for any worsening of symptoms or the appearance of new symptoms. If symptoms persist or worsen, Kelvin should seek further medical evaluation. Additionally, he is advised to receive a flu vaccine at a later date.","patientName":"Kelvin Corsami"}