🩺 Record Detail
Patient Info
Transcript
Doctor: Patient is a case of acute febrile illness, having cold, cough and fever since last 5 days. Taking medicines Paracetamol 650 twice daily. After food for 5 days. AZ 500 daily once for 5 days. Moxiforce CV 650 twice daily for 5 days. After food investigation advised. LFT, KFT, CBC follow up after 5 days. Instructions avoid hot, chilly, cold food. Take liquid diets and take regular rest. Visit www.FEMA.gov
Clinical Notes
Subjective
-
Patient: PATIENT_NAME
-
Primary Concern: Acute febrile illness.
- Symptoms include cold, cough, and fever for the past 5 days.
Objective
-
Medical History:
- Currently taking Paracetamol 650 mg twice daily, AZ 500 mg once daily, and Moxiforce CV 650 mg twice daily for 5 days.
-
Behavioral Observations:
- No specific behavioral observations noted.
Assessment
- Acute Febrile Illness: Symptoms consistent with viral or bacterial infection.
Plan
-
Diagnostics:
- Conduct LFT, KFT, and CBC tests.
-
Lifestyle Modifications:
-
Avoid hot, chilly, and cold foods.
-
Maintain a liquid diet and ensure regular rest.
-
-
Follow-Up:
- Schedule a follow-up appointment after 5 days to review test results and symptoms.
Medications | Name | Brand | Dosage | Frequency | Duration (Days) | |---------------|-------|----------|-----------------------------------------|-----------------| | Paracetamol | – | 650 mg | Twice daily after food | 5 | | AZ | – | 500 mg | Once daily | 5 | | Moxiforce CV | – | 650 mg | Twice daily after food | 5 |