🩺 Record Detail
Patient Info
Transcript
Doctor: Patient Rajesh is a case of acute febrile illness, having cold and fever since last five days, responding to paracetamol, on medication, having paracetamol twice daily, Moxiforce CV twice daily, azithromycin 500 twice daily, advised rest, investigation advised, CBC, LFT, KFT, not to stop medicine, follow up after five days.
Clinical Notes
Subjective
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Patient: Rajesh, age unspecified.
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Primary Concern: Acute febrile illness.
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Experiencing cold and fever for the past five days.
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Responding to paracetamol.
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Objective
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Medical History:
- Currently on medication: paracetamol, Moxiforce CV, and azithromycin 500.
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Behavioral Observations:
- Advised to rest.
Assessment
- Acute Febrile Illness: Symptoms include cold and fever, responding to paracetamol.
Plan
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Diagnostics:
- Conduct CBC, LFT, and KFT tests.
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Medication Management:
- Continue current medications: paracetamol, Moxiforce CV, and azithromycin 500.
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Follow-Up:
- Schedule a follow-up appointment in five days.
Medications | Name | Brand | Dosage | Frequency | Duration (Days) | |---------------|--------------|----------|-----------------------------------------|-----------------| | Paracetamol | – | unspecified | Twice daily | unspecified | | Moxiforce CV | – | unspecified | Twice daily | unspecified | | Azithromycin | – | 500 mg | Twice daily | unspecified |