🩺 Record Detail
Patient Info
Transcript
Doctor: Patient Rajesh is a case of acute febrile illness, having fever, cold, cough from last 5 days. Medication advised, paracetamol, moxiforce CV for 5 days, twice daily, follow-up after 5 days.
Clinical Notes
Subjective
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Patient: PATIENT_NAME, unspecified age.
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Primary Concern: Acute febrile illness.
- Experiencing fever, cold, and cough for the last 5 days.
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Family History:
- Not specified.
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Lifestyle Factors:
- Not specified.
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Reproductive History:
- Not specified.
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Psychosocial Stressors:
- Not specified.
Objective
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Medical History:
- Not specified.
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Behavioral Observations:
- Not specified.
Assessment
- Acute Febrile Illness: Symptoms include fever, cold, and cough persisting for 5 days.
Plan
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Diagnostics:
- Not specified.
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Lifestyle Modifications:
- Not specified.
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Workplace Support:
- Not specified.
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Mental Health Support:
- Not specified.
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Follow-Up:
- Schedule a follow-up appointment after 5 days to reassess symptoms and recovery progress.
Medications | Name | Brand | Dosage | Frequency | Duration (Days) | |---------------|-------|----------|-----------------------------------------|-----------------| | Paracetamol | – | unspecified | unspecified | unspecified | | Moxiforce CV | – | unspecified | Twice daily | 5 | | | – | unspecified | unspecified | unspecified |