🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-07-24 12:19:03

Transcript

<p><strong>Doctor</strong>: The patient is an old case of CAD having filed a cold cough since the last 5 days. Medicine advised that as it am all 650 for 5 days, twice daily. As it reminds me twice daily for 5 days. The cold cold cough for 5 days, twice daily. It's CBC and the urine keratinum done for a lot of after 5 days. The patient is non-case of CAD and hypertension. The patients have not prescribed, but we will see and check after the tests are done. But how to proceed with the further actions.</p><p><strong>Patient</strong>: Patient has also explained that he is facing issues in seeing the vision.</p>

Clinical Notes

Subjective

  • Patient: Old case of CAD with a cold cough for the last 5 days.

  • Primary Concern: Cold cough for 5 days, twice daily.

  • Additional Symptoms: Issues with vision.

  • Medical History: Non-case of CAD and hypertension.

Objective

  • Medical History: CAD and hypertension.

Assessment

  1. Upper Respiratory Tract Infection: Cold cough symptoms for the last 5 days.

  2. Vision Issues: Patient reported facing vision problems.

Plan

  1. Medication:

  2. Prescribe Amoxicillin 650 mg twice daily for 5 days.

  3. Investigations:

  4. Order CBC and urine keratin test after 5 days to assess the condition.

  5. Follow-Up:

  6. Reevaluate the patient after test results to determine further actions regarding the vision issues.
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