🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-07-24 12:16:29

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.

  • Medication History: Prescribed Amoxicillin 650 mg for 5 days, twice daily.

  • Complaints: Patient experiencing vision issues.

Objective

  • Medical History: CAD and hypertension.

  • Tests: CBC and urine keratin done, awaiting results.

Assessment

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

  2. Vision Issues: Patient reports difficulties with vision.

Plan

  1. Follow-Up:

    • Await test results to guide further treatment decisions.

    • Evaluate vision issues and consider appropriate referrals if needed.

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