🩺 Record Detail

Patient Info

Name: Anuji
Age: 52 years
Date: 2025-07-19 22:26:18

Transcript

[00:00 → 00:10] Hi doctor, my name is Anuji, I am 52 years of age, I came with, you know, this is a lot
[00:10 → 00:18] of breathlessness issue I have for last 3-4 days, and I have some blood pressure this
[00:18 → 00:26] day, and also, you know, under the feverish for the last 2 days with some cough as well
[00:26 → 00:33] as some respiratory problem. So, okay, so you are recommending me to take a moxucleic
[00:33 → 00:39] lean as antibiotic and paracetamol, okay, so can you just prescribe these things so that
[00:39 → 00:43] I can buy from the doctor or from the pharmacist, okay, thank you doctor.

Clinical Notes

Subjective

  • Patient: Anuji, 52 years old.

  • Primary Concern: Presenting with breathlessness for the last 3-4 days, high blood pressure today, fever for the last 2 days, cough, and respiratory issues.

  • Medications: Doctor recommended moxuclean as an antibiotic and paracetamol.

Objective

  • No objective data provided.

Assessment

  1. Respiratory Infection: Symptoms of fever, cough, and respiratory issues suggest a possible respiratory infection.

  2. Hypertension: High blood pressure reported today.

Plan

  1. Medications:

  2. Prescribe moxuclean as an antibiotic and paracetamol for symptom management.

  3. Follow-Up:

  4. Advise the patient to follow up after taking the prescribed medications for reevaluation.

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