🩺 Record Detail
Patient Info
Name: Unknown
Age: Unknown
Date: 2025-09-10 07:37:47
Transcript
Doctor: Patient Ritesh is a case of acute febrile illness since last 5 days, having cold, cough and fever since last 5 days, on medication paracetamol 650 twice daily, moxiforce CV twice daily for 5 days, advised rest, advised investigation LFT, KFT and CBC follow up after 5 days.
Clinical Notes
Subjective
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Patient: Ritesh, age unspecified.
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Primary Concern: Acute febrile illness.
- Experiencing cold, cough, and fever for the past 5 days.
Objective
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Medical History:
- Currently on paracetamol 650 mg twice daily and Moxiforce CV twice daily for 5 days.
Assessment
- Acute Febrile Illness: Likely viral or bacterial infection given symptoms of cold, cough, and fever.
Plan
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Diagnostics:
- Conduct Liver Function Test (LFT), Kidney Function Test (KFT), and Complete Blood Count (CBC).
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Lifestyle Modifications:
- Advise rest to support recovery.
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Follow-Up:
- Schedule a follow-up appointment in 5 days to review test results and assess recovery progress.
Medications | Name | Brand | Dosage | Frequency | Duration (Days) | |---------------|------------|----------|-----------------------------------------|-----------------| | Paracetamol | – | 650 mg | Twice daily | 5 | | Moxiforce CV | – | unspecified | Twice daily | 5 | | | – | unspecified | unspecified | unspecified |