🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-07-21 05:55:19

Transcript

[00:00 → 00:15] Patient Rajesh is having symptoms of vital fever, cold and cough, pain seldom and fever
[00:15 → 00:19] responding to parisitamol.
[00:19 → 00:26] Temperature rises to 102 degree Fahrenheit in the evening.
[00:26 → 00:48] It is feeling busy and contains body ache, investigations advised, CBC blood test and
[00:48 → 01:05] also medications to be provided parisitamol 650 twice daily for 5 days, augmenting 625 twice
[01:05 → 01:17] daily for 6 days, patient is advised to follow after one week, also it is advised to monitor
[01:17 → 01:24] for temperature, if the fever rises then only take parisitamol 625.

Clinical Notes

Subjective

  • Patient: Rajesh

  • Symptoms:

  • Vital fever, cold, cough, occasional pain, and fever.
  • Fever responds to paracetamol.
  • Temperature rises to 102 degrees Fahrenheit in the evening.
  • Feeling busy and experiencing body aches.

Objective

  • Medical History:
  • Symptoms of vital fever, cold, cough, occasional pain, and fever.
  • Temperature rises to 102 degrees Fahrenheit in the evening.

  • Investigations advised: CBC blood test.

  • Medications:

  • Paracetamol 650 mg twice daily for 5 days.
  • Augmentin 625 mg twice daily for 6 days.

Assessment

  1. Upper Respiratory Tract Infection:

  2. Presenting with symptoms of cold, cough, and fever.

  3. Body Aches:

  4. Experiencing body aches along with other symptoms.

Plan

  1. Medications:
  2. Continue paracetamol 650 mg twice daily for 5 days.

  3. Start Augmentin 625 mg twice daily for 6 days.

  4. Follow-Up:

  5. Advised to follow up after one week.
  6. Monitor temperature regularly.
  7. Take paracetamol 625 mg only if the fever rises.
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