🩺 Record Detail
Patient Info
Transcript
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<tbody><tr><td id="fragmentid_1"><div><p><strong class="Doctor">Doctor</strong>: The patient is a case of acute fibrile illness and having stomach ache from last 8 days also having constipation since last 4 days fever is responding to parasitamol body temperature goes up to 103 degrees Celsius in the evening.</p></div></td></tr></tbody>
Clinical Notes
Clinical Notes
Doctor: DOCTOR_NAME
Patient: PATIENT_NAME
Date: SESSION_DATE
Symptoms:
Chief Complaints:
- Acute fibrile illness
- Stomach ache for the last 8 days
- Constipation for the last 4 days
- Fever responding to parasitamol, with body temperature rising up to 103 degrees Celsius in the evening
Findings:
General Examination Findings:
- Acute fibrile illness
- Stomach ache
- Constipation
- Fever
Medical History:
History of present illness:
- Patient experiencing stomach ache for 8 days
- Constipation for 4 days
- Fever responding to parasitamol
Medicines:
Prescribed Medicines:
- Parasitamol
Diagnosis:
Diagnosis after General examination:
- Acute fibrile illness
Investigation:
Advised Investigations:
- None
Instruction:
General Instructions related to Medication and Diet, Exercise:
- Continue taking parasitamol as prescribed
- Maintain hydration
- Follow up if symptoms persist or worsen
Follow up:
Date/Notes:
- Follow up in 3 days for reassessment and further management