Patient Electronic Health Records
Amit Verma • 34 yrs, Male • Phone: +919811223344
Blood Group
A+
Total Visits
1 Visits
Known Allergies
Penicillin
Chronic Conditions
Allergic Rhinitis
Clinical Case History (1 Visits)
Visit #1
08 Sep 2026, 10:54 AM
In person
Complaint:
Fever and throat pain for 3 days
Blood Pressure
120/80 mmHg
Pulse Rate
78 bpm
Temperature
99.8 F °F
Oxygen (SpO2)
98%%
S - Subjective (Patient Narrative)
Patient reports moderate fever starting 3 days ago accompanied by dry cough, throat irritation, and mild body ache. No shortness of breath.
O - Objective (Physical Exam)
Throat congested, erythematous tonsils without exudate. Chest clear on auscultation.
A - Assessment & Diagnosis
Acute Viral Upper Respiratory Tract Infection (URTI) with Pharyngitis
P - Treatment Plan & Advice
Hydration, warm saline gargles, antipyretics and antihistamines. Review if fever persists past 5 days.
Prescriptions (2)
View / Print Rx
Paracetamol
Tablet
• Take 1 tablet when body temperature exceeds 99.5F, max 3 times a day.
1-0-1 (SOS for fever)
3d (after food)
Levocetirizine + Montelukast
Tablet
• Take at night before sleep.
0-0-1
5d (bedtime)
Attached Care Instructions Leaflets (1)
📄 Warm Salt Water Gargles 3 Times A Day. Adequate Rest.