DR. MD.

MOTLABUR RAHMAN
Medicine Specialist
Associate Professor, Medicine Dept.
Dhaka Medical College & Hospital, Dhaka

Name: Md Rezwanul Haque Visit ID: 11137

Age: 27 Gender: Male Visit Date: 15.06.2023

History

Symptoms started 03 days ago. Patient took paracetamol and antihistamine with benefit.

Constitutional: Positive for fevers and chills.

Skin: Negative for rash, erythema, lesions.
ENT: Positive for for rhinorrhea.
Respiratory: Positive for severe productive cough with thick and yellow phlegm. Negative for dyspnea, orthopnea.
Gastrointestinal: Positive for abdominal pain, nausea, vomiting, Negative for diarrhea, constipation.
Genitourinary: Negative for dysuria, hematuria, retention, urinary frequency,
hesitancy, genital lesions, dyspareunia.

Family Histiry: no sick contact.

Socio-Eonomic History: resides in Green road Dhaka.

Vital
Pulse: 90/ min RR: 24/ min Temp: 100.8 F Weight: 80 KG Height: 192 cm

Physical Examination

Heart- normal, s1 s2 audible, no added sounds.

Lungs - bilateral basal crepitations with occasional rhonchi on both lungs.
Abdomen: Soft, non-tender, normal bowel sounds, no organomegaly, and no masses.

Diagnosis
The patient is diagnosed with Upper Respiratory Tract Infection or URI.

Medicines
azithromycin 500 mg 0+0+1 for 7 days
Napa Extra 500 + 65 mg PNR for fever
Basokof Syrup 15ml 1+0+1 for 7 days
Alarid 1+0+1 for 7 days

Advised, warm liquids with steam inhalation for nasal congestion.

Avoid School/College/Office/Public Transport for minimum 3 days.
Call/Re-visit, if symptoms do not resolve in 2-3 days.

BANGLADESH SPECIALIZED HOSPITAL