Care made simple.

Reason for Visit

Fever and sore throat for the past 3 days.

Clinical Notes

Patient reports intermittent fever associated with painful swallowing and a mild dry cough. Denies shortness of breath, chest pain, or wheezing. Appetite is slightly reduced, though fluid intake remains adequate. No significant medical history relevant to the current illness.

Assessment

Likely viral upper respiratory tract infection (URTI) with no signs of bacterial infection or respiratory distress.

Prescription

Paracetamol 650 mg — 1 tablet when required for fever (max 3 times daily) · 5 days

Cetirizine 10 mg — 1 tablet at bedtime · 5 days

Benzocaine + Menthol lozenges — 1 lozenge every 4–6 hours as needed · 5 days

Advice

Drink plenty of warm fluids.

Warm saltwater gargles 3–4 times a day.

Get adequate rest and eat soft, nutritious foods.

Wear a mask and avoid close contact while symptomatic.

Follow-up

Review if fever persists beyond 5 days, symptoms worsen, breathing becomes difficult, or swallowing fluids becomes hard. Otherwise no routine follow-up needed.

Reason for Visit

Fever and sore throat for the past 3 days.

Clinical Notes

Patient reports intermittent fever associated with painful swallowing and a mild dry cough. Denies shortness of breath, chest pain, or wheezing. Appetite is slightly reduced, though fluid intake remains adequate. No significant medical history relevant to the current illness.

Assessment

Likely viral upper respiratory tract infection (URTI) with no signs of bacterial infection or respiratory distress.

Prescription

Paracetamol 650 mg — 1 tablet when required for fever (max 3 times daily) · 5 days

Cetirizine 10 mg — 1 tablet at bedtime · 5 days

Benzocaine + Menthol lozenges — 1 lozenge every 4–6 hours as needed · 5 days

Advice

Drink plenty of warm fluids.

Warm saltwater gargles 3–4 times a day.

Get adequate rest and eat soft, nutritious foods.

Wear a mask and avoid close contact while symptomatic.

Follow-up

Review if fever persists beyond 5 days, symptoms worsen, breathing becomes difficult, or swallowing fluids becomes hard. Otherwise no routine follow-up needed.