Hospital Visit 1
- Date: 12/03/2023
- Presenting Complaint: Fever and cough
- History of Present Illness: Fever for 3 days, cough with sputum production, no shortness of breath
- Physical Examination: Elevated temperature, mild wheezing on auscultation
- Diagnosis: Upper respiratory tract infection
- Treatment: Prescribed antibiotics and fever reducer, advised rest and hydration
- Follow-Up: In one week if symptoms persist
Hospital Visit 2
- Date: 25/06/2023
- Presenting Complaint: Abdominal pain and vomiting
- History of Present Illness: Sudden onset of abdominal pain, vomiting for the past 24 hours, no diarrhea
- Physical Examination: Tenderness in the lower abdomen, no rebound tenderness
- Diagnosis: Gastroenteritis
- Treatment: Oral rehydration solution, antiemetics, advised light diet
- Follow-Up: In three days or sooner if symptoms worsen
Hospital Visit 3
- Date: 14/09/2023
- Presenting Complaint: Rash and itching
- History of Present Illness: Rash developed over the past 2 days, associated itching, no fever