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Male · 45 yrs · DOB: 15 Jan 1980 · ABHA: 1234-5678-9012
10 Mar 2026
Dr. Neha Sharma · General Medicine · City Clinic
Chief Complaint
Fever (102°F) for 3 days, runny nose, mild body ache, fatigue.
Diagnosis
Doctor's Notes
Acute viral illness. Vitals stable. Lungs clear. Paracetamol SOS. Follow-up in 5 days.
Vitals Recorded
Follow-up
15 Mar 202628 Feb 2026
Dr. Priya Menon · Dermatology · Skin Wellness Clinic
Chief Complaint
Itchy red patches on forearms and neck for 2 weeks. Worsening at night.
Diagnosis
Doctor's Notes
Contact dermatitis. Skin patch test recommended. Antihistamine and topical steroid prescribed.
15 Feb 2026
Dr. Neha Sharma · General Medicine · City Clinic
Chief Complaint
Routine BP follow-up. Mild headache in mornings. No chest pain.
Diagnosis
Doctor's Notes
BP well controlled. Low-salt diet, 30 min walk daily. Continue Amlodipine 5mg.
Vitals Recorded
Follow-up
15 Mar 202601 Feb 2026
Dr. Arjun Kapoor · Cardiology · Heart Care Center
Chief Complaint
Annual cardiac check-up. Mild exertion dyspnea. No palpitations.
Diagnosis
Doctor's Notes
ECG normal sinus rhythm. Echo EF 60%. No valvular disease. Target weight 73kg.
Prescription — 10 Mar 2026
Dr. Neha Sharma · Reg: MH12345 · City Clinic
Medicines Prescribed
Paracetamol 500mg
1 tab · TID · After meals · 5 days
Cetirizine 10mg
1 tab · OD · Night · 5 days
Nasal Saline Drops
2 drops each nostril · BD · 7 days
Advice
Rest 3 days. Warm fluids. Steam inhalation BD. Return if fever > 103°F.
Prescription — 28 Feb 2026
Dr. Priya Menon · Reg: MH67890 · Skin Wellness
Medicines Prescribed
Hydroxyzine 25mg
1 tab · OD · Night · 10 days
Betamethasone Cream 0.05%
Thin layer on area · BD · 7 days
Long-term / Ongoing Medications
Metformin 500mg
1 tab · BD · After meals · Ongoing
Dr. Arjun Kapoor · Since Jan 2025
Amlodipine 5mg
1 tab · OD · Morning · Ongoing
Dr. Neha Sharma · Since Mar 2024
Recent Lab Reports
HbA1c Blood Test
08 Mar 2026 · Thyrocare
HbA1c: 6.8% — BorderlineLipid Profile
01 Mar 2026 · SRL
Cholesterol: 185 — NormalECG Report
01 Feb 2026 · Heart Care
Normal Sinus RhythmComplete Blood Count
20 Jan 2026 · Metropolis
All Values NormalThyroid Function Test
10 Jan 2026 · Thyrocare
TSH: 2.4 — NormalChest X-Ray
05 Jan 2026 · Apollo
No AbnormalityUpload New Report
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10 Mar 2026 · Viral Fever, URTI
3 medications prescribed
08 Mar 2026 · Thyrocare · HbA1c: 6.8%
28 Feb 2026 · Allergic Dermatitis
2 medications prescribed
15 Feb 2026 · BP Follow-up
01 Feb 2026 · Annual Cardiac Check-up
ECG Report attached
Jan 2025 — Metformin started for Type 2 Diabetes
Mar 2024 — Hypertension diagnosed. Amlodipine started.