Free Medical Case Note Template
Medical Case Note
Prepared by: Ethan Harris,
StellarTech Dynamics
Date: November 28, 2050
Patient Presentation
The patient presented with symptoms consistent with influenza, including high fever, chills, cough, sore throat, runny or stuffy nose, muscle or body aches, headaches, and fatigue. The patient did not report travel history or contact with individuals known to have influenza.
Medical Assessment and Diagnosis
Upon initial assessment, the patient was engaged in differential diagnostic testing. Tested positive for influenza via the Rapid Influenza Diagnostic Test (RIDT). The patient was made aware of the diagnosis, and the contagious nature of the virus was explained.
Treatment Plan
The patient was prescribed a five-day course of antiviral medication to reduce both the severity and duration of the symptoms. Specifically, Oseltamivir (commonly known as Tamiflu) was recommended.
Advice and Follow-Up
The patient was advised to maintain adequate rest, hydration, and nutrition. In addition, the patient was instructed to avoid contact with others where possible to prevent further spread of the virus. A telehealth follow-up appointment was scheduled seven days post-diagnosis to monitor the patient's recovery.
Remarks:
The patient was generally in good health prior to influenza diagnosis and is expected to recover well with the prescribed treatment and rest. Case will be updated after the follow-up appointment.
