Vitals
Recorded by Nursing at 09:15Height162 cm
Weight58 kg
BMI22.1
BP160/92 mmHg Elevated
Pulse88 bpm
Temp37.1°C
SpO298%
Resp. Rate18/min
Documentation
Diagnosis
| ICD Code | Description | Type | Rank |
|---|---|---|---|
| J06.9 | Acute upper respiratory infection, unspecified | Provisional | Primary |
| E11.9 | Type 2 diabetes mellitus without complications | Final | Secondary |
e-Prescription
Allergy interaction warning.
Amoxicillin belongs to the Penicillin group — this patient has a documented Penicillin allergy. Overriding requires a doctor-level reason.
| Drug | Dose | Route | Frequency | Duration | Qty |
|---|---|---|---|---|---|
| Amoxicillin 500mg | 1 tab | Oral | TDS | 5 days | 15 |
| Paracetamol 500mg | 1 tab | Oral | PRN | 5 days | 10 |
| Cetirizine 10mg | 1 tab | Oral | OD | 5 days | 5 |