🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-07-21 05:06:56

Transcript

[00:00 → 00:13] The patient is having fever with seizures and is a known case of C-A-D and rest advice for one week.
[00:15 → 00:23] The fever is responding to paracetamol and the patient is also having headache and severe
[00:23 → 00:24] pain in the back.

Clinical Notes

Subjective

  • Patient: Presenting with fever, seizures, headache, and severe back pain.

  • Medical History:

    • Known case of Coronary Artery Disease (C-A-D).
    • Advised rest for one week.

  • Symptoms:

    • Fever responding to paracetamol.
    • Experiencing headache and severe back pain.

Objective

  • No objective data provided.

Assessment

  1. Fever with Seizures:
  2. Fever responding to paracetamol.

  3. Seizures reported.

  4. Headache:

  5. Present along with other symptoms.

  6. Severe Back Pain:

  7. Reported by the patient.

  8. Coronary Artery Disease (C-A-D):

  9. Known medical history.

Plan

  1. Symptomatic Treatment:
  2. Continue paracetamol for fever.
  3. Monitor and manage seizures.

  4. Address headache and back pain with appropriate medications.

  5. Further Evaluation:

  6. Consider additional investigations to assess the cause of fever, seizures, headache, and back pain in the context of C-A-D.

  7. Follow-Up:

  8. Schedule a follow-up appointment to review response to treatment and adjust management accordingly.
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