🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-07-08 07:28:25

Transcript

[00:00 → 00:07] Dr. Amit Kashyap, Good Morning. Please have a seat. What brings you in today? Neeraj.
[00:07 → 00:15] Good Morning, Dr. Bas tabiyat Kuch thik Nai lag Rahi Hai. Kal se Bohot headache ho Rahi Hai,
[00:15 → 00:21] Aur sardi Bi Hai. Bukar Bi Aya tha raat ko. Dr. Amit Kashyap.
[00:23 → 00:26] I see. Since when exactly are you feeling like this?
[00:27 → 00:34] Neeraj. Kal subha se Hai He De Kshoru Ho Geya Thee, Parsham Ticket Nabad Geya Kiongong K
[00:34 → 00:41] Upper Dard Ho Rahi Thee. Todaviral Jai Salag Rahi Hai. Dr. Amit Kashyap.
[00:41 → 00:48] Okay. Arthand Lag Rahi Hai. Gail Kharap Hai Yaseer Phnak Ban Hai. Neeraj.
[00:49 → 00:58] Nocto Bilkul Ban Hai, Argaila Bi Toda Dard Khar Rahi Hai. Kasi Tonai Hai, Parwaz Bhari Hoga Yee Hai.
[00:58 → 01:08] Dr. amit Kashyap. Have you taken any medicine so far? Neeraj. Han, Ek krasandli Ti Kall Rahi Kho.
[01:08 → 01:15] Bukar Kham Hoga Eto Di Dhe Kali A, Parha De Khabi Bi Hai. Dr. Amit Kashyap.
[01:16 → 01:19] All right, let me check your temperature and blood pressure first.
[01:20 → 01:28] Check vitals. You've got mild fever, 99.8 degrees Fahrenheit, and BP is normal.
[01:28 → 01:32] Headache with blocked nose and fever usually points to viral fluya sinus pressure.
[01:33 → 01:41] Neeraj. Han, Ekkrasandli Ti Kshoru Ho Geya Kha. Dr. Amit Kashyap.
[01:41 → 01:48] That's sinus congestion most likely. Abhi Kali A, I'll prescribe you a decongestant,
[01:48 → 01:53] an anti-inflammatory medicine for headache, and a steam inhalation routine.
[01:53 → 02:00] Neeraj. Dr. Kia Antibiotic Leni Padagi. Dr. Amit Kashyap.
[02:01 → 02:08] 9. Neeraj, Viral Infections Main Antibiotic Kisarurut Nihoti. Yea Viral Hai, Rest,
[02:08 → 02:15] Hydration, Arsaheem Arasand Sevi Kho Jeya. Naraj. Ti Kha Doctor.
[02:15 → 02:23] Con Main Cooch Restriction Hai Kia. Dr. Amit Kashyap. Han, Dandapani, Dahi,
[02:23 → 02:31] Cold drinks Avoid Karo. Grampani Pio, Keech Di Yohalke Grampana Loh. R2-3 Dine Rest Loh.
[02:31 → 02:37] Neeraj. Are Compiana safe high? Dr. Amit Kashyap.
[02:38 → 02:44] 9. Viral Infection Contagious Hota Hai, Kamze Kam Tudin Garpi Rest Loh.
[02:44 → 02:50] A. Gar Symptoms Worsen Ho Jeyin, Jai Sabo Karbade Yusands Lina Main Ditt Ho,
[02:50 → 02:56] Then Call Me Immediately. Neeraj. Okay Doctor. Thank you so much.
[02:56 → 03:02] Dr. Amit Kashyap. You're welcome, Neeraj. Yea Prescription Lalo.
[03:03 → 03:09] Igar Tudin Main Farrick Nala Gaito Dovara Anna. Get well soon. Neeraj.
[03:10 → 03:13] Zarur, Doctor. Dunavad.

Clinical Notes

Subjective

  • Patient: Neeraj.

  • Primary Concern:

  • Feeling unwell with a headache, cold, and fever since yesterday.
  • Reports upper back pain and sinus pressure.

  • Taking a decongestant for the fever and headache.

  • Symptoms:

  • Headache, blocked nose, mild fever (99.8 degrees Fahrenheit).

  • Sinus congestion and pressure.

  • Medication History:

  • Taking a decongestant for symptoms.

Objective

  • Vitals:
  • Mild fever of 99.8 degrees Fahrenheit.

  • Blood pressure is normal.

  • Clinical Findings:

  • Symptoms suggestive of viral flu and sinus pressure.

Assessment

  1. Viral Infection: Likely causing the symptoms of headache, fever, and sinus congestion.

  2. Sinus Congestion: Present based on symptoms reported by the patient.

Plan

  1. Treatment:
  2. Prescribe a decongestant for sinus congestion.
  3. Recommend an anti-inflammatory medicine for headache.

  4. Advise a steam inhalation routine for relief.

  5. Medication:

  6. No antibiotics needed as viral infections do not require antibiotics.

  7. Emphasize rest, hydration, and symptomatic relief.

  8. Lifestyle Modifications:

  9. Restrict consumption of cold foods and drinks.

  10. Encourage warm fluids intake and rest for 2-3 days.

  11. Follow-Up:

  12. Instruct to monitor symptoms, and if they worsen, contact the doctor immediately.
  13. Provide prescription for current symptoms and advise to revisit if needed.
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