🩺 Record Detail

Patient Info

Name: Rajat Kapoor
Age: 42 years
Date: 2025-05-01 05:41:29

Transcript

[00:00 → 00:06] Good morning, can you please confirm your name and age before we begin?
[00:06 → 00:08] Sure, I am Rajat Kapoor 42 years old.
[00:08 → 00:11] Thanks Rajat, what's bringing you in today?
[00:11 → 00:14] I have been having this doubt in my lower back for the past few days.
[00:14 → 00:18] It started after I lifted some heavy boxes while moving.
[00:18 → 00:21] On a scale of 1 to 10, how severe is the pain?
[00:21 → 00:24] I'd say around 6 is the worst in the mornings.
[00:24 → 00:27] Any pain going down your legs or just in the lower back?
[00:27 → 00:29] No, it's only in the lower back.
[00:29 → 00:34] Any fever, fatigue, appetite change or fatigue?
[00:34 → 00:37] No fever or appetite issues, just feeling stiff.
[00:37 → 00:40] Any fast back injuries or similar episodes?
[00:40 → 00:44] No, though I do say a lot, I am a software developer.
[00:44 → 00:47] All right, I will just check your posture and flexibility, cupping.
[00:49 → 00:52] You have got mild stiffness and neurological signs.
[00:52 → 00:56] I will recommend you less and use a hot compress
[00:56 → 00:59] and take parasitamol as needed.
[00:59 → 01:03] If this preserves beyond a week, we will get a mariner.
[01:03 → 01:05] Sounds good, thank you.
[01:05 → 01:10] Take care, Rajat, and avoid lifting your hands sitting with face.

Clinical Notes

Subjective

  • Patient: Rajat Kapoor, 42 years old.

  • Primary Concern: Doubt in lower back for the past few days, started after lifting heavy boxes while moving.

  • Pain: Rated pain as around 6 out of 10, worse in the mornings.

  • Symptoms:

    • Pain localized to the lower back.
    • Feeling stiff, no fever, fatigue, or appetite changes.

  • Occupation: Software developer.

Objective

  • Physical Examination:
    • Mild stiffness and neurological signs observed.
    • Posture and flexibility checked.

Assessment

  1. Acute Back Pain:
    • Likely due to lifting heavy boxes, with mild stiffness and neurological signs.

Plan

  1. Treatment:

    • Recommend rest, use of hot compress, and taking paracetamol as needed.
    • Advise avoiding lifting heavy objects and maintaining proper posture.

  2. Follow-Up:

    • If symptoms persist beyond a week, consider further evaluation with imaging (MRI).

  3. Education:

    • Educate on proper lifting techniques and ergonomics to prevent future episodes.

  4. Symptom Monitoring:

    • Instruct to monitor pain levels and any new symptoms for follow-up assessment.
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