🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-07-21 05:07:00

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 headaches and severe back pain.

Objective

  • No objective data provided.

Assessment

  1. Fever with Seizures: Presenting symptoms include fever and seizures.

  2. Headache and Back Pain: Experiencing headache and severe back pain.

Plan

  1. Symptomatic Treatment:

    • Continue paracetamol for fever management.
    • Monitor seizure activity.
    • Consider additional pain management for headache and back pain.
    • Evaluate response to rest advice for C-A-D.

  2. Further Evaluation:

    • Consider imaging or further investigations to assess the cause of back pain.
    • Monitor for any changes in symptoms and overall condition.
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