🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-06-28 03:28:29

Transcript

[00:00 → 00:08] So what can I do for you today? Well, I seem to have a very sore back and also a sore throat.
[00:08 → 00:22] Oh, I'm sorry to hear that. Um, what, uh, when did this all start? Well, the sore throat started about three days ago when they sore back about, uh, I don't know, about, uh, two weeks ago.
[00:22 → 00:30] Oh, so what happened when you hurt your back? Well, I just twisted it because I was carrying something very heavy.
[00:30 → 00:38] Oh, okay, and what about the sore throat? Well, I just started getting sore throat a few days ago.
[00:38 → 00:44] Not much else to say. I was smoking heavily at the time.
[00:44 → 00:52] Oh, and so as far as your back goes, um, what, what makes it worse? Well, if I lean forward, it hurts more.
[00:52 → 00:57] Oh, really? What about when you lean backward? Um, no, it doesn't hurt to really at all.
[00:57 → 01:04] And I also get tingling in my left leg. Oh, really? And what about, does any pain go into the left leg?
[01:04 → 01:10] Yeah, it goes in the left leg. It goes up my back and across the side and up to my neck.
[01:10 → 01:18] Well, and that's also where my sore throat goes like into my neck and down my back and into my toes.
[01:18 → 01:23] Well, that sounds very serious. Yes. Well, let me take a look at you. I'm just going to examine your throat.
[01:23 → 01:28] It does not look great. There's no pus. It looks pretty good. I don't know, let's examine your back.
[01:28 → 01:35] You have seen to have full range of motion. Does any of that hurt? No, it actually seems to be much better.
[01:35 → 01:46] Well, I would suggest that we put you on some anti-inflammatory medication. I'm in the right of prescription for nappers and 500 milligrams TID.
[01:46 → 01:53] And that should help with both of those problems. Oh, that sounds really good. But if it doesn't help, then you come back and see me.
[01:53 → 02:00] And otherwise, I think I'm due to see you in about three weeks for your B12 injection. Yes, that's true.
[02:00 → 02:03] Okay, but we'll see you then. Okay, bye.

Clinical Notes

Subjective

  • Patient: Complains of a sore back and a sore throat.

  • Sore throat started three days ago, while the sore back began about two weeks ago after twisting it while carrying something heavy.

  • Mentioned heavy smoking at the time of symptoms.

  • Symptoms:

  • Pain worsens when leaning forward.

  • Reports tingling in the left leg, with pain radiating up the back, across the side, up to the neck, and down to the toes.

Objective

  • Physical Examination:

  • Throat examination showed no pus, appears good.

  • Full range of motion observed in the back without pain.

  • Medication:

  • Prescribed naproxen 500mg TID for anti-inflammatory effect.

Assessment

  1. Musculoskeletal Pain:

  2. Sore back likely due to heavy lifting, with pain exacerbated by forward bending.

  3. Radiating pain and tingling in the left leg suggest possible nerve involvement.

  4. Sore Throat:

  5. Recent onset, associated with heavy smoking.

Plan

  1. Treatment:

  2. Initiate naproxen 500mg TID for pain relief and anti-inflammatory effects.

  3. Follow-Up:

  4. Advise patient to return if symptoms persist.

  5. Scheduled follow-up in three weeks for B12 injection.

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