🩺 Record Detail

Patient Info

Name: Rajit Kapoor
Age: 42 years
Date: 2025-05-01 04:56:16

Transcript

[00:00 → 00:05] Good morning, can we please confirm your name at age before we begin?
[00:05 → 00:08] Sure, I am Rajit Kapoor 42 years old.
[00:08 → 00:10] Thanks Rajit, what brings you in today?
[00:10 → 00:14] I have been having this dull pain in my lower back for the past three days.
[00:14 → 00:17] It started after I lifted some 3 boxes while moving.
[00:17 → 00:20] On a scale of 1 to 10, how severe is the pain?
[00:20 → 00:23] I'd say around 6, it's worse in the mid-morning.
[00:23 → 00:27] Are you being going down your legs or just in the lower back?
[00:27 → 00:29] No, it's only in the lower back.
[00:29 → 00:32] Any fever, appetite change and fatigue?
[00:32 → 00:36] No fever or appetite issues, just feeling stiff.
[00:36 → 00:39] Any past back injuries or similar episodes?
[00:39 → 00:42] No, though I do sit a lot, I'm a software developer.
[00:42 → 00:48] Alright, I will just check your posture and flexibility quickly.
[00:48 → 00:52] You got some mild stiffness, but no neurological signs.
[00:52 → 00:58] I will recommend you rest and use a hot compression and take paracetamol as needed.
[00:58 → 01:04] If this persists beyond a week, we will get a amarieter.
[01:04 → 01:05] Sounds good.
[01:05 → 01:06] Thank you.
[01:06 → 01:07] Thank you very much.
[01:07 → 01:09] I'm going to lift and prolong sitting without break.

Clinical Notes

Subjective

  • Patient: Rajit Kapoor, 42 years old.

  • Primary Concern: Dull pain in the lower back for the past three days, started after lifting boxes while moving. Pain severity around 6, worse in the mid-morning.

  • Symptoms:

    • Pain localized to the lower back.
    • Feeling stiff, no fever, appetite changes, or fatigue.
    • No previous back injuries or similar episodes.

  • Occupation: Software developer, reports prolonged sitting.

Objective

  • Physical Examination:
    • Mild stiffness noted, no neurological signs observed.

Assessment

  1. Acute Back Pain:
    • Likely musculoskeletal in nature, related to recent lifting activity and prolonged sitting.

Plan

  1. Treatment:

    • Recommend rest, hot compression, and paracetamol for pain relief.
    • Advise to avoid lifting and prolonged sitting without breaks.

  2. Follow-Up:

    • If symptoms persist beyond a week, consider further evaluation with an amarieter.
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