🩺 Record Detail
Patient Info
Transcript
Doctor: Good morning, Mrs. Sharma. It's good to see you again. How have you been feeling since our last session? Patient: Good morning. Honestly, not great. The pain in my left hand has gotten worse. It's sharp, constant, and sometimes it feels like it's burning from the inside. And, I don't know how to say this. I've started seeing things that aren't there. Doctor: I'm really sorry to hear that. Let's take things one at a time. About the hand pain that's likely due to nerve involvement from the cancer spreading. I'll adjust your pain medication and add a nerve pain reliever. Something like gabapentin may help ease that burning sensation. Patient: Thank you.
Clinical Notes
Subjective
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Patient: Mrs. Sharma
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Primary Concern: Worsening pain in the left hand and hallucinations.
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Reports sharp, constant pain with a burning sensation in the left hand.
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Experiencing visual hallucinations.
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Objective
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Medical History:
- Pain likely due to nerve involvement from cancer spreading.
Assessment
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Nerve Pain: Likely due to cancer spreading, causing sharp and burning sensations.
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Hallucinations: New symptom, requires further investigation.
Plan
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Medications:
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Adjust current pain medication.
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Add gabapentin to address nerve pain and burning sensation.
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Diagnostics:
- Investigate the cause of hallucinations.
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Follow-Up:
- Schedule a follow-up appointment to reassess pain management and hallucination symptoms.
Medications | Name | Brand | Dosage | Frequency | Duration (Days) | |---------------|-------|----------|-----------------------------------------|-----------------| | Gabapentin | – | unspecified | unspecified | unspecified | | - | – | unspecified | unspecified | unspecified | | | – | unspecified | unspecified | unspecified |