🩺 Record Detail
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{"type": "language", "data": "en"}
{"type": "transcription", "speaker": "Identifying", "segmentId": "76470b18-7b34-4232-9c7f-810a7c5e2e64", "text": "Doctor, good morning, Mrs. Sharma. It's good to see you again. How have you been feeling", "start": "00:00", "end": "00:06", "start_sec": 0.0, "end_sec": 6.88, "roman": "Doctor, good morning, Mrs. Sharma. It's good to see you again. How have you been feeling", "native": "Doctor, good morning, Mrs. Sharma. It's good to see you again. How have you been feeling", "nativeScript": "Latin", "romanDiffersFromNative": false}
{"type": "transcription", "speaker": "Identifying", "segmentId": "25568b5b-56ab-452b-96ed-028d6b9c5faa", "text": "since our last session? Patient, good morning, doctor. Honestly, not great. The pain in my", "start": "00:06", "end": "00:15", "start_sec": 6.88, "end_sec": 15.5, "roman": "since our last session? Patient, good morning, doctor. Honestly, not great. The pain in my", "native": "since our last session? Patient, good morning, doctor. Honestly, not great. The pain in my", "nativeScript": "Latin", "romanDiffersFromNative": false}
{"type": "transcription", "speaker": "Identifying", "segmentId": "d2286a42-6ad3-46dc-92a2-c12de2f7cc79", "text": "left hand has gotten worse. It's sharp, constant, and sometimes it feels like it's burning from", "start": "00:15", "end": "00:21", "start_sec": 15.5, "end_sec": 21.44, "roman": "left hand has gotten worse. It's sharp, constant, and sometimes it feels like it's burning from", "native": "left hand has gotten worse. It's sharp, constant, and sometimes it feels like it's burning from", "nativeScript": "Latin", "romanDiffersFromNative": false}
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{"type": "transcription", "speaker": "Identifying", "segmentId": "7482cfa8-a4cd-4f05-bb75-c69d22ba8df8", "text": "the inside. And I don't know how to say this. I've started seeing things that aren't there.", "start": "00:21", "end": "00:28", "start_sec": 21.44, "end_sec": 28.52, "roman": "the inside. And I don't know how to say this. I've started seeing things that aren't there.", "native": "the inside. And I don't know how to say this. I've started seeing things that aren't there.", "nativeScript": "Latin", "romanDiffersFromNative": false}
{"type": "transcription", "speaker": "Identifying", "segmentId": "7c26f133-6a2d-4d93-8bfc-654737d6f9ca", "text": "Doctor, I'm really sorry to hear that. Let's take things one at a time. About the hand", "start": "00:29", "end": "00:35", "start_sec": 29.36, "end_sec": 35.82, "roman": "Doctor, I'm really sorry to hear that. Let's take things one at a time. About the hand", "native": "Doctor, I'm really sorry to hear that. Let's take things one at a time. About the hand", "nativeScript": "Latin", "romanDiffersFromNative": false}
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{"type": "transcription", "speaker": "Identifying", "segmentId": "bafc2113-2e2b-40c6-a98b-2a9836b91a9a", "text": "pain that's likely due to nerve involvement from the cancer spreading. I'll adjust your", "start": "00:35", "end": "00:40", "start_sec": 35.82, "end_sec": 40.74, "roman": "pain that's likely due to nerve involvement from the cancer spreading. I'll adjust your", "native": "pain that's likely due to nerve involvement from the cancer spreading. I'll adjust your", "nativeScript": "Latin", "romanDiffersFromNative": false}
{"type": "transcription", "speaker": "Identifying", "segmentId": "02e205a6-eb3c-4c60-882a-03e08f8473be", "text": "pain medication and add a nerve pain reliever. Something like gabapentin may help ease that", "start": "00:40", "end": "00:46", "start_sec": 40.74, "end_sec": 46.22, "roman": "pain medication and add a nerve pain reliever. Something like gabapentin may help ease that", "native": "pain medication and add a nerve pain reliever. Something like gabapentin may help ease that", "nativeScript": "Latin", "romanDiffersFromNative": false}
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{"type": "transcription", "speaker": "Identifying", "segmentId": "19026cda-cb45-42a4-9431-d9b4889af03d", "text": "burning sensation. Patient, thank you. That pain has been unbearable at times. Doctor,", "start": "00:46", "end": "00:53", "start_sec": 46.22, "end_sec": 53.76, "roman": "burning sensation. Patient, thank you. That pain has been unbearable at times. Doctor,", "native": "burning sensation. Patient, thank you. That pain has been unbearable at times. Doctor,", "nativeScript": "Latin", "romanDiffersFromNative": false}
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{"type": "transcription", "speaker": "Identifying", "segmentId": "ff09497c-29e5-4946-920a-95fd5f605d18", "text": "I can imagine. Now, about the hallucinations are you seeing or hearing things? And how", "start": "00:54", "end": "01:00", "start_sec": 54.07, "end_sec": 60.8, "roman": "I can imagine. Now, about the hallucinations are you seeing or hearing things? And how", "native": "I can imagine. Now, about the hallucinations are you seeing or hearing things? And how", "nativeScript": "Latin", "romanDiffersFromNative": false}
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{"type": "transcription", "speaker": "Identifying", "segmentId": "83c848b0-fb81-4ae0-9133-efc2558c1a79", "text": "often does it happen? Patient, mostly at night. I sometimes see people in my room or hear", "start": "01:00", "end": "01:07", "start_sec": 60.8, "end_sec": 67.62, "roman": "often does it happen? Patient, mostly at night. I sometimes see people in my room or hear", "native": "often does it happen? Patient, mostly at night. I sometimes see people in my room or hear", "nativeScript": "Latin", "romanDiffersFromNative": false}
{"type": "transcription", "speaker": "Identifying", "segmentId": "a0ac1114-502b-43ca-83bd-ac2c5de91114", "text": "voices calling my name. I know they're not real, but it's terrifying. Doctor, that sounds", "start": "01:07", "end": "01:14", "start_sec": 67.62, "end_sec": 74.72, "roman": "voices calling my name. I know they're not real, but it's terrifying. Doctor, that sounds", "native": "voices calling my name. I know they're not real, but it's terrifying. Doctor, that sounds", "nativeScript": "Latin", "romanDiffersFromNative": false}
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{"type": "transcription", "speaker": "Identifying", "segmentId": "0ff38bc0-1936-4e95-8469-c3be3e975cb0", "text": "distressing. It could be a side effect of the high-dose opioids or just the progression", "start": "01:14", "end": "01:19", "start_sec": 74.72, "end_sec": 79.82, "roman": "distressing. It could be a side effect of the high-dose opioids or just the progression", "native": "distressing. It could be a side effect of the high-dose opioids or just the progression", "nativeScript": "Latin", "romanDiffersFromNative": false}
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{"type": "finalTranscript", "data": {"transcript": [{"speaker": "Doctor", "text": "Good morning, Mrs. Sharma. It's good to see you again. How have you been feeling since our last session?"}, {"speaker": "Patient", "text": "Good morning, doctor. 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."}, {"speaker": "Doctor", "text": "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."}, {"speaker": "Patient", "text": "Thank you. That pain has been unbearable at times."}, {"speaker": "Doctor", "text": "I can imagine. Now, about the hallucinations are you seeing or hearing things? And how often does it happen?"}, {"speaker": "Patient", "text": "Mostly at night. I sometimes see people in my room or hear voices calling my name. I know they're not real, but it's terrifying."}, {"speaker": "Doctor", "text": "That sounds distressing. It could be a side effect of the high-dose opioids or just the progression of the illness. I'll refer you to our palliative care psychiatrist. Meanwhile, I'll reduce your opioid slightly and introduce a low dose of haloperidol. It should help manage the hallucinations."}, {"speaker": "Patient", "text": "Thank you, doctor. It's just been so hard. I feel like I'm losing control."}, {"speaker": "Doctor", "text": "You're not alone, Mrs. Sharma. We're here to support you every step of the way. We'll keep monitoring and adjusting things to give you as much comfort and peace as possible."}, {"speaker": "Patient", "text": "I'm grateful for that, really."}], "speakers": {"Doctor": "Usually asks diagnostic questions or gives medical instructions", "Patient": "Usually describes symptoms or answers", "Family Member": "Third-party participant when contextually clear"}}, "isFinal": true}
Clinical Notes
Subjective
-
Patient: Mrs. Sharma
-
Primary Concern: Worsening pain and hallucinations.
-
Reports sharp, constant pain in the left hand, sometimes with a burning sensation, likely due to nerve involvement from cancer spreading.
-
Experiencing hallucinations, mostly at night, seeing people or hearing voices that are not real.
-
-
Family History: Not discussed.
-
Lifestyle Factors: Not discussed.
-
Reproductive History: Not discussed.
-
Psychosocial Stressors:
- Feels like losing control due to the pain and hallucinations.
Objective
-
Medical History:
- Current high-dose opioid use for pain management.
-
Behavioral Observations:
- Patient expresses significant distress and fear related to hallucinations and pain.
Assessment
- Cancer-related Pain: Likely due to nerve involvement from cancer spreading.
- Hallucinations: Possibly a side effect of high-dose opioids or progression of illness.
- Emotional Distress: Due to uncontrolled symptoms and fear of losing control.
Plan
-
Medication Adjustments:
- Adjust pain medication and add gabapentin for nerve pain relief.
- Reduce opioid dosage slightly and introduce a low dose of haloperidol to manage hallucinations.
-
Specialist Referral:
- Refer to palliative care psychiatrist for further evaluation and management of hallucinations.
-
Monitoring and Support:
- Continue to monitor symptoms and adjust treatment to provide comfort and peace.
- Provide emotional support and reassurance to the patient.
-
Follow-Up:
- Schedule follow-up to assess response to medication changes and overall comfort.
Medications | Name | Brand | Dosage | Frequency | Duration (Days) | |---------------|-------|----------|-----------------------------------------|-----------------| | Gabapentin | – | unspecified | unspecified | unspecified | | Haloperidol | – | low dose | unspecified | unspecified | | Opioid | – | reduced dose | unspecified | unspecified |