🩺 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, 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. 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. That pain has been unbearable at times. Doctor: I can imagine. Now, about the hallucinations are you seeing or hearing things? And how often does it happen? Patient: 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. Doctor: 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. Patient: Thank you, doctor. It's just been so hard. I feel like I'm losing control. Doctor: 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. Patient: I'm grateful for that, really.
Clinical Notes
Wood Knee Consult
ref:43year old F
Past medical history:
- Medications: Gabapentin, Haloperidol
- Allergies- •NKDA
Social
- non-smoker
- minimal alcohol intake
- retired [ ]
HPI:
They state that they have had • years of • knee pain. They complain of stiffness and swelling in the morning. There [is][is not] significant night time pain. They are able to walk for [10] minutes on flat ground until they are limited by knee pain
Treatments tried
[Bracing]
[physio]
[Injections]
[Activity modification]
[weight loss]
OE
There are no skin changes.
ROM
Alignment
Ligaments are intact of the ACL/PCL/MCL/LCL
power •/5 in quadricep
distal neurovascular intact
Xray shows •
Imp/plan:
We had a lengthy discussion today with the patient today about both nonoperative and operative options for their • knee OA.
We answered all of his questions today. We reviewed the risks and benefits including but not limited to infection, hitting local structures, risk of DVT, PE, stroke, MI, death, fracture, patellar maltracking, dislocation, soft tissue irritation, swelling pain, numbness, crepitus, difficulty kneeling, stiffness as well as the rehabilitative protocol. They understood the risks and signed consent.