🩺 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.
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, likely due to nerve involvement from cancer spreading.
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Experiences hallucinations, mostly at night, seeing people in her room or hearing voices calling her name.
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Objective
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Medical History:
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Current pain management requires adjustment.
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No specific mention of current medications in the transcript.
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Behavioral Observations:
- Patient expresses significant distress due to pain and hallucinations.
Assessment
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Nerve Pain: Likely due to cancer spreading, causing sharp, burning pain in the left hand.
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Hallucinations: Occurring mostly at night, causing significant distress.
Plan
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Pain Management:
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Adjust current pain medication.
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Add a nerve pain reliever, such as gabapentin, to address the burning sensation.
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Mental Health Support:
- Further evaluate the cause of hallucinations and consider appropriate interventions.
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Follow-Up:
- Schedule a follow-up appointment to assess the effectiveness of medication adjustments and address any ongoing concerns.
Medications | Name | Brand | Dosage | Frequency | Duration (Days) | |---------------|-------|----------|-----------------------------------------|-----------------| | Gabapentin | – | unspecified | unspecified | unspecified | | - | – | unspecified | unspecified | unspecified | | | – | unspecified | unspecified | unspecified |