🩺 Record Detail
Patient Info
Transcript
<thead>
<tr>
<th><strong>Original Transcription</strong></th>
</tr>
</thead>
<tbody><tr><td id="fragmentid_1"><div><p><strong>Doctor</strong>: Good morning, Mrs. Sharma. It's good to see you again. How have you been feeling since our last session?</p></div></td></tr><tr><td id="fragmentid_2"><div><p><strong>Patient</strong>: 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.</p></div></td></tr><tr><td id="fragmentid_3"><div><p><strong>Doctor</strong>: 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.</p></div></td></tr><tr><td id="fragmentid_4"><div><p><strong>Patient</strong>: Thank you. That pain has been unbearable at times.</p></div></td></tr><tr><td id="fragmentid_5"><div><p><strong>Doctor</strong>: I can imagine. Now, about the hallucinations are you seeing or hearing things? And how often does it happen?</p></div></td></tr><tr><td id="fragmentid_6"><div><p><strong>Patient</strong>: 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.</p></div></td></tr><tr><td id="fragmentid_7"><div><p><strong>Doctor</strong>: That sounds distressing. It could be a side effect of the hydrosopioids 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 halopiridol. It should help manage the hallucinations.</p></div></td></tr><tr><td id="fragmentid_8"><div><p><strong>Patient</strong>: Thank you, doctor. It's just been so hard. I feel like I'm losing control.</p></div></td></tr><tr><td id="fragmentid_9"><div><p><strong>Doctor</strong>: 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.</p></div></td></tr><tr><td id="fragmentid_10"><div><p><strong>Patient</strong>: I'm grateful for that, really.</p></div></td></tr></tbody>
Clinical Notes
Patient Information - Patient Name: Mrs. Sharma - Age: N/A - Gender: Female - Contact Number: N/A - Date of Visit: N/A
Chief Complaint / Reason for Visit Mrs. Sharma presents with worsening left hand pain and hallucinations.
Subjective Mrs. Sharma reports that the pain in her left hand has intensified, described as sharp, constant, and sometimes with a burning sensation. She also mentions experiencing hallucinations, mainly at night, seeing people in her room and hearing voices calling her name.
Objective N/A
Assessment 1. Left hand pain likely due to nerve involvement from cancer spreading. 2. Hallucinations, possibly a side effect of hydrosopioids or disease progression.
Plan 1. Adjust pain medication and add a nerve pain reliever like gabapentin for the hand pain. 2. Refer to palliative care psychiatrist for hallucinations. 3. Reduce opioid dosage slightly and introduce a low dose of halopiridol to manage hallucinations. 4. Monitor and adjust treatment to provide comfort and support to Mrs. Sharma.