🩺 Record Detail
Patient Info
Transcript
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<tbody><tr><td id="fragmentid_1"><div><p><strong class="Doctor">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 class="Patient">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 class="Doctor">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 class="Patient">Patient</strong>: Thank you. That pain has been unbearable at times.</p></div></td></tr><tr><td id="fragmentid_5"><div><p><strong class="Doctor">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 class="Patient">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 class="Doctor">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 class="Patient">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 class="Doctor">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 class="SPEAKER-01">SPEAKER-01:</strong> Something like gabapentin may help ease that</p></div></td></tr></tbody>
Clinical Notes
Patient Information • Patient Name: Mrs. Sharma • Date of Birth: N/A • Date of Visit: N/A • Gender: Female • Patient ID: N/A
Chief Complaint (CC): "Patient complains of worsening left hand pain and hallucinations."
History of Present Illness (HPI): • Onset: Progressive • Duration: Since last session • Location: Left hand • Quality: Sharp, constant, burning sensation • Associated Symptoms: Hallucinations - seeing people in room, hearing voices at night
Past Medical History (PMH): • Chronic Conditions: Cancer • Allergies: N/A • Current Medications: Pain medication, hydrosopioids
Physical Examination (PE): • Not available
Assessment: • Primary Diagnosis: Nerve pain due to cancer spread, hallucinations likely related to medication side effects or disease progression • Secondary Diagnosis: N/A
Plan: • Adjust pain medication • Add nerve pain reliever (e.g., gabapentin) • Refer to palliative care psychiatrist • Reduce opioid dosage • Introduce low dose of haloperidol • Monitor and adjust treatment for comfort and peace