🩺 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="SPEAKER-01">SPEAKER-01:</strong> It's sharp, constant, and sometimes it feels like it's burning from</p></div></td></tr><tr><td id="fragmentid_5"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> And I don't know how to say this. I've</p></div></td></tr><tr><td id="fragmentid_6"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Doctor, I'm really sorry to</p></div></td></tr><tr><td id="fragmentid_7"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: Let's take things one at a time.</div></td></tr><tr><td id="fragmentid_8"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> About the hand pain that's likely due to nerve involvement from the cancer</p></div></td></tr><tr><td id="fragmentid_9"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> I'll adjust your pain medication and add a nerve pain</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 - Age: Not specified - Gender: Female - Date of Visit: Not specified
Chief Complaint Patient reports worsening pain in the left hand, described as sharp, constant, and sometimes with a burning sensation. Also experiencing visual hallucinations.
Subjective Mrs. Sharma expresses feeling not great since the last session. She reports worsening pain in her left hand, characterized by sharp, constant pain with a burning sensation. Additionally, she mentions experiencing visual hallucinations.
Objective No objective data provided.
Assessment Likely nerve involvement from cancer spreading causing the pain in the left hand. Visual hallucinations reported by the patient.
Plan 1. Adjust pain medication. 2. Add a nerve pain reliever such as gabapentin to help ease the burning sensation. 3. Monitor the response to the adjusted pain management regimen.