🩺 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.
Clinical Notes
Subjective
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Patient: Mrs. Sharma, age unspecified.
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Primary Concern: Pain in left hand and hallucinations.
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Reports sharp, constant pain in the left hand, sometimes described as burning from the inside.
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Experiencing visual hallucinations.
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Family History:
- Not mentioned.
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Lifestyle Factors:
- Not mentioned.
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Reproductive History:
- Not mentioned.
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Psychosocial Stressors:
- Not mentioned.
Objective
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Medical History:
- Not mentioned.
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Behavioral Observations:
- Patient expresses concern about worsening hand pain and new onset of hallucinations.
Assessment
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Hand Pain: Likely neuropathic in nature, given the description of sharp and burning sensations.
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Hallucinations: New symptom that requires further evaluation to determine underlying cause.
Plan
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Diagnostics:
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Consider imaging studies or nerve conduction studies to assess the cause of hand pain.
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Evaluate for potential neurological or psychiatric causes of hallucinations.
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Pain Management:
- Discuss potential medication adjustments or additions to address neuropathic pain.
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Mental Health Support:
- Referral to a psychiatrist or neurologist for further assessment of hallucinations.
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Follow-Up:
- Schedule a follow-up appointment to review test results and adjust treatment plan as necessary.
Medications | Name | Brand | Dosage | Frequency | Duration (Days) | |---------------|-------|----------|-----------------------------------------|-----------------| | - | – | unspecified | unspecified | unspecified | | - | – | unspecified | unspecified | unspecified | | | – | unspecified | unspecified | unspecified |