🩺 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="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 - Name: Mrs. Sharma - Date of Birth: SESSION_DATE - Patient ID: 123456 - Gender: Female - Contact Number: (123) 456-7890 - Address: Patient Address
Medical History - Previous Diagnoses: Cancer - Surgeries: Not mentioned - Allergies: Not mentioned - Current Medications: Pain medication - Family Medical History: Not mentioned
Current Visit - Reason for Visit: Experiencing worsening pain in the left hand with burning sensation and hallucinations.
Vital Signs - Blood Pressure: Not documented - Heart Rate: Not documented - Temperature: Not documented - Respiratory Rate: Not documented - Weight: Not documented - Height: Not documented
Physical Examination - Not documented
In this consultation, Mrs. Sharma reported worsening pain in her left hand with a burning sensation, which the doctor attributed to nerve involvement from cancer spreading. Pain medication adjustments were made, and gabapentin was suggested for nerve pain relief. Mrs. Sharma also mentioned experiencing hallucinations, which the doctor inquired about for further evaluation and management.