🩺 Record Detail
Patient Info
Transcript
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<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
[Clinical Notes]
- Doctor: Dr. DOCTOR_NAME
- Patient: Mrs. Sharma
- Session Date: SESSION_DATE
Patient Identifying Information - Patient Name: Mrs. Sharma
Chief Complaint Mrs. Sharma reports worsening pain in her left hand, described as sharp, constant, and sometimes with a burning sensation. She also mentions experiencing hallucinations, primarily at night.
History of Presenting Illness Mrs. Sharma's hand pain is suspected to be due to nerve involvement from cancer spread. Pain medication will be adjusted, and a nerve pain reliever like gabapentin will be added. Hallucinations may be related to hydrosopioids' side effects or disease progression. Referral to a palliative care psychiatrist will be made. Opioid dosage will be reduced, and haloperidol will be introduced to manage the hallucinations.
Past Medical History Mrs. Sharma has a history of cancer.
Medications Mrs. Sharma is on pain medication and hydrosopioids.
Psychiatric Diagnoses Hallucinations related to cancer progression or medication side effects.
Treatment Plan - Pain management adjustment. - Introduction of gabapentin for nerve pain. - Referral to a palliative care psychiatrist. - Reduction of opioid dosage. - Introduction of haloperidol for hallucination management.
Prognosis Prognosis will be monitored closely to provide comfort and peace to Mrs. Sharma.
Follow-Up Plan Regular monitoring and adjustments will be made to ensure Mrs. Sharma's comfort and well-being.
This is the generated clinical note based on the provided transcription.