🩺 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: - Name: Mrs. Sharma
Chief Complaint: Mrs. Sharma reports worsening pain in her left hand, described as sharp, constant, and sometimes burning. She also mentions experiencing hallucinations, mainly 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. She experiences hallucinations at night, seeing people in her room and hearing voices calling her name.
Past Medical History: Mrs. Sharma has a history of cancer.
Medications: Mrs. Sharma is on pain medication and hydrosopioids. The doctor plans to adjust the medication and introduce halopiridol to manage hallucinations.
Psychiatric Referral: Mrs. Sharma will be referred to the palliative care psychiatrist for further evaluation and management of hallucinations.
Prognosis: The prognosis will be based on the response to medication adjustments and psychiatric intervention.
Follow Up Plan: Mrs. Sharma will have regular monitoring and adjustments to ensure comfort and peace.
The above notes are based on the conversation between Dr. DOCTOR_NAME and Mrs. Sharma on SESSION_DATE.