🩺 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="Patient">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 class="Doctor">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 class="Patient">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 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
Clinical Notes
- Doctor: Dr. DOCTOR_NAME
- Patient: Mrs. Sharma
- Session Date: SESSION_DATE
Subjective: Mrs. Sharma reported feeling not great since the last session. She mentioned experiencing worsening sharp, constant pain in her left hand, sometimes feeling like a burning sensation. Additionally, she disclosed experiencing visual hallucinations, seeing people in her room and hearing voices calling her name, particularly at night.
Assessment and Plan: 1. Hand pain likely due to nerve involvement from cancer spread. Adjusted pain medication and added gabapentin for nerve pain relief. 2. Referred patient to palliative care psychiatrist for hallucinations, suspected to be a side effect of hydrosopioids or disease progression. Reduced opioid dosage and introduced low-dose haloperidol to manage hallucinations.
Mrs. Sharma expressed gratitude for the adjustments in her treatment plan due to the unbearable pain and distressing hallucinations she has been experiencing.