🩺 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="Doctor">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 class="Patient">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 burning. She also mentions experiencing hallucinations, mainly at night.
History of Presenting Illness Mrs. Sharma's hand pain is likely due to nerve involvement from cancer spreading. Pain medication will be adjusted, and a nerve pain reliever like gabapentin will be added. Regarding hallucinations, she reports seeing people in her room and hearing voices calling her name, mostly at night.
Past Medical History Mrs. Sharma has a history of cancer.
Medications - Pain medication adjustment - Addition of gabapentin for nerve pain - Reduction of opioids - Introduction of haloperidol for managing hallucinations
Psychiatric Consultation Mrs. Sharma will be referred to the palliative care psychiatrist for further evaluation and management of the hallucinations.
Prognosis The medical team will continue to monitor and adjust medications to provide Mrs. Sharma with comfort and support during her illness.
Follow Up Plan Mrs. Sharma will have regular follow-up appointments to assess her symptoms and adjust treatment as needed.
This note is generated based on the provided transcript and includes the necessary information for the patient's medical record.