🩺 Record Detail
Patient Info
Transcript
<div><b>Doctor</b>: Good morning, Mrs. Sharma. It's good to see you again. How have you been feeling since our last session?</div><br><div><b>Patient</b>: 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.</div><br><div><b>Doctor</b>: 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.</div><br><div><b>Patient</b>: Thank you. That pain has been unbearable at times.</div><br><div><b>Doctor</b>: I can imagine. Now, about the hallucinations are you seeing or hearing things? And how often does it happen?</div><br><div><b>Patient</b>: 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.</div><br><div><b>Doctor</b>: 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.</div><br><div><b>Patient</b>: Thank you, doctor. It's just been so hard. I feel like I'm losing control.</div><br><div><b>Doctor</b>: 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.</div><br><div><b>Patient</b>: I'm grateful for that, really.</div><br>
Clinical Notes
Patient Information • Patient Name: Mrs. Sharma • Date of Birth: N/A • Date of Visit: [Date] • Gender: Female • Patient ID: N/A
Chief Complaint (CC): "Patient complains of worsening sharp, constant pain in the left hand and experiencing hallucinations, mainly at night."
History of Present Illness (HPI): • Onset: Progressive • Duration: Since last session • Location: Left hand • Quality: Sharp, burning sensation • Timing: Constant, worse at times • Associated Symptoms: Hallucinations - seeing people in the room, hearing voices • Aggravating/Relieving Factors: N/A
Past Medical History (PMH): • Chronic Conditions: Cancer • Past Surgeries/Hospitalizations: N/A • Allergies: N/A • Current Medications: Pain medication, hydrosopioids
Social History: • Smoking / Alcohol / Drug Use: N/A • Occupation: N/A • Living Situation: N/A
Review of Systems (ROS): • General: N/A • ENT: N/A • Respiratory: N/A • GI: N/A
Physical Examination (PE): • Vital Signs: N/A • General Appearance: N/A • HEENT: N/A • Chest/Lungs: N/A • Cardiovascular: N/A • Abdomen: N/A • Neurological: N/A • Skin: N/A
Assessment: • Primary Diagnosis: Progression of cancer with nerve involvement leading to worsening left hand pain and hallucinations • Secondary Diagnosis: Side effects of hydrosopioids or illness progression leading to hallucinations
Plan: • Investigations: N/A • Medications Prescribed: Adjust pain medication, add gabapentin for nerve pain, reduce opioids, introduce halopiridol for hallucinations • Supportive Care: Referral to palliative care psychiatrist for hallucinations management • Follow-Up: Monitoring and adjustment of medications for comfort and peace.