🩺 Record Detail
Patient Info
Name: Unknown
Age: Unknown
Date: 2025-08-06 07:12:30
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
Patient Information
- Patient Name: Mrs. Sharma
Chief Complaint / Reason for Visit
Mrs. Sharma reports worsening pain in her left hand and experiencing hallucinations.
Medical History
- Chronic Illnesses: Cancer
- Current Medications: Pain medication
- Allergies: Not specified
Vital Signs
- Blood Pressure: Not documented
- Pulse Rate: Not documented
- Temperature: Not documented
- Respiratory Rate: Not documented
- Oxygen Saturation (SpO2): Not documented
- Weight: Not documented
- Height: Not documented
- BMI: Not documented
General Physical Examination
- Appearance: Not documented
- Eyes: Not documented
- Ears/Nose/Throat: Not documented
- Skin: Not documented
- Heart Sounds: Not documented
- Lung Sounds: Not documented
- Abdomen: Not documented
- Extremities: Not documented
- Neurological: Not documented
Assessment / Diagnosis
- Worsening pain in the left hand likely due to nerve involvement from cancer spreading.
- Hallucinations, possibly a side effect of medication or disease progression.
Plan
- Adjust pain medication and add a nerve pain reliever like gabapentin.
- Refer to palliative care psychiatrist for hallucinations.
- Reduce opioid medication slightly and introduce a low dose of haloperidol.
- Monitor and adjust treatment for comfort and support.