🩺 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

  1. Worsening pain in the left hand likely due to nerve involvement from cancer spreading.
  2. Hallucinations, possibly a side effect of medication or disease progression.

Plan

  1. Adjust pain medication and add a nerve pain reliever like gabapentin.
  2. Refer to palliative care psychiatrist for hallucinations.
  3. Reduce opioid medication slightly and introduce a low dose of haloperidol.
  4. Monitor and adjust treatment for comfort and support.
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