🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-09-02 06:15:28

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 high-dose opioids 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 haloperidol. 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 • Date of Birth: • Date of Visit: SESSION_DATE • Gender: • Patient ID:

Chief Complaint (CC): "Patient complains of worsening pain in the left hand and experiencing hallucinations mostly at night."

History of Present Illness (HPI): • Onset: • Duration: • Location: Left hand • Quality (e.g., sharp, dull): Sharp, burning sensation • Severity (scale of 1–10): • Timing (constant/intermittent): Constant • Associated Symptoms: Hallucinations (seeing people, hearing voices) • Aggravating/Relieving Factors: • Previous episodes: • Medications tried: • Recent Travel / Sick Contacts / Exposure:

Past Medical History (PMH): • Chronic Conditions: Cancer • Past Surgeries/Hospitalizations: • Allergies: • Current Medications:

Social History: • Smoking / Alcohol / Drug Use: • Occupation: • Living Situation:

Review of Systems (ROS): • General: • ENT: • Respiratory: • GI: • Others as relevant: Hallucinations (seeing people, hearing voices)

Physical Examination (PE): • Vital Signs: Temp: °C, HR: __ bpm, BP: /, RR: , SpO₂: __% • General Appearance: • HEENT: • Chest/Lungs: • Cardiovascular: • Abdomen: • Neurological: • Skin:

Assessment: • Primary Diagnosis: Nerve pain due to cancer spread • Secondary Diagnosis (if any): Hallucinations possibly due to high-dose opioids or illness progression

Plan: • Investigations: • Medications Prescribed: Gabapentin for nerve pain, Haloperidol for hallucinations • Supportive Care: Adjust opioid dosage • Referral: Palliative care psychiatrist • Follow-Up:

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