🩺 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 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
DOB / Age: _________
Gender: _________
Medical Record # (MRN): _________
Date & Time of Encounter: _________
Provider Name: DOCTOR_NAME
Chief Complaint (CC) Patient presents with: Worsening pain in left hand and experiencing hallucinations.
History of Present Illness (HPI) Onset: _________
Location: Left hand
Duration: _________
Characteristics: Sharp, constant pain with burning sensation; hallucinations mostly at night.
Aggravating/Relieving Factors: _________
Timing: Pain is constant; hallucinations mostly occur at night.
Severity: Unbearable at times
Additional Notes: Patient reports seeing people and hearing voices that are not real.
Review of Systems (ROS) General: ☐ Fatigue ☐ Fever ☐ Weight Change ☐ Other: _____
HEENT: ☐ Headache ☐ Vision Changes ☐ Sore Throat ☐ Other: Hallucinations
Cardiovascular: ☐ Chest Pain ☐ Palpitations ☐ Other: _____
Respiratory: ☐ Cough ☐ Shortness of Breath ☐ Other: _____
Gastrointestinal: ☐ Nausea ☐ Vomiting ☐ Abdominal Pain ☐ Other: ___
Musculoskeletal: ☐ Joint Pain ☐ Muscle Weakness ☐ Other: Left hand pain
Neurological: ☐ Dizziness ☐ Numbness ☐ Other: ___
Psychiatric: ☐ Anxiety ☐ Depression ☐ Other: Hallucinations
Past Medical History (PMH) Conditions: Cancer
Surgeries: ___________
Allergies: ___________
Medications: High-dose opioids
Physical Examination Vital Signs: BP: _ HR: Temp: _ RR: SpO₂: ____
General Appearance: _________
HEENT: _______
Cardiac: _______
Respiratory: _________
Abdominal: _________
Extremities: _________
Neurological: _______
Assessment Primary Diagnosis: Nerve pain due to cancer spreading
Secondary Diagnoses: Hallucinations likely due to high-dose opioids or illness progression
Plan Medications: Adjust pain medication, add gabapentin, reduce opioid dosage, introduce low dose of haloperidol
Diagnostics/Labs Ordered: ________
Procedures: _________
Referrals: Palliative care psychiatrist
Follow-Up: Continue monitoring and adjust treatment as necessary for comfort and peace.