🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-09-20 12:26:49

Transcript

Doctor: Good morning, Mrs. Sharma. It's good to see you again. How have you been feeling since our last session? Patient: 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. Doctor: 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. Patient: Thank you. That pain has been unbearable at times. Doctor: I can imagine. Now, about the hallucinations are you seeing or hearing things? And how often does it happen? Patient: 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. Doctor: 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. Patient: Thank you, doctor. It's just been so hard. I feel like I'm losing control. Doctor: 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. Patient: I'm grateful for that, really.

Clinical Notes

General Check-Up Template

Patient Information

  • Patient Name: Mrs. Sharma
  • Age / DOB: _________
  • Gender: _________
  • Contact Number: _________
  • Date of Visit: SESSION_DATE

Chief Complaint / Reason for Visit

Pain in left hand, hallucinations.

Medical History

Chronic Illnesses (if any):

  • Cancer
  • Other: _____

Surgeries / Hospitalizations:

________________________________________

Current Medications:

  • Opioids
  • Gabapentin (for nerve pain)
  • Haloperidol (for hallucinations)

Allergies (Drugs/Food):

________________________________________ ________________________________________

Lifestyle Details

  • Smoking: ☐ Yes ☐ No
  • Alcohol Consumption: ☐ Yes ☐ No
  • Exercise Routine: ☐ Regular ☐ Occasional ☐ Sedentary
  • Diet: ☐ Balanced ☐ High-Fat ☐ Low-Carb ☐ Vegetarian ☐ Other: _

Vital Signs
Vital Reading
Blood Pressure ____ mmHg
Pulse Rate ____ bpm
Temperature ____ °C
Respiratory Rate ____ breaths/min
Oxygen Saturation (SpO2) ____ %
Weight ____ kg
Height ____ cm
BMI __________

General Physical Examination

  • Appearance: ☐ Well ☐ Pale ☐ Fatigued
  • Eyes: ☐ Normal ☐ Redness ☐ Jaundice
  • Ears/Nose/Throat: ☐ Normal ☐ Infection
  • Skin: ☐ Normal ☐ Rash ☐ Dryness
  • Heart Sounds: ☐ Normal ☐ Murmur
  • Lung Sounds: ☐ Clear ☐ Wheezing ☐ Crackles
  • Abdomen: ☐ Soft ☐ Tender ☐ Distended
  • Extremities: ☐ Normal ☐ Swollen
  • Neurological: ☐ Alert ☐ Oriented ☐ Other: Hallucinations __________

Investigations (If Needed)

  • ☐ Blood Test
  • ☐ Urine Test
  • ☐ ECG
  • ☐ Chest X-Ray
  • ☐ Others: Referral to palliative care psychiatrist __________

Assessment / Diagnosis

Nerve pain due to cancer progression, hallucinations possibly due to high-dose opioids.

Treatment / Medications Prescribed

  • Adjusted pain medication
  • Gabapentin for nerve pain
  • Reduced opioid dosage
  • Haloperidol for hallucinations

Doctor's Advice & Recommendations

  • ☐ Healthy Diet
  • ☐ Regular Exercise
  • ☐ Hydration
  • ☐ Stress Management
  • ☐ Follow-up Visit on: ___
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