🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-08-07 12:13:51

Transcript

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                                             <tbody><tr><td id="fragmentid_1"><div><p><strong>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>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>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>Patient</strong>: Thank you. That pain has been unbearable at times.</p></div></td></tr><tr><td id="fragmentid_5"><div><p><strong>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>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>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>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>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>Patient</strong>: I'm grateful for that, really.</p></div></td></tr></tbody>

Clinical Notes

Clinical Notes

Subjective: - Chief Complaint: Pain in left hand, described as sharp, constant, and sometimes burning. Patient experiencing hallucinations, seeing people in the room and hearing voices at night. - History of Present Illness: Patient reports worsening pain in the left hand, likely due to nerve involvement from cancer spreading. Also experiencing distressing hallucinations at night. - Past Medical History: History of cancer. - Medications: Pain medication to be adjusted, nerve pain reliever (e.g., gabapentin) to be added. Opioid to be reduced, and haloperidol to be introduced for managing hallucinations. - Allergies: Not reported. - Social History: Not documented.

Objective: - Vitals: Not documented. - Physical Exam: Not documented.

Assessment: - Nerve pain in left hand likely due to cancer spread. - Hallucinations possibly related to medication side effects or disease progression.

Plan: - Adjust pain medication and add nerve pain reliever. - Refer to palliative care psychiatrist for hallucinations management. - Reduce opioid dosage and introduce haloperidol. - Monitor and adjust treatment for patient comfort and peace.

Follow-up: - Regular monitoring and adjustments to treatment plan. - Support provided throughout the patient's journey.

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