🩺 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 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 • Age / DOB: SESSION_DATE • Gender: SESSION_DATE • Contact Number: SESSION_DATE • Date of Visit: SESSION_DATE
Chief Complaint / Reason for Visit Mrs. Sharma presented with worsening pain in her left hand, described as sharp, constant, and sometimes burning. She also reported experiencing hallucinations, mainly at night, seeing people in her room and hearing voices calling her name.
Medical History • Chronic Illnesses (if any): - Cancer
Current Medications: - Pain medication - Gabapentin (to be added for nerve pain relief) - Hydrosopioids (opioid medication) - Haloperidol (to be introduced for managing hallucinations)
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: _
Investigations (If Needed) • ☐ Blood Test • ☐ Urine Test • ☐ ECG • ☐ Chest X-Ray • ☐ Others: _____
Assessment / Diagnosis 1. Worsening pain in the left hand likely due to nerve involvement from cancer spread. 2. Hallucinations, possibly a side effect of hydrosopioids or disease progression.
Treatment / Medications Prescribed 1. Adjustment of pain medication. 2. Addition of gabapentin for nerve pain relief. 3. Reduction of opioids. 4. Introduction of haloperidol for managing hallucinations.
Doctor's Advice & Recommendations • ☐ Healthy Diet • ☐ Regular Exercise • ☐ Hydration • ☐ Stress Management • ☐ Follow-up Visit on: SESSION_DATE