🩺 Record Detail
Patient Info
Name: Unknown
Age: Unknown
Date: 2025-08-12 05:55:01
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
Subjective
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Patient: Mrs. Sharma.
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Primary Concern: Worsening pain in the left hand with sharp, constant, burning sensations. Experiencing hallucinations, mainly at night, seeing people in the room and hearing voices calling her name.
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Psychosocial Stressors:
- Expresses feeling like she's losing control and finding the situation hard to cope with.
Objective
- Medical History:
- Cancer spreading causing nerve involvement.
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Experiencing distressing hallucinations, possibly due to hydrosopioids or disease progression.
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Behavioral Observations:
- Patient expresses significant distress and fear related to hallucinations and pain.
Assessment
- Nerve Pain: Likely due to cancer spreading.
- Hallucinations: Distressing, possibly related to medication or disease progression.
Plan
- Medication:
- Adjust pain medication and add a nerve pain reliever like gabapentin.
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Reduce opioid slightly and introduce a low dose of halopiridol to manage hallucinations.
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Referral:
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Refer to palliative care psychiatrist for further evaluation and support.
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Support:
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Ensure continuous monitoring and adjustments to provide comfort and support.
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Follow-Up:
- Schedule regular follow-ups to monitor the effectiveness of medication adjustments and support provided.