🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-08-01 04:43:37

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

SOAP Note

  • Subjective: Mrs. Sharma reports worsening pain in her left hand, described as sharp, constant, and sometimes burning. She also mentions experiencing hallucinations, primarily at night, seeing people in her room and hearing voices calling her name, acknowledging they are not real but distressing.

  • Objective:

  • Pain likely due to nerve involvement from cancer spreading.
  • Plan to adjust pain medication and add a nerve pain reliever like gabapentin.
  • Hallucinations could be a side effect of hydrosopioids or disease progression.
  • Referral to palliative care psychiatrist for further evaluation.

  • Introduce low-dose haloperidol to manage hallucinations.

  • Assessment:

  • Worsening pain in the left hand likely due to nerve involvement from cancer.

  • Hallucinations, possibly related to medication side effects or disease progression.

  • Plan: Mrs. Sharma will have her pain medication adjusted, and gabapentin will be added for nerve pain relief. Opioid dosage will be slightly reduced, and haloperidol will be introduced to manage hallucinations. Referral to the palliative care psychiatrist for further evaluation and support. Regular monitoring and adjustments will be made to optimize comfort and well-being.

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