🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-09-04 06:41:45

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 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.</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

  • Patient: Mrs. Sharma

  • Primary Concern: Worsening pain in the left hand and hallucinations.

    • Reports sharp, constant, and burning pain in the left hand.

    • Experiencing visual and auditory hallucinations, mostly at night.

  • Family History: Not mentioned.

  • Lifestyle Factors: Not mentioned.

  • Reproductive History: Not mentioned.

  • Psychosocial Stressors:

    • Feels like losing control due to the symptoms.

Objective

  • Medical History:

    • Cancer with nerve involvement causing pain.

    • High-dose opioid use for pain management.

  • Behavioral Observations:

    • Patient expresses significant distress due to pain and hallucinations.

Assessment

  1. Nerve Pain: Likely due to cancer spreading, causing sharp and burning sensations.

  2. Hallucinations: Possibly a side effect of high-dose opioids or illness progression.

  3. Emotional Distress: Patient feels a loss of control, contributing to anxiety.

Plan

  1. Medications:

    • Adjust current pain medication.

    • Add gabapentin for nerve pain relief.

    • Introduce a low dose of haloperidol to manage hallucinations.

  2. Referral:

    • Refer to palliative care psychiatrist for further evaluation and support.

  3. Monitoring:

    • Regularly monitor and adjust medications to ensure comfort.

  4. Support:

    • Provide emotional support and reassurance to the patient.

  5. Follow-Up:

    • Schedule a follow-up to assess the effectiveness of medication adjustments and overall well-being.

Medications | Name | Brand | Dosage | Frequency | Duration (Days) | |---------------|-------|----------|-----------------------------------------|-----------------| | Gabapentin | – | unspecified | unspecified | unspecified | | Haloperidol | – | unspecified | unspecified | unspecified | | | – | unspecified | unspecified | unspecified |

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