🩺 Record Detail
Patient Info
Name: Unknown
Age: Unknown
Date: 2025-10-15 06:52:32
Transcript
Doctor: Good morning, Mrs. Sharma. It's good to see you again. How have you been feeling since our last session? Patient: 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. Doctor: 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. Patient: Thank you. That pain has been unbearable at times. Doctor: I can imagine. Now, about the hallucinations are you seeing or hearing things? And how often does it happen? Patient: 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. Doctor: 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. Patient: Thank you, doctor. It's just been so hard. I feel like I'm losing control. Doctor: 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. Patient: I'm grateful for that, really.
Clinical Notes
Allergies
No significant allergy history.
Chief Complaints / HOPI / Examination
- Sharp, constant pain in left hand
- Burning sensation in left hand
- Hallucinations, mostly at night
- Seeing people or hearing voices that aren't there
Provisional Diagnosis/Diagnosis:
- Nerve pain due to cancer spreading
- Hallucinations possibly due to high-dose opioids or illness progression
Investigations / Medication Advised
Laboratory:
- NA
Radiology:
- NA
Medication
| Sr. | Drug Name | Route | Dose | Frequency | Duration | Remarks |
|---|---|---|---|---|---|---|
| 1 | Gabapentin | Oral | - | - | - | For nerve pain |
| 2 | Haloperidol | Oral | Low dose | - | - | For hallucinations |
Advice / Follow-Up
- Referral to palliative care psychiatrist
- Monitor and adjust medications as needed for comfort and peace