🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-07-24 08:57:13

Transcript

<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><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><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><p><strong>Patient</strong>: Thank you. That pain has been unbearable at times.</p><p><strong>Doctor</strong>: I can imagine. Now, about the hallucinations are you seeing or hearing things? And how often does it happen?</p><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><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><p><strong>Patient</strong>: Thank you, doctor. It's just been so hard. I feel like I'm losing control.</p><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><p><strong>Patient</strong>: I'm grateful for that, really.</p>

Clinical Notes

Subjective

  • Patient: Mrs. Sharma.

  • Primary Concern:

    • Worsening sharp, constant, and burning pain in the left hand, likely due to nerve involvement from cancer spread.
    • Experiencing hallucinations, mainly at night, seeing people in the room and hearing voices calling her name.

  • Emotional State:

    • Expresses distress, feeling like losing control.

Objective

  • Medical History:
    • Under treatment for cancer.
    • Experiencing hallucinations, likely related to medication side effects or disease progression.

Assessment

  1. Pain Management:

    • Adjust pain medication and add a nerve pain reliever like gabapentin for the burning sensation.

  2. Hallucinations:

    • Likely a side effect of medication or disease progression.
    • Referral to palliative care psychiatrist.
    • Reduce opioid dosage and introduce haloperidol to manage hallucinations.

  3. Emotional Distress:

    • Patient expresses feelings of distress and loss of control.

Plan

  1. Medication Adjustment:

    • Adjust pain medication to manage nerve pain.
    • Introduce gabapentin for pain relief.
    • Reduce opioid dosage and start haloperidol for hallucination management.

  2. Referral:

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

  3. Support:

    • Ensure ongoing monitoring and adjustments to provide comfort and peace.
    • Reassure patient of continuous support throughout the treatment process.
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