🩺 Record Detail
Patient Info
Name: Unknown
Age: Unknown
Date: 2025-07-31 12:50:29
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
Patient Name: Mrs. Sharma
Date of Visit: [Date]
CC: Worsening left hand pain, described as sharp, constant, and burning, associated with hallucinations.
Subjective:
Mrs. Sharma reports that the pain in her left hand has worsened, characterized as sharp, constant, and at times with a burning sensation. She also mentions experiencing hallucinations, mainly at night, seeing people in her room and hearing voices calling her name, despite being aware that they are not real. She expresses feeling overwhelmed and a sense of losing control.
Objective:
- No specific objective findings mentioned in the transcription.
Assessment:
- Worsening left hand pain likely due to nerve involvement from cancer spread.
- Hallucinations, possibly related to medication side effects or disease progression.
Plan:
- Adjust pain medication:
- Consider adding a nerve pain reliever like gabapentin to alleviate the burning sensation.
- Referral to palliative care psychiatrist for management of hallucinations.
- Medication adjustment:
- Reduce opioid dosage slightly.
- Introduce a low dose of haloperidol to help manage hallucinations.
- Continual monitoring and adjustment of treatment to provide comfort and support to Mrs. Sharma.