🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-09-09 10:55:11

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

Subjective

  • Patient: Mrs. Sharma

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

    • Reports sharp, constant pain with a burning sensation in the left hand.

    • Experiences visual and auditory hallucinations, mostly at night.

  • Psychosocial Stressors:

    • Feels like losing control due to the progression of the illness and side effects of medication.

Objective

  • Medical History:

    • Cancer with nerve involvement causing pain.

    • High-dose opioid use for pain management.

  • Behavioral Observations:

    • Patient expresses distress over hallucinations and pain, indicating a need for adjusted medication and support.

Assessment

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

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

  3. Emotional Distress: Related to the experience of hallucinations and chronic pain.

Plan

  1. Medication Adjustments:

    • Adjust current pain medication and add gabapentin for nerve pain relief.

    • Reduce opioid dosage slightly and introduce a low dose of haloperidol to manage hallucinations.

  2. Specialist Referral:

    • Refer to a palliative care psychiatrist for further evaluation and management of hallucinations.

  3. Supportive Care:

    • Provide ongoing support and reassurance to help the patient feel more in control.

  4. Follow-Up:

    • Schedule regular follow-ups to monitor pain levels, hallucinations, 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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