🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-07-24 07:50:23

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 pain in the left hand described as sharp, constant, and sometimes burning.
  • Experiencing hallucinations, seeing people in the room and hearing voices, mainly at night.

Objective

  • Medical History:
  • Cancer with nerve involvement.
  • Currently on pain medication.
  • Experiencing hallucinations, possibly related to medication or disease progression.

Assessment

  1. Pain Management:
  2. Worsening left hand pain likely due to nerve involvement from cancer spread.

  3. Adjusted pain medication and added gabapentin for nerve pain relief.

  4. Hallucinations:

  5. Experiencing distressing hallucinations, possibly related to medication side effects or disease progression.
  6. Referral to palliative care psychiatrist for further evaluation.

  7. Reduced opioid dosage and introduced haloperidol to manage hallucinations.

  8. Psychological Distress:

  9. Patient expresses feelings of losing control and distress due to symptoms.

Plan

  1. Medication Management:
  2. Continue monitoring and adjusting pain medication for optimal relief.

  3. Monitor the effectiveness of haloperidol in managing hallucinations.

  4. Psychiatric Referral:

  5. Follow up with the palliative care psychiatrist for further assessment and management of hallucinations.

  6. Support and Monitoring:

  7. Ensure ongoing support and monitoring to provide comfort and peace to the patient.
  8. Encourage open communication regarding symptoms and concerns for timely adjustments.
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