🩺 Record Detail
Patient Info
Name: Unknown
Age: Unknown
Date: 2025-08-02 06:11:00
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 Identifying Information
- Mrs. Sharma
Chief Complaint
- Experiencing worsening pain in the left hand, described as sharp, constant, and sometimes burning.
- Reporting visual hallucinations, seeing people in the room and hearing voices, especially at night.
History of Presenting Illness
Mrs. Sharma reports worsening pain in her left hand, likely due to nerve involvement from cancer spreading. She describes the pain as sharp, constant, and sometimes burning. Additionally, she reports experiencing visual hallucinations, seeing people in her room and hearing voices, predominantly at night.
Assessment
- Pain in the left hand: Likely due to nerve involvement from cancer spreading.
- Visual hallucinations: Possibly a side effect of medication or disease progression.
Plan
Pain Management
- Adjust pain medication and add a nerve pain reliever such as gabapentin to alleviate the burning sensation in the left hand.
Hallucinations Management
- Refer Mrs. Sharma to the palliative care psychiatrist for further evaluation of the visual hallucinations.
- Reduce opioid medication slightly and introduce a low dose of haloperidol to help manage the hallucinations.
Prognosis
With ongoing monitoring and adjustments to the treatment plan, the aim is to provide Mrs. Sharma with comfort and peace amidst her symptoms.