🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-09-09 09:46:12

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, burning pain likely due to nerve involvement from cancer spreading.

    • Experiences hallucinations, mostly at night, seeing people or hearing voices.


Objective

  • Medical History:

    • Current high-dose opioid use for pain management.
  • Behavioral Observations:

    • Patient expresses feelings of losing control and distress due to hallucinations.

Assessment

  1. Nerve Pain: Likely due to cancer progression causing nerve involvement.

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


Plan

  1. Medications:

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

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

  2. Referrals:

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

    • Regular follow-up to monitor pain levels and effectiveness of new medication regimen.
  4. Support:

    • Provide reassurance and ongoing support to manage distress and improve quality of life.

Medications | Name | Brand | Dosage | Frequency | Duration (Days) | |---------------|-------|----------|-----------------------------------------|-----------------| | Gabapentin | – | unspecified | unspecified | unspecified | | Haloperidol | – | unspecified | unspecified | unspecified |

⬅ Back to History