🩺 Record Detail
Patient Info
Name: Unknown
Age: Unknown
Date: 2025-08-28 08:43:23
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
DOCTOR NAME: DOCTOR_NAME
PATIENT NAME: Mrs. Sharma
SESSION DATE: SESSION_DATE
Chief Complaint: Worsening pain in the left hand and hallucinations.
History of Present Illness: Mrs. Sharma reports that the pain in her left hand has intensified. The pain is described as sharp, constant, and sometimes feels like a burning sensation. Additionally, she has started experiencing hallucinations, mostly at night, where she sees people in her room or hears voices calling her name. She acknowledges that these are not real but finds them terrifying.
Assessment/Plan:
- The worsening hand pain is likely due to nerve involvement from cancer spreading. The plan is to adjust the current pain medication and add a nerve pain reliever, such as gabapentin, to help with the burning sensation.
- The hallucinations could be a side effect of high-dose opioids or the progression of the illness. The plan includes a referral to a palliative care psychiatrist. Meanwhile, the opioid dosage will be slightly reduced, and a low dose of haloperidol will be introduced to help manage the hallucinations.
Medications:
- Gabapentin - for nerve pain relief.
- Haloperidol - to manage hallucinations.
Follow-up: Continue monitoring the patient's symptoms and adjust medications as needed to provide comfort and peace.