🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-08-04 05:29:07

Transcript

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                                                   <th><strong>Original Transcription</strong></th>
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                                             <tbody><tr><td id="fragmentid_1"><div><p><strong class="Doctor">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 class="Patient">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 class="Doctor">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 class="Patient">Patient</strong>: Thank you. That pain has been unbearable at times.</p></div></td></tr><tr><td id="fragmentid_5"><div><p><strong class="Doctor">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 class="Patient">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 class="Doctor">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 class="Patient">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 class="Doctor">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 class="Patient">Patient</strong>: I'm grateful for that, really.</p></div></td></tr></tbody>

Clinical Notes

Patient Identifying Information

  • Mrs. Sharma

Subjective

Mrs. Sharma reports feeling not great since the last session. She describes sharp, constant pain in her left hand, sometimes feeling like it's burning from the inside. Additionally, she mentions experiencing hallucinations, mainly at night, seeing people in her room, and hearing voices calling her name. She acknowledges that these hallucinations are not real but finds them terrifying. She expresses gratitude for the support received.

Objective

  • No objective findings provided in the transcription.

Assessment

  • Nerve involvement from cancer spreading likely causing left hand pain.
  • Hallucinations, possibly a side effect of hydrosopioids or disease progression.

Plan

  • Adjust pain medication and add a nerve pain reliever like gabapentin for the hand pain.
  • Refer to palliative care psychiatrist for hallucinations.
  • Reduce opioid slightly and introduce a low dose of halopiridol to manage hallucinations.
  • Monitor and adjust treatment to provide comfort and support to Mrs. Sharma.
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