🩺 Record Detail
Patient Info
Name: Unknown
Age: Unknown
Date: 2025-07-30 11:57:26
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 Name: Mrs. Sharma
Date of Visit: [Date]
CC: Experiencing worsening sharp, constant left hand pain with a burning sensation, and visual hallucinations mainly at night.
Subjective:
Mrs. Sharma reports that the pain in her left hand has worsened, describing it as sharp, constant, and sometimes with a burning sensation. She also mentions experiencing visual hallucinations, mainly at night, seeing people in her room and hearing voices calling her name. These hallucinations are distressing and terrifying for her.
Objective:
- No objective findings provided in the transcription.
Assessment:
- Left Hand Pain:
- Likely due to nerve involvement from cancer spreading.
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Adjust pain medication and consider adding a nerve pain reliever like gabapentin.
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Visual Hallucinations:
- Mostly occurring at night.
- Could be a side effect of hydrosopioids or disease progression.
- Referral to palliative care psychiatrist for further evaluation.
- Plan to reduce opioids slightly and introduce haloperidol to manage hallucinations.
Plan:
- Adjust pain medication to address left hand pain.
- Referral to palliative care psychiatrist for evaluation of visual hallucinations.
- Reduce opioid dosage and introduce haloperidol to manage hallucinations.
- Continual monitoring and adjustments to provide comfort and support to Mrs. Sharma.