🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-09-10 07:48:33

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 left hand and hallucinations.

    • Reports sharp, constant, burning pain in left hand.

    • Experiencing visual and auditory hallucinations, mostly at night.

  • Family History:

    • Not discussed in this session.

  • Lifestyle Factors:

    • Not discussed in this session.

  • Reproductive History:

    • Not discussed in this session.

  • Psychosocial Stressors:

    • Feels like losing control due to the symptoms and illness progression.

Objective

  • Medical History:

    • Cancer with possible nerve involvement causing pain.

    • Currently on high-dose opioids.

  • Behavioral Observations:

    • Patient expresses significant distress over hallucinations and pain.

Assessment

  1. Nerve Pain: Likely due to cancer spreading, causing sharp and burning sensation in left hand.

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

  3. Emotional Distress: Due to loss of control over symptoms and illness.

Plan

  1. Medication Adjustments:

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

    • Reduce opioid dosage slightly and introduce low dose haloperidol for hallucination management.

  2. Specialist Referral:

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

  3. Monitoring and Support:

    • Continue to monitor symptoms closely and adjust treatment plan as needed.

    • Provide emotional support and reassurance to the patient.

  4. Follow-Up:

    • Schedule follow-up to assess effectiveness of medication adjustments and overall symptom management.

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

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