🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-09-02 10:03:58

Transcript

<thead>
                                                <tr>
                                                   <th><strong>Original Transcription</strong></th>
                                                </tr>
                                             </thead>
                                             <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 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.</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

Allergies

No significant allergy history.

Chief Complaints / HOPI / Examination
  • Sharp, constant pain in the left hand
  • Burning sensation in the hand
  • Hallucinations, mostly at night
  • Seeing people or hearing voices that aren't there
Provisional Diagnosis/Diagnosis:
  • Nerve pain due to cancer spreading
  • Hallucinations possibly due to high-dose opioids or illness progression
Investigations / Medication Advised
Laboratory:
  • NA
Radiology:
  • NA
Medication

| Sr. | Drug Name | Route | Dose | Frequency | Duration | Remarks | | 1 | Gabapentin | Oral | - | - | - | For nerve pain | | 2 | Haloperidol | Oral | Low dose | - | - | To manage hallucinations |

Advice / Follow-Up
  • Referral to palliative care psychiatrist
  • Monitoring and adjustment of medications for comfort and peace
⬅ Back to History