🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-05-29 07:18:15

Transcript

[00:00 → 00:04] Doctor, good morning, Mrs. Sharma. It's good to see you again.
[00:05 → 00:08] How have you been feeling since our last session?
[00:09 → 00:16] Patient, good morning, doctor. Honestly, not great. The pain in my left hand has gotten worse.
[00:17 → 00:22] It's sharp, constant, and sometimes it feels like it's burning from the inside.
[00:22 → 00:28] And I don't know how to say this. I've started seeing things that aren't there.
[00:29 → 00:31] Doctor, I'm really sorry to hear that.
[00:32 → 00:34] Let's take things one at a time.
[00:35 → 00:39] About the hand pain that's likely due to nerve involvement from the cancer spreading.
[00:39 → 00:43] I'll adjust your pain medication and add a nerve pain reliever.
[00:44 → 00:47] Something like gabapentin may help ease that burning sensation.
[00:48 → 00:52] Patient, thank you. That pain has been unbearable at times.
[00:53 → 00:55] Doctor, I can imagine.
[00:55 → 00:59] Now, about the hallucinations are you seeing or hearing things?
[01:00 → 01:01] And how often does it happen?
[01:02 → 01:04] Patient, mostly at night.
[01:05 → 01:08] I sometimes see people in my room or hear voices calling my name.
[01:09 → 01:12] I know they're not real, but it's terrifying.
[01:13 → 01:15] Doctor, that sounds distressing.
[01:16 → 01:20] It could be a side effect of the high dose opioids or just the progression of the illness.
[01:21 → 01:24] I'll refer you to our palliative care psychiatrist.
[01:25 → 01:30] Meanwhile, I'll reduce your opioids slightly and introduce a low dose of halopiridol.
[01:30 → 01:32] It should help manage the hallucinations.
[01:33 → 01:38] Patient, thank you. Doctor, it's just been so hard.
[01:39 → 01:40] I feel like I'm losing control.
[01:41 → 01:44] Doctor, you're not alone, Mrs. Sharma.
[01:45 → 01:47] We're here to support you every step of the way.
[01:48 → 01:53] We'll keep monitoring and adjusting things to give you as much comfort and peace as possible.
[01:53 → 01:56] Patient, I'm grateful for that, really.

Clinical Notes

Subjective

  • Patient: Mrs. Sharma.

  • Primary Concern:

  • Experiencing worsening sharp, constant pain in the left hand, sometimes with a burning sensation.
  • Reports visual and auditory hallucinations, mainly at night, seeing people in the room and hearing voices calling her name.

Objective

  • Medical History:
  • Cancer with suspected nerve involvement.
  • High dose opioid therapy.

Assessment

  1. Pain Management:
  2. Left hand pain likely due to nerve involvement from cancer spread.

  3. Adjust pain medication and add a nerve pain reliever like gabapentin.

  4. Hallucinations:

  5. Likely related to high dose opioids or disease progression.
  6. Referral to palliative care psychiatrist for further evaluation.
  7. Plan to reduce opioids slightly and introduce haloperidol to manage hallucinations.

Plan

  1. Medication Adjustment:
  2. Adjust pain medication to manage nerve pain.
  3. Introduce gabapentin for burning sensation.

  4. Reduce opioids and start low-dose haloperidol for hallucination management.

  5. Psychiatric Referral:

  6. Refer to palliative care psychiatrist for evaluation and support.

  7. Support and Monitoring:

  8. Ensure continuous monitoring and adjustment of treatment for comfort and peace.
  9. Provide ongoing support throughout the treatment process.
⬅ Back to History