🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-07-24 06:55:39

Transcript

<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><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><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><p><strong>Patient</strong>: Thank you. That pain has been unbearable at times.</p><p><strong>Doctor</strong>: I can imagine. Now, about the hallucinations are you seeing or hearing things? And how often does it happen?</p><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><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><p><strong>Patient</strong>: Thank you, doctor. It's just been so hard. I feel like I'm losing control.</p><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><p><strong>Patient</strong>: I'm grateful for that, really.</p>

Clinical Notes

Subjective

  • Patient: Mrs. Sharma.

  • Primary Concern:

    • Experiencing worsening sharp, constant, and burning pain in the left hand, likely due to nerve involvement from cancer spread.
    • Reporting visual and auditory hallucinations, mainly at night, seeing people in the room and hearing voices calling her name, causing distress and fear.

  • Emotional State:

    • Expresses gratitude for the support but feeling like losing control and finding the situation hard.

Objective

  • Medical History:

    • Undergoing cancer treatment.
    • Experiencing severe pain in the left hand.
    • Reporting visual and auditory hallucinations, especially at night.

  • Medications:

    • Currently on opioids for pain management.

Assessment

  1. Pain Management:

    • Worsening left hand pain, likely due to nerve involvement from cancer spread.
    • Plan to adjust pain medication and introduce a nerve pain reliever like gabapentin.

  2. Hallucinations:

    • Visual and auditory hallucinations, possibly related to medication side effects or disease progression.
    • Referral to palliative care psychiatrist for further evaluation and management.
    • Plan to reduce opioids slightly and start haloperidol to address hallucinations.

  3. Emotional State:

    • Patient expresses feelings of losing control and finding the situation challenging.

Plan

  1. Pain Management:

    • Adjust pain medication to address worsening pain in the left hand.
    • Introduce gabapentin for nerve pain relief.

  2. Hallucinations Management:

    • Refer to palliative care psychiatrist for evaluation and support.
    • Reduce opioid dosage and start haloperidol to manage visual and auditory hallucinations.

  3. Support and Monitoring:

    • Ensure continuous monitoring and adjustment of treatment to provide comfort and support to the patient.
⬅ Back to History