🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-09-16 04:08:52

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 the 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 progression of illness and symptoms.

Objective

  • Medical History:

    • Cancer with nerve involvement causing pain.

    • High-dose opioid use for pain management.

  • Behavioral Observations:

    • Patient expresses significant distress due to pain and hallucinations.

Assessment

  1. Nerve Pain: Likely due to cancer spreading, causing sharp and burning sensations.

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

  3. Emotional Distress: Feelings of losing control due to symptoms and illness progression.

Plan

  1. Medications:

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

    • Reduce opioid dosage and introduce low-dose haloperidol for hallucinations.

  2. Referrals:

    • Refer to palliative care psychiatrist for further management of hallucinations.

  3. Monitoring:

    • Continue to monitor symptoms and adjust treatment for comfort and peace.

  4. Support:

    • Provide reassurance and emotional support to the patient.

  5. Follow-Up:

    • Schedule follow-up to assess the effectiveness of medication adjustments and overall well-being.

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

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