🩺 Record Detail
Patient Info
Transcript
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<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
Date: SESSION_DATE
Patient: Mrs. Sharma
Provider: DOCTOR_NAME
Diagnosis: Cancer with nerve involvement and hallucinations
Presenting Problem: Mrs. Sharma presented with worsening pain in her left hand, described as sharp, constant, and burning. She also reported experiencing hallucinations, mainly at night, where she sees people in her room or hears voices calling her name.
Mental Status: Mrs. Sharma appeared alert and oriented. Mood was reported as distressed due to the pain and hallucinations. Speech was clear and coherent. Thought process was logical, though affected by the hallucinations. No suicidal ideation was reported.
History of Present Illness: The patient reported increased pain in her left hand, likely due to nerve involvement from cancer spreading. She also described experiencing hallucinations, which could be a side effect of high-dose opioids or the progression of her illness.
Past Psychiatric History: [Patient's Past Psychiatric History, if applicable]
Medical History: Cancer with nerve involvement
Social History: [Patient's Social History, if applicable]
Family History: [Patient's Family History, if applicable]
Medications: Adjusted pain medication, added gabapentin for nerve pain, reduced opioid dosage, and introduced a low dose of haloperidol for hallucinations.
Treatment Plan:
• Adjust pain management strategy by adding gabapentin for nerve pain relief.
• Reduce opioid dosage slightly to manage potential side effects.
• Introduce a low dose of haloperidol to help manage hallucinations.
• Refer to palliative care psychiatrist for further evaluation and support.
Goals:
• Alleviate pain and burning sensation in the left hand.
• Manage and reduce the frequency of hallucinations.
• Provide emotional support and maintain quality of life.
Prognosis: Prognosis is guarded, but symptoms can be managed with appropriate adjustments in medication and support.
Next Steps:
• Schedule follow-up appointment to monitor pain and hallucination management.
• Continue to provide emotional and psychological support.
Notes:
• Mrs. Sharma expressed gratitude for the support and adjustments in her treatment plan.
• She remains engaged in her care and is willing to try new strategies to manage her symptoms.