🩺 Record Detail
Patient Info
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
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Patient: Mrs. Sharma
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Primary Concern: Worsening pain in the left hand and hallucinations.
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Describes the pain as sharp, constant, and burning, likely due to nerve involvement from cancer spreading.
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Reports seeing people and hearing voices, mostly at night, which are recognized as hallucinations.
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Objective
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Medical History:
- Currently on high-dose opioids for pain management.
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Behavioral Observations:
- Patient expresses significant distress over the hallucinations and worsening pain.
Assessment
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Pain Management: Increased nerve pain likely due to cancer progression.
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Hallucinations: Possibly a side effect of high-dose opioids or illness progression.
Plan
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Medication Adjustments:
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Adjust pain medication and add gabapentin for nerve pain relief.
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Reduce opioid dosage slightly and introduce a low dose of haloperidol to manage hallucinations.
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Referral:
- Refer to palliative care psychiatrist for further evaluation and support regarding hallucinations.
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Follow-Up:
- Continue monitoring pain levels and hallucination frequency for further adjustments.
Medications | Name | Brand | Dosage | Frequency | Duration (Days) | |---------------|-------|----------|-----------------------------------------|-----------------| | Gabapentin | – | unspecified | unspecified | unspecified | | Haloperidol | – | unspecified | unspecified | unspecified | | | – | unspecified | unspecified | unspecified |