🩺 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
Pain Management Consult
Patient Name: Mrs. Sharma
Date of Visit: SESSION_DATE
ID: [Patient ID]
CC: Left hand pain, hallucinations.
HPI: Mrs. Sharma is a [age] year old female presenting to the clinic today for a pain management consult. She reports experiencing worsening pain in her left hand. The pain is described as sharp, constant, and sometimes feels like burning from the inside. Additionally, she reports experiencing hallucinations, mostly at night, where she sees people in her room or hears voices calling her name. She acknowledges that these are not real but finds them terrifying.
Symptoms:
- Neurological: Hallucinations (visual and auditory)
- Pain: Left hand pain, sharp, constant, burning sensation
Physical Exam: Normal
Past Medical History:
- Cancer
Family History:
- Not discussed
Medications:
- High-dose opioids
- Gabapentin (newly added for nerve pain)
- Haloperidol (newly added for hallucinations)
Investigations:
- None discussed
Labwork:
- None discussed
Neurological Symptoms:
- Hallucinations: Visual and auditory, mostly at night.
Pain Symptoms:
- Left Hand Pain: Sharp, constant, burning sensation, likely due to nerve involvement from cancer spreading.
Dietary History:
- Not discussed
Neurological Findings: Pending
Neurological Procedures:
- Referral to palliative care psychiatrist
Imaging Studies:
- None performed at this time.
Impression/Plan:
Diagnosis:
- Possible nerve involvement due to cancer spreading, causing left hand pain.
- Hallucinations possibly due to high-dose opioids or progression of illness.
Plan:
- Medication Adjustment: Reduce opioid dosage slightly and introduce gabapentin for nerve pain and haloperidol for hallucinations.
- Psychiatric Referral: Referral to palliative care psychiatrist for further evaluation and management of hallucinations.
- Follow-up: Regular monitoring and adjustments to medications to provide comfort and manage symptoms effectively.
Note: This report is based on the information provided in the transcript. Further investigations and evaluations are necessary to establish a definitive diagnosis and treatment plan.