🩺 Record Detail
Patient Info
Transcript
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<tbody><tr><td id="fragmentid_1"><div><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></div></td></tr><tr><td id="fragmentid_2"><div><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></div></td></tr><tr><td id="fragmentid_3"><div><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></div></td></tr><tr><td id="fragmentid_4"><div><p><strong>Patient</strong>: Thank you. That pain has been unbearable at times.</p></div></td></tr><tr><td id="fragmentid_5"><div><p><strong>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>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>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></div></td></tr><tr><td id="fragmentid_8"><div><p><strong>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>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>Patient</strong>: I'm grateful for that, really.</p></div></td></tr></tbody>
Clinical Notes
SOAP Note
- Subjective:
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Mrs. Sharma reports feeling not great since the last session. She describes sharp, constant pain in her left hand, sometimes with a burning sensation. Additionally, she mentions experiencing hallucinations, mainly at night, seeing people in her room and hearing voices calling her name, acknowledging that these are not real but terrifying.
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Objective:
- The doctor discusses adjusting Mrs. Sharma's pain medication due to likely nerve involvement from cancer spreading, suggesting adding a nerve pain reliever like gabapentin. The patient expresses gratitude for addressing the unbearable pain.
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The doctor addresses the hallucinations, considering them a side effect of hydrosopioids or disease progression. Referral to a palliative care psychiatrist is planned, along with a reduction in opioids and the introduction of haloperidol to manage the hallucinations.
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Assessment:
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Mrs. Sharma is experiencing worsening left hand pain likely due to nerve involvement from cancer spread. She is also encountering distressing hallucinations, possibly related to medication side effects or disease progression.
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Plan:
- Adjust pain medication by adding gabapentin for nerve pain relief.
- Refer Mrs. Sharma to a palliative care psychiatrist for management of hallucinations.
- Reduce opioid medication slightly and introduce haloperidol to help manage the hallucinations.
- Ensure continuous monitoring and adjustments to provide comfort and support to the patient.