🩺 Record Detail
Patient Info
Transcript
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<th><strong>Original Transcription</strong></th>
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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
Subjective
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Patient: Mrs. Sharma
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Primary Concern: Worsening pain in left hand and hallucinations.
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Reports sharp, constant pain with a burning sensation in the left hand.
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Experiences visual and auditory hallucinations, mostly at night.
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Family History: Not mentioned.
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Lifestyle Factors: Not mentioned.
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Reproductive History: Not mentioned.
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Psychosocial Stressors:
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Feels like losing control due to the symptoms.
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Finds the hallucinations terrifying.
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Objective
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Medical History:
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Cancer with nerve involvement causing pain.
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Currently on high-dose opioids.
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Behavioral Observations:
- Patient expresses significant distress and fear related to hallucinations and pain.
Assessment
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Nerve Pain: Likely due to cancer spreading, causing sharp and burning sensations in the left hand.
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Hallucinations: Possibly a side effect of high-dose opioids or progression of illness.
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 and introduce a low dose of haloperidol for hallucination management.
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Specialist Referral:
- Refer to palliative care psychiatrist for further evaluation and support.
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Monitoring and Support:
- Continue to monitor symptoms and adjust treatment as needed to ensure patient comfort.
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Follow-Up:
- Schedule regular follow-ups to reassess pain management and mental health support.
Medications | Name | Brand | Dosage | Frequency | Duration (Days) | |---------------|-------|----------|-----------------------------------------|-----------------| | Gabapentin | – | unspecified | unspecified | unspecified | | Haloperidol | – | unspecified | unspecified | unspecified | | | – | unspecified | unspecified | unspecified |