🩺 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
Patient Identifying Information Mrs. Sharma
Chief Complaint Pain in the left hand, hallucinations.
History of Presenting Illness Mrs. Sharma reports that the pain in her left hand has worsened. She describes it as sharp, constant, and sometimes burning from the inside. Additionally, she has started 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.
Past Psychiatric History Not discussed in the current session.
Past Medical History Mrs. Sharma has a history of cancer, which is likely spreading and causing nerve involvement leading to her hand pain.
Medications Mrs. Sharma is currently on high-dose opioids for pain management. The doctor plans to adjust her pain medication, add gabapentin for nerve pain relief, and introduce a low dose of haloperidol to manage hallucinations.
Social History Not discussed in the current session.
Allergies Not discussed in the current session.
Family History Not discussed in the current session.
Mental Status Exam Mrs. Sharma is alert and oriented. She reports experiencing visual and auditory hallucinations, primarily at night. She expresses feelings of losing control but remains coherent in conversation.
Diagnostic Assessment Based on Mrs. Sharma's presentation, the following considerations are made: • Nerve pain due to cancer progression. • Hallucinations potentially due to high-dose opioid use or illness progression.
Psychiatric Diagnoses Not explicitly diagnosed in the current session.
Treatment Plan
Safety Mrs. Sharma is experiencing distressing hallucinations but is aware they are not real. She is deemed safe at this time with ongoing monitoring.
Biological • Medication Management Plan: Adjust current pain medication, add gabapentin for nerve pain, and introduce a low dose of haloperidol to manage hallucinations.
Psychosocial • Referral to Palliative Care Psychiatry: Mrs. Sharma will be referred to a palliative care psychiatrist for further evaluation and management of her hallucinations.
Prognosis With appropriate adjustments to her medication and support from palliative care, Mrs. Sharma's symptoms can be managed to improve her comfort and quality of life.
Follow Up Plan Mrs. Sharma will be closely monitored, and her treatment plan will be adjusted as needed to ensure her comfort and manage her symptoms effectively.
Recommendations Mrs. Sharma is encouraged to communicate any changes in her symptoms and to reach out for support as needed.