🩺 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
Clinical Notes
- Doctor Name: Not mentioned
- Patient Name: Mrs. Sharma
- Session Date: SESSION_DATE
Chief Complaint (CC): Mrs. Sharma presented with worsening pain in her left hand, described as sharp, constant, and occasionally burning. She also reported experiencing hallucinations, primarily at night.
Medical History: - Cancer: Spread with nerve involvement causing hand pain. - Hallucinations: Nighttime visual and auditory hallucinations.
Medications: - Pain Medication: Adjustment planned to address hand pain. - Gabapentin: To be added for nerve pain relief. - Hydrosopioids: Possible contributor to hallucinations, dosage reduction considered. - Haloperidol: Low dose to be introduced to manage hallucinations.
Referral: Mrs. Sharma will be referred to the palliative care psychiatrist for further evaluation and management of the hallucinations.
Prognosis: The prognosis is guarded due to the progression of the illness and symptom management challenges. Close monitoring and adjustments will be made to optimize comfort and quality of life.
Follow-up Plan: Follow-up appointments will be scheduled to monitor Mrs. Sharma's response to the medication adjustments and referral to the psychiatrist.
Patient Education: Emphasis was placed on providing support and reassurance to Mrs. Sharma throughout her treatment journey.