🩺 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 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 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
[Clinical Notes]
- Doctor: Dr. DOCTOR_NAME
- Patient: Mrs. Sharma
- Session Date: SESSION_DATE
Patient Identifying Information: - Name: Mrs. Sharma
Chief Complaint: Mrs. Sharma reports worsening pain in her left hand, described as sharp, constant, and sometimes with a burning sensation. She also mentions experiencing hallucinations, seeing people in her room and hearing voices calling her name.
History of Presenting Illness: Mrs. Sharma's hand pain is attributed to nerve involvement from cancer spread. Pain management will be adjusted, and a nerve pain reliever like gabapentin will be added. The hallucinations, mostly occurring at night, are concerning, and she will be referred to the palliative care psychiatrist. Opioid medication will be reduced, and haloperidol will be introduced to manage the hallucinations.
Past Medical History: - Cancer
Medications: - Pain medication - Gabapentin - Opioids - Haloperidol
Psychiatric Diagnoses: - Hallucinations secondary to illness progression
Treatment Plan: 1. Adjust pain management for nerve pain. 2. Refer to palliative care psychiatrist for hallucinations. 3. Reduce opioid medication and introduce haloperidol. 4. Monitor and adjust treatment for comfort and peace.
Prognosis: Prognosis is guarded due to the progression of the illness and associated symptoms.
Follow-Up Plan: Mrs. Sharma will have regular monitoring and adjustments to her treatment plan to optimize comfort and symptom management.
Recommendations: Mrs. Sharma is encouraged to communicate any changes in symptoms or concerns promptly for ongoing support and care.