🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-09-30 18:21:08

Transcript

Doctor: Good morning, Mrs. Sharma. It's good to see you again. How have you been feeling since our last session? Patient: 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. Doctor: 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. Patient: Thank you. That pain has been unbearable at times. Doctor: I can imagine. Now, about the hallucinations are you seeing or hearing things? And how often does it happen? Patient: 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. Doctor: 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. Patient: Thank you, doctor. It's just been so hard. I feel like I'm losing control. Doctor: 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. Patient: I'm grateful for that, really.

Clinical Notes

General Consultation

Standardized SOAP Note

Chief Complaint Pain in left hand and hallucinations

History of Presenting Illness Mrs. Sharma is a female presenting to the clinic today with worsening pain in her left hand and new onset of hallucinations. The pain is described as sharp, constant, and burning, likely due to nerve involvement from cancer spreading. She reports the hallucinations occur mostly at night, involving seeing people or hearing voices that are not present. She acknowledges the hallucinations are not real but finds them terrifying.

Past Medical History

  • Cancer

Surgical History

  • Not mentioned

Family History

  • Not mentioned

Investigations

  • Referral to palliative care psychiatrist

Medications

  • Current pain medication (adjusted)
  • Gabapentin (added for nerve pain)
  • Haloperidol (added for hallucinations)

Labwork

  • Not mentioned

Social History

  • Not mentioned

Review of Systems

  • Constitutional: No symptoms reported
  • Neurological: Hallucinations
  • Musculoskeletal: Pain in left hand
  • Psychiatric: Hallucinations
  • Other systems: No symptoms reported

Physical Examination

  • Not mentioned

Assessment

Pain in left hand due to nerve involvement from cancer, hallucinations possibly due to high-dose opioids or illness progression.

Plan

  • Adjust current pain medication and add gabapentin for nerve pain.
  • Reduce opioid dosage and introduce low dose of haloperidol for hallucinations.
  • Referral to palliative care psychiatrist for further evaluation and management.
  • Continue monitoring and adjusting treatment for comfort and peace.
⬅ Back to History