🩺 Record Detail
Patient Info
Name: Unknown
Age: Unknown
Date: 2026-01-23 10:58:09
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
Pain Management Consult
Standardized SOAP Note
Chief Complaint Worsening left hand pain and hallucinations
History of Presenting Illness Mrs. Sharma is a female presenting to the clinic today for evaluation of worsening left hand pain and new onset hallucinations. The hand pain has become sharp, constant, and sometimes feels like a burning sensation. She reports that the hallucinations occur mostly at night, where she sees people in her room or hears voices calling her name, although she is aware they are not real.
Past Medical History
- Cancer with nerve involvement
Surgical History
- Not mentioned
Family History
- Not mentioned
Investigations
- Not mentioned
Medications
- Adjusted pain medication
- Gabapentin for nerve pain
- Reduced opioid dosage
- Haloperidol for hallucinations
Labwork
- Not mentioned
Social History
- Not mentioned
Review of Systems
- Neurological: Hallucinations (visual and auditory)
- Musculoskeletal: Worsening left hand pain, burning sensation
- Psychiatric: Hallucinations
Physical Examination
- Not performed
Assessment
Worsening left hand pain likely due to nerve involvement from cancer; hallucinations possibly due to high-dose opioids or illness progression.
Plan
- Adjust pain medication and add gabapentin for nerve pain.
- Reduce opioid dosage and introduce a low dose of haloperidol for hallucinations.
- Referral to palliative care psychiatrist for further evaluation and management.
- Continue monitoring and adjusting treatment to provide comfort and support.