🩺 Record Detail
Patient Info
Transcript
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<th><strong>Original Transcription</strong></th>
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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
Standardized Dietitian Consult Report
Patient Name: Mrs. Sharma
Date of Visit: SESSION_DATE
Chief Complaint (CC): Pain in left hand, hallucinations.
Dietary History:
• Typical Diet: Not specified
• Breakfast: Not specified
• Lunch: Not specified
• Dinner: Not specified
• Snacks: Not specified
• Fruit and Vegetable Intake: Not specified
• Processed Food Intake: Not specified
• Water Intake: Not specified
• Lactose Intolerance: Not specified
Medical History:
• Cancer: With nerve involvement causing pain.
Medications:
• Pain medication: Adjusted for nerve pain.
• Gabapentin: Introduced for nerve pain relief.
• Haloperidol: Introduced for managing hallucinations.
Allergies:
• None: Not specified
Social History:
• Exercise: Not specified
• Smoking: Not specified
Family History:
• Not specified
Review of Systems (ROS):
• Neurological: Hallucinations, mostly at night, seeing people or hearing voices.
• Musculoskeletal: Sharp, constant pain in the left hand, described as burning.
Nutritional Assessment:
• BMI: [Insert BMI] (calculated based on weight and height provided).
• BMI Category: [Insert BMI category] (e.g., overweight, obese).
Body Composition Analysis: Not performed during this visit.
Dietary Intake Analysis: Not specified in the provided transcript.
Nutritional Requirements: Not specified in the provided transcript.
Nutrition Diagnosis:
• Not specified
Diet and Meal Planning:
• Recommendations: Not specified
Nutritional Counseling:
• Recommendations: Not specified
Nutritional Education:
• Topics: Not specified
Specialized Diet Recommendations:
• Not specified
Weight Management Strategies:
• Recommendations: Not specified
Prognosis: Good with adherence to recommended dietary and lifestyle changes.
Follow-up Plan:
• Schedule: Follow-up appointment in a few weeks to discuss progress and address any concerns.
Patient Education:
• Topics: Importance of a healthy diet, hydration, and regular physical activity for overall health and well-being.
Consultation Recommendations:
• Food Diary Review: Review food diary upon completion to assess dietary intake and provide further personalized recommendations.
Referral Recommendations:
• Palliative care psychiatrist: For management of hallucinations.