🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2026-01-22 10:13:39

Transcript

Doctor: Good morning, please have a seat here. What's the problem? Patient: I have a terrible stomachache. Doctor: Do you have diarrhea? Patient: Yes, I do. Doctor: Do you have any other symptoms? Patient: Yes, I feel sick. Doctor: You mean you feel nauseous? Patient: That's right. I feel like vomiting and right now I feel dizzy too. Doctor: When did the symptoms start? Patient: This morning. Yesterday evening I ate something raw. Doctor: All right, please take off your clothes to the waist and lie down there. Just tell me if it hurts when I do this. Patient: It doesn't hurt. Ouch! It hurts there. Doctor: Okay, let's hope it's just indigestion, but we'll need to run some diagnostic tests to be sure. We'll run a blood test and we'll also need a urine sample. Patient: Can you give me something for the time being? Doctor: Yes, I'll give you a prescription for indigestion tablets.

Clinical Notes

Dietitian Consult

Standardized Dietitian Consult Report

Patient Name: PATIENT_NAME

Date of Visit: SESSION_DATE

Chief Complaint (CC): Terrible stomachache, diarrhea, nausea, dizziness.

Dietary History:

  • Typical Diet:
    • Breakfast: Not specified
    • Lunch: Not specified
    • Dinner: Not specified
    • Snacks: Not specified
  • Fruit and Vegetable Intake: Not specified
  • Processed Food Intake: Consumed something raw yesterday evening.
  • Water Intake: Not specified
  • Lactose Intolerance: Not specified

Medical History:

  • Indigestion: Suspected based on symptoms.

Medications:

  • Indigestion Tablets: Prescribed for suspected indigestion.

Allergies:

  • None: Not specified

Social History:

  • Exercise: Not specified
  • Smoking: Not specified

Family History:

  • None: Not specified

Review of Systems (ROS):

  • Constitutional: Dizziness
  • Gastrointestinal: Stomachache, diarrhea, nausea, vomiting
  • Sleep: Not specified

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

Nutritional Requirements: Not specified in the provided transcript.

Nutrition Diagnosis:

  • Suspected Indigestion: Based on symptoms of stomachache, diarrhea, nausea, and dizziness.

Diet and Meal Planning:

  • Recommendations: Not specified

Nutritional Counseling:

  • Recommendations: Not specified

Nutritional Education:

  • Topics: Not specified

Specialized Diet Recommendations:

  • Recommendations: Not specified

Weight Management Strategies:

  • Recommendations: Not specified

Follow-up Plan:

  • Schedule: Follow-up appointment to discuss test results and progress.

Patient Education:

  • Topics: Importance of reporting any worsening symptoms or new symptoms.

Consultation Recommendations:

  • Diagnostic Tests: Blood test and urine sample to confirm diagnosis.

Referral Recommendations:

  • None: No referrals indicated at this time.
⬅ Back to History