🩺 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 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: Mentioned as spreading, causing nerve involvement.
Medications: • Gabapentin: For nerve pain relief. • Haloperidol: For managing hallucinations. • Opioids: High-dose, adjusted due to side effects.
Allergies: • None: Not specified
Social History: • Exercise: Not specified • Smoking: Not specified
Family History: • Not specified
Review of Systems (ROS): • Neurological: Hallucinations, seeing and hearing things mostly at night. • Musculoskeletal: Sharp, constant, burning pain in left hand.
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: • Not specified due to lack of dietary information.
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: • Not specified.
Prognosis: Good with adherence to recommended medication adjustments and psychiatric support.
Follow-up Plan: • Schedule: Follow-up appointment to monitor medication adjustments and psychiatric referral outcomes.
Patient Education: • Topics: Importance of medication adherence and monitoring for side effects.
Consultation Recommendations: • Psychiatric Referral: Referral to palliative care psychiatrist for hallucination management.
Referral Recommendations: • Psychiatric Referral: As mentioned above.