🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-09-20 10:43:10

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

Dietitian Consult

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 in the provided transcript.
  • Fruit and Vegetable Intake: Not specified in the provided transcript.
  • Processed Food Intake: Not specified in the provided transcript.
  • Water Intake: Not specified in the provided transcript.
  • Lactose Intolerance: Not specified in the provided transcript.

Medical History:

  • Cancer: With nerve involvement causing pain in the left hand.

Medications:

  • Gabapentin: For nerve pain relief.
  • Haloperidol: For managing hallucinations.
  • Opioids: High-dose, slightly reduced due to side effects.

Allergies:

  • None: Not specified in the provided transcript.

Social History:

  • Exercise: Not specified in the provided transcript.
  • Smoking: Not specified in the provided transcript.

Family History:

  • Not specified: Not specified in the provided transcript.

Review of Systems (ROS):

  • Constitutional: Not specified in the provided transcript.
  • Gastrointestinal: Not specified in the provided transcript.
  • Sleep: Hallucinations mostly at night.

Nutritional Assessment:

  • BMI: Not specified in the provided transcript.
  • BMI Category: Not specified in the provided transcript.

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: Not specified in the provided transcript.

Diet and Meal Planning:

  • Recommendations: Not specified in the provided transcript.

Nutritional Counseling:

  • Recommendations: Not specified in the provided transcript.

Nutritional Education:

  • Topics: Not specified in the provided transcript.

Specialized Diet Recommendations:

  • Not specified: Not specified in the provided transcript.

Weight Management Strategies:

  • Recommendations: Not specified in the provided transcript.

Follow-up Plan:

  • Schedule: Follow-up appointment to monitor and adjust medications as needed.

Patient Education:

  • Topics: Importance of managing symptoms and medication side effects for overall well-being.

Consultation Recommendations:

  • Referral to palliative care psychiatrist for hallucinations management.

Referral Recommendations:

  • Palliative care psychiatrist: To address hallucinations and provide additional support.
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