🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-09-20 11:42:50

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): Worsening pain in left hand, hallucinations.

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: Not specified
  • Water Intake: Not specified
  • Lactose Intolerance: Not specified

Medical History:

  • Cancer: Nerve involvement causing pain in left hand.

Medications:

  • Gabapentin: For nerve pain relief.
  • Haloperidol: For managing hallucinations.
  • Opioids: Previously prescribed for pain management, dosage adjusted.

Allergies:

  • None: Not specified

Social History:

  • Exercise: Not specified
  • Smoking: Not specified

Family History:

  • Not specified

Review of Systems (ROS):

  • Constitutional: Not specified
  • Gastrointestinal: Not specified
  • Sleep: Hallucinations mostly at night.

Nutritional Assessment:

  • BMI: Not specified
  • BMI Category: Not specified

Body Composition Analysis: Not performed during this visit.

Dietary Intake Analysis: Not specified.

Nutritional Requirements: Not specified.

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

Follow-up Plan:

  • Schedule: Follow-up appointment with palliative care psychiatrist to address hallucinations.

Patient Education:

  • Topics: Importance of medication adherence and monitoring symptoms.

Consultation Recommendations:

  • Psychiatric Referral: Referral to palliative care psychiatrist for hallucinations.

Referral Recommendations:

  • Palliative Care Psychiatrist: To manage hallucinations and provide additional support.
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