🩺 Record Detail
Patient Info
Name: Unknown
Age: Unknown
Date: 2025-09-10 05:42:34
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: Nerve involvement from cancer spreading.
Medications:
- Gabapentin: For nerve pain relief.
- Haloperidol: For managing hallucinations.
- Opioids: High-dose, adjusted 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 provided in the transcript.
Review of Systems (ROS):
- Neurological: Hallucinations, seeing and hearing things that aren't there.
- Pain: Sharp, constant, burning pain in left hand.
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: No specific nutritional diagnosis provided in the 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: No specialized diet recommendations provided in the transcript.
Weight Management Strategies:
- Recommendations: Not specified in the provided transcript.
Follow-up Plan:
- Schedule: Follow-up with palliative care psychiatrist for hallucinations.
Patient Education:
- Topics: Support and management of symptoms related to cancer and medication side effects.
Consultation Recommendations:
- Palliative Care Psychiatrist: Referral for management of hallucinations.
Referral Recommendations:
- Palliative Care Psychiatrist: For hallucinations management.