🩺 Record Detail
Patient Info
Transcript
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<th><strong>Original Transcription</strong></th>
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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 the left hand, described as sharp, constant, and burning; visual and auditory hallucinations.
Dietary History:
• Typical Diet: Not specified in the provided transcript.
• 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: With nerve involvement causing pain.
Medications:
• Opioids: High-dose, to be reduced.
• Gabapentin: To be added for nerve pain.
• Haloperidol: To be introduced for managing hallucinations.
Allergies:
• None: Not specified in the provided transcript.
Social History:
• Exercise: Not specified.
• Smoking: Not specified.
Family History:
• Not specified in the provided transcript.
Review of Systems (ROS):
• Neurological: Visual and auditory hallucinations, mostly at night.
• Pain: Sharp, constant, burning pain in the 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: To be completed based on a food diary for the next few days.
Nutritional Requirements: Not specified in the provided transcript.
Nutrition Diagnosis:
• 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 in the provided transcript.
Weight Management Strategies:
• Recommendations: Not specified in the provided transcript.
Prognosis: Good with adherence to recommended medical and lifestyle changes.
Follow-up Plan:
• Schedule: Follow-up appointment to monitor medication adjustments and address any concerns.
Patient Education:
• Topics: Importance of medication adherence and monitoring symptoms.
Consultation Recommendations:
• Psychiatric Referral: Referral to palliative care psychiatrist for hallucination management.
Referral Recommendations:
• Palliative Care Psychiatrist: For management of hallucinations.