🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-09-04 10:50:47

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 left hand, hallucinations.

Dietary History: • Typical Diet: Not specified in the provided transcript.
• Breakfast: Not specified in the provided transcript.
• Lunch: Not specified in the provided transcript.
• Dinner: Not specified in the provided transcript.
• Snacks: 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: Involvement causing nerve pain.

Medications: • Gabapentin: For nerve pain.
• Opioids: High-dose, adjusted.
• Haloperidol: For hallucinations.

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 in the provided transcript.

Review of Systems (ROS): • Neurological: Hallucinations, seeing and hearing things that aren't there.
• Pain: Sharp, constant, burning sensation 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: 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 dietary and lifestyle changes.

Follow-up Plan: • Schedule: Follow-up appointment in a few weeks to discuss progress and address any concerns.

Patient Education: • Topics: Importance of a healthy diet, hydration, and regular physical activity for overall health and well-being.

Consultation Recommendations: • Food Diary Review: Review food diary upon completion to assess dietary intake and provide further personalized recommendations.

Referral Recommendations: • Palliative care psychiatrist: For management of hallucinations.

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