Scribe BC - Gynaecoloy Oncology Note

[Insert patient name] is a very pleasant Sarah Jones, [insert patient age] 54-year-old female who is referred to the Gynecology Oncology unit for abnormal vaginal bleeding. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Subjective: - Chief Complaint: Patient reports experiencing abnormal vaginal bleeding for the past three months, including heavy periods and spotting between periods. The bleeding is associated with lower abdominal cramping and fatigue. It significantly impacts her daily activities, causing her to miss work and social engagements. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.) - History of Present Illness: The patient's symptoms began gradually three months ago, with increasing frequency and severity of bleeding. She has tried over-the-counter pain relievers with minimal relief. The bleeding has worsened over time, and she now experiences significant fatigue. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.) - Menstrual History: Last menstrual period was 1 month ago. Cycles are typically regular, every 28 days, but have become irregular in the last three months. No postmenopausal bleeding. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.) - Obstetric History: Gravida 2, Para 2. Two vaginal deliveries. No miscarriages or abortions. No pregnancy complications. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.) - Gynecologic History: No previous gynecologic surgeries. Pap smears have been normal in the past. Uses an IUD for contraception. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.) - Past Medical History: Hypertension, controlled with medication. No previous cancers. No genetic predispositions. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.) - Medications and Supplements: 1. Lisinopril 10mg daily 2. Multivitamin daily (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely. Use a numbered list format) - Allergies: 1. No known allergies. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely. Use numbered list format) - Social History: Non-smoker. Drinks alcohol occasionally, one to two glasses of wine per week. No recreational drug use. Works as a teacher. Supportive family. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.) Objective: - Vital Signs: Blood pressure 130/80 mmHg, heart rate 78 bpm, temperature 37.0°C, respiratory rate 16 breaths/min, oxygen saturation 98% on room air, weight 70 kg, BMI 26. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely. If height and weight have been mentioned then calculate the body mass index and add it to the vitals signs as BMI) - Physical Examination Findings: General appearance is well-nourished and in no acute distress. ECOG performance status 1. No palpable lymphadenopathy. Cardiovascular and pulmonary exams are unremarkable. Abdomen is soft, non-tender, and without masses. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.) - Abdominal Examination: Soft, non-tender, no masses, no organomegaly, no ascites. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.) - Pelvic Examination: External genitalia are normal. Vaginal walls are pink and moist. Cervix appears normal. Uterus is slightly enlarged and mobile. No adnexal masses. Rectovaginal exam unremarkable. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.) - Laboratory Results: Complete blood count: within normal limits. CA-125: 35 U/mL. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.) - Imaging Studies: Pelvic ultrasound shows a thickened endometrium. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.) Assessment: - Diagnosis: Endometrial hyperplasia without atypia. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.) - Clinical Impression: The patient has endometrial hyperplasia without atypia. Prognosis is good with appropriate treatment. The patient is a candidate for hormonal therapy. Multidisciplinary team recommendations: consultation with a gynecologic oncologist. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.) Plan: - Treatment Plan: Start on oral progestin therapy. Consider endometrial biopsy if bleeding persists. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely. If recommending surgery make the recommended procedure bold and underlined) - Medications Prescribed: Medroxyprogesterone acetate 10mg daily for 14 days, then re-evaluate. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.) - Patient Education and Counseling: Discussed the diagnosis, treatment options, and potential side effects. Explained the importance of follow-up. Provided resources for support. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.) - Follow-Up Plan: Schedule a follow-up appointment in 3 months to assess response to treatment. Monitor for any changes in bleeding patterns. Coordinate care with the gynecologic oncologist. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.) "This document was created using AI Ambient Scribe and Front-End Speech Recognition software and may include incorrect spelling/words. Consent for usage of AI was obtained by patient/guardian."