Scribe BC - Medical Oncology Consult

**Identification** Mr. John Smith, a 68-year-old male, presents for an initial consultation due to a recent diagnosis of Stage IIIB non-small cell lung cancer (NSCLC). **History** Mr. Smith reports a persistent cough and shortness of breath over the past three months. The cough is dry and occasionally produces small amounts of blood. He denies any chest pain or fever. The shortness of breath worsens with exertion. He initially noticed the symptoms after a bout of the flu. He has no significant family history of cancer. Biopsy findings from a recent bronchoscopy revealed adenocarcinoma of the lung. Immunohistochemical staining showed positive results for TTF-1 and Napsin A, confirming the diagnosis. The tumour cells were negative for EGFR mutations. The pathology report indicates a moderately differentiated tumour. CT scan of the chest, abdomen, and pelvis on October 25, 2024, revealed a 5.2 cm mass in the right upper lobe of the lung, with associated mediastinal lymphadenopathy. No distant metastases were identified. PET scan showed increased uptake in the primary lung mass and involved lymph nodes. Laboratory results from October 28, 2024, showed a slightly elevated LDH of 250 U/L (normal range: 120-240 U/L). Complete blood count (CBC) and comprehensive metabolic panel (CMP) were within normal limits. Consultation with a pulmonologist on October 29, 2024, confirmed the diagnosis and recommended staging investigations. The pulmonologist also recommended pulmonary function tests (PFTs), which are scheduled for next week. **Past Medical History** * Hypertension, managed with lisinopril 10mg daily. * Hyperlipidemia, managed with atorvastatin 20mg daily. **Medications** * Lisinopril 10mg daily. * Atorvastatin 20mg daily. **Allergies** Mr. Smith reports an allergy to penicillin, resulting in a mild rash. **Social History** Mr. Smith is a retired accountant, married for 40 years, and lives with his wife. He is a former smoker, having quit 10 years ago. He reports drinking alcohol socially. He has no significant social support issues. **Physical Examination** Patient appears in no acute distress, is alert and oriented, and has a mild cough. **Assessment / Plan** Mr. Smith has been diagnosed with Stage IIIB NSCLC. The definitive pathological diagnosis is adenocarcinoma of the lung. The staging is based on the CT and PET scan findings. We discussed treatment options, including chemotherapy with carboplatin and paclitaxel, followed by consolidation with durvalumab. The patient expressed understanding and agreement with the proposed treatment plan. We discussed the potential side effects of chemotherapy, including nausea, fatigue, and hair loss. The patient is aware of the risks and benefits. Pre-treatment evaluations, including PFTs and an echocardiogram, are scheduled for next week. Treatment will commence as soon as the results of these evaluations are available. Treatment will be initiated as soon as possible. The patient was instructed to monitor for any new or worsening symptoms, such as fever, shortness of breath, or chest pain, and to seek immediate medical attention if they occur. Follow-up imaging will be performed after four cycles of chemotherapy. "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."