Scribe BC - Sarcoma on Treatment Follow up

"patient demographics including name, age, gender, and primary diagnosis": "Mr. John Smith, a 62-year-old male, presents with a diagnosis of high-grade undifferentiated pleomorphic sarcoma (UPS). He is currently undergoing treatment for this condition.", "Date of Diagnosis": "12 June 2024", "Molecular Features": "TP53 mutation detected.", "Treatment": "1. Surgery: Wide local excision with negative margins, 15 June 2024.", "2. Adjuvant Chemotherapy: Doxorubicin and Ifosfamide, 1 July 2024 - 1 October 2024." "Current Treatment": "Currently on surveillance following completion of adjuvant chemotherapy.", "Interval History": "The patient is accompanied by his wife, Mary Smith.", "description of new symptoms, including onset, location, characteristics, and related details": "The patient reports mild fatigue over the past two weeks, but denies any new pain, shortness of breath, or other concerning symptoms. He states that the fatigue is manageable and does not significantly impact his daily activities.", "patient's ECOG performance status and its interpretation": "ECOG performance status is 0, indicating the patient is fully active and able to carry on all pre-disease performance without restriction.", "HR": "72 bpm", "BP": "130/80 mmHg", "SpO2": "98% on room air", "WT": "78 kg", "general appearance and specific physical findings, particularly those related to the chief complaint": "The patient appears well-nourished and in no acute distress. He is alert and oriented. There is no palpable mass or tenderness at the surgical site. The incision is well-healed.", "CT Chest Abdo Pelvis w/ Contrast": "28 October 2024", "COMPARISON": "Compared to CT scan from 1 October 2024.", "IMPRESSION": "1. No evidence of recurrent or metastatic disease.", "2. Stable appearance of the surgical site.", "3. No new pulmonary nodules or pleural effusions." "assessment of patient's current condition, correlation with symptoms, and differential diagnoses considered": "Mr. Smith is doing well following completion of adjuvant chemotherapy. His mild fatigue is likely related to the treatment and is improving. The differential diagnoses include treatment-related side effects and potential recurrence, although imaging does not suggest recurrence.", "discussion of treatment options, patient preferences, and recommended plan, including medications and next steps": "The patient will continue with surveillance imaging every three months for the next two years. We discussed the importance of early detection of any recurrence. The patient expressed understanding and agreed to the plan. No new medications are required.", "patient instructions and follow-up plan, including when to contact the office": "The patient is instructed to contact the office immediately if he experiences any new symptoms, such as pain, swelling, or shortness of breath. He is scheduled for a follow-up appointment in three months. He was provided with written educational materials about sarcoma and its management." "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."