Wagner NEW PCa patient

Urology Referring Physician: [Referring physician's name] (only include referring physician's name if it has been explicitly mentioned in the transcript or notes, otherwise include the section header but leave the placeholder blank.) SHORT SUMMARY OF TODAY'S VISIT: [summarize today's visit and plan in no more than 4 sentences] **Chief Complaint:** [Describe the patient's chief complaint] (only include referring physician's name if it has been explicitly mentioned in the transcript or notes, otherwise include the section header but leave the placeholder blank.) **History of Present Illness:** This is a [age] year old [sex] with a [Describe history of present illness, including any relevant dates, diagnostic findings, and past interventions.] (include all details explicitly mentioned.) - **PSA History:** [List patient's PSA history with dates and values.] - **Imaging Findings:** [Describe relevant imaging findings, including date and type of imaging.] - Biopsy Findings: [Summarize biopsy results, including locations, scores, and specific notes.] - **Urinary ROS:** [Mention any urinary symptoms or lack thereof.] - [Describe other related findings relevant to the patient's visit.](only include referring information in this section if it has been explicitly mentioned in the transcript or notes, otherwise omit completely.) -**Sexual Function review:** [Mention sexual activity and any challenges including the need for PDE-5 inhibitors like viagra or cialis] **Past Medical History:** [List all past medical conditions mentioned, one per bullet.] (only include explicitly mentioned conditions.) - [Diagnosis A, date, additional detail] - [Diagnosis B, date, additional detail] **Past Surgical History:** [List all past surgeries, including laterality and dates.] (only include explicitly mentioned surgeries.) - [Procedure A, laterality, surgeon title, date, additional detail] - [Procedure B, laterality, surgeon title, date, additional detail] **Family History:** - Family history of cancer/condition: [Provide Details about family history of relevant illness/condition, including number of relatives, age, or metastatic status.] (only include if explicitly mentioned.) **Social History:** (only include information if it has been explicitly mentioned in the transcript or notes, otherwise include the section header and state "not mentioned".) - Tobacco use: [Details on tobacco use, including pack years, if applicable.] - Alcohol use: [Details on alcohol consumption, if mentioned.] - Occupation: [Detailes of work and occupation.] - Social support: [Describe social support system, if mentioned.] - Hobbies: [List hobbies, if mentioned.] **Allergies:** - [List allergies explicitly mentioned or note "No Known Allergies" if nothing is mentioned.] **Medications:** [Provide a detailed list of all current medications, including dosage, frequency, and special instructions] (use a structured bullet list.) - [Medication A, dosage, frequency, special instruction] - [Medication B, dosage, frequency, special instruction] **Review of Systems:** [Summarize findings from the review of systems.] **Physical Exam:** (only include information if it has been explicitly mentioned in the transcript or notes, otherwise include the section header and state "not mentioned".) - General Appearance: [Details about general appearance.] - HEENT: [Details about head, eyes, ears, nose, throat exam.] - Cardiac: [Details about cardiovascular exam.] - Resp: [Details about respiratory exam.] - Abdomen: [Details about abdominal exam.] - Genitourinary: [Details about genitourinary exam, if performed.] **Laboratory Findings:** [List relevant laboratory findings, including dates and results.] (only include findings explicitly mentioned.) **Biopsy Results:** [Date of biopsy] (only include date of biopsy if explicitly mentioned in the transcript, contextual notes, or clinical note.) - **[Location A]:**   - [Description of findings, including relevant pathology details, measurements, and diagnostic notes.] (only include description of findings if explicitly mentioned in the transcript, contextual notes, or clinical note.) - **[Location B]:**   - [Description of findings, including relevant pathology details, measurements, and diagnostic notes.] (only include description of findings if explicitly mentioned in the transcript, contextual notes, or clinical note.) etc. **Imaging Results:** [Summarize imaging results, including details such as gland size, PIRADS scores, and other findings.] **Assessment:** (only include information if explicitly mentioned in the transcript, contextual notes, or clinical note. Do not come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care) This is a [patient's age] year old [patient's gender] presenting with [description of condition or diagnosis, including severity or staging]. (include prostate cancer risk stratification if mentioned during visit) [If patient is new and here primarily for prostate cancer then include the following in the note] "We reviewed the options: including active surveillance, external beam radiation, brachytherapy, and radical prostatectomy." [if active surveillance was discussed then include these 2 paragraphs, if not then omit] "Active surveillance was discussed and is appropriate for patients with low risk, Gleason 6 disease and select patients with Gleason 3+4 disease. It requires periodic PSA checks (Q 3-6 months) and prostate exams every 6 months. Additionally, prostate biopsies are required at years 1 then every 1-3 years thereafter. We have found that in appropriately screened patients, there is less than 1% risk of death from prostate cancer in this cohort. Regard to active surveillance in patients with Gleason 3+4 disease, this is a newer philosophy and is almost certainly safe at least in the short-term. We have found in our Prostate Cancer Active Surveillance Study (Canary-PASS) that in about 180 patients with Gleason 3+4 disease approximately two thirds require treatment by the 5-year point however none of these patients have developed metastatic disease suggesting that short-term surveillance is safe." We spent much of our discussion on the pros and cons of moving forward with robotic prostatectomy. Certainly, it will offer him a reasonable chance of cure, give us important pathological data including lymph node status, make post-treatment evaluation very straightforward with a PSA test of high sensitivity and specificity, and gives us the opportunity to treat secondarily with external beam radiation in the event of cancer recurrence. We would approach this robotically which requires two to three hours of surgery and overnight hospital stay, <1% risk of blood transfusion, and one week catheterization. Other rare complications are possible including damage to other organs (ureters or intestine), DVT/PE, or MI. Ileus occurs in about 1 in 50 cases requiring readmission. We will consider a pelvic lymph node dissection which does carry with it a slightly higher risk of DVT or PE in the postop setting, as well as small risk of lower extremity lymphedema. Most men are able to resume normal physical activity and excercise in 3 weeks. Most men experience urinary incontinence that can continues on average for about three to six months. There is a 5% risk of permanent, socially significant incontinence. We discussed and illustrated the anatomy of the prostate, including its relationship with the bladder, urethra, and rectum. I explained how separation of the prostate and the bladder disrupts the internal urethral sphincter, and that his urinary control is dependent almost solely on the external urethral sphincter during healing of the vesicourethral anastamosis, which results in temporary stress urinary incontinence. I showed him how cavernosal nerves that help control erections are intimately related to the lateral and posterior aspect of the prostate, and usually damaged or stretched during radical prostatectomy, resulting in temporary or sometimes permanent erectile dysfunction. We mentioned that it is possible that he may require further procedures after prostatectomy to treat his prostate cancer. I reassured the patient that we focus on optimizing patients' quality of life and that I expect that he will be satisfied with his recovery, but that if he is not, that further medications or procedures to help him with his urinary or sexual side effects will be made available to him throughout his recovery. In particular, I explained our programs in pelvic floor physical therapy and sexual rehabilitation, which can accelerate recovery of both health domains, and would be made available to him both before and after surgery. He would be a candidate for nerve sparing after which would have a fair chance of regaining erectile function suitable for intercourse, but probably would not regain baseline sexual function and he would likely need at least the help of PDE 5 inhibitors, if not other erection aids including penile vacuum device or penile injections. " 2‌. [Medical issue 2 (condition name and ICD-10 code if applicable)] - [Assessment: Current assessment of the condition. (include only if mentioned, otherwise leave blank)] - [Plan: Proposed plan for management or follow-up. (include only if mentioned, always include discussion of risks of procedure/treatment, otherwise leave blank)] - [Counseling: Description of the condition, natural history, or similar, only if discussed. (include only if mentioned, otherwise leave blank)] 3‌. [Medical issue 3, 4, 5, etc (condition name and ICD-10 code if applicable)] - [Assessment: Current assessment of the condition. (include only if mentioned, otherwise leave blank)] - [Plan: Proposed plan for management or follow-up. (include only if mentioned, always include discussion of risks of procedure/treatment, otherwise leave blank)] - [Counseling: Description of the condition, natural history, or similar, only if discussed. (include only if mentioned, otherwise leave blank)] **Plan:** [List specific plans, including diagnostics, follow-ups, or treatments.] - [Diagnostic tests to schedule, such as imaging or biopsies.] - [Surgical plans, if applicable, including lymph node dissection or nerve-sparing approach.] - [Referral to specialists, if applicable.] - [Any other planned interventions or follow-ups.] - [state which hospital the surgery will be at] **Signed By:** [Clinician's name, designation, and date of signing.] **Time Spent:** Total time spent for face-to-face and non-face-to-face care, excluding procedures and other services, on the day of this encounter is [total time spent for care] “Consent for the use of AI-assisted tools for documentation was obtained from the patient and all other participants in the visit prior to this encounter. All questions were answered. Patient understands that they may decline the use of AI-assisted tools at future visits.” (write this verbatim and include in every note generated) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely. Use as many lines, paragraphs, or bullet points as needed to capture all the relevant information from the transcript.) (only include referring physician's name if it has been explicitly mentioned in the transcript or notes, otherwise include the section header but leave the placeholder blank.)