I reviewed Mrs. Evelyn Carter regarding Multiple Myeloma. Mrs. Carter has now completed 6 cycles of chemotherapy and is responding well to treatment.
Mrs. Carter reported some mild fatigue and occasional nausea. The treatment plan includes ongoing supportive care with anti-emetics as needed and encouraging adequate rest and hydration. We discussed the importance of maintaining good oral hygiene to prevent infections.
**The treatment plan includes:**
* Cycle 7 of chemotherapy with Bortezomib, Cyclophosphamide, and Dexamethasone.
* Review of blood counts and renal function prior to each cycle.
* Regular monitoring for side effects.
**Investigations:**
* 15/08/2024: ANC 2.1, Hb 115 g/L, WCC 6.5, PLT 250, Creat 80, Calcium 2.4, K/L ratio 1.2, BJP negative.
* 01/10/2024: Repeat skeletal survey showed stable disease.
**Impression:**
* Stable disease with good response to chemotherapy.
* Patient tolerating treatment well with manageable side effects.
**Next Review:**
I will review Mrs. Carter prior to her next scheduled chemotherapy treatment on 01/12/2024.
**Patient Education:**
I advised Mrs. Carter about the importance of reporting any new symptoms or worsening of existing symptoms. We discussed the importance of infection prevention and the need for regular follow-up appointments. I also provided information on support groups and resources for patients with Multiple Myeloma.
Thank you for your ongoing care. If any questions or concerns arise, please feel welcome to contact my rooms.
I reviewed [patient first name] regarding [specific diagnosis]. [patient first name] has now completed [number] cycles of chemotherapy and is responding [response to treatment].
[summary of any concerns or side effects the patient reported, followed by the treatment plan addressing these concerns] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a short paragraph of full sentences.)
[any relevant additional comments relating to the diagnosis or treatment discussed during the review] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a short paragraph of full sentences.)
**The treatment plan includes:**
[details of treatment plan including number of cycles, specific procedures, and timelines] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as bullet points.)
**Investigations:**
[details of investigation results and their interpretation, including laboratory tests such as ANC, Paraprotein, Kappa, Lambda, K/L ratio, CBE, Flow cytometry, BJP, Hb, WCC, PLT, Biochem, Calcium, Creat, and imaging findings such as CT skeletal survey] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list, starting with the oldest investigation and continuing to the most recent. Each investigation should be dated, followed by specific findings. Use original format as entered in the context notes — do not summarise.)
**Impression:**
[summary of clinical impression] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as bullet points.)
**Next Review:**
I will review [patient first name] prior to [his/her/their] next scheduled chemotherapy treatment on [date of upcoming chemo in date/month format].
[details of any deferred treatments and reasons for deferral] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a short paragraph of full sentences.)
[details of any additional tests or follow-up actions planned] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a paragraph of full sentences.)
[details of any changes in medication, dosage, or treatment] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a paragraph of full sentences.)
**Patient Education:**
[summary of any advice given to the patient regarding their condition and treatment plan] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in short paragraphs of full sentences.)
Thank you for your ongoing care. If any questions or concerns arise, please feel welcome to contact my rooms.
(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, depending on the format, as needed to capture all the relevant information from the transcript.)