**Reason for Consultation**
"Dear Dr. Emily Carter,"
Patient is a 68-year-old male referred for consultation regarding newly diagnosed stage III non-small cell lung cancer. Pathology confirmed adenocarcinoma. The patient underwent a left upper lobectomy on 10/15/2024.
Patient presents today with his wife for discussion of adjuvant chemotherapy options.
**Consent**
"The patient provided verbal consent to use the AI scribe during this visit, understanding its purpose, potential benefits, and any associated privacy and security risks"
**steroids:**
None
**anti-epileptic:**
None
**History of Present Illness**
The patient initially presented with a persistent cough and shortness of breath. A chest X-ray revealed a mass in the left upper lobe. Subsequent CT scan confirmed the presence of a 4.5 cm mass with associated mediastinal lymphadenopathy. The patient underwent a PET scan, which showed increased uptake in the primary tumour and several mediastinal lymph nodes.
Surgical intervention included a left upper lobectomy with mediastinal lymph node dissection. Pathology revealed stage IIIA non-small cell lung cancer, adenocarcinoma, with positive margins. The patient recovered well post-operatively.
**Problem List/Past Medical History**
* Non-small cell lung cancer, stage IIIA
* Hypertension
* Hyperlipidemia
**Social History**
The patient is a retired accountant and lives with his wife. He is a former smoker, having quit 5 years ago. He drinks alcohol occasionally. He has full health benefits.
**Family History**
* Mother: History of breast cancer
* Father: History of heart disease
**Performance Status**
"ECOG (Zubrod)" 1
"KPS" 90
**Physical Exam**
Patient is alert and oriented to person, place, and time. Speech is clear. No neurological deficits are noted. Lungs are clear to auscultation bilaterally.
**Assessment/Plan**
Patient has stage IIIA non-small cell lung cancer, adenocarcinoma. The management plan involves adjuvant chemotherapy with carboplatin and paclitaxel. The patient and his wife understand the diagnosis and treatment plan.
Treatment goals are to improve disease-free survival and overall survival.
The patient will receive 4 cycles of carboplatin and paclitaxel, starting next week. The patient has provided consent for treatment.
**Follow-up plan and closing remarks**
- Patient and family education on the current status of cancer, overview of the treatment plan, potential side effects, and symptom management
- Discussion of patient preferences and goals of care, including advance care planning and quality of life considerations
- Any specific patient or family concerns addressed regarding the cancer diagnosis, treatment options, or prognosis
"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."
Medical Oncology
**Reason for Consultation**
"Dear Dr. [Insert name of referring physician],"
[Referral details including patient demographics, diagnosis, relevant pathology, date and extent of surgery] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in a single paragraph.)
[Reason for current visit and accompanying individuals, including interpreters] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in a single paragraph.)
**Consent**
"The patient provided verbal consent to use the AI scribe during this visit, understanding its purpose, potential benefits, and any associated privacy and security risks"
**steroids:**
[details of steroid use] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.)
**anti-epileptic:**
[details of anti-epileptic use and seizure history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.)
**History of Present Illness**
[Description of initial presentation, symptoms, and events leading to current diagnosis, including changes in consciousness, cognitive decline, and other relevant symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.)
[Summary of initial diagnostic imaging findings, including CT and MRI results, measurements, and relevant observations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.)
[Information regarding surgical intervention, including date, surgeon, specific procedures performed, post-operative findings, complications, and discharge details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.)
[Details of subsequent consultations or treatments, including recommendations from other specialists and considerations for additional therapies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.)
[Patient's current overall status, functional independence (ADLs/IADLs), remaining symptoms, medication tapering, and daily activities] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.)
**Problem List/Past Medical History**
[List of active and resolved medical problems] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a bulleted list.)
**Social History**
[Include alcohol use, smoking history, recreational drug use, as well as additional social context including occupation, living arrangements, and extended health benefits] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in a single paragraph.)
**Family History**
[Relevant family medical history, including specific conditions and relationships] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a bulleted list.)
**Performance Status**
"ECOG (Zubrod)" [ECOG performance status and description] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.)
"KPS" [Karnofsky Performance Status] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.)
**Physical Exam**
[Results of physical examination including orientation, speech, cognitive assessments, cranial nerve function, motor strength, and gait] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.)
**Assessment/Plan**
[Patient's diagnosis, key characteristics of the disease, and discussion of the management plan with the patient and family] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.)
[Discussion regarding disease aggressiveness, treatment goals, patient understanding of the disease, and prognosis discussions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.)
[Recommended treatment plan, including type of radiation and chemotherapy, and discussion with other specialists] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.)
[Detailed plan for chemotherapy administration, including dosage, cycle, potential toxicities, and patient consent for treatment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.)
[Important notes regarding other concurrent treatments or patient practices] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in a single paragraph.)
[Follow-up plan and closing remarks] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in a single paragraph.)
- [Patient and family education on the current status of cancer, overview of the treatment plan, potential side effects, and symptom management] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.)
- [Discussion of patient preferences and goals of care, including advance care planning and quality of life considerations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the placeholder completely.)
- [Any specific patient or family concerns addressed regarding the cancer diagnosis, treatment options, or prognosis] (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."
Medical Oncology
(Never come up with your own patient details, assessment, plan, interventions, evaluation, or 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.)
