Scribe BC - CNS med onc treatment note

"Identification": "Mrs. Evelyn Reed, a 68-year-old female, presents today for a routine follow-up appointment. She has a history of Stage III HER2-positive breast cancer, diagnosed in March 2022. She underwent a lumpectomy, followed by chemotherapy with docetaxel, carboplatin, and trastuzumab. She completed radiation therapy in September 2022. Her recent PET scan in August 2024 showed no evidence of disease." "Reason for Visit": "Mrs. Reed is here today for a follow-up to discuss her ongoing treatment with pertuzumab and trastuzumab, and to assess for any side effects or concerns. She is accompanied by her daughter, Sarah. No interpreter was required." "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": "Dexamethasone 4mg orally twice daily." "anti-epileptic": "Keppra 500mg twice daily, no history of seizures." "Interval History": "Since her last visit, Mrs. Reed reports feeling well, with no significant changes in her overall well-being. She denies any new symptoms. She reports mild fatigue, which she attributes to her ongoing treatment. She is able to perform all her activities of daily living without difficulty." "Living Situation": "Mrs. Reed lives at home with her husband. She is able to manage her own care and requires no assistance with daily activities." "Physical Exam": "ECOG performance status": "1 (Capable of light housework, but unable to work.)" "Neurological Exam": "Neurological exam is within normal limits. Cranial nerves II-XII grossly intact. Strength 5/5 in all extremities. Sensation intact to light touch and pinprick. No pronator drift. Finger-to-nose and heel-to-shin testing are normal. Gait is steady." "Assessment/Plan": "Mrs. Reed continues to do well on her current treatment regimen. Her physical exam is stable and she reports no new symptoms. The plan is to continue pertuzumab and trastuzumab as scheduled. Dexamethasone is indicated to manage any side effects from the chemotherapy." "Treatment Plan": "Continue pertuzumab 840mg IV every 3 weeks and trastuzumab 600mg SC every 3 weeks. Dexamethasone 4mg orally twice daily. Cycle length is 21 days. Potential toxicities include fatigue, nausea, and myelosuppression. Patient consents to the treatment plan." "Follow-up Plan": "Next appointment in 3 weeks for treatment. Repeat blood work prior to each treatment cycle. Schedule a follow-up PET scan in 6 months." "Document Footer": "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."