**DIAGNOSIS**
Mrs. Eleanor Vance, a 68-year-old female, was initially diagnosed with Stage IIIB non-small cell lung cancer (NSCLC) in March 2024, with spread to the mediastinal lymph nodes. Initial presentation included a persistent cough, shortness of breath, and a 20-pound weight loss over three months. Baseline laboratory values showed an elevated LDH of 250 and a CEA of 8.2.
- Chemotherapy: Four cycles of Carboplatin and Paclitaxel, initiated on 15 April 2024 and completed on 12 July 2024.
- Radiation Therapy: Concurrent with chemotherapy, 60 Gy in 30 fractions to the primary lung tumor and mediastinal lymph nodes, completed on 12 July 2024.
**INTERVAL HISTORY**
I spoke with Eleanor for a follow-up appointment today, 1 November 2024. The visit was conducted with Eleanor present, and her daughter, Sarah, was also present for support. Eleanor reported that she is feeling much better overall, with a significant reduction in cough and improved breathing. She stated that she has regained some of her lost weight and is now eating well.
Eleanor reports occasional fatigue, which she manages with rest. She denies any new or worsening symptoms, including chest pain, difficulty swallowing, or neurological changes. We discussed the importance of maintaining a healthy lifestyle, including regular exercise and a balanced diet. I also provided reassurance regarding the potential side effects of radiation therapy and chemotherapy, and the importance of reporting any new symptoms promptly.
Most recent laboratory results from 28 October 2024, showed an LDH of 180 and a CEA of 3.1, indicating a positive response to treatment. Previous measurements from 15 July 2024 showed an LDH of 200 and a CEA of 4.5.
Eleanor is scheduled for follow-up CT scans of the chest and abdomen in three months, on 1 February 2025, to assess for any recurrence or progression of disease. She was advised to contact the clinic immediately if she experiences any new or concerning symptoms, such as persistent cough, chest pain, or unexplained weight loss.
AI CONSENT
The patient provided verbal consent to use the AI scribe during this visit, understanding its purpose, potential benefits, and limitations, as well as the need for a temporary audio recording for documentation and associated privacy and security risks.
**DIAGNOSIS**
[Use the previous diagnosis section from prior notes in the context tab to describe the patient's primary diagnosis, including details such as stage, spread, and initial presentation, and any relevant initial laboratory values] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in a paragraph.)
- [list initial and subsequent treatments, including medications and specific dates or durations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Sort list by type of treatment and by date of treatment. Write as a list of bullet points. Write out full dates.)
**INTERVAL HISTORY**
I spoke with [patient's first name] for follow up [describe who was present during the meeting and the context of the visit] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in a paragraph of full sentences.)
[describe the patient's current well-being, including any new or ongoing symptoms, and specific discussions or advice provided regarding these symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in a paragraph of full sentences.)
[document the most recent laboratory results, including the date, specific values for relevant markers, and interpretation of changes since previous measurements, including relevant previous measurements and dates] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Do not include units. Write in a paragraph of full sentences.)
[describe the plan for future follow-up, including the rationale and timeframe and any instructions for the patient regarding interim contact] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in a paragraph of full sentences.)
AI CONSENT
The patient provided verbal consent to use the AI scribe during this visit, understanding its purpose, potential benefits, and limitations, as well as the need for a temporary audio recording for documentation and associated privacy and security risks.
(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.)