Scribe BC - Adjuvant breast consult

[patient demographic information including full name, date of birth, age, and gender] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) [date and time of consultation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) Reason for Consultation: [reason for current visit or consultation with relevant clinical context] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) History of Present Illness: [detailed chronological account of the patient's current medical condition, including the onset, progression, and characteristics of symptoms; any treatments received for the current illness and their efficacy and side effects; and relevant diagnostic tests and their results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) Past Medical History: [summary of significant past medical conditions, including chronic diseases, previous surgeries, hospitalizations, and other relevant health issues] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) Medication [list of all current medications, including prescription drugs, over-the-counter medications, supplements, and herbal remedies, along with dosages, frequencies, and routes of administration] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) Allergies [list of known allergies to medications, foods, or environmental factors, specifying the type of reaction] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) Social History [information regarding the patient's lifestyle, including smoking status, alcohol consumption, illicit drug use, occupation, living situation, and social support system] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) Family History [relevant family medical history including genetic predispositions and hereditary conditions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) Physical Exam [Include specific abnormal physical examination findings including vital signs, general appearance, lymphadenopathy, cardiovascular abnormalities, respiratory findings, abdominal examination abnormalities, neurological findings, skin changes, breast examination abnormalities, or any other system-specific findings] (If any abnormal physical examination findings are explicitly mentioned in the transcript, contextual notes or clinical note, include those specific findings here. If no physical examination findings are mentioned or if examination is described as normal, use the following default text instead: "Alert, attentive, and in no distress. There is no evidence of peripheral lymphadenopathy. Cardiovascular and respiratory exams are unremarkable. No tenderness on palpation of the spine. Abdominal is soft and nontender, with no palpable masses. No hepatosplenomegaly. No peripheral edema. Bilateral breast exam was unremarkable with no worrisome masses or skin changes.") Investigations [diagnostic tests, imaging studies, laboratory results, and pathology reports with findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) Assessment/Plan [Patient first name] is a [age] [male/female] with a pT[tumor stage]([tumor size]) N[lymph node status]([lymph node details]) MX, grade [tumor grade], ER+([estrogen receptor percentage]) PR[progesterone receptor status]([progesterone receptor percentage]) HER2-negative, [invasive ductal carcinoma/invasive lobular carcinoma/other histology] of the [left/right] breast. Overall, [patient first name] has a stage [cancer stage] breast cancer. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely.) (If Oncotype test is mentioned, use the following next: "An OncotypeDx test was performed and her recurrence score is [recurrence score] which is associated with a 9 year distant recurrence risk of [distant recurrence risk percentage]. The absolute chemotherapy benefit is estimated to be [chemotherapy benefit percentage].") (If no Oncotype is mentioned, use the following: "I have estimated her 10-year risk of recurrence with no further treatment to be approximately [estimated recurrence risk]. This can be reduced to [reduced risk percentage] with a combination of [treatment combination].") "Since [patient first name]'s breast cancer is estrogen receptor positive, hormone therapy is strongly recommended. I have recommended 5 years of [letrozole/tamoxifen]." (If Letrozole is ordered, add: "I discussed the side effects which include, but are not limited to, myalgias, arthralgias, hot flashes, fatigue, and a risk of osteopenia and osteoporosis over time. 5 years of letrozole would be expected to reduce her relative risk of recurrence by 50%.") (If Tamoxifen is ordered, add: "I discussed the side effects which include, but are not limited to, hot flashes, myalgias, arthralgias, fatigue, and an under 1% risk of endometrial cancer and VTE. She understands the teratogenic risks of tamoxifen. 5 years of tamoxifen would be expected to reduce her relative risk of recurrence by 50%.") (If radiation is recommended, add: "I will also refer her to see one of my radiation oncology colleagues to discuss adjuvant radiation.") Finally, we discussed chemotherapy. (If low risk oncotype mentioned, add: "Given the low risk features of this patient's breast cancer, I have not recommended adjuvant chemotherapy since any small potential benefit would likely be outweighed by the potential disadvantages and side effects. I will get this patient started on adjuvant hormonal therapy soon. I will order a baseline bone mineral density test. I will assess her again in 3 months. If all is well at that time, I will likely discharge her back to the care of her family doctor for ongoing surveillance.") (If AC paclitaxel chemotherapy recommended, add: "Given her high risk breast cancer, I have recommended the chemotherapy regimen BRAJACTG which is expected to decrease her relative risk of recurrence by 1/3. This is an 8 cycle regimen with doxorubicin and cyclophosphamide given every 2 weeks for 4 cycles, followed by paclitaxel given every 2 weeks for another 4 cycles. The side effects include, but are not limited to, myelosuppression and a risk of febrile neutropenia, chemotherapy associated alopecia, fatigue, nausea, vomiting, diarrhea, mucositis, peripheral neuropathy, myalgias and arthralgias, hypersensitivity reactions, and a small risk of cardiotoxicity. I have recommended G-CSF support given the myelosuppressive nature of this chemotherapy and have arranged this today. I have also given her a prescription for antinausea medications. She has consented to starting chemotherapy and I will arrange for her first cycle to start in the next few weeks. I will see her prior to cycle #2.") (If DC chemotherapy recommended, add: "Given her high OncotypeDx recurrence score, I have recommended the chemotherapy regimen BRAJDC which is expected to decrease her relative risk of recurrence by 1/3. This is a 4 cycle regimen with docetaxel and cyclophosphamide given every 3 weeks. The side effects include, but are not limited to, myelosuppression and a risk of febrile neutropenia, chemotherapy associated alopecia, fatigue, nausea, vomiting, diarrhea, mucositis, peripheral neuropathy, myalgias and arthralgias. I have recommended G-CSF support given the myelosuppressive nature of this chemotherapy and have arranged this today. I have also given her a prescription for antinausea medications. She has consented to starting chemotherapy and I will arrange for her first cycle to start in the next few weeks. I will see her prior to cycle #2.") "Thank you, it has been a pleasure to be involved in the care of [patient first name]." Medical Oncology "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." 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