Scribe BC - Oncology Clinic Note

**Synopsis** Mrs. Eleanor Vance, a 68-year-old female, was initially diagnosed with Stage IIIB non-small cell lung cancer (NSCLC) in 2022. Histopathology revealed adenocarcinoma. She completed concurrent chemoradiation and is currently on maintenance immunotherapy with pembrolizumab. There is no evidence of disease recurrence or metastasis at this time. **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" **History of Present Illness** Mrs. Vance presents today for routine follow-up. She reports mild fatigue, which she attributes to her ongoing immunotherapy. She denies any new cough, shortness of breath, chest pain, or other concerning symptoms. She reports she has been tolerating her pembrolizumab well. Her last CT scan, performed on 15 October 2024, showed no evidence of disease progression. **Physical Examination** - **General:** Appears well, performance status is ECOG 1. - **Cardiovascular:** Regular rate and rhythm, no murmurs. - **Respiratory:** Clear to auscultation bilaterally. - **Gastrointestinal:** Soft, non-tender abdomen. - **Neurological:** Alert and oriented. - **Other:** No palpable lymphadenopathy. **Lab Results** - CEA: 1.8 ng/mL (within normal limits) - Full blood count: Within normal limits - Renal and liver function tests: Within normal limits **Diagnostics** - CT Chest/Abdomen/Pelvis (15 October 2024): No evidence of recurrent or metastatic disease. **Problems / Past Medical History** - Non-small cell lung cancer (Stage IIIB, adenocarcinoma) - Hypertension **Procedure / Surgical History** - Right upper lobectomy (2022) - Mediastinal lymph node dissection (2022) - Port placement **Medications** - Pembrolizumab 200mg IV every 3 weeks - Amlodipine 5mg daily **Allergies** - NKDA **Assessment / Plan** 1. Stable disease, tolerating pembrolizumab well. 2. Continue pembrolizumab as scheduled. 3. Discussed fatigue management strategies, including rest and hydration. 4. Schedule follow-up appointment in 3 months and repeat CT scan in 6 months.