Scribe BC- CNS Med Onc Consult

**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