Reason for Consultation
"Dear Dr. Emily Carter,"
This is a consultation for a 62-year-old female, Mrs. Sarah Jones, referred for management of newly diagnosed Stage IIIB adenocarcinoma of the lung. The diagnosis was confirmed on 10 October 2024, following a CT scan and subsequent biopsy. The patient is accompanied by her daughter, Emily.
**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. Jones presents with a 3-month history of worsening cough, accompanied by shortness of breath and fatigue. She initially attributed these symptoms to a recent cold, but they have persisted and intensified. She reports a 10-pound weight loss over the past two months. A chest X-ray revealed a suspicious mass, prompting further investigation with a CT scan, which confirmed the presence of a 5cm mass in the right upper lobe with mediastinal lymph node involvement. A bronchoscopy with biopsy was performed, confirming the diagnosis of adenocarcinoma. She has not received any prior treatment.
Pathology
Pathology results from the lung biopsy, dated 10 October 2024, confirmed the diagnosis of adenocarcinoma. Immunohistochemistry (IHC) staining showed positive staining for TTF-1 and Napsin A. Molecular testing is pending to assess for EGFR, ALK, and ROS1 mutations.
Lab Results
Relevant lab results include: Complete Blood Count (CBC) within normal limits; Comprehensive Metabolic Panel (CMP) within normal limits; Elevated CA 19-9 at 45 U/mL (normal range <37 U/mL).
Diagnostics Results
CT scan of the chest, abdomen, and pelvis performed on 08 October 2024, revealed a 5cm mass in the right upper lobe with mediastinal lymph node involvement. There was no evidence of distant metastasis. PET scan is pending.
Medications
Home Medications
Best possible medication history obtained. Current medications include: lisinopril 10mg daily for hypertension, and a multivitamin.
Allergies
No known drug allergies.
Problem List/Past Medical History
* Hypertension, diagnosed in 2018, well-controlled with medication.
* Former smoker, quit 10 years ago (30 pack-year history).
Social History
Mrs. Jones is a retired teacher. She lives with her husband. She quit smoking 10 years ago. She drinks alcohol occasionally, and denies any illicit drug use.
Family History
Her mother had breast cancer diagnosed at age 70. Her father had a history of coronary artery disease.
Performance Status
ECOG performance status: 1 (able to carry out light work).
Physical Exam
General: Alert and oriented female in no acute distress.
Vitals: BP 130/80, HR 78, RR 16, SpO2 98% on room air.
Lungs: Decreased breath sounds in the right upper lobe.
Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops.
Abdomen: Soft, non-tender, no masses.
Neurological: Normal.
Assessment/Plan
Assessment: Newly diagnosed Stage IIIB adenocarcinoma of the lung.
Plan: Discussed treatment options with the patient, including chemotherapy, radiation therapy, and immunotherapy. The patient expressed a preference for chemotherapy as the initial treatment. We discussed the potential side effects of chemotherapy, including nausea, fatigue, and hair loss. We also discussed the importance of supportive care, including anti-emetics and nutritional support. We will schedule a PET scan to further assess for distant metastasis. We will schedule the patient for a consultation with a radiation oncologist. We will initiate chemotherapy with a platinum-based doublet regimen. Follow-up in two weeks to assess tolerance and response to treatment.
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
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."
Reason for Consultation
"Dear Dr. [consulting physician name],"
[Acknowledge referral of the patient, including age, gender, and relevant medical history leading to the current presentation. Include diagnosis, date of diagnosis, staging (TNM), and pertinent pathology details and molecular markers. Also include who the patient is accompanied by if anyone.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.)
**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
[Describe the patient's past medical history relevant to the current presentation, including diagnoses, dates, and previous treatments. Elaborate on the presenting symptoms, their duration, and any associated features. Detail the chronological sequence of events, including consultations, investigations, and hospital admissions, along with their findings and implications. Include details about current symptoms, their severity, aggravating/alleviating factors, and impact on daily activities. Document any recent changes in symptoms or general well-being. Mention current medication adherence and any related observations.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.)
Pathology
[Detail the pathology results, including the date of the report, the type of specimen, and the final diagnosis. Provide a summary of the key findings and their clinical significance.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.)
Lab Results
[Provide a comprehensive list of relevant lab results, including test names, dates, and values. Highlight any abnormal findings and their clinical interpretation.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.)
Diagnostics Results
[Summarize findings from diagnostic imaging and procedures, including the type of imaging/procedure, date, and detailed report. Focus on descriptions of organs, identified lesions, measurements, and any changes from previous studies. Include impression or conclusion of the diagnostic reports.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.)
Medications
Home Medications
[Document current home medications, including details on whether a best possible medication history was obtained and any discrepancies or adherence issues.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.)
Allergies
[List any known allergies, including medication, food, or environmental, and describe the nature of the reactions.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.)
Problem List/Past Medical History
[Provide a structured problem list or past medical history, detailing each condition with relevant historical context, key events, and previous management. Include details such as diagnosis dates, relevant prior admissions or treatments, and any related complications or ongoing issues.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in a list with bullet points for sub-items.)
Social History
[Document details about the patient's social history, including lifestyle habits (e.g., smoking, alcohol, drug use), living situation, occupation, and financial or social supports. Include duration and frequency of habits, and impact on health.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.)
Family History
[Describe relevant family medical history, including significant illnesses, genetic conditions, and age of diagnosis in family members. Focus on conditions pertinent to the patient's current presentation or risk factors.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.)
Performance Status
[Assess and document the patient's performance status using a recognized scale (e.g., ECOG/Zubrod), providing details on their functional abilities, activity levels, and independence in daily tasks.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.)
Physical Exam
[Provide a systematic report of the physical examination findings, categorized by body system. Include general appearance, vital signs, and specific findings for each system examined, noting any abnormalities or significant observations.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.)
Assessment/Plan
[Provide a comprehensive assessment of the patient's condition, integrating historical, physical, and investigative findings to formulate a diagnosis or clinical impression. Detail the rationale for the diagnosis and discuss the prognosis. Outline the management plan, including further investigations, treatments, referrals, and patient education. Document discussions with the patient regarding their condition, treatment options, potential risks/benefits, and shared decision-making. Include follow-up plans, monitoring, and any specific instructions given to the patient. Detail communications with other healthcare providers involved in the patient's care.] [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] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.)
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."
(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.)
