Scribe BC- GI Med Onc Consult

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."