Scribe BC- GI treatment note

Identification Patient is a 68-year-old male with a history of Stage III colon cancer diagnosed in January 2023, status post-hemicolectomy and adjuvant chemotherapy (FOLFOX) completed in July 2023. He presented today for his routine follow-up appointment. No hospitalizations or treatment pauses since last visit. Reason for visit, cycle number: Follow-up appointment, cycle 12. Comorbidities: * Hypertension * Type 2 Diabetes Mellitus * Hyperlipidemia Interval History Patient reports feeling well overall. He denies any new or worsening symptoms. He is compliant with his medications, including lisinopril, metformin, and atorvastatin. He reports no alcohol or illicit drug use. He is currently working full time and reports no functional limitations. He denies any behavioral or emotional concerns. ECOG performance status: 0 Physical Exam General: Well-appearing male in no acute distress. HEENT: Normocephalic, atraumatic. Pupils equal, round, and reactive to light. Neck: Supple, no lymphadenopathy. Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops. Respiratory: Clear to auscultation bilaterally. Abdomen: Soft, non-tender, no masses or organomegaly. Extremities: No edema. Labs * Complete Blood Count (CBC): Within normal limits. * Comprehensive Metabolic Panel (CMP): Within normal limits. * CEA: 1.2 ng/mL Diagnostics * CT scan of chest, abdomen, and pelvis: Completed on 25 October 2024, no evidence of recurrence. Assessment/Plan Patient continues to do well and shows no signs of recurrence. The patient is tolerating his current treatment plan well. The patient has been educated on the importance of regular follow-up appointments and screening. The patient has been encouraged to maintain a healthy lifestyle, including a balanced diet and regular exercise. The patient has been provided with educational materials regarding potential side effects and when to seek medical attention. The patient has been advised to continue with his current medication regimen. The patient will continue to be monitored with routine blood work and imaging every 6 months. "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."