**Identification**
Mr. John Smith, a 68-year-old male, presents for an initial consultation due to a recent diagnosis of Stage IIIB non-small cell lung cancer (NSCLC).
**History**
Mr. Smith reports a persistent cough and shortness of breath over the past three months. The cough is dry and occasionally produces small amounts of blood. He denies any chest pain or fever. The shortness of breath worsens with exertion. He initially noticed the symptoms after a bout of the flu. He has no significant family history of cancer.
Biopsy findings from a recent bronchoscopy revealed adenocarcinoma of the lung. Immunohistochemical staining showed positive results for TTF-1 and Napsin A, confirming the diagnosis. The tumour cells were negative for EGFR mutations. The pathology report indicates a moderately differentiated tumour.
CT scan of the chest, abdomen, and pelvis on October 25, 2024, revealed a 5.2 cm mass in the right upper lobe of the lung, with associated mediastinal lymphadenopathy. No distant metastases were identified. PET scan showed increased uptake in the primary lung mass and involved lymph nodes.
Laboratory results from October 28, 2024, showed a slightly elevated LDH of 250 U/L (normal range: 120-240 U/L). Complete blood count (CBC) and comprehensive metabolic panel (CMP) were within normal limits.
Consultation with a pulmonologist on October 29, 2024, confirmed the diagnosis and recommended staging investigations. The pulmonologist also recommended pulmonary function tests (PFTs), which are scheduled for next week.
**Past Medical History**
* Hypertension, managed with lisinopril 10mg daily.
* Hyperlipidemia, managed with atorvastatin 20mg daily.
**Medications**
* Lisinopril 10mg daily.
* Atorvastatin 20mg daily.
**Allergies**
Mr. Smith reports an allergy to penicillin, resulting in a mild rash.
**Social History**
Mr. Smith is a retired accountant, married for 40 years, and lives with his wife. He is a former smoker, having quit 10 years ago. He reports drinking alcohol socially. He has no significant social support issues.
**Physical Examination**
Patient appears in no acute distress, is alert and oriented, and has a mild cough.
**Assessment / Plan**
Mr. Smith has been diagnosed with Stage IIIB NSCLC. The definitive pathological diagnosis is adenocarcinoma of the lung. The staging is based on the CT and PET scan findings.
We discussed treatment options, including chemotherapy with carboplatin and paclitaxel, followed by consolidation with durvalumab. The patient expressed understanding and agreement with the proposed treatment plan. We discussed the potential side effects of chemotherapy, including nausea, fatigue, and hair loss. The patient is aware of the risks and benefits.
Pre-treatment evaluations, including PFTs and an echocardiogram, are scheduled for next week. Treatment will commence as soon as the results of these evaluations are available.
Treatment will be initiated as soon as possible. The patient was instructed to monitor for any new or worsening symptoms, such as fever, shortness of breath, or chest pain, and to seek immediate medical attention if they occur. Follow-up imaging will be performed after four cycles of chemotherapy.
"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."
**Identification**
[describe patient's age, gender, and the primary reason for consultation, including initial diagnosis or presenting condition] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single sentence.)
**History**
[describe the chronology of the patient's symptoms, including onset, progression, and any associated conditions or events leading to the current presentation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.)
[detail any biopsy findings, including specific markers, morphological and immunohistochemical results, and the diagnostic conclusion or status of the review] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.)
[summarize relevant imaging findings, including the type of scan, date, and specific measurements, SUV values, and descriptive details of any identified lesions or abnormalities] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.)
[report significant laboratory results, including test names, values, and dates, highlighting any abnormalities or key findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.)
[document any consultations with other specialists, their recommendations, and any subsequent changes in the patient's symptomatic status based on these consultations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences. Always use the format Month DD, YYYY for all dates that appear in this note. If day is not mentioned in transcript then use Month-YYYY format.)
**Past Medical History**
[list past medical conditions, their management, and any relevant historical details, including specific treatments or monitoring plans] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a bullet point list.)
**Medications**
[list current medications, including dosage, frequency, and purpose, specifying any PRN use or other supplementary treatments] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a bullet point list.)
**Allergies**
[state any reported allergies, including specific substances and reactions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single sentence.)
**Social History**
[describe relevant social context, including living situation, marital status, employment, and any pertinent benefits or support systems] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.)
**Physical Examination**
[document key physical examination findings, noting general appearance and specific observations related to the presenting complaint or overall health status] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single sentence.)
**Assessment / Plan**
[summarize the current assessment, including the likely diagnosis, staging, and any high-risk features, along with details regarding the definitive pathological diagnosis] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.)
[outline the proposed management plan, including discussions with the patient regarding treatment options, specific chemotherapy regimens, dosages, frequency, and any planned modifications or substitutions (e.g., omission of certain drugs). Also, include details on supportive care, monitoring requirements, and any anticipated need for growth factors or other adjunctive therapies.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.)
[detail the review of potential side effects, including specific symptoms discussed, and the patient's agreement or consent to proceed with the treatment plan. Also, mention any pending pre-treatment evaluations or tests] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.)
[describe the urgency of treatment, any referrals made, and specific instructions or precautions given to the patient regarding symptom monitoring and when to seek immediate medical attention. Also, include plans for follow-up imaging or evaluations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.)
"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.)
