Scribe BC - Medical Oncology Follow-up

**Identification** Mr. David Miller, a 68-year-old male, presents with a history of Stage III non-small cell lung cancer (NSCLC), diagnosed in January 2023. He underwent chemotherapy with carboplatin and paclitaxel, followed by radiation therapy. The initial treatment resulted in a partial response, with subsequent consolidation with durvalumab. He has been in remission for 10 months. **History** 1. The initial presentation involved a persistent cough and shortness of breath, leading to a CT scan that revealed a 6 cm mass in the right lung. A biopsy confirmed NSCLC. He was staged as Stage III due to mediastinal lymph node involvement. He commenced chemotherapy with carboplatin and paclitaxel in February 2023. 2. After four cycles of chemotherapy, a repeat CT scan in June 2023 showed a partial response. He then received concurrent radiation therapy to the primary tumour and mediastinal lymph nodes. Following completion of radiation, he was started on durvalumab as consolidation therapy in September 2023. 3. He has tolerated durvalumab well, with no significant side effects. A recent PET scan in October 2024 showed no evidence of disease recurrence. He continues to be followed closely with regular imaging and clinical assessments. **Current Treatment** Mr. Miller is currently receiving maintenance therapy with durvalumab every three weeks. **Current Status** Patient reports feeling well, with no cough, shortness of breath, or other symptoms. He is active and able to perform his daily activities. He denies any constitutional symptoms such as weight loss or fatigue. Labs November 2024 show hemoglobin 14.2 g/dL, white blood cell count 5.8 x10^9/L, and platelets 280 x10^9/L. Liver and kidney function tests are within normal limits. CT scan November 2024 shows no evidence of recurrent or progressive disease. The lungs are clear, and there is no evidence of new or enlarging lymph nodes. **Assessment / Plan** Mr. Miller is in complete remission from his NSCLC. Continue durvalumab maintenance therapy as scheduled. Follow-up with repeat CT scan in three months. Instruct patient to report any new symptoms, such as cough, shortness of breath, or chest pain. Discussed potential long-term side effects of durvalumab. Encouraged patient to maintain a healthy lifestyle, including regular exercise and a balanced diet. "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."