DIAGNOSIS
Non-small cell lung cancer, Stage IIIB, with a 5cm lesion in the right upper lobe. Confirmed by CT scan and PET/CT. EGFR mutation negative.
PLAN SUMMARY
Stereotactic body radiation therapy (SBRT) to the right upper lobe lesion, 60 Gy in 15 fractions.
68-year-old male, seen today for a consultation regarding a new diagnosis of lung cancer. Accompanied by his wife.
The patient initially presented with a persistent cough and shortness of breath. A chest X-ray revealed a suspicious nodule in the right upper lobe, prompting a CT scan which confirmed a 5cm mass. Subsequent PET/CT scan showed increased FDG uptake in the lesion, with no evidence of distant metastasis. The patient was referred to Dr. Emily Carter, a pulmonologist, for further evaluation, including bronchoscopy.
Bronchoscopy and EBUS were performed, revealing a biopsy-proven non-small cell lung cancer. The patient also consulted with Dr. David Lee, a medical oncologist, who recommended concurrent chemoradiation. The patient was also seen by Dr. Sarah Jones, a thoracic surgeon, who deemed the patient unsuitable for surgical resection due to the size and location of the tumour.
The patient reports a worsening cough, occasional shortness of breath, and mild fatigue. He denies any hemoptysis, chest pain, or new neurological symptoms. His appetite is slightly decreased, but he maintains a good performance status.
INVESTIGATIONS
* CT Chest: Confirmed 5cm mass in the right upper lobe.
* Bronchoscopy/EBUS: Biopsy-proven non-small cell lung cancer.
* PET/CT: Increased FDG uptake in the right upper lobe lesion, SUV max 12. No evidence of metastasis.
PAST MEDICAL HISTORY
* Hypertension (diagnosed 2018)
* Hyperlipidemia (diagnosed 2020)
PAST SURGICAL HISTORY
* Appendectomy (2005)
CURRENT MEDICATIONS
* Lisinopril 10mg daily
* Atorvastatin 20mg daily
ALLERGIES
No known drug allergies.
SOCIAL HISTORY
The patient lives with his wife in a single-family home. He is a retired accountant. He has a 40 pack-year smoking history, having quit smoking 5 years ago. He drinks alcohol socially, approximately 2-3 units per week. No recreational drug use.
FAMILY HISTORY
* Mother: Breast cancer, diagnosed age 68, deceased.
PHYSICAL EXAMINATION
Height: 178 cm
Weight: 85 kg
Vitals: BP 130/80 mmHg, HR 78 bpm, RR 16 breaths/min, SpO2 98% on room air, Temp 37.0°C
General: Alert and oriented, appears in no acute distress.
Cardiorespiratory: Clear to auscultation bilaterally. No wheezes or crackles.
Lymph: No palpable lymphadenopathy.
Neurologic: Normal neurological exam.
ASSESSMENT AND PLAN
The patient has been diagnosed with Stage IIIB non-small cell lung cancer. The differential diagnoses include other types of lung cancer and metastatic disease. The patient and his wife were informed of the treatment options, including chemotherapy, radiation therapy, and concurrent chemoradiation. The risks and benefits of each option were discussed in detail.
SBRT will be delivered to the right upper lobe lesion, with a total dose of 60 Gy in 15 fractions. The patient was informed of the potential acute side effects, including fatigue, shortness of breath, cough, and chest tenderness. The patient was also informed of the potential delayed side effects, including esophagitis and radiation pneumonitis. The estimated likelihood of long-term local control is 80%. The patient was also informed of the potential for injury to surrounding structures.
The patient has decided to proceed with SBRT. The rationale behind this choice is the desire for a shorter course of treatment and the potential for fewer side effects compared to concurrent chemoradiation. The next steps include scheduling the simulation and treatment planning appointments. The patient will be seen weekly during treatment for assessment and management of side effects. Contact information for the radiation oncology clinic was provided.
AI CONSENT
The patient provided verbal consent to use the AI scribe during this visit, understanding its purpose, potential benefits, and limitations, as well as the need for a temporary audio recording for documentation and associated privacy and security risks.
DIAGNOSIS
[Outline the primary diagnosis, including the suspected type of lesion, size, and TNM staging. Include any relevant biomarker or genetic results.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.)
PLAN SUMMARY
[Summarize the proposed treatment plan, including the type of radiotherapy, dosage, and fractionation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.)
[Patient's age]-year-old [gender], seen today for [reason for visit]. [State any companions to the patient who are also present at the visit] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Document the patient's initial presentation, including symptoms, date of onset, initial investigations, findings, and specialist consultations. Describe the history of the lesion, including its discovery, initial size, and growth trajectory on serial imaging.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.)
[Detail subsequent diagnostic procedures, including bronchoscopy findings, EBUS results, and PET/CT scan findings, specifically mentioning any identified FDG accumulation and related investigations for other areas of uptake. Include outcomes from other consultations, including surgeons and medical oncologists, mentioning the consultant by name.] (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 patient's current symptoms, including dyspnea, cough characteristics, associated symptoms like phlegm, and any aggravating or alleviating factors. Document the absence of hemoptysis, chest pain, and new neurological symptoms. Include observations about changes in appetite, energy, and overall performance status.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.)
INVESTIGATIONS
[List all relevant imaging and procedural investigations with their dates and key findings, specifically detailing CT chest results, bronchoscopy/EBUS outcomes, and PET/CT scan findings, including measurements, SUV max values, and absence of metastasis. Include any subsequent investigations related to incidental findings. Do not include outcomes from consultations.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a bulleted list.)
PAST MEDICAL HISTORY
[List all past medical conditions chronologically, if dates are available. Otherwise, list in bullet point format.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a bulleted list.)
PAST SURGICAL HISTORY
[List all past surgical procedures with their respective dates.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a bulleted list.)
CURRENT MEDICATIONS
[List all current medications, including dosage if available, and any supplements.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a bulleted list.)
ALLERGIES
[State any known drug allergies or report no known drug allergies.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as a single line.)
SOCIAL HISTORY
[Provide details about the patient's living situation, including location, marital status, occupation, smoking history (including pack-years and quit date), alcohol consumption, and any history of recreational drug use.] (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
[List significant family cancer history, specifying the relationship, the type of malignancy or condition, and including dates or ages of diagnosis and death, if available.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise include section mentioning that there is no relevant family history. Write as a bulleted list.)
PHYSICAL EXAMINATION
Height: [Patient's height in cm]
Weight: [Patient's weight in kg]
Vitals: [Patient's blood pressure, heart rate, respiratory rate, oxygen saturation, and temperature]
General: [General appearance and demeanor of the patient]
Cardiorespiratory: [Findings related to heart sounds, breath sounds, and presence/absence of adventitious sounds]
Lymph: [Findings regarding palpable lymphadenopathy in the neck or other areas]
Neurologic: [Findings related to neurologic examination] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write as described above.)
ASSESSMENT AND PLAN
[Provide a summary of the patient's case, including the diagnosis. Discuss the differential diagnoses. Detail the management options discussed with the patient.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.)
[Elaborate on the proposed treatment plan, including the planned fractionation and a comprehensive discussion of expected acute and delayed side effects, detailing potential complications such as fatigue, shortness of breath, cough, chest tenderness, esophagitis, radiation pneumonitis, and injury to surrounding structures. Include the estimated likelihood of long-term local control.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.)
[State the patient's decision regarding treatment, the rationale behind their choice, and the next steps in their care plan, including scheduling appointments and providing contact information.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.)
AI CONSENT
The patient provided verbal consent to use the AI scribe during this visit, understanding its purpose, potential benefits, and limitations, as well as the need for a temporary audio recording for documentation and associated privacy and security risks.
(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.)
