AI Scribe for Oncologists

SUBJECTIVE:
54-year-old premenopausal female with stage IIB invasive ductal carcinoma of the right breast (cT2N1M0, ER+ 95%, PR+ 80%, HER2-negative by IHC and FISH, Ki-67 28%) presents for cycle 3 day 1 of neoadjuvant AC-T (doxorubicin/cyclophosphamide x 4 cycles followed by paclitaxel x 12 weekly). Two cycles of AC completed, today initiates cycle 3.

Tolerating treatment fairly well. Reports moderate fatigue grade 2 (CTCAE) requiring afternoon naps on day 2-5 post-infusion. Nausea well-controlled on olanzapine 5mg + ondansetron + dexamethasone regimen, no breakthrough vomiting. Alopecia grade 2, using cold cap with partial preservation. No mucositis, no hand-foot syndrome. Bowels regular. Menstrual periods stopped after cycle 1 (chemotherapy-induced amenorrhea).

Current medications: Cycle pre-meds as below, ondansetron 8mg PRN, lorazepam 0.5mg PRN, ranitidine 150mg BID, multivitamin.

ECOG PS 1 (mildly symptomatic, fully ambulatory). Working part-time from home as a financial analyst.

OBJECTIVE:
Vitals: BP 124/78, HR 84, RR 16, Temp 98.4F, Wt 68.5 kg (down 1.8 kg from baseline), SpO2 99% RA, BSA 1.73 m2.

General: Well-appearing female, alopecia notable, no acute distress.
HEENT: Mucous membranes moist, no oral lesions, no thrush.
CV: Regular rate and rhythm, no murmurs, no gallop. JVP not elevated.
Pulm: Clear to auscultation bilaterally.
Breast: Right breast - prior biopsy site healed. Mass at 10 o'clock position now palpable at approximately 1.8 cm (baseline 3.2 cm by exam, 3.4 cm by ultrasound). No skin changes. Right axillary lymphadenopathy now non-palpable (was 2.0 cm at presentation). Left breast and axilla unremarkable.
Abdomen: Soft, non-tender, no hepatomegaly.
Extremities: No edema, no peripheral neuropathy. Port site clean, dry, no signs of infection.
Skin: No rash. Mild palmar erythema, grade 1.
Neuro: Alert and oriented x3, no focal deficits. No paresthesias.

Labs (today, pre-cycle):
- CBC: WBC 4.2 (ANC 2.6), Hgb 10.8, Plt 198. Mild anemia, no neutropenia.
- CMP: Cr 0.7, eGFR >60, AST 24, ALT 28, Bili 0.5, Alb 4.0.
- Mg 2.0, K 4.1.
- Echo (baseline pre-AC): LVEF 62%. Repeat post-cycle 4 per protocol.

Imaging (breast MRI 1 week ago, mid-treatment):
- Right breast index lesion: 1.8 cm (baseline 3.4 cm, prior MRI cycle 2 was 2.6 cm). Sum of single target lesion: 1.8 cm.
- Right axillary lymph node: 1.1 cm short axis (baseline 2.0 cm).
- Background parenchymal enhancement minimal, decreased.
- Compared to baseline: 47% decrease in target lesion sum. RECIST 1.1: Partial Response.

ASSESSMENT:
1. Stage IIB invasive ductal carcinoma right breast (cT2N1M0, ER+/PR+/HER2-) on neoadjuvant AC-T - excellent partial response after 2 cycles AC, initiating cycle 3 today.
2. Chemotherapy-related fatigue, grade 2, manageable with rest. No dose modification indicated.
3. Chemotherapy-induced amenorrhea - counseled regarding fertility (patient with two children, family complete).
4. Mild anemia (Hgb 10.8), grade 1 - no transfusion or growth factor indicated.

PLAN:
1. Continue AC: doxorubicin 60 mg/m2 (104 mg) IV push + cyclophosphamide 600 mg/m2 (1038 mg) IV today, cycle 3 day 1.
2. Pre-medications: dexamethasone 12 mg IV, ondansetron 16 mg IV, fosaprepitant 150 mg IV, olanzapine 5 mg PO.
3. Post-treatment: olanzapine 5 mg PO daily x 4 days, dexamethasone 8 mg PO daily x 3 days, ondansetron 8 mg q8h PRN.
4. CBC and CMP day 10-14 of cycle (febrile neutropenia precautions reviewed, T >= 100.4F triggers immediate ED visit).
5. Cycle 4 of AC scheduled in 14 days. Pre-cycle 4 echo for cardiotoxicity surveillance.
6. After completing 4 cycles AC, transition to weekly paclitaxel x 12 weeks. Surgical oncology consult will be requested between AC and T for definitive surgical planning.
7. Continue cold cap during infusions - patient highly motivated.
8. Discussed long-term ovarian function and bone health implications - bone density scan in 6 months.
9. Return for next cycle in 14 days. Office number 24/7 for fevers, severe vomiting, or any new symptoms.

Billing: 99214 (moderate complexity - one acute, on treatment, on chemo with high risk of complications, multiple data reviewed). Infusion CPT (separate billing): 96413 (initial chemo IV push, up to 1 hour) x 1 unit, 96415 (each additional hour) x 1 unit. Z51.11 + C50.911 + D64.81 + Z85.3.