Document Type: Provider Note   Document Subject: Consult Note   Performed By: MD on January 26, 2023 21:00 EST   Verified By: MD on January 26, 2023 21:00 EST   Encounter Info: Oncology, Outpatient, 01/26/23 - 01/26/23    * Final Report *        Reason for Consultation   consult  Referral Source     Subjective     Reason for consultation: Liver mets and prostate cancer.  History of present illness patient is a very pleasant 82-year-old man who was diagnosed to have prostate cancer recently.  Patient did undergo transurethral resection of the prostate in June 2022.  Pathology at that time revealed High grade intraepithelial neoplasia but no overt cancer.  PSA in 2018 was less than 2.  It was not checked again in view of his age and he was on expectant surveillance follow-up.  Patient PSA was increased to 35 after the surgery.  But it has increased to more than 102.30 in December 2022.  Patient was seen by Dr. in December 2022 in view of recurrent retention and also significantly elevated PSA.  He is also noted to have elevated alkaline phosphatase and decreased kidney function as well.  Patient underwent CT scan of the abdomen and pelvis that was significant for multiple liver metastatic lesions.  But on bone scan there was no evidence of any bony metastatic disease noted.  Patient was initiated on Casodex and also arranged to receive Lupron that was given on 1/11/2023.  Patient underwent cystoscopy with bilateral ureteral stent placement in view of right hydronephrosis.  At this time the biopsy of the prostate is significant for prostate adenocarcinoma with ductal features, Gleason score 4+4 equal 8.  Patient had a follow-up CT scan of the abdomen and pelvis on 1/19/2023: Multiple large liver masses noted unchanged from 12/29/2022.  Bilateral ureteral stents have been placed compared to the prior study without any persistent hydronephrosis.  Enlarged prostate gland with indentation or invasion of the floor of the urinary bladder noted.  Colonic diverticulosis without evidence of diverticulitis noted.  He also was noted to have shallow left femoral hernia containing small portion of the descending colon without complication.   Presently patient is here to review the treatment options.   Overall patient is feeling better except that having the stent causing him leaking all the time since the procedure.  He is wearing depends.  He is eating better now since he had stent placement.  He is eating without any nausea or changes in the bowel habits.  He remains fairly active.  He takes out his dog every 2 hours.  They have 5 acres and remains active all the time according to his wife.  He is sleeping fine.  His functional status appears to be 90% on KPS.  Past medical history: Type 2 diabetes, hyperlipidemia, hypertension, stage III chronic kidney disease, gout history of gout, allergic rhinitis, actinic keratosis.  Snoring.  Decreased hearing. Procedure history: Laparoscopic cholecystectomy in 2020, colonoscopy, right shoulder arthroscopic surgery several years ago, diabetic retinal eye exam polyp, left rotator cuff repair, lithotripsy with stone extraction.  As above recent cystoscopy with bilateral stent placement. Allergies: No known drug allergies. Immunization history: He received a flu vaccine pneumonia and all other childhood vaccines including all COVID vaccines and boosters.  He also had pneumococcal vaccine both the 23 and 13 Valent vaccines. Social history: Patient is married and lives with his wife.  He worked and retired in mid 90s.  He did smoke 1 pack/day for about 30 years duration but he quit in 1966.  There is no history of any alcohol or any drug abuse. Family history: Father died of lung cancer at the age of 65 years and he used to smoke pipe all the time.  Mother died of heart problems at 71 years.  He has 1 brother alive from: Colon cancer.  Other brother is in good health who is 72 years old.  1 brother died of liver cancer at 65 years.  Another brother died of lung cancer at 74 years.  1 brother died of COVID infection in 2019 at 72 years.  1 sister died of heart problem.  Another sister died of leukemia around 65 years.  She lived about 5 years after the diagnosis.  They have 4 sons and 1 daughter.  They are all healthy.  The daughter is coming along with them for this visit.  Staging       No information available        Review of Systems     Constitutional: He lost weight before he had the stent placement.  Now he is improving and appetite.  Overall he feels healthy at this time.  Vision: Bifocal glasses.  He never had any cataract surgery.  Hearing.  Decreased in both years wearing hearing aids.  He feels that this is related to damage from working.  Cardiopulmonary system review is negative for any specific symptoms.  GI his appetite was decreased earlier but it is back to near normal normal at this time.  Last colonoscopy was in 2015.  GU as per HPI.  Musculoskeletal negative for any significant joint pains or stiffness.  Endocrine significant for type 2 diabetes and has been compliant with his medications.  Rest of the 14 point system review is negative.  Objective  Vitals & Measurements last 24 hours  VITAL SIGNS  Temp C:       36.3 DegC  Heart Rate:       67 bpm  BP:       128 / 76 mmHg  SpO2 (%):       98 %     Height CM: 180.3 cm  Weight KG: 90.1 kg  BSAM2 Weight in kg: 2.12 m2  BMI Weight in kg: 27.7 kg/m2  Ideal Body Weight: 75.26 kg   Last 6 Weights  Weight KG: 90.1 kg (01/26/23 16:06:00)  Weight KG: 90.2 kg (01/11/23 14:57:00)  Weight KG: 90.2 kg (01/05/23 13:34:00)  Weight KG: 94.1 kg (12/19/22 14:44:00)  Weight KG: 94.1 kg (12/14/22 07:58:00)  Weight KG: 95.5 kg (08/16/22 09:46:00)   Performance Scales and Status  Karnofsky Performance Scale: Able to Carry on Normal Activity; Minor Symptoms of Disease.  Karnofsky Performance Score: 90   Physical Exam     Patient is very pleasant and moderately built and nourished in no respiratory distress at rest noted.  HEENT: Extraocular movements are normal, there is no icterus.  He does not have any teeth and wearing dentures.  Neck: Negative for any palpable lymph nodes, there is no JVD, thyroid not enlarged.  Lungs: Clear to auscultation.  There is no wheezing.  Heart: S1, S2 and regular.  Abdomen: Soft and liver and spleen are not palpable.  There is no tenderness.  Bowel sounds are noted.  Extremities negative for swelling or pedal edema.  Musculoskeletal: Normal range of motion noted.  Neurologic no focal deficit noted.    Assessment/Plan       1. Prostate cancer   C61  Patient is noted to have a significantly elevated PSA of over 100 very quickly when his initial biopsy was not suggestive of prostate cancer.  At this time patient is noted to have Gleason score 4+4 prostate adenocarcinoma.  At this Gleason score it is very unusual to have liver mets.  Discussed about different treatment options if it is related to prostate cancer.  In view of the liver mets patient will require chemotherapy.  But we need to rule out if this is different malignancy.  He is not keen on having chemotherapy as quality of life is more important for him. They were recommended to take time to review and inform us about his decision.   2. Hydronephrosis   N13.30  Patient is having leakage but doing well otherwise.  Overall he is feeling better after he had the stent placement.   3. Liver metastases   C78.7  Patient and the family members were reviewed CT scan findings that he has extensive liver mets and also noted to have abnormal liver function test.  It is important to obtain biopsy of this liver lesions to confirm if it is definitely prostate cancer or aggressive prostate cancer or neuroendocrine features of prostate cancer then treatment will be different.  He is also discussed that even he has biopsy it does not mean that he need to receive chemotherapy.   4. Stage 3 chronic kidney disease   N18.30  Stable at this time clinically.   5. Hypertension   I10  Blood pressure: 128/76.  Patient is compliant with all his medications.   6. Advanced directives, counseling/discussion   Z71.89  Patient does not have advanced directive or assigned POA.  But patient is not sure whether he wants to have aggressive treatments as he had bad experience with his brother is going through the chemotherapy.  He wants to take time to decide on considering biopsy and/or any other treatment options.   Time spent with the patient and the family members and reviewing all the above and counseling is over 70 minutes.  Goals of Care  Palliation.     Chronic Problem List    Actinic keratosis  Advanced directives, counseling/discussion  Allergic rhinitis  Benign localized hyperplasia of prostate with urinary retention  Diabetes mellitus with complication  Encounter for long-term current use of medication  Gout  Hydronephrosis  Hyperlipidemia  Hypertension  Liver metastases  Microalbuminuria due to type 2 diabetes mellitus  Nasal septal deviation  Prostate cancer  Prostate cancer metastatic to liver  Seborrheic keratoses  Snoring  Stage 3 chronic kidney disease  Type 2 diabetes mellitus with renal complication  Procedure/Surgical History  ?Diabetic retinal eye exam (08/09/2022) ?Diabetic retinal eye exam (08/03/2021) ?Laparoscopic cholecystectomy (10/21/2020) ?Colonoscopy (08/15/2014) ?colonoscopy (10/2005) ?right shoulder arthroscopy (09/23/2005) ?Diabetic retinal eye exam ?left rotator cuff repair ?lithotripsy, stone extraction   Surgical History Internal  01/05/2023    Cystoscopy Insert Ureteral Stent or Cath  (Right)   MD  06/09/2022    TUR Prostate    MD  10/21/2020    Cholecystectomy Laparoscopic    MD  Medications  Home Medications (13) Active  amLODIPine 5 mg oral tablet 5 mg = 1 Tablet, Orally, Daily  atorvastatin 10 mg oral tablet 10 mg = 1 Tablet, Orally, QHS  bicalutamide 50 mg oral tablet 50 mg = 1 Tablet, Orally, Q24H, start as soon as possible  Blood Glucose Test Strips See Instructions, Check daily Whatever brand insurance covers  Coreg 3.125 mg oral tablet 3.125 mg = 1 Tablet, Orally, BID  finasteride 5 mg oral tablet 5 mg = 1 Tablet, Orally, Daily, to help shrink prostate  Lancets Check daily, Other, Unscheduled, dx e11.9  losartan 100 mg oral tablet 100 mg = 1 Tablet, Orally, Daily, I10  metFORMIN 500 mg oral tablet 500 mg = 1 Tablet, Orally, BID  multivitamin 1 Tablet, Orally, Daily  pioglitazone 30 mg oral tablet 30 mg = 1 Tablet, Orally, Daily  tamsulosin 0.4 mg oral capsule 0.4 mg = 1 Capsule, Orally, Daily, Take between supper and bedtime; for prostate/urination  TRUETRACK TEST STRIPS See Instructions, dailydx E11.40  Allergies   NKA  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Employment/School   Retired, Work/School description:     Home/Environment   Lives with Spouse.   Nutrition/Health   Diet: Regular.   Substance Abuse   Denies   Tobacco   Tobacco Use: Former smoker, quit more than 30 days ago. Started age 7.0 Years. Stopped age 22 Years.  Family History   Cancer of colon: Brother.  Diabetes mellitus type 2: Father.  Heart attack..: Uncle.  Leukemia: Sister.  Liver cancer..: Brother.  Lung cancer..: Father.       Diagnostics     (01/19/2023 13:54 EST CT Abd/Pelvis W/O IV Contrast)            Document Type:       CT Abd/Pelvis W/O IV Contrast  Document Subject:       CT Abd/Pelvis W/O IV Contrast  Performed By:       MD on January 19, 2023 13:54 EST  Verified By:       MD on January 19, 2023 14:18 EST  Encounter Info:       Hospital, Outpatient, 01/19/23 - 01/19/23  * Final Report *    Reason For Exam  prostate cancer mets to liver; hydronephrosis s/p stent placement - eval for ongoing hydronephrosis and any evidence cancer progress    Report  EXAMINATION:   CT ABDOMEN, PELVIS WITHOUT INTRAVENOUS CONTRAST     DATE: 01/19/2023 13:54     INDICATION: Prostate cancer with liver metastases.       COMPARISON:  12/29/2022.     TECHNIQUE: Helical computed tomography imaging of the abdomen and  pelvis was performed without intravenous or oral contrast as  requested. The evaluation is therefore somewhat limited. Images were  obtained from the diaphragm through the pubic symphysis. Images were  reformatted in the coronal and sagittal planes. Dose reduction  techniques include at least one of the following: automated exposure  control, dose modulation, and iterative reconstruction.     Number of known potential high-dose imaging studies (CT and cardiac  nuclear) in the last 12 months (including this one): 4.      FINDINGS:      The visualized lung bases are free of active disease. The gallbladder  is surgically absent. Multiple large liver metastases are again  demonstrated. They do not appear significantly changed when compared  to 12/29/2022. There are calcified granulomata in the spleen. The  pancreas and adrenal glands are stable and within normal limits.  Bilateral ureteral stents are present. Small exophytic renal cysts  remain as before. There is no evidence of urinary tract calculus or  obstruction. There is atherosclerotic calcification in the nondilated  abdominal aorta. No significant retroperitoneal lymphadenopathy is  identified. There are diverticular changes along the distal colon  without evidence of acute diverticulitis. The wall of the urinary  bladder is thickened and has an irregular appearance along its  inferior margin. The prostate gland remains enlarged with a  transverse diameter of 6.8 cm. A left inguinal hernia contains a  short portion of the junction of the descending and sigmoid colon.  There are degenerative changes throughout the visualized spine. No  acute osseous pathology is identified.     IMPRESSION:      Status post cholecystectomy.     Multiple large liver masses appear unchanged from 12/29/2022.     Bilateral ureteral stents have been placed without evidence of  persistent hydronephrosis.     Enlarged prostate gland with indentation or invasion of the floor of  the urinary bladder.     Colonic diverticulosis without evidence of acute diverticulitis.     Shallow left femoral hernia containing a small portion of the  descending colon without complication.     Electronically Signed by: Staff  Dictated on: 1/19/2023 2:10 PM                 Signature Line Electronically Signed on 01/26/23 21:00 EST ________________________________________________________ MD