Document Type: Hem Onc OP MD H&P/Initial Consult   Document Subject: AMB Consult Note   Performed By: MD on October 21, 2022 17:30 EST   Verified By: MD on October 25, 2022 19:44 EDT   Encounter Info: Oncology, Outpatient, 10/21/22 - 10/21/22    * Final Report *        Reason for Consultation   consult  Referral Source       Subjective      I had the pleasure of seeing this patient for metastatic colon cancer.  Diagnosis:  -Left colon cancer, adenocarcinoma, microsatellite stable, stage IV, T3 N0 M1.  K-ras mutated (KRAS G 12 A), HER2 negative.  -Liver and peritoneal metastasis  -Iron deficiency anemia  -Left lung mass  Plan of care:  Chemotherapy with FOLFIRI  HPI:  Patient is a pleasant 71-year-old male who presented with right lower abdominal pain.  He underwent a right hip replacement in September 2022, was recovering at home.  During that time, he developed new onset diffuse abdominal pain and also had 3 episodes of emesis.  A CT scan of chest, abdomen and pelvis on 10/7/2022 (at the County Hospital) showed a 2.4 cm mass or consolidation in the left upper lobe, medial aspect abutting the mediastinal pleural surface.  There was a 2 mm noncalcified nodule in the right middle lobe but no significant adenopathy.  No suspicious bony lesions were noted.  The CT abdomen and pelvis showed an 8 cm mass involving the splenic flexure of the colon and lateral paracolic fat.  Extensive bilobar hepatic metastatic disease was seen with at least 15 liver lesions, the largest lesion measuring 6.3 cm involving segments 2 and 3 and another 6.4 cm involving segments 5 and 8.  Multiple additional small peritoneal metastasis in the left upper quadrant, suspected metastatic adenopathy in the porta hepatis and peripancreatic regions were seen, adrenal glands looked abnormal with thickening, this could be acute infarctions of the adrenal glands or early metastatic disease or adrenal hyperplasia.  Prostate enlargement was noted.  The patient was transferred to the Hospital; he never had a colonoscopy prior to this episode.  A CT-guided liver biopsy on October 10, 2022 showed metastatic colorectal adenocarcinoma, MMR proficient with mucinous features.  The tumor cells were positive for CK20, CDX2, negative for CK7 and HER2 was negative by IHC (1+).  A colonoscopy on 10/11/2022 demonstrated a large mass in the descending/transverse colon that could not be traversed, it was biopsied.  The surgical pathology from this colon mass biopsy showed a tubulovillous adenoma with at least intramucosal adenocarcinoma in the background of high-grade dysplasia.  Repeat colonoscopy was done on 10/12/2022 with placement of a stent.  On 10/7/2022, serum CEA was high at 919, CA 19?9 also high at 600.  The patient and his family would like to do chemotherapy closer to their home, they were referred to our center.  Subjective:  The patient felt better today, abdominal pain has improved.  He was accompanied by his wife and both of them provided the history.  I reviewed his test results which were as mentioned above.  On 10/8/2022, his WBC was 18, hemoglobin 9, MCV 77.  Liver enzymes and total bilirubin were in the normal range, serum creatinine 0.85.  On 10/11/2022, serum iron was 19, iron saturation 8%.  Chronic problem list, procedure/surgical history, allergies, medications, social and family history:  These were reviewed.  Chronic problem list  Hypertension  Review of Systems     Constitutional: Poor Appetite  Musculoskeletal: Other: difficulty walking  The rest of the review was negative.  Physical Exam/Objective  Vitals & Measurements last 24 hours     VITAL SIGNS   Temp C:   36.5 DegC  Heart Rate:   99 bpm  BP #1:   103 / 66 mmHg  SpO2 (%):   99 %    Height CM: 182.9 cm  Weight KG: 71.2 kg  BSAM2 Weight in kg: 1.9 m2  BMI Weight in kg: 21.3 kg/m2  Ideal Body Weight: 77.62 kg           General: Alert, ?No acute?distress.         Eye:  Extraocular movements are intact, Normal conjunctiva.         HEENT:  Normocephalic, ?normal?hearing        Neck:  Supple, Non-tender, No thyromegaly.         Cardiovascular:  ?Regular rate?, ?Normal?rhythm, ?No murmur?.         Respiratory: Respirations are  ?non-labored?,  ?Lungs are clear to auscultation?, Breath sounds are equal.        Lymphatics:  ?no palpable lymph nodes?.         Integumentary: No ?Rash?, slight ?Pallor?.         Neurologic:  ?Alert & Oriented x 3, no cognitive impairment?,  No focal defects       Psychiatric:  Cooperative, Appropriate mood & affect.         Gastrointestinal:  ?Non-distended?, Soft,  ?Non-tender?.      Musculoskeletal:  ?No swelling?,??in a wheel chair.         Assessment/Plan       1. Cancer of left colon   C18.6   We plan to start chemotherapy with FOLFIRI (5-FU, leucovorin and irinotecan).  Additional molecular tests (extended RAS panel) have been sent, the result was pending at the time of his visit.   Ordered:   Outside Surgery - General Consult     2. Liver metastases   C78.7   See note above.   Ordered:   Outside Surgery - General Consult     3. Mass of left lung   R91.8   This could be a metastasis from the colon cancer, a different primary tumor or a benign lesion.  We have requested the CT scan from Salem to be uploaded to our system.   Ordered:   Outside Surgery - General Consult     4. Iron deficiency anemia   D50.0   We will repeat his blood counts and give IV iron infusion.     Orders:   Auto Diff  CA 19-9 Ser QN  CBC w/Differential  CEA SerPl QN  Comp Metabolic Panel  Ferritin SerPl QN  Folate SerPl QN  Iron Profile  Vitamin B12 SerPl QN   -Poor venous access  The patient will get a port or a PICC line  -Status post right hip replacement  His surgeon has been contacted for further instructions regarding rehab for hip and approval to start chemotherapy.  The possible adverse effects of 5-FU and irinotecan include, but are not limited to, nausea/vomiting, diarrhea, hair thinning or loss, fatigue, low blood counts and increased risk of infections.  He will receive supportive care and his condition will be monitored.  He has metastatic, stage IV colon cancer, the therapy would be palliative in nature but is expected to improve his symptoms and survival.  The above-mentioned issues were discussed with them, they were agreeable with the plan of care as outlined.  Thank you for allowing me to participate in his care.  The time spent in this encounter was 74 minutes, more than half of which was spent in coordination of care and consultation.   Addendum:  I received the results of molecular testing on this tumor: KRAS G 12 A mutation was present. BRAF, NTRK 1-3 mutations were not detected.  IHC for MMR showed preserved expression of MMR proteins, MSI testing by PCR also showed microsatellite stable tumor.  Treatment options based on molecular testing: Bevacizumab/onvansertib/FOLFIRI could be a second line option.   Chronic Problem List    Cancer of left colon  Essential hypertension  Iron deficiency anemia  Liver metastases  Lumbar degenerative disc disease  Mass of left lung  Positive colorectal cancer screening using Cologuard test  Routine health maintenance  Procedure/Surgical History  ?History of left hip replacement (09/22/2022) ?History of right hip replacement (07/01/2022)   Surgical History Internal      04/28/2016   Skin Tag Excision     MD Medications     Home Medications (3) Active  amLODIPine 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily  DME Automated Home Blood Pressure Monitoring Device Not Applicable, Other, Unscheduled  Xarelto , Orally, Daily  Allergies   No Known Medication Allergies  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Employment/School   Retired   Home/Environment   married; 1 child, Lives with Spouse.   Substance Abuse   Denies   Tobacco   Tobacco Use: Former smoker, quit more than 30 days ago. Started age 16.0 Years. Stopped age 41 Years.  Family History   Heart failure..: Father.  Stomach cancer..: Mother.  Stroke: Father.                Signature Line Electronically Signed on 10/25/22 19:44 EDT ________________________________________________________  MD