Visit Notes

Michael S Hodavance, MD at 4/25/2016 11:14 AM

Status: Signed

Vascular Interventional Radiology

Chief Complaint: Hepatic Metastasis

History of Present Illness: Mr. Schuttler is a 45 y.o. Caucasian male here today with presumed hepatic colorectal metastasis at the request of Dr. Shah for evaluation of radioembolization.

Oncology History: Mr. Schuttler underwent a colonoscopy on 9/24/15 which showed a 6 mm polyp in the rectum and a fungating partially obstructing large mass was found at the distal sigmoid. Pathology came back as Adenocarcinoma. CT demonstrated multiple hepatic masses. He underwent neoadjuvant chemotherapy most recently FOLFOX +avastin; see oncology notes for compete details. Most recent imaging demonstrates decreased size of hepatic lesions but still multiple lesions in the bilateral liver consistent with metastatic disease. At the most recent hepatobiliary multidisciplinary conference, patient was recommended for consideration of locoregional therapy, specifically radioembolization.

Mr. Schuttler feels well today. He denies abdominal pain, nausea/vomiting, SOB, chest pain or other symptoms. Fatigue and appetite are improved since stopping chemotherapy. He still notes some neuropathy related to chemotherapy treatments.

Physical Exam
Constitutional: He is oriented to person, place, and time and well-developed, well-nourished, and in no distress.
HENT:
Head: Normocephalic and atraumatic.
Eyes: Pupils are equal, round, and reactive to light.
Neck: Normal range of motion. Neck supple.
Cardiovascular: Normal rate and regular rhythm.
Pulmonary/Chest: Effort normal and breath sounds normal.
Abdominal: Soft. Bowel sounds are normal.
Musculoskeletal: Normal range of motion.
Neurological: He is alert and oriented to person, place, and time.
Skin: Skin is warm and dry.
Psychiatric: Affect and judgment normal.

Karnofsky Scale: 100 Normal, no c/o, NED

ECOG Score: (0) Fully active, able to carry on all predisease performance without restriction

Laboratory Results:
Lab Results
Component
Value
Date

WBC
4.8
04/19/2016

HGB
14.4
04/19/2016

HCT
42.6
04/19/2016

PLT
92*
04/19/2016

Lab Results
Component
Value
Date

NA
140
04/19/2016

K
3.6
04/19/2016

CL
106
04/19/2016

CO2
26
04/19/2016

BUN
9
04/19/2016

CREATININE
0.8
04/19/2016

GLUCOSE
135
04/19/2016

Lab Results
Component
Value
Date

AST
38
04/19/2016

ALT
46
04/19/2016

ALKPHOS
58
04/19/2016

TBILI
0.6
04/19/2016

ALB
4.2
04/19/2016

TOTALPROTEIN
6.9
04/19/2016

Lab Results
Component
Value
Date

APTT
32.1
12/09/2015

INR
1.1
12/09/2015

Imaging: MR 4/4/2016 reviewed

Assessment: Mr. Schuttler is a 45 yo with metastatic disease to the liver. He is a good candidate for radioembolization based on his good baseline liver function and functional status. Dr. Paul Suhocki had a lengthy discussion regarding the risks, benefits and alternatives to radioembolization. The patient was given the opportunity to ask questions and to have those questions answered to his satisfaction

Plan:
Plan for radioembolization to be scheduled in the next few weeks. Most of the the patient’s lab values are current but we will redraw an INR in clinic today.

I personally interviewed the patient with a fellow.

Revision History
4/26/2016 2:00 PM
Paul Suhocki, MD

4/25/2016 11:47 AM
Michael S Hodavance, MD
Sign at close encounter