Benjamin Tan, MD - 08/15/2024 3:15 PM CDTFormatting of this note is different from the original.Images from the original note were not included.Oncology Medicine History and PhysicalAlexander R TowellDOB:8/4/1975 DATE OF VISIT:8/15/2024Referring Provider: Syed M. Arshad, MD Cancer Staging No matching staging information was found for the patient.Oncology History Overview Note DIAGNOSIS:Sigmoid Adenocarcinoma Stage IIIMetastaticTerminal Ileum Adenocarcinoma, MSS, RAS WT, with liver metastasesGENOMIC DATA:1. TEMPUS XT for small bowel adenocarcinoma2. TEMPUS XF- ONCOLOGIC HISTORY:presented with anemia with tiredness, constipation, abdominal pain and fatigue back in 2021. He required blood transfusions- 11/22/2021 Colonoscopy showed malignant appearing mas in descending colon with ulceration and partial obstruction- 11/23/2021 labs notes wbc 3.8, Hb 9.4, platelets 310K, creatinine 1.8, bilirubin 0.3, CEA 1.4- 12/09/2021 CT scan showed exophytic sigmoid colon mass (2.6 cm) with Lymph nodes suspicious for metastatic disease and sclerotic focus in the left iliac bone.- 12/10/2021 Consultation with Dr. Syed (Oncology)- 12/29/2021 laparsocopic sigmoid colectomy pathology showed moderately differentiated colon adenocarcinoma 1 of 23 LN +, MSS, RAS WT- stage IIIB pT4N1M0- 02/16/2022 to 08/29/2022 adjuvant FOLFOX x 12 cycles with dose reduction. Toxicities include neuropathy and diarrhea, fatigue- 01/01/2023 CT scans showed no recurrence- 01/09/2023 Colonoscopy showed normal findings- 12/29/2023 CT showed no metastases- 05/29/2024 Colonoscopy showed large ulcerated mass in the terminal ileum, biopsy confirmed moderately differentiated adenocarcinoma- 07/01/2024 right hemicolectomy - showed 4 of 14 LN +, PNI+, no LVI, RAS WT, MSS- 07/11/2024 Tempus XF - 07/25/2024 PET scan done showed liver lesions. Started chemotherapy with Cycle 1 FOLFIRI- 08/12/2024 Cycle 2 FOLFIRI/bevacizumab: has diarrhea treated with immodium- 08/15/2024 Consultation with medical oncology (tan) to discuss HAI pump therapyTREATMENT HISTORY: laparsocopic sigmoid colectomy 12/29/2021Adjuvant FOLFOX x 12 cycles 2/16/2022- 8/2022Right hemicolectomy 7/1/2024FRONTLINE FOLFIRI/Bevacizumab- 07/25/2024 Cycle 1 FOLFIRI- 08/12/2024 Cycle 2 FOLFIRI/BevacizumabMalignant neoplasm metastatic to liver (HCC) 8/16/2024 Initial Diagnosis Malignant neoplasm metastatic to liver (HCC)Active Treatment & Therapy Plans for Towell, Alexander R Towell, Alexander R does not have any active plans of the following types: Oncology Chemotherapy Treatment, Oncology Treatment (2), Oncology Treatment (3), Oncology Supportive Care, Specialty Infusion Treatment, Blood Products, BMT, HematologySubjective Mr. Alexander R Towell is a 49 y.o. Non-Hispanic male who comes to the Gastrointestinal Oncology Clinic at Washington University for second opinion for his metastatic colon cancer.In brief, Mr. Alexander R Towell presented with anemia with tiredness, constipation, abdominal pain and fatigue back in 2021. He required blood transfusions- 11/22/2021 Colonoscopy showed malignant appearing mas in descending colon with ulceration and partial obstruction- 11/23/2021 labs notes wbc 3.8, Hb 9.4, platelets 310K, creatinine 1.8, bilirubin 0.3, CEA 1.4- 12/09/2021 CT scan showed exophytic sigmoid colon mass (2.6 cm) with Lymph nodes suspicious for metastatic disease and sclerotic focus in the left iliac bone.- 12/10/2021 Consultation with Dr. Syed (Oncology)- 12/29/2021 laparsocopic sigmoid colectomy pathology showed moderately differentiated colon adenocarcinoma 1 of 23 LN +, MSS, RAS WT- stage IIIB pT4N1M0- 02/16/2022 to 08/29/2022 adjuvant FOLFOX x 12 cycles with dose reduction. Toxicities include neuropathy and diarrhea, fatigue- 01/01/2023 CT scans showed no recurrence- 01/09/2023 Colonoscopy showed normal findings- 12/29/2023 CT showed no metastases- 05/29/2024 Colonoscopy showed large ulcerated mass in the terminal ileum, biopsy confirmed moderately differentiated adenocarcinoma- 07/01/2024 right hemicolectomy - showed 4 of 14 LN +, PNI+, no LVI, RAS WT, MSS- 07/11/2024 Tempus XF - 07/25/2024 PET scan done showed liver lesions. Started chemotherapy with Cycle 1 FOLFIRI- 08/12/2024 Cycle 2 FOLFIRI/bevacizumab: has diarrhea treated with immodium- 08/15/2024 Consultation with medical oncology (tan) to discuss HAI pump therapyToday, he comes and noted :- feeling well- mild loose stools- no fever, chills- no nausea, vomiting- no abdominal pain- no chest pain, SOBPast Medical

History: Diagnosis Date Anemia Cancer (CMS/HCC) (HCC) Peripheral neuropathy Thyroid disease Past Surgical

History: Procedure Laterality Date COLON SURGERY 12/30/2021 SMALL BOWEL RESECTION 07/01/2024 Prior to Admission medications Medication Sig Start Date End Date Taking? Authorizing Provider levothyroxine (SYNTHROID) 88 mcg tablet Take 1 tablet (88 mcg total) by mouth daily 3/23/23 Provider, Historical, MD No Known AllergiesSocial History Tobacco Use Smoking status: Never Smokeless tobacco: None Substance and Sexual Activity Drug use: None Sexual activity: None Alcohol Use: Not on file Family History Problem Relation Age of Onset Prostate cancer Father 69 Review of SystemsReview of Systems Constitutional: Negative. HENT: Negative. Eyes: Negative. Respiratory: Negative. Cardiovascular: Negative. Gastrointestinal: Negative. Endocrine: Negative. Genitourinary: Negative. Musculoskeletal: Negative. Skin: Negative. Neurological: Negative. Hematological: Negative. Psychiatric/Behavioral: Negative. Pain: negative.Review of SystemsObjective Vitals:BP: 127/83Temp: 36.3 °C (97.4 °F)Temp src: OralPulse: 68Resp: 16SpO2: 97 %Height: 184.2 cm (6’ 0.52")Weight: 88.2 kg (194 lb 6.4 oz)ECOG:0PHYSICAL EXAMINATIONPhysical ExamVitals reviewed. Constitutional: General: He is not in acute distress. Appearance: Normal appearance. HENT: Head: Normocephalic and atraumatic. Nose: Nose normal. Eyes: General: No scleral icterus. Conjunctiva/sclera: Conjunctivae normal. Cardiovascular: Rate and Rhythm: Normal rate and regular rhythm. Pulses: Normal pulses. Heart sounds: Normal heart sounds. Pulmonary: Effort: Pulmonary effort is normal. Breath sounds: Normal breath sounds. No wheezing or rales. Abdominal: General: Abdomen is flat. Bowel sounds are normal. There is no distension. Palpations: Abdomen is soft. There is no mass. Tenderness: There is no abdominal tenderness. Musculoskeletal: General: Normal range of motion. Cervical back: Normal range of motion. Right lower leg: No edema. Left lower leg: No edema. Lymphadenopathy: Cervical: No cervical adenopathy. Skin: General: Skin is warm and dry. Coloration: Skin is not jaundiced. Neurological: General: No focal deficit present. Mental Status: He is alert and oriented to person, place, and time. Psychiatric: Mood and Affect: Mood normal. Behavior: Behavior normal. Thought Content: Thought content normal. Judgment: Judgment normal. Lab/Radiology/Diagnostic Review:No results found for this or any previous visit (from the past 24 hour(s)). PATHOLOGY REVIEW:7/1/20245/29/202411/22/20219/20/2022THYROID, RIGHT LOBE, RIGHT LOBECTOMY:- NODULAR HYPERPLASIA (NODULAR GOITER)-ADDITIONAL PATHOLOGIC FINDINGS - ONE (1) LYMPH NODE NEGATIVE FOR METASTASIS (0/1).- LYMPHOCYTIC THYROIDITIS:- PARATHYROID GLAND(S): ONE PRESENT IN THE LOWER POLE, WITHOUT HISTOLOGIC ABNORMALITIES.7/29/2022THYROID LOBE, RIGHT, ULTRASOUND GUIDED NEEDLE BIOPSY:- ADEQUATE FOR INTERPRETATION. - SUSPICIOUS FOR FOLLICULAR NEOPLASM. BETHESDA CLASS IV. 5/11/2022A. THYROID LOBE, RIGHT, (1ST NODULE), ULTRASOUND-GUIDED NEEDLE BIOPSY; - ADEQUATE FOR INTERPRETATION.- BENIGN, CONSISTENT WITH BENIGN FOLLICULAR NODULE (INCLUDES ADENOMATOID NODULE, COLLOID NODULE, ETC.). BETHESDA CLASS II.B. THYROID LOBE, RIGHT (2ND NODULE), ULTRASOUND-GUIDED NEEDLE BIOPSY: - ADEQUATE FOR INTERPRETATION.- ATYPIA OF ON DETERMINE SIGNIFICANCE. FOLLICULAR CELLS WITH MILD FOCAL ARCHITECTURAL ATYPIA. BETHESDA CLASS IIIctDNA7/11/2024RADIOLOGY REVIEW:PET OSH 7/25/2024 CONSULT1. At least four hypermetabolic liver lesions involving segment II,VII and VIII compatible with metastatic disease.2. Two intensely hypermetabolic soft tissue nodule deposits in therectovesical pouch are compatible with metastatic diseaseThe findings, conclusions and recommendations within this report donot replace the initial findings, conclusions and recommendationsmade at the facility where the study was performed based upon theimaging and clinical condition at that time. Comparison with theprior report and clinical history is necessary. The provided imagesmay or may not represent the native source data set and thus maycontain changes that may lower the accuracy of this second-opinioninterpretation..SURGERY 7/1/2024Colonoscopy 5/29/2024Bone scan 5/22/2024CT AP OSH 5/7/2024CT AP 12/28/2023ASSESSMENT AND PLAN:Alexander R Towell is a 49 y.o. Non-Hispanic male with metastatic small bowel adenocarcinoma with liver and pelvis metastases who presents for second opinionMetastatic Terminal Ileum Adenocarcinoma, MSS, RAS WT, with liver and pelvic metastases- I reviewed available records per epic prior to the visit- I also reviewed records sent by patient through the portal after the visit and summarized and outlined as above- I have reviewed the PET scan images noting at least 4 liver lesions and also uptake in the rectovesical region of the pelvis concerning for extrahepatic disease- I have reviewed his TEMPUS XT and XF noting no RASS alterations, MSS and a TP53 alteration also seen in the tumor and blood- With the limited data during the visit, we recommended proceeding with an MRI abdomen and Pelvis to assess fully these liver lesions. We also had his PET scan from outside consulted as above.- Unclear if HAI pump therapy appropriate for him as he has pelvis disease. I would like to review his MRI imaging once available and refer him to our colorectal surgeons and hepatobiliary/transplant surgeons to assess resection of both pelvis disease as well as liver disease, as well as options for possible locoregional therapies to the liver, including ablation, Y90, TARE, SBRT.- At this point, he is to continue his current systemic therapy locally.All of his questions were answered. He understands and was in agreement with the plan of care. He knows to call the office in the interim with any symptoms, questions, or concerns.Benjamin R. Tan, MD My total encounter time on 8/15/2024 was 66 minutes which was spent in the activities documented in the note. This includes time spent prior to the visit and after the visit in direct care of the patient. This time does not include time spent in any separately reportable services. Electronically signed by Benjamin Tan, MD at 08/16/2024 9:21 PM CDTdocumented in this encounter