Oncology Clinic Note

Synopsis

Synopsis: Mr. Arthur Pendelton (MRN: 849-204-11, DOB: 12/04/1958) is a 67-year-old male diagnosed in 2024 with stage IIIB (cT3N1M0) moderately differentiated adenocarcinoma of the sigmoid colon. Following low anterior resection in 11/2024, he is currently in the adjuvant treatment phase, having completed cycle 4 of 8 planned cycles of CAPOX chemotherapy with no documented recurrence or metastases to date.

Consent

"The patient gave verbal consent for use of an AI scribe during this visit and understood its purpose, possible benefits, and related privacy and security risks."

History of Present Illness

Mr. Pendelton presents for pre-cycle 5 evaluation of adjuvant CAPOX, having received his cycle 4 oxaliplatin infusion on 14/02/2025. He reports new-onset grade 1 cold-induced paresthesias in his fingertips and toes, which resolve within 4 days of infusion and do not impair fine motor function or buttoning clothes.

He experienced mild nausea during the first 3 days post-infusion, which was adequately controlled with PRN ondansetron. He denies diarrhea, mucositis, palmar-plantar erythrodysesthesia, chest pain, or fevers, and maintains a stable appetite and weight.

Physical Examination

• General: The patient is alert, oriented, in no acute distress, with an ECOG performance status of 1.
• Cardiovascular: Regular rate and rhythm with normal S1 and S2, no murmurs, and BP is 128/78 mmHg with HR 74 bpm.
• Respiratory: Lungs are clear to auscultation bilaterally with normal respiratory effort and SpO2 98 % on room air.
• Gastrointestinal: The abdomen is soft and non-tender with normoactive bowel sounds and no palpable masses or hepatosplenomegaly.
• Neurological: Cranial nerves II–XII are intact, motor strength is 5/5 throughout, and there is mild decreased sensation to light touch at the distal phalanges bilaterally with normal gait.
• Other: The right chest subcutaneous port site is clean and intact without erythema, and the midline abdominal surgical scar is well-healed with no cervical or supraclavicular lymphadenopathy.

Lab Results

• CBC (05/03/2025): WBC 4.8 x 10^9/L, ANC 2.6 x 10^9/L, Hb 124 g/L, Platelets 142 x 10^9/L.
• Chemistry (05/03/2025): Creatinine 82 µmol/L, eGFR 84 mL/min, AST 28 U/L, ALT 31 U/L, Total Bilirubin 12 µmol/L.
• Tumour Markers (05/03/2025): CEA 2.1 µg/L (down from 6.8 µg/L pre-operatively).

Diagnostics

• CT Chest/Abdomen/Pelvis (15/10/2024): Demonstrated a 4.2 cm circumferential sigmoid mass with regional pericolic lymphadenopathy and no distant metastatic disease in the liver or lungs.

Problems / Past Medical History

• Essential hypertension.
• Type 2 diabetes mellitus.
• Post-operative iron deficiency anemia (resolved).

Procedure / Surgical History

• Laparoscopic low anterior resection (18/11/2024).
• Right chest wall BardPort insertion (02/12/2024).
• Colonoscopy and biopsy (04/10/2024).

Medications

• oxaliplatin (Eloxatin®) 130 mg/m2 IV Day 1 q21d.
• capecitabine (Xeloda®) 1,000 mg/m2 PO BID Days 1–14 q21d.
• ondansetron (Zofran®) 8 mg PO TID PRN nausea.
• prochlorperazine (Stemetil®) 10 mg PO q6h PRN breakthrough nausea.
• amlodipine (Norvasc®) 5 mg PO daily.
• metformin (Glucophage®) 500 mg PO BID.

Allergies

• Iodinated contrast media (urticaria; requires pre-medication protocol).
• sulfamethoxazole/trimethoprim (Septra®) (maculopapular rash).

Assessment / Plan

1. Mr. Pendelton has stage IIIB sigmoid adenocarcinoma and is tolerating adjuvant CAPOX well with stable counts and only grade 1 oxaliplatin-induced peripheral neuropathy.
2. We will proceed with Cycle 5 of CAPOX at 100 % dose intensity starting 07/03/2025, as hematologic and hepatic parameters are satisfactory.
3. He will continue ondansetron PRN for acute emesis and avoid cold exposure to mitigate neuropathic symptoms, with instructions to report persistent paresthesias between cycles.
4. He will return to the oncology clinic in 3 weeks on 28/03/2025 with repeat CBC, renal, and hepatic panels prior to Cycle 6.