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INTRODUCTION

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CASE LEARNING OBJECTIVES

  • Identify the risk factors for colorectal cancer

  • Recognize the signs and symptoms of colorectal cancer

  • Describe the treatment options for colorectal cancer on the basis of patient-specific factors, such as stage of disease, age of the patient, and previous treatment received

  • Develop a monitoring plan to assess the efficacy and toxicity of agents used in colorectal cancer

  • Educate patients about the adverse effects of chemotherapy that require patient-specific counseling

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PATIENT PRESENTATION

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Chief Complaint

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"I've been tired for the past 3 months and have this pain in my stomach that is getting worse. Today I noticed some blood in my stool and got scared. I'm not sure what is going on."

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History of Present Illness

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John Braxton is a 62-year-old Caucasian male who presented to his primary care physician with generalized fatigue for 3 months, abdominal pain, and new blood in his stool. Over-the-counter famotidine had been recommended for the abdominal pain, and provided no relief. He also reports that he has not been able to eat like he normally does due to "feeling full all the time" and constipation. A CBC revealed microcytic anemia and iron profile was consistent with iron deficiency. Fecal occult blood test was positive. Colonoscopy demonstrated a 5-cm (2-inch) frond-like, nonobstructing, villous lesion arising from the descending colon. Biopsies were positive for low-grade, moderately differentiated adenocarcinoma. Tumor marker carcinoembryonic antigen (CEA) was 80 ng/mL (80 mcg/L; normal 0−5 ng/mL [0−5 mcg/L]). There was no evidence of metastatic disease on staging CT scans. Pathology revealed 1.8-in. (4.5-cm), low-grade, moderately differentiated adenocarcinoma invading into the muscularis propria. Twenty-four lymph nodes were removed and four were positive for malignancy. The final diagnosis was stage 3 colorectal cancer. Postoperatively, CEA decreased to <0.1 ng/mL (<0.1 mcg/L). He underwent surgical resection with clear margins and is being evaluated 4 weeks later in your clinic for adjuvant treatment regimens.

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Past Medical History

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HTN

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Hypercholesterolemia

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Past Surgical History

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Left-sided hemicolectomy for the colon mass

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Family History

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Mother deceased at age 75 with MI. Father deceased at age 60 with colorectal cancer diagnosed at the age of 58. Sister diagnosed with breast cancer at the age of 52; no additional family history of cancer in family per the patient's report.

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Social History

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The patient is a lifelong resident of the state of Florida. He currently works as a piano teacher. He is married and has two children.

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Tobacco/Alcohol/Substance Use

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The patient has been a lifetime nonsmoker, drinks alcohol socially, and denies any drug use.

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Allergies/Intolerances/Adverse Drug Events

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Not known

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Medications (Current)

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Atenolol 50 mg PO q 24 h

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Atorvastatin 10 mg PO q 24 h

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Famotidine 20 mg PO PRN abdominal pain

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