Anesthesia Postprocedure Evaluation - Samuel Erlinger, MD - 12/18/2025 4:41 PM CSTFormatting of this note is different from the original.Patient: Alexander R TowellProcedure Summary Date: 12/18/25 Room / Location: BJH OR POD 5 ROOM 230 / BJH OR POD 5 Anesthesia Start: 1309 Anesthesia Stop: 1608 Procedure: XI LIVER RESECTION - LAPAROSCOPIC ROBOTIC ASSISTED SEGMENT 5 8 and 4B, INTRAOPERATIVE ULTRASOUND and TAP BLOCK (Abdomen)

Diagnosis: Metastatic colon cancer to liver (Metastatic colon cancer to liver [C18.9, C78.7]) Surgeons: Chapman, William Cavanaugh, MD Responsible Provider: King, Christopher R., MD PhD Anesthesia Type: general ASA Status: 3 Anesthesia Type: generalLast vitalsVitals Value Taken Time BP 143/94 12/18/25 16:40 Temp 36.7 °C (98.1 °F) 12/18/25 16:00 Pulse 70 12/18/25 16:40 Resp 18 12/18/25 16:40 SpO2 93 % 12/18/25 16:40 Vitals shown include unfiled device data. Anesthesia Post EvaluationPatient location during evaluation: PACUPatient participation: complete - patient participatedLevel of consciousness: follows simple commands and fully awakePain management: adequateAirway patency: adequateCardiovascular status: acceptable and hemodynamically stableRespiratory status: acceptableHydration status: acceptablePt is: normothermicNausea/Vomiting status: noneElectronically signed by Samuel Erlinger, MD at 12/18/2025 4:42 PM CSTAnesthesia Procedure Notes - Lucas Maxey, CRNA - 12/18/2025 2:05 PM CSTAssociated Order(s): Peripheral IV CatheterFormatting of this note might be different from the original.Peripheral IV CatheterPatient location: ORStaff:Placed by:CRNA: Maxey, Lucas Aaron, CRNAPreprocedure prep:Prep solution: alcoholPPE: glovesPIV line:Laterality: rightSite: forearmCatheter size: 14 gTechnique: anatomical landmarks and direct visualizationProcedure details: good blood return and occlusive dressing appliedNumber of attempts: 1

Assessment:Events: patient tolerated procedure well with no complicationsElectronically signed by Lucas Maxey, CRNA at 12/18/2025 2:05 PM CSTAnesthesia Procedure Notes - Lucas Maxey, CRNA - 12/18/2025 2:05 PM CSTAssociated Order(s): Arterial LineFormatting of this note might be different from the original.Arterial LinePatient location: ORIndication: continuous blood pressure monitoring and blood sampling neededUltrasound assisted: yesStaff:Placed by:CRNA: Maxey, Lucas Aaron, CRNAProcedure prep:Prep solution: chlorhexadine/alcoholPrep: provider hat/mask, sterile gloves and sterile probe coverArterial line:Catheter size: 20 gaugeCatheter length: 1 and 3/4 inchCatheter type: wire-guided catheterSeldinger technique: yesLaterality: leftSite: radial arteryLine secured: tape and TegadermResults: good waveform and good blood returnNumber of attempts: 1

Assessment:Events: patient tolerated procedure well with no complicationsElectronically signed by Lucas Maxey, CRNA at 12/18/2025 2:05 PM CSTAnesthesia Procedure Notes - Lucas Maxey, CRNA - 12/18/2025 2:04 PM CSTAssociated Order(s): AirwayFormatting of this note might be different from the original.AirwayPatient location: ORUrgency: electiveIndications for airway management: anesthesiaDifficult airway: noStaff: Placed by:CRNA: Maxey, Lucas Aaron, CRNAEmergent airway documentation: Risks and benefits discussed: yesConsent obtained: yesConsent given by: patientAirway prep:Preoxygenated: yesPatient position: sniffingMask difficulty assessment: 1 - vent by maskSpontaneous ventilation during airway: absentSedation level during airway: GAFinal airway details: Final airway type: endotracheal airwayTube type: ETTETT size: 7.5 mmCuffed: yesTechnique used for successful ETT placement: video laryngoscopyDevices/Methods used in placement: styletInsertion site: oralBlade type: MacintoshVideo blade type: McGrathBlade size: 4Cormack-Lehane (video): grade I - full view of glottisInitial cuff pressure: 25 cm H2OCuff volume: 7 mLCuff inflated with: airETT to lips: 22 cmPlacement verified by: auscultationAirway secured with: silk tapeNumber of attempts: 1Electronically signed by Lucas Maxey, CRNA at 12/18/2025 2:05 PM CSTAnesthesia Preprocedure Evaluation - Christopher King, MD PhD - 11/26/2025 10:03 AM CSTFormatting of this note is different from the original.Images from the original note were not included.Center for Preoperative Assessment and PlanningPreoperative Evaluation RecordEvaluation type/location: CPAP BJHPlanned procedure site: BJH South OR (Pods 2/3/5/CPC)Date: 11/26/25_____________________________________________________________Anesthesia EvaluationXI LIVER RESECTION - LAPAROSCOPIC ROBOTIC ASSISTED (Abdomen)Pre-Op Diagnosis Codes: * Metastatic colon cancer to liver [C18.9, C78.7]HISTORYHPIAlexander R Towell is a 50 y.o. male w/ notable PMHx of anemia, thrombocytopenia, hypothyroidism, metastatic colon cancer s/p laparoscopic sigmoid colectomy (12/29/2021) with subsequent right sided hemicolectomy (7/1/2024) and liver resection (5/2025) who is being evaluated preoperatively prior to planned robotic-assisted laparoscopic liver resection for metastatic colon cancer to liverPast Medical HistoryInformation obtained from: patient and chart.Information obtained during: In PersonNeurological + Neuromuscular disease (peripheral neuropathy)Pertinent negatives: seizures; CVA/stroke; TIA; CEA; ICA stenosis; dementia/mild cognitive impairment and carotid artery stentCardiovascular Pertinent negatives: hypertension ; CAD ; MI ; CABG ; systolic/diastolic dysfunction w/o CHF ; valvular heart disease; valve replacement; atrial fibrillation; arrhythmia; pacemaker/ICD; PVD; DVT/PE; negative for CHF; drug-eluting stent(s); bare metal stent(s) and coronary angioplastyRespiratory Pertinent negatives: COPD; asthma; sleep apnea (OSA); pulmonary hypertension; no O2 use outside the hospital; non-smoker and no tracheostomyHepatic / Heme + Liver disease (liver mets)+ History of anemia (normal H&H on 11/20/2025)+ History of thrombocytopenia (Plts= 131k on 11/20/25)Pertinent negatives: history of Coombs positiveGastrointestinal Pertinent negatives: GERD and hiatal herniaRenal / GU Pertinent negatives: renal disease; dialysis and nephrolithiasisMusculoskeletal/Pain Pertinent negatives: chronic pain; chronic opioid use and previous treatment for opioid use disorderEndocrine / Other + Thyroid disease - hypothyroidism+ Cancer history- metastatic cancer and s/p chemo. Cancer type: colon cancer w/ mets to liver.Pertinent negatives: diabetes mellitus; obesity (BMI >30); rheumatological disease; transplanted organ and infectious diseaseFunctional Capacity Functional capacity: 6-10 METsComments: Jogs short distances for exercise with no CP/SOB.Able to lie supine with no dyspneaReview of Systems + previous transfusion (“years ago”)+ numbness/tingling (peripheral neuropathy)+ vision loss (glasses)+ heartburn (occasional sx’s)+ nausea/vomiting (from chemo)+ dentures/partials (upper partial)Pertinent negatives: productive cough; wheezing; SOB; recent cold/flu; fever; chest pain; palpitations; orthopnea; pedal edema; PND; Sickle Cell disease/trait; transfusion reaction; melena/hematochezia; easy bruising; bleeding problems; syncope; dizziness; muscle weakness; chronic pain; hard of hearing; dysphagia; diarrhea; chipped/loose teeth; abdominal pain; diaphoresis and no unexpected weight changeComments: Denies URI/UTI symptomsPAT Summary and Plans Cardiac risk classification of planned procedure: intermediate cardiac risk.Preoperative assessment status: lab tests ordered.Additional comments: Alexander R Towell is a 50 y.o. male who is being evaluated prior to undergoing an intermediate cardiac risk surgery. Revised Cardiac Risk Index factors are (none) for a total RCRI of 0 out of 6. Functional capacity is 6-10 METs.Obstructive sleep apnea (OSA) screening status is LOW risk; STOP-BANG is 1. Pt denies h/o OSA. Blood bank needs for day of procedure: T&C 2 unit pRBCsMay need updated T&S depending on DOS: TBDPending labs/tests include: CBC T&SCBC and CMP reviewed from 11/20/25 and notable for: (otherwise unremarkable from an anesthesia perspective)Plts= 131kPreoperative evaluation performed by Kelly Ann Wilkens, NP on 11/26/25 at 10:35 AM. .Follow up noteLabs reviewed and are without significant findings.Surgeon’s office reviews laboratory results independently, including final results of surgeon ordered labs.CPAP process complete. Follow-up completed by: Barbara E. Brake, NP on 12/01/25 at 8:50 AMPatient Active Problem List Diagnosis Date Noted H/O resection of liver 08/01/2025 Metastasis to liver 05/14/2025 Metastatic colon cancer to liver 04/30/2025 Adenocarcinoma of ileum (HCC) 08/23/2024 Malignant neoplasm metastatic to liver (HCC) 08/16/2024 Past Medical

History: Diagnosis Date Anemia Peripheral neuropathy Primary colon cancer with metastasis to other site (HCC) Thyroid disease Past Surgical

History: Procedure Laterality Date COLON SURGERY 12/30/2021 SMALL BOWEL RESECTION 07/01/2024 THYROIDECTOMY, PARTIAL Right 2022 No Known Allergies Med List Status: Nurse Complete Set By: Miller, Dawn K., RN at 11/26/2025 9:57 AM Taking? Last Dose Start Date End Date Provider cetirizine (ZyrTEC) 10 mg tablet Past Week 10/08/25 – Provider, Historical, MD docusate sodium (COLACE) 100 mg capsule 11/25/2025 – – Provider, Historical, MD levothyroxine (SYNTHROID) 125 mcg tablet 11/26/2025 10/03/25 – Provider, Historical, MD loperamide (IMODIUM A-D) 2 mg tablet Past Month – – Provider, Historical, MD LORazepam (ATIVAN) 0.5 mg tablet 11/25/2025 09/12/25 – Tan, Benjamin R., MD Take 1 tablet (0.5 mg total) by mouth every 8 (eight) hours as needed for anxiety multivitamin with minerals tablet 11/26/2025 – – Provider, Historical, MD prochlorperazine (COMPAZINE) 10 mg tablet Past Month 07/08/25 11/26/25 Tan, Benjamin R., MD Take 1 tablet (10 mg total) by mouth 3 (three) times a day as needed for nausea propranoloL (INDERAL) 20 mg tablet 11/26/2025 – – Provider, Historical, MD zolpidem (AMBIEN) 5 mg tablet 11/25/2025 09/12/25 – Tan, Benjamin R., MD Take 1 tablet (5 mg total) by mouth nightly as needed for sleep – – – – Current Outpatient Medications: cetirizine (ZyrTEC) 10 mg tablet docusate sodium (COLACE) 100 mg capsule levothyroxine (SYNTHROID) 125 mcg tablet loperamide (IMODIUM A-D) 2 mg tablet LORazepam (ATIVAN) 0.5 mg tablet multivitamin with minerals tablet prochlorperazine (COMPAZINE) 10 mg tablet propranoloL (INDERAL) 20 mg tablet zolpidem (AMBIEN) 5 mg tabletSocial History Tobacco Use Smoking Status Never Smokeless Tobacco Never Alcohol Use: Not At Risk (11/26/2025) AUDIT-C Frequency of Alcohol Consumption: Never Average Number of Drinks: Patient does not drink Frequency of Binge Drinking: Not on file Substance and Sexual Activity Drug Use Never Family History Problem Relation Age of Onset Prostate cancer Father 69 Anesthesia problems Neg Hx PAT Physical ExamAirway Exam: Mallampati: IICervical ROM: FROMTM distance: normalPatient presents with mustache and beard.Upper lip bite test class: 1Cardiovascular Exam:Rate: regularRhythm: regularNegative for Murmur No extra heart sounds appreciated Negative for peripheral edema Pulmonary Exam:LCTA, bilatEENT Exam:trachea midlineDental Exam:Appears intactSkin Exam:Skin is warm and dry.Abdominal exam: Abdomen is soft.Bowel sounds are present.Current state:Patient’s current state is cooperative and interactive.Line/Drains/Tubes/Devices:Lines in situ (left chest wall): port Vitals: 11/26/25 1000 11/26/25 1002 BP: 126/82 133/70 Pulse: 51 Resp: 16 SpO2: 98% Relevant diagnostics:ECG(s):N/AEchocardiogram(s):TTE10/8/2021Summary Normal left ventricular size and systolic function, estimated ejection fraction, 55-65%. Mild Left ventricular hypertrophy. Normal Diastolic function. The mitral valve leaflets show non specific thickening with no stenosis or prolapse. Trace mitral regurgitation is present. Aortic valve appears tri-leaflet with mild sclerosis and without significant stenosis or regurgitation. Tricuspid doppler reveals trace regurgitation with calculated right ventricular systolic pressure at 28 mmHG, suggesting no hemodynamic significance. Left atrium is mildly enlarged. Normal Right heart size and right ventricular systolic function. No evidence of pericardial effusion. Stress test(s):N/ACardiac catheterization(s):N/APFT(s):N/AVascular studies:N/AOther:MRI Abd/Pelvis11/9/2025

IMPRESSION:Interval development of two hepatic segment 4A/8 lesions, suspicious for metastatic disease.CT Chest11/6/2025

IMPRESSION:1. Stable right lower lobe indeterminate pulmonary nodule. 2. Stable groundglass nodule in the left lower lobe. 3. No disease progression in the chest.PET Scan11/19/2025

IMPRESSION:Suggestion of subtle uptake in the area of queriedhepatic segment 4A enhancing lesion on recent MRI, which may represent metastasis versus physiologic artifact. No evidence of hypermetabolic disease elsewhere.PT: No results found for requested labs within last 30 days.INR: No results found for requested labs within last 30 days.APTT: No results found for requested labs within last 30 days.Hgb A1C: No results found for requested labs within last 30 days.CBCRBC: 11/20/2025: 4.70 M/cummRDW: No results found for requested labs within last 30 days.MCHC: 11/20/2025: 34.9 g/dLMCH: 11/20/2025: 32.6 pgMCV: 11/20/2025: 93.4 fLHct: 11/20/2025: 43.9 %Hgb: 11/20/2025: 15.3 g/dLWBC: 11/20/2025: 4.35 K/cummMPV: 11/20/2025: 9.8 fLPlatelets: 11/20/2025: 131 K/cumm (L)RDW CV: 11/20/2025: 14.1 %RDW Sd: 11/20/2025: 48.0 fLBMPGlucose: 11/20/2025: 105 mg/dLCalcium: 11/20/2025: 9.0 mg/dLSodium: 11/20/2025: 140 mmol/LPotassium: 11/20/2025: 4.0 mmol/LCO2: 11/20/2025: 27 mmol/LChloride: 11/20/2025: 106 mmol/LBUN: 11/20/2025: 23 mg/dLCreatinine: 11/20/2025: 1.11 mg/dLSTOP-Bang Total Score: 1Barthel index score: 100DOS Physical ExamDate of Last Liquid: 12/18/25, Time of Last Liquid: 0000Date of Last Solid: 12/17/25, Time of Last Solid: 2100Medical history, medications, and allergies reviewed.Attestation: I endorse the findings of the anesthesia pre-evaluation assessment dated: 11/26/2025.Airway Exam: Mallampati: IICervical ROM: FROMTM distance: normalCardiovascular Exam:Rate: regularRhythm: regularPulmonary Exam:LCTA, bilatEENT Exam:trachea midlineDental Exam:Missing and otherwise appears intactAnesthesia PlanASA 3My patient is approved for the Anesthesia Controlled Medication protocol when under care of a CRNA Planned anesthesia: GeneralTeam communication plan: oral ET tubeInvasive Monitors Planned:Invasive monitors planned: arterial line.Induction:Induction: intravenous.Postoperative

Plan:Postoperative administration opioids intended.No postoperative mechanical ventilation intended.Patient’s planned disposition post procedure is Floor.Informed Consent:Discussed plan with attending and CRNA.Anesthesia plan and risks discussed with patient and spouse.Consent and Attending signature:I and/or my designee have discussed the anesthesia plan, benefits, possible alternatives, parental presence at time of induction (if indicated), and clinically relevant risks that may include dental injury, unintentional awareness, and/or other complications. The patient and/or parent/legal guardian understand, and agree to proceed. All questions answered.Electronically signed by Kelly Wilkens, NP at 11/26/2025 10:35 AM CSTElectronically signed by Barbara Brake, NP at 12/01/2025 8:50 AM CSTElectronically signed by Christopher King, MD PhD at 12/18/2025 10:55 AM CSTElectronically signed by Christopher King, MD PhD at 12/18/2025 4:19 PM CSTElectronically signed by Christopher King, MD PhD at 12/18/2025 4:21 PM CSTElectronically signed by Christopher King, MD PhD at 12/18/2025 4:24 PM CSTdocumented in this encounter