Author James PowellAnderson HealthcareJuly 22nd, 2024 1:23pm

Note Date/Time July 22nd, 2024 1:23pm

Anderson Hospital 6800 State Route 162 Maryville, IL 62062 Anesthesiology Progress Note SignedPatient: Towell,Alexander R MR#: M000499848 DOB: 08/04/1975 Acct:V00003688837Age: 48 ADM Date: 07/22/24 Loc: ANHSURGERY Attending Dr: Pei Chang Chung M.D.cc: ~Anes - Initial Pre Proc EvalProcedure: Operation Date: 07/22/24 14:00Proposed Proceduresp Insertion Porta Cath - Pei Chang Chung, MDDate/Time: 07/22/24 13:23Surgeon: Pei Chang Chung, MDPre Op

Diagnosis: malig neoplasm of colonPatient DataAge: 48Gender: MHeight: 1.85 mWeight: 90.5 kg Last Vital SignsTemp 36.6 C 07/22/24 12:42Pulse 57 L 07/22/24 12:42Resp 16 07/22/24 12:42BP 121/73 07/22/24 12:42Pulse Ox 100 07/22/24 12:42O2 Del Method Room Air 07/22/24 12:42 AllergiesAllergy/AdvReac Type Severity Reaction Status Date / TimeNo Known Allergies Allergy Verified 07/22/24 12:21 Home Medications Medication Instructions Recorded Confirmed Typecholecalciferol (vitamin D3) 25 25 mcg PO DAILY 01/12/24 07/22/24 Historymcg (1,000 unit) tablet (Vitamin D3) levothyroxine 100 mcg tablet 100 mcg PO DAILY 01/12/24 07/22/24 Historymultivitamin with minerals-folic 1 tablet PO DAILY 01/12/24 07/22/24 Historyacid 200 mcg chewable tablet (Adult Multivitamin Gummies) ferrous sulfate 325 mg (65 mg 650 mg PO DAILY 06/26/24 07/22/24 Historyiron) tablet omega-3 fatty acids 1,000 mg PO DAILY 06/26/24 07/22/24 HistoryPatient hx anesthesia problems: noneFamily hx anesthesia problems: noneResults Review: All pre-operative results and documents have been reviewed as part of the pre-operative evaluation.PMFSHPast Medical HistoryMedical History (Reviewed 07/22/24 @ 13:23 by James S. Powell, MD)Colon cancerIron deficiency anemia (Unknown)Mass of colon (~12/2021)Surgical HistorySurgical History (Reviewed 07/22/24 @ 13:23 by James S. Powell, MD)History of colon resection 12/29/2021 - hand assisted laparoscopic sigmoid colectomy with mobilization of the splenic flexureHistory of partial thyroidectomyFamily HistoryFamily History (Reviewed 07/22/24 @ 13:23 by James S. Powell, MD)Father Hypertension Malignant neoplasm of prostateMother Deceased COPD (chronic obstructive pulmonary disease)Social HistorySocial History (Reviewed 07/22/24 @ 13:23 by James S. Powell, MD)Smoking status: Never smoker Second hand tobacco smoke exposure: No Alcohol intake: never Drinks per week: 1 Alcohol use details: LAST DRINK 2015 Substance use: never Substance use type: does not use Do You Feel Safe in your Home?: Yes Lack of Transportation: No Lack of Food: Never True Current Housing: I Have Housing Concerned About Future Housing: No Difficulty Paying Gas/Electric Bills: No Difficulty Paying for Meds: No Currently Unemployed: No Education: Master’s Degree or Higher Difficulty w/ Childcare or Family Care: No Living arrangements: with family Additional living arrangements comments: with sp Spiritual care concerns: No Anes - Eval Final PreProcedureDay of Procedure07/22/24 13:23Patient weight: overweightHeart: regular rate and rhythmLungs: clear to auscultationAirway: Mallampati scale class IINeurological: alert and orientedLast oral intake: >/= 8 hoursASA classification: IIIEmergent: noAnesthetic plan: proceedAnesthesia type and monitoring: general GIVS and standard monitoringResults Review: All pre-operative results and documents have been reviewed as part of the pre-operative evaluation.Informed Consent: The patient’s anesthetic plan and its attendant risks and benefits were discussed with the patient/family/POA. Questions were solicited and answers provided to the satisfaction of the patient/family/POA.This report may have been done utilizing a voice recognition system. Attempts have been made to correct errors. However, there may be uncorrected grammatical,spelling, and recognition errors present.Report Initialized date/time: Powell, James S. II MD 07/22/24 / 1323Electronically signed by: Powell, James S. II MD 07/22/24 1323