Caroline Godfrey, MD - 12/18/2025 11:45 AM CSTFormatting of this note might be different from the original.I have reviewed the H&P, examined the patient, and endorse the findings as written. Plan of Care : Based on the above findings, I consider Alexander R Towell to be an acceptable risk for : Procedure(s):XI LIVER RESECTION - LAPAROSCOPIC ROBOTIC ASSISTED– Segment 8Cosigned by William Chapman, MD at 12/18/2025 3:27 PM CSTElectronically signed by Caroline Godfrey, MD at 12/18/2025 11:45 AM CSTElectronically signed by William Chapman, MD at 12/18/2025 3:27 PM CSTAssociated attestation - William Chapman, MD - 12/18/2025 3:27 PM CSTFormatting of this note might be different from the original.50 year old man admitted for planned resection of 2 metastatic sites in the liver. The patient and his family seem to understand the issues and agree with the plans.Source Note - Morgen Rockel, PA - 11/26/2025 9:00 AM CSTFormatting of this note is different from the original.PATIENT NAME: Alexander R TowellDOB: 8/4/197511/26/2025 CHIEF COMPLAINT: Metastatic terminal ileum adenocarcinoma to the liverHISTORY OF PRESENT ILLNESS: Mr. Towell is a 50 y.o. male with a history of sigmoid adenocarcinoma, metastatic terminal ileum adenocarcinoma to the liver s/p segment 2 hepatic resection in 5/2025 with two new lesions concerning for metastasis in segment 8. He returns to discuss repeat hepatic resection. He recovered very well after XI hepatic resection without complications. He continues chemotherapy with Dr. Tan, with last treatment 3 weeks ago. Surveillance MRI 11/9 showed 2 new lesions, 1.2 and 0.6 cm, followed by PET scan with very slight uptake.He feels wells overall, good appetite, no weight loss. CURRENT MEDICATIONS:Current Outpatient Medications: cetirizine (ZyrTEC) 10 mg tablet, Take 1 tablet every day by oral route for 90 days., Disp: , Rfl: cyanocobalamin (Vitamin B-12) 100 mcg tablet, Take 1 tablet (100 mcg total) by mouth early morning before breakfast, Disp: , Rfl: docusate sodium (COLACE) 100 mg capsule, Take 1 capsule (100 mg total) by mouth 2 (two) times a day as needed for constipation, Disp: , Rfl: iron bisgly,ps-FA-B-C#12-succ 65 mg-65 mg -1,000 mcg (24) tablet, Take 1 tablet by mouth 3 (three) times a week, Disp: , Rfl: levothyroxine (SYNTHROID) 112 mcg tablet, Take 1 tablet (112 mcg total) by mouth early morning before breakfast (Patient taking differently: Take 125 mcg by mouth early morning before breakfast), Disp: , Rfl: loperamide (IMODIUM A-D) 2 mg tablet, Take 1 tablet (2 mg total) by mouth 4 (four) times a day as needed for diarrhea, Disp: , Rfl: LORazepam (ATIVAN) 0.5 mg tablet, Take 1 tablet (0.5 mg total) by mouth every 8 (eight) hours as needed for anxiety, Disp: 30 tablet, Rfl: 0 multivitamin with minerals tablet, Take 1 tablet by mouth daily with dinner, Disp: , Rfl: omega-3 fatty acids-fish oil 300-1,000 mg capsule, Take 2 capsules (2 g total) by mouth daily with dinner, Disp: , Rfl: prochlorperazine (COMPAZINE) 10 mg tablet, Take 1 tablet (10 mg total) by mouth 3 (three) times a day as needed for nausea, Disp: 60 tablet, Rfl: 3 propranoloL (INDERAL) 20 mg tablet, Take 1 tablet (20 mg total) by mouth 2 (two) times a day, Disp: , Rfl: zolpidem (AMBIEN) 5 mg tablet, Take 1 tablet (5 mg total) by mouth nightly as needed for sleep, Disp: 30 tablet, Rfl: 0ALLERGIES: No Known AllergiesSOCIAL HISTORY:Social History Tobacco Use Smoking Status Never Smokeless Tobacco Never Alcohol: None reports no history of drug use.The patient is partner and presents to clinic with Kim. Occupation: Researcher. REVIEW OF SYSTEMS:Reports No acute concernsDenies fever/chills, n/v/d/c, or abdominal pain.PHYSICAL EXAM: VitalsBP 125/78 Pulse 61 Temp 36.1 °C (97 °F) Ht 185.4 cm (6’ 1") Wt 105.6 kg (232 lb 12.8 oz) BMI 30.71 kg/m² General Appearance: awake, alert, oriented x3, in no acute distressSkin: there are no suspicious lesions, rashes or jaundiceHead: NCATEyes: EOMI and Sclera nonictericNeck: neck- supple, no massLungs: Chest wall: symmetricHeart: Heart regular rate and rhythmAbdomen: Soft, non-tender, no organomegaly or masses. Hernias: none. Small incisional scars present. Extremities: no edemaNeurologic: negative findings: cranial nerves 2-12 grossly intact, gait normalLABS:Lab Results Component Value Date WBC 4.35 11/20/2025 HGB 15.3 11/20/2025 HCT 43.9 11/20/2025 MCV 93.4 11/20/2025 Lab Results Component Value Date SODIUM 140 11/20/2025 POTASSIUM 4.0 11/20/2025 CHLORIDE 106 11/20/2025 CO2 27 11/20/2025 ANIONGAP 8 11/20/2025 GLUCOSE 105 11/20/2025 BUNSER 23 11/20/2025 CREATININE 1.11 11/20/2025 CALCIUM 9.0 11/20/2025 ALBUMIN 4.3 11/20/2025 ALKPHOS 80 11/20/2025 ALT 46 11/20/2025 AST 28 11/20/2025 BILITOT 0.9 11/20/2025 IMAGING:MRI 11/9/25

FINDINGS: Liver: Postsurgical changes of hepatic segment 2 resection, withotherwise normal hepatic morphology. No surface nodularity. Noabnormal hepatic fat or iron deposition. - Bile ducts: Nondilated.- Focal liver lesions: There are 2 new arterially enhancing lesionswithin the periphery of hepatic segment 4A/8 measuring 1.2 and 0.6 cm(series 21, image 35 and 34/88, respectively), with associatedhepatobiliary phase hypoenhancement (series 39, image 27 and 24/88).Evaluation of associated diffusion restriction is limited due tosusceptibility artifact.- Vasculature: Conventional hepatic arterial anatomy.Gallbladder: Normal.Pancreas: Normal.Spleen: Normal.Adrenals: Normal.Kidneys: A tiny T2 hyperintense lesion within the left mid kidneylikely represents a simple renal cyst. Kidneys are otherwise normal,without hydronephrosis.Bladder: Nondistended.Reproductive organs: Bilateral hydroceles. Sequela of prostatitis. Other Findings: Heart size is normal, without pericardial effusion.No pleural effusion or pulmonary consolidation. No evidence of bowelobstruction. Post surgical changes of right hemicolectomy. Abdominalaorta is normal in course and caliber. No suspicious osseous lesion.

IMPRESSION:Interval development of two hepatic segment 4A/8 lesions, suspiciousfor metastatic disease.PET 11/19/25

IMPRESSION:Suggestion of subtle uptake in the area of queriedhepatic segment 4A enhancing lesion on recent MRI, which mayrepresent metastasis versus physiologic artifact. No evidence ofhypermetabolic disease elsewhere.ASSESSMENT:50 y.o. year old male with a history of metastatic terminal ileum adenocarcinoma to the liver s/p segment 2 hepatic resection in 5/2025, now with two new hepatic lesions in segment 8 which are concerning for metastatic disease warranting resection. PLAN:Recent MRI and PET scan were reviewed. We will plan for a robotic hepatic segment 8 wedge resection. Procedure described in detail, consents obtained. He would like to avoid scheduling 12/8-12/11 due to a planned trip. I, Morgen Rockel, PA-C, MMS, have personally taken a history, examined the patient, and documented the assessment and plan as noted. The patient was seen with Dr. Chapman in the Center for Advanced Medicine. Morgen Terrell Rockel, PA-C, MMSPatient Care Team:Beard, Kelsey Michelle, NP as PCP - General (Nurse Practitioner)Arshad, Syed M., MD as Referring Physician (Hematology)Tan, Benjamin R., MD as Medical Oncologist/Hematologist (Medical Oncology)Tan, Benjamin R., MD as Medical Oncologist/Hematologist (Medical Oncology)Chapman, William Cavanaugh, MD as Consulting Physician (Transplant Surgery)Chapman, William C. Jr., MD as Consulting Physician (Colon and Rectal Surgery)Cosigned by William Chapman, MD at 11/28/2025 10:10 AM CSTElectronically signed by Morgen Rockel, PA at 11/26/2025 2:27 PM CSTElectronically signed by William Chapman, MD at 11/28/2025 10:10 AM CSTdocumented in this encounter