Anesthesia Postprocedure Evaluation - Archana Bharadwaj, MD - 05/14/2025 3:06 PM CDTFormatting of this note is different from the original.Patient: Alexander R TowellProcedure Summary Date: 05/14/25 Room / Location: BJH OR POD 5 ROOM 230 / BJH OR POD 5 Anesthesia Start: 1221 Anesthesia Stop: 1439 Procedure: XI LIVER RESECTION - LAPAROSCOPIC ROBOTIC ASSISTED, TAP Block (Abdomen)

Diagnosis: Metastatic colon cancer to liver (HCC) (Metastatic colon cancer to liver (HCC) [C18.9, C78.7]) Surgeons: Chapman, William Cavanaugh, MD Responsible Provider: Zoller, Jonathan Kramer, MD Anesthesia Type: general ASA Status: 2 Anesthesia Type: generalLast vitalsBP 137/89 (BP Location: Left arm, Patient Position: HOB 30 degrees) | Pulse 84 | Temp 36.2 °C (97.2 °F) (Temporal) | Resp 14 | SpO2 94% Anesthesia Post EvaluationPatient location during evaluation: PACUPatient participation: complete - patient participatedLevel of consciousness: fully awakePain score: 4Pain management: adequateAirway patency: patentEvidence of recall: noCardiovascular status: acceptableRespiratory status: acceptableHydration status: stablePt is: normothermicNausea/Vomiting status: noneNo notable events documented.Cosigned by Ahmet Bermede, MD at 05/14/2025 3:08 PM CDTElectronically signed by Archana Bharadwaj, MD at 05/14/2025 3:07 PM CDTElectronically signed by Ahmet Bermede, MD at 05/14/2025 3:08 PM CDTAnesthesia Procedure Notes - Bradley Lewis, DO - 05/14/2025 12:54 PM CDTAssociated Order(s): Peripheral IV CatheterFormatting of this note might be different from the original.Peripheral IV CatheterPatient location: ORStaff:Placed by:Resident: Lewis, Bradley Mitchell, DOPreprocedure prep:Prep solution: chlorhexadinePPE: gloves and provider hat/maskPIV line:Laterality: leftSite: wristCatheter size: 18 gTechnique: direct visualizationProcedure details: good blood returnNumber of attempts: 1

Assessment:Events: patient tolerated procedure well with no complicationsElectronically signed by Bradley Lewis, DO at 05/14/2025 12:54 PM CDTAnesthesia Procedure Notes - Bradley Lewis, DO - 05/14/2025 12:54 PM CDTAssociated 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:Supervising provider: Zoller, Jonathan Kramer, MDPlaced by:Resident: Lewis, Bradley Mitchell, DOProcedure prep:Prep solution: chlorhexadine/alcoholPrep: provider hat/mask and sterile glovesArterial line:Catheter size: 20 gaugeCatheter type: wire-guided catheterLaterality: leftSite: radial arteryLine secured: tapeResults: good waveform and good blood returnNumber of attempts: 1

Assessment:Events: patient tolerated procedure well with no complicationsElectronically signed by Bradley Lewis, DO at 05/14/2025 12:54 PM CDTAnesthesia Procedure Notes - Bradley Lewis, DO - 05/14/2025 12:48 PM CDTAssociated Order(s): AirwayFormatting of this note might be different from the original.AirwayPatient location: ORIndications for airway management: anesthesia and airway protectionDifficult airway: noStaff: Placed by:Anesthesiologist: Zoller, Jonathan Kramer, MDResident: Lewis, Bradley Mitchell, DOEmergent 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: 8.0 mmCuffed: yesTechnique used for successful ETT placement: direct laryngoscopyBlade type: MacintoshBlade size: 4Cormack-Lehane (direct): grade I - full view of glottisETT to lips: 24 cmPlacement verified by: auscultation and CO2 detectionAirway secured with: silk tapeNumber of attempts: 1Electronically signed by Bradley Lewis, DO at 05/14/2025 12:49 PM CDTAnesthesia Preprocedure Evaluation - Jonathan Zoller, MD - 05/01/2025 7:36 AM CDTFormatting 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: Not ScheduledDate: 05/01/25_____________________________________________________________Anesthesia EvaluationAlexander R Towell is a 49 y.o. maleXI LIVER RESECTION - LAPAROSCOPIC ROBOTIC ASSISTED (Abdomen)Pre-Op Diagnosis Codes: * Metastatic colon cancer to liver (HCC) [C18.9, C78.7]HISTORYHPIAlexander Towell is a 49 yo male who presents for evaluation prior to undergoing a laparoscopic liver resection VS ablation for colon cancer with mets to the liver. He was diagnosed with T4 N1 M0 stage IIIB moderately differentiated adenocarcinoma sigmoid colon s/p laparoscopic sigmoid colectomy done on 12/29/2021 with subsequent right sided hemicolectomy done on 7/1/2024. Other PMH of hypothyroid, anemia, neuropathy, OSA. Past Medical HistoryInformation obtained from: patient and chart.Information obtained during: In PersonNeurological Pertinent negatives: seizures; neuromuscular disease; CVA/stroke; TIA; CEA; ICA stenosis; dementia/mild cognitive impairment and carotid artery stentCardiovascular Pertinent negatives: hypertension ; CAD ; MI ; CABG ; 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 + Sleep apnea (OSA) (Per sleep study 2023: Mild sleep disordered breathing without clinically significant obstructive sleep apnea)Pertinent negatives: COPD; asthma; pulmonary hypertension; no O2 use outside the hospital; non-smoker and no tracheostomyHepatic / Heme + Liver disease (Colon cancer with mets to the liver)+ History of anemia - in neoplastic diseasePertinent negatives: history of thrombocytopenia and history of Coombs positiveComments: F/b Dr. Syed M Arshad Mercy Hem/Onc LOV 4/16/2025 and Dr. Tan WU oncology LOV 8/15/2024 Gastrointestinal Pertinent negatives: GERD and hiatal herniaComments: Colon cancer s/p hemicolectomy; SBO s/t cancerRenal / GU Pertinent negatives: renal disease; dialysis and nephrolithiasisMusculoskeletal/Pain + Chronic pain - neuropathic pain.+ Headaches (throughout chemo therapy)Pertinent negatives: chronic opioid use and previous treatment for opioid use disorderEndocrine / Other + Thyroid disease (s/p right thyroidectomy 2022) - hypothyroidism+ Cancer history (Maintenance chemotherapy with 5-FU leucovorin and Avastin started on February 12, 2025.)- current cancer and metastatic cancer. Cancer type: Colon s/p hemicolectomy.Pertinent negatives: diabetes mellitus; obesity (BMI >30); rheumatological disease and transplanted organComments: F/b Dr. Wonil Tae OSF endocrinology 4/3/2025.Functional Capacity Functional capacity: 4-6 METsComments: Able to perform ADLs independently. Able to walk 2 city blocks and climb 2 flights of stairs. Denies CP or SOB. Review of Systems + previous transfusion (iron infusions only; last 4 years ago)+ muscle weakness (generalized s/t chemo)+ chronic pain+ numbness/tingling (neuropathy s/t chemo)+ vision loss (glasses)+ nausea/vomiting (after chemo for 24 hours)+ dentures/partials (upper partial)+ diarrhea (s/t chemo; no recent changes)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; hard of hearing; heartburn; dysphagia; chipped/loose teeth; abdominal pain; diaphoresis and no unexpected weight changeComments: Denies UTI symptoms. PAT Summary and Plans Cardiac risk classification of planned procedure: intermediate cardiac risk.Preoperative assessment status: lab tests ordered.Initial preoperative evaluation discussed with: Song, Ziyan, MDAdditional comments: Alexander R Towell is a 49 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 4-6 METs.Obstructive sleep apnea (OSA) screening status is HIGH RISK due to known OSABlood bank needs for day of procedure: T&C 2 unit pRBCsPending labs/tests include: CBC CMP T&S PT PTT-right chest wall port-Patient reports taking 325 mg of aspirin for headaches only and was educated to stop taking 1 week prior to procedure. Preoperative evaluation performed by Mccalle Erin Wilkey, NP on 05/01/25 at 7:39 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: Renee Michelle Figura, NP on 05/02/25 at 10:18 AMPatient Active Problem List Diagnosis Date Noted Metastatic colon cancer to liver (HCC) 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 Cancer (HCC) Peripheral neuropathy Sleep apnea 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 05/01/2025 7:50 AM Taking? Last Dose Start Date End Date Provider aspirin 325 mg 4/30/2025 – – Provider, Historical, MD cyanocobalamin (Vitamin B-12) 100 mcg tablet 5/1/2025 – – Provider, Historical, MD docusate sodium (COLACE) 100 mg capsule Past Month – – Provider, Historical, MD fluticasone propionate (FLONASE) 50 mcg/actuation nasal spray Past Week – – Provider, Historical, MD iron bisgly,ps-FA-B-C#12-succ 65 mg-65 mg -1,000 mcg (24) tablet 4/30/2025 – – Provider, Historical, MD levothyroxine (SYNTHROID) 112 mcg tablet 5/1/2025 03/26/25 – Provider, Historical, MD loperamide (IMODIUM A-D) 2 mg tablet Past Month – – Provider, Historical, MD LORazepam (ATIVAN) 0.5 mg tablet 4/30/2025 04/28/25 – Provider, Historical, MD multivitamin with minerals tablet 4/30/2025 – – Provider, Historical, MD omega-3 fatty acids-fish oil 300-1,000 mg capsule 4/30/2025 – – Provider, Historical, MD SUMAtriptan (IMITREX) 50 mg tablet 4/30/2025 09/05/24 – Provider, Historical, MD zolpidem (AMBIEN) 5 mg tablet 4/30/2025 03/24/25 – Provider, Historical, MD – – Current Outpatient Medications: aspirin 325 mg cyanocobalamin (Vitamin B-12) 100 mcg tablet docusate sodium (COLACE) 100 mg capsule fluticasone propionate (FLONASE) 50 mcg/actuation nasal spray iron bisgly,ps-FA-B-C#12-succ 65 mg-65 mg -1,000 mcg (24) tablet levothyroxine (SYNTHROID) 112 mcg tablet loperamide (IMODIUM A-D) 2 mg tablet LORazepam (ATIVAN) 0.5 mg tablet multivitamin with minerals tablet omega-3 fatty acids-fish oil 300-1,000 mg capsule SUMAtriptan (IMITREX) 50 mg tablet zolpidem (AMBIEN) 5 mg tabletNo current facility-administered medications for this visit.Social History Tobacco Use Smoking Status Never Smokeless Tobacco Never Alcohol Use: Not At Risk (5/1/2025) AUDIT-C Frequency of Alcohol Consumption: Never Average Number of Drinks: Patient does not drink Frequency of Binge Drinking: Never Substance and Sexual Activity Drug Use Never Family History Problem Relation Age of Onset Prostate cancer Father 69 PAT Physical ExamAirway Exam: Mallampati: IIICervical ROM: FROMTM distance: >4Upper lip bite test class: 1Cardiovascular Exam:Rate: regularRhythm: regularNegative for Murmur No extra heart sounds appreciated Negative for peripheral edema JVD negativeNegative for weak pulses Pulmonary Exam:LCTA, bilatEENT Exam:trachea midlineDental Exam:Upper partials and otherwise appears intactSkin Exam:Skin is warm.Capillary refill is < 3 seconds.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 (right chest wall port): port Vitals: 05/01/25 0740 05/01/25 0741 BP: 143/90 144/94 Pulse: 65 Resp: 18 SpO2: 97% Relevant diagnostics:ECG(s):N/AEchocardiogram(s):TTE 10/8/2021:Conclusions Summary 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:PET/CT FDG skull to thigh 11/21/2024:

IMPRESSION:1. Interval resolution of the previously seen four hypermetabolicliver lesions and hepatic segments 2, 7, and 8. Of note, smallhepatic lesions are difficult to characterize with PET/CT accuratelyand would be better evaluated with MRI if there is clinical concern. 2. Interval resolution of the hypermetabolic soft tissue nodules inthe rectovesicular pouch.3. Persistent activity in the right hilar region, which isindeterminate.CT chest abdomen pelvis outside consult 10/24/2024:

IMPRESSION:1. The lesions seen on hepatobiliary phase of the prior MRI are muchsmaller on this exam. It is not certain whether this representsresponse to therapy or differences in technique, particularly giventhat the lesions could not be seen on portal venous phase of theprior MRI as well. Adequate comparison would require a repeat MRIexamination with hepatobiliary phase.2. Stable indeterminate 8 mm solid nodule in the right lower lobe. This was not hypermetabolic on the prior CT examination, but a righthilar lymph node which measures at the upper limits of normal forsize was hypermetabolic and could represent a metastasis.3. Small stable 7 mm groundglass nodule left lower lobe.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: No results found for requested labs within last 30 days.RDW: No results found for requested labs within last 30 days.MCHC: No results found for requested labs within last 30 days.MCH: No results found for requested labs within last 30 days.MCV: No results found for requested labs within last 30 days.Hct: No results found for requested labs within last 30 days.Hgb: No results found for requested labs within last 30 days.WBC: No results found for requested labs within last 30 days.MPV: No results found for requested labs within last 30 days.Platelets: No results found for requested labs within last 30 days.RDW CV: No results found for requested labs within last 30 days.RDW Sd: No results found for requested labs within last 30 days.BMPGlucose: No results found for requested labs within last 30 days.Calcium: No results found for requested labs within last 30 days.Sodium: No results found for requested labs within last 30 days.Potassium: No results found for requested labs within last 30 days.CO2: No results found for requested labs within last 30 days.Chloride: No results found for requested labs within last 30 days.BUN: No results found for requested labs within last 30 days.Creatinine: No results found for requested labs within last 30 days.STOP-Bang Total Score: 1Barthel index score: 100DOS Physical ExamMedical history, medications, and allergies reviewed.Attestation: This PAT evaluation 5/14/2025.Airway Exam: Mallampati: IICervical ROM: FROMTM distance: >4Cardiovascular Exam:Rate: regularRhythm: regularDental Exam:(Missing upper central right incisor)Current state:Patient’s current state is cooperative.Anesthesia PlanASA 2Planned anesthesia: GeneralTeam communication plan: oral ET tubeInvasive Monitors Planned:Invasive monitors planned: arterial line.Induction:Induction: intravenous.Informed Consent: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 McCalle Wilkey, NP at 05/01/2025 8:37 AM CDTElectronically signed by Renee Figura, NP at 05/02/2025 10:19 AM CDTElectronically signed by Jonathan Zoller, MD at 05/14/2025 11:25 AM CDTdocumented in this encounter