Clinical Notes

Procedure SummaryProcedure NameResponsible AnesthesiologistAnesthesia Start TimeAnesthesia Stop TimeXI LIVER RESECTION - LAPAROSCOPIC ROBOTIC ASSISTED, TAP Block (Abdomen)Zoller, Jonathan Kramer, MD05/14/25 122105/14/25 1439EventsDateTimeEventComment05/14/20251005In Preop1220In Room1221An Start1221An Start Data1227An InductionThe patient was reevaluated immediately before moderate or deep sedation use and before anesthesia induction.1230An Intubation1238Anesthesia Ready1248Arterial Line sampling artifact1308Proc Start1308Incision Start1403Local injected by surgeon1417Proc Fin1424An Extubation1427Out of Room1439Handoff to RNI completed my handoff to the receiving nurse during which we: 1. Patient identified 2. Responsible provider identified 3. Pertinent medical history reviewed 4. Procedure type and surgical course discussed 5. Intraoperative anesthetic management and any significant issues discussed 6. Expectations and concerns for postop period discussed 7. Questions solicited from receiving nurse 8. Patient disposition at the time of handoff: No value filed.1439An StopMedsNameTotallidocaine (cardiac) syringe 2 %100 mgpropofol200 mgfentaNYL100 mcgHYDROmorphone 2 mg/mL0.8 mgrocuronium150 mgphenylephrine 100 mcg/mL1.11 mgondansetron PF (ZOFRAN) 2 mg/mL injection4 mgglycopyrrolate0.4 mgcefOXitin (MEFOXITIN) 2,000 mg/20 mL in sterile water (premix) 2,000 mg2,000 mgmagnesium sulfate 2 g/50 mL2 gsugammadex200 mgLactated Ringer’s (LR) infusion700 mLAgentsNameO2% ExpiredN2O ExpiredO2N2OAirExpired SevofluraneInspired SevofluraneBloodNo blood administrations on file.Lines, Drains, and AirwaysTypeDetailsPlacementRemovalImplanted PortExisting LDA Placed by: Other hospital (Placed at Anderson); Type: Non-power (Per patient); Orientation: Left; Location: Chest05/01/25 0739 by Peripheral IVPlacement Date: 05/14/25; Placement Time: 1020; Catheter Size: 20 G; Orientation: Right; Location: Forearm; Removal Date: 05/15/25; Removal Time: 0911; Removal Reason: Discharge05/14/25 1020 by Estes, Sydney, RN05/15/25 0911 by Evjen, Sofia Amanda, RNUrethral CatheterPlacement Date: 05/14/25; Placement Time: 1235; Inserted by: G. St. Pierre, RN; Type: Double-lumen, Non-latex, Straight-tip, Temperature probe; Balloon Size: 10 mL; Urine Returned: Yes; Removal Date: 05/15/25; Removal Time: 0011; Removal Reason: Therapy complete05/14/25 1235 by St. Pierre, Grace Marguerite, RN05/15/25 0011 by Chesnut, Caden Riley, RNETTPlacement Date: 05/14/25; Placement Time: 1249 (created via procedure documentation); Mask Ventilation: 1; Technique: Direct laryngoscopy; Type: ETT - single; Single Lumen Tube Size: 8 mm; Cuffed: Yes; Laryngoscope: Macintosh; Blade Size: 4; Grade View: Grade I; Insertion Attempts: 1; Placement Verification: Auscultation, Capnometry; Removal Date: 05/14/25; Removal Time: 142405/14/25 1249 by Lewis, Bradley Mitchell, DO05/14/25 1424 by Lewis, Bradley Mitchell, DOArterial LinePlacement Date: 05/14/25; Placemnt Time: 1254 (created via procedure documentation); Size: 20 G; Orientation: Left; Location: Radial; Removal Date: 05/14/25; Removal Time: 1458; Removal Reason: Per order05/14/25 1254 by Lewis, Bradley Mitchell, DO05/14/25 1458 by Price, Austin Matthew, RNPeripheral IVPlacement Date: 05/14/25; Placement Time: 1254 (created via procedure documentation); Catheter Size: 18 G; Orientation: Left; Location: Wrist; Site Prep: Chlorhexidine; Insertion Attempts: 1; Removal Date: 05/15/25; Removal Time: 0911; Removal Reason: Discharge05/14/25 1254 by Lewis, Bradley Mitchell, DO05/15/25 0911 by Evjen, Sofia Amanda, RNWound05/14/25; 1406; Incision; Abdomen; 5 port sites; 11/26/25; Unknown05/14/25 1406 by St. Pierre, Grace Marguerite, RN11/26/25 0000 by Miller, Dawn K., RNdocumented in this encounter

Procedure SummaryProcedure NameResponsible AnesthesiologistAnesthesia Start TimeAnesthesia Stop TimeXI LIVER RESECTION - LAPAROSCOPIC ROBOTIC ASSISTED SEGMENT 5 8 and 4B, INTRAOPERATIVE ULTRASOUND and TAP BLOCK (Abdomen)King, Christopher R., MD PhD12/18/25 130912/18/25 1608EventsDateTimeEventComment12/18/20250949In Preop10561308In Room1309An Start1309An Start Data1319An InductionThe patient was reevaluated immediately before moderate or deep sedation use and before anesthesia induction.1324An Intubation1336Anesthesia Ready1405Proc Start1405Incision Start1544An Extubation1547Incision Close1547Proc Fin1551an stop data1553Out of Room1608Handoff to RNI completed my handoff to the receiving nurse during which we: 1. Patient identified 2. Responsible provider identified 3. Pertinent medical history reviewed 4. Procedure type and surgical course discussed 5. Intraoperative anesthetic management and any significant issues discussed 6. Expectations and concerns for postop period discussed 7. Questions solicited from receiving nurse 8. Patient disposition at the time of handoff: PACU1608An StopMedsNameTotalmidazolam PF2 mglidocaine (cardiac) syringe 2 %100 mgpropofol130 mgfentaNYL200 mcgHYDROmorphone 2 mg/mL1.2 mgrocuronium180 mgphenylephrine 100 mcg/mL100 mcgePHEDrine5 mgondansetron PF (ZOFRAN) 2 mg/mL injection4 mgglycopyrrolate0.2 mgcefOXitin (MEFOXITIN) 2,000 mg/20 mL in sterile water (premix) 2,000 mg4,000 mgmannitol 25 %12.5 gphenylephrine 5,000 mcg/50 mL (100 mcg/mL) SYR1.27 mgfamotidine20 mgsugammadex400 mgLactated Ringer’s (LR) infusion1,300 mLAgentsNameO2% ExpiredN2O ExpiredO2N2OAirExpired SevofluraneInspired SevofluraneBloodNo blood administrations on file.Lines, Drains, and AirwaysTypeDetailsPlacementRemovalImplanted PortExisting LDA Placed by: Other hospital (Placed at Anderson); Type: Non-power (Per patient); Orientation: Left; Location: Chest05/01/25 0739 by Wound12/18/25; 1454; N; Incision; Abdomen; 5 port sites12/18/25 1454 by Boehmer, Natalie Nicole, RNPeripheral IVPlacement Date: 12/18/25; Placement Time: 1008; Catheter Size: 18 G; Orientation: Left; Location: Wrist; Removal Date: 12/19/25; Removal Time: 1001; Removal Reason: Discharge12/18/25 1008 by Estes, Sydney, RN12/19/25 1001 by Evjen, Sofia Amanda, RNUrethral CatheterPlacement Date: 12/18/25; Placement Time: 1336; Inserted by: Andy RN; Type: Non-latex, Straight-tip, Temperature probe; Balloon Size: 10 mL; Urine Returned: Yes; Removal Date: 12/18/25; Removal Time: 1543; Removal Reason: Discontinued in OR12/18/25 1336 by Boehmer, Natalie Nicole, RN12/18/25 1543 by Boehmer, Natalie Nicole, RNETTPlacement Date: 12/18/25; Placement Time: 1405 (created via procedure documentation); Mask Ventilation: 1; Technique: Video laryngoscopy; Type: ETT - single; Single Lumen Tube Size: 7.5 mm; Cuffed: Yes; Laryngoscope: Macintosh; Blade Size: 4; Location: Oral; Insertion Attempts: 1; Placement Verification: Auscultation; Removal Date: 12/18/25; Removal Time: 155112/18/25 1405 by Maxey, Lucas Aaron, CRNA12/18/25 1551 by Maxey, Lucas Aaron, CRNAArterial LinePlacement Date: 12/18/25; Placemnt Time: 1405 (created via procedure documentation); Size: 20 G; Orientation: Left; Location: Radial; Removal Date: 12/18/25; Removal Time: 170912/18/25 1405 by Maxey, Lucas Aaron, CRNA12/18/25 1709 by Tabor, Caroline Eleanore, RNPeripheral IVPlacement Date: 12/18/25; Placement Time: 1405 (created via procedure documentation); Catheter Size: 14 G ; Orientation: Right; Location: Forearm; Site Prep: Alcohol; Insertion Attempts: 1; Removal Date: 12/19/25; Removal Time: 1001; Removal Reason: Discharge12/18/25 1405 by Maxey, Lucas Aaron, CRNA12/19/25 1001 by Evjen, Sofia Amanda, RNdocumented in this encounter

Encounter Date Assessment Date Assessment LastModified by Organization Details LastModified Time

10/27/2025 10/27/2025

MEDICAL HISTORY: Colon cancer - stave 4. Anemia. Hypothyroidism. Renal impairment.

CURRENT ASSESSMENT:

On intake, patient presents with established treatment and no mood complaints, although does endorse some anxiety when he considers mortality. States he was given 1 year to live 1.5 years ago.

Patient currently completing PhD in computer science. Denies history of hospitalization or adverse life events.

RISK/SAFETY:

Denies SIHISIB, endorses having many things to accomplish, AVH, new or increased use of substance of abuse.

Endorses history of alcohol use in remission since 2015.

MEDICATION MANAGEMENT:

• continue Lorazepam 0.5mg PO daily PRN for breakthrough anxiety.

Zolpidem 5mg tablet PO daily PRN for sleep.

VITALS: UTA

LABS: 4/2025

• UDS: 10/28/25

REFERRALS: none

PLAN/DISCUSSION: continue current treatment plan

Discussed with patient plan to take over medications once UDS complete. Patient will present to clinic for UDS. Will continue treatment

Patient is encouraged to adhere to prescribed medication regimen to ensure optimal efficacy. Patient advised to contact provider before discontinuing any medication, particularly if adverse symptoms occur.

Psychoeducation and brief supportive counseling were provided.

Encouraged engagement with therapy; referrals will be made if necessary

Encouraged to follow up with medical provider if necessary

Discussed importance of nutrition, exercise, and sleep hygiene.

Discussed r/b, side effects, alternatives of _____, or choice to forgo pharmacological treatment with patient. Patient agreed to start trial.

CONSENT: Patient was given opportunity to ask questions and has verbally consented to the current treatment plan and any recommended changes.

Encouraged to seek care at ED if SI/HI with plan/intent develops or to call office if symptoms worsen

RELEVANT HISTORY:

nbennett54 Not available 10/29/2025 22:52:17

11/25/2025 11/25/2025

MEDICAL HISTORY: Colon cancer - stave 4. Anemia. Hypothyroidism. Renal impairment.

CURRENT ASSESSMENT:

11/25/25 - Patient presents with no pervasive mood concern.

RELEVANT HISTORY

On intake, patient presents with established treatment and no mood complaints, although does endorse some anxiety when he considers mortality. States he was given 1 year to live 1.5 years ago.

Patient currently completing PhD in computer science. Denies history of hospitalization or adverse life events. Discussed with patient plan to take over medications once UDS complete. Patient will present to clinic for UDS. Will continue treatment

RISK/SAFETY:

Denies SIHISIB, endorses having many things to accomplish, AVH, new or increased use of substance of abuse.

Endorses history of alcohol use in remission since 2015.

MEDICATION MANAGEMENT:

• continue Lorazepam 0.5mg PO daily PRN for breakthrough anxiety.

Zolpidem 5mg tablet PO daily PRN for sleep.

VITALS: VSS

LABS: 4/2025

• UDS: 10/28/25

REFERRALS: none

PLAN/DISCUSSION: continue current treatment plan

Patient is encouraged to adhere to prescribed medication regimen to ensure optimal efficacy. Patient advised to contact provider before discontinuing any medication, particularly if adverse symptoms occur.

Psychoeducation and brief supportive counseling were provided.

Encouraged engagement with therapy; referrals will be made if necessary

Encouraged to follow up with medical provider if necessary

Discussed importance of nutrition, exercise, and sleep hygiene.

Discussed r/b, side effects, alternatives of _____, or choice to forgo pharmacological treatment with patient. Patient agreed to start trial.

CONSENT: Patient was given opportunity to ask questions and has verbally consented to the current treatment plan and any recommended changes.

Encouraged to seek care at ED if SI/HI with plan/intent develops or to call office if symptoms worsen

RELEVANT HISTORY:

nbennett54 Not available 11/25/2025 09:27:47

01/26/2026 01/26/2026

MEDICAL HISTORY: Colon cancer - stave 4. Anemia. Hypothyroidism. Renal impairment.

CURRENT ASSESSMENT:

1/26 - No pervasive mood complaint or concern.

RELEVANT HISTORY

On intake, patient presents with established treatment and no mood complaints, although does endorse some anxiety when he considers mortality. States he was given 1 year to live 1.5 years ago.

Patient currently completing PhD in computer science. Denies history of hospitalization or adverse life events. Discussed with patient plan to take over medications once UDS complete. Patient will present to clinic for UDS. Will continue treatment

11/25/25 - Patient presents with no pervasive mood concern. Denies SIHISIB, endorses having many things to accomplish, AVH, new or increased use of substance of abuse. Endorses history of alcohol use in remission since 2015.

RISK/SAFETY:

Denies SIHISIB, AVH, new or increased use of substances

MEDICATION MANAGEMENT:

• continue Lorazepam 0.5mg PO daily PRN for breakthrough anxiety.

Zolpidem 5mg tablet PO daily PRN for sleep.

VITALS: UTA

LABS: 4/2025

• UDS: 10/28/25

REFERRALS: none

PLAN/DISCUSSION: C ontinue current treatment plan

Patient is encouraged to adhere to prescribed medication regimen to ensure optimal efficacy. Patient advised to contact provider before discontinuing any medication, particularly if adverse symptoms occur.

Psychoeducation and brief supportive counseling were provided.

Encouraged engagement with therapy; referrals will be made if necessary

Encouraged to follow up with medical provider if necessary

Discussed importance of nutrition, exercise, and sleep hygiene.

Discussed r/b, side effects, alternatives of _____, or choice to forgo pharmacological treatment with patient. Patient agreed to start trial.

CONSENT: Patient was given opportunity to ask questions and has verbally consented to the current treatment plan and any recommended changes.

Encouraged to seek care at ED if SI/HI with plan/intent develops or to call office if symptoms worsen

RELEVANT HISTORY:

nbennett54 Not available 01/27/2026 13:59:54

Diagnosis Onset Date Resolution Status

Anemia

acute

History of colon cancer

acute

Small bowel obstruction

acute

Status post partial resection of colon

acute

History of colon cancer

acute

Iron deficiency anemia

acute

Status post partial resection of colon

acute

History of colon cancer

acute

Ileum ulcer

acute

Iron deficiency anemia

acute

Adenocarcinoma of small bowel

acute

Anemia

acute

History of colon cancer

acute

Status post partial resection of colon

acute

Adenocarcinoma of small bowel

acute

Anemia

acute

Colon cancer

acute

History of colon cancer

acute

Status post partial resection of colon

acute

Adenocarcinoma of small bowel

acute

Diagnosis Onset Date Resolution Status

Anemia

acute

Anemia

acute

BMI 31.0-31.9,adult

acute

Dysplasia of colon

acute

Mass of colon

acute

Mass of colon

acute

Diagnosis Onset Date Resolution Status

Anemia

acute

Anemia

acute

BMI 31.0-31.9,adult

acute

Dysplasia of colon

acute

Mass of colon 2021

acute

BMI 31.0-31.9,adult

acute

Iron deficiency anemia

acute

Mass of colon 2021

acute

BMI 31.0-31.9,adult

acute

Colon cancer metastasized to intra-abdominal lymph node

acute

Encounter for surgical aftercare following surgery on the digestive system

acute

Diagnosis Onset Date Resolution Status

Anemia

acute

Anemia

acute

BMI 31.0-31.9,adult

acute

Dysplasia of colon

acute

Mass of colon 2021

acute

BMI 31.0-31.9,adult

acute

Iron deficiency anemia

acute

Mass of colon 2021

acute

BMI 31.0-31.9,adult

acute

Colon cancer metastasized to intra-abdominal lymph node

acute

Encounter for surgical aftercare following surgery on the digestive system

acute

Diagnosis Onset Date Resolution Status

Anemia

acute

Anemia

acute

BMI 31.0-31.9,adult

acute

Dysplasia of colon

acute

Mass of colon 2021

acute

BMI 31.0-31.9,adult

acute

Iron deficiency anemia

acute

Mass of colon 2021

acute

BMI 31.0-31.9,adult

acute

Colon cancer metastasized to intra-abdominal lymph node

acute

Encounter for surgical aftercare following surgery on the digestive system

acute

Diagnosis Onset Date Resolution Status

BMI 31.0-31.9,adult

acute

Iron deficiency anemia

acute

Mass of colon 2021

acute

BMI 31.0-31.9,adult

acute

Colon cancer metastasized to intra-abdominal lymph node

acute

Encounter for surgical aftercare following surgery on the digestive system

acute

No assessment information available

Diagnosis Onset Date Resolution Status

Encounter for removal of vascular catheter

acute

Colon cancer metastasized to intra-abdominal lymph node

chronic

Anemia

acute

History of colon cancer

acute

Small bowel obstruction

acute

Status post partial resection of colon

acute

Diagnosis Onset Date Resolution Status

Encounter for removal of vascular catheter

acute

Colon cancer metastasized to intra-abdominal lymph node

chronic

Anemia

acute

History of colon cancer

acute

Small bowel obstruction

acute

Status post partial resection of colon

acute

History of colon cancer

acute

Iron deficiency anemia

acute

Status post partial resection of colon

acute

History of colon cancer

acute

Ileum ulcer

acute

Iron deficiency anemia

acute

Adenocarcinoma of small bowel

acute

Anemia

acute

History of colon cancer

acute

Status post partial resection of colon

acute

Adenocarcinoma of small bowel

acute

Anemia

acute

Colon cancer

acute

History of colon cancer

acute

Status post partial resection of colon

acute

Diagnosis Onset Date Resolution Status

Anemia

acute

History of colon cancer

acute

Small bowel obstruction

acute

Status post partial resection of colon

acute

History of colon cancer

acute

Iron deficiency anemia

acute

Status post partial resection of colon

acute

History of colon cancer

acute

Ileum ulcer

acute

Iron deficiency anemia

acute

Adenocarcinoma of small bowel

acute

Anemia

acute

History of colon cancer

acute

Status post partial resection of colon

acute

Adenocarcinoma of small bowel

acute

Anemia

acute

Colon cancer

acute

History of colon cancer

acute

Status post partial resection of colon

acute

Adenocarcinoma of small bowel

acute

Chief Complaint SBO, Hx colon CA s/p partial colectomyMalignant neoplasm of colon, unspecifiedAbnormal Imaging of abdomen, Pers.Hx. Col CASmall bowel obstructionColorectal cancerSm Bowel Ca / Surg 7-01small bowel catreatmentTesting 07-22-2024malig neoplasm of colon

Reason for Visit AnemiaHistory of colon cancerSmall bowel obstructionStatus post partial resection of colonHistory of colon cancerIron deficiency anemiaStatus post partial resection of colonHistory of colon cancerIleum ulcerIron deficiency anemiaAdenocarcinoma of small bowelAnemiaHistory of colon cancerStatus post partial resection of colonAdenocarcinoma of small bowelAnemiaColon cancerHistory of colon cancerStatus post partial resection of colonAdenocarcinoma of small bowel

Chief Complaint Occult blood in stooloccult GI bleed, Anemiad50.9/k63.89Abdominal complaintsIron defincy anemialeft colon mass 12-29left colon mass

Reason for Visit AnemiaAnemiaBMI 31.0-31.9,adultDysplasia of colonMass of colonMass of colon

Chief Complaint Occult blood in stooloccult GI bleed, Anemiad50.9/k63.89Abdominal complaintsIron defincy anemialeft colon mass 12-29left colon massRoutine post-operative visitMalignant neoplasm of sigmoid colon

Reason for Visit AnemiaAnemiaBMI 31.0-31.9,adultDysplasia of colonMass of colonBMI 31.0-31.9,adultIron deficiency anemiaMass of colonBMI 31.0-31.9,adultColon cancer metastasized to intra-abdominal lymph nodeEncounter for surgical aftercare following surgery on the digestive system

Chief Complaint Occult blood in stooloccult GI bleed, Anemiad50.9/k63.89Abdominal complaintsIron defincy anemialeft colon mass 12-29left colon massRoutine post-operative visitMalignant neoplasm of sigmoid colonPRE-OP TESTING 2/9

Reason for Visit AnemiaAnemiaBMI 31.0-31.9,adultDysplasia of colonMass of colonBMI 31.0-31.9,adultIron deficiency anemiaMass of colonBMI 31.0-31.9,adultColon cancer metastasized to intra-abdominal lymph nodeEncounter for surgical aftercare following surgery on the digestive system

Chief Complaint Occult blood in stooloccult GI bleed, Anemiad50.9/k63.89Abdominal complaintsIron defincy anemialeft colon mass 12-29left colon massRoutine post-operative visitMalignant neoplasm of sigmoid colonPRE-OP TESTING 2/9Malignant neoplasm of sigmoid colon

Reason for Visit AnemiaAnemiaBMI 31.0-31.9,adultDysplasia of colonMass of colonBMI 31.0-31.9,adultIron deficiency anemiaMass of colonBMI 31.0-31.9,adultColon cancer metastasized to intra-abdominal lymph nodeEncounter for surgical aftercare following surgery on the digestive system

Chief Complaint left colon mass 12-29left colon massRoutine post-operative visitMalignant neoplasm of sigmoid colonPRE-OP TESTING 2/9Malignant neoplasm of sigmoid colontreatment

Reason for Visit BMI 31.0-31.9,adultIron deficiency anemiaMass of colonBMI 31.0-31.9,adultColon cancer metastasized to intra-abdominal lymph nodeEncounter for surgical aftercare following surgery on the digestive system

Chief Complaint oncologist sent - diarrhea since mondaytreatment

Chief Complaint Malignant neoplasm of sigmoid colonPort-A-Cath no longer neededtreatmentSBO, Hx colon CA s/p partial colectomy

Reason for Visit Encounter for removal of vascular catheterColon cancer metastasized to intra-abdominal lymph nodeAnemiaHistory of colon cancerSmall bowel obstructionStatus post partial resection of colon

Chief Complaint Port-A-Cath no longer neededSBO, Hx colon CA s/p partial colectomyMalignant neoplasm of colon, unspecifiedtreatmentAbnormal Imaging of abdomen, Pers.Hx. Col CASmall bowel obstructionColorectal cancerSm Bowel Ca / Surg 7-01small bowel ca

Reason for Visit Encounter for removal of vascular catheterColon cancer metastasized to intra-abdominal lymph nodeAnemiaHistory of colon cancerSmall bowel obstructionStatus post partial resection of colonHistory of colon cancerIron deficiency anemiaStatus post partial resection of colonHistory of colon cancerIleum ulcerIron deficiency anemiaAdenocarcinoma of small bowelAnemiaHistory of colon cancerStatus post partial resection of colonAdenocarcinoma of small bowelAnemiaColon cancerHistory of colon cancerStatus post partial resection of colon

Chief Complaint SBO, Hx colon CA s/p partial colectomyMalignant neoplasm of colon, unspecifiedAbnormal Imaging of abdomen, Pers.Hx. Col CASmall bowel obstructionColorectal cancerSm Bowel Ca / Surg 7-01small bowel catreatmentTesting 07-22-2024malig neoplasm of colon

Reason for Visit AnemiaHistory of colon cancerSmall bowel obstructionStatus post partial resection of colonHistory of colon cancerIron deficiency anemiaStatus post partial resection of colonHistory of colon cancerIleum ulcerIron deficiency anemiaAdenocarcinoma of small bowelAnemiaHistory of colon cancerStatus post partial resection of colonAdenocarcinoma of small bowelAnemiaColon cancerHistory of colon cancerStatus post partial resection of colonAdenocarcinoma of small bowel

Author Pei ChungAnderson HealthcareMay 9th, 2024 9:58am

Note Date/Time May 8th, 2024 12:12pm

Anderson Hospital 6800 State Route 162 Maryville, IL 62062 General Surgery Consult Note SignedPatient: Towell,Alexander R MR#: M000499848 DOB: 08/04/1975 Acct:V00003663948Age: 48 ADM Date: 05/08/24 Loc: ANH3MEDSUR 327-01 Attending Dr: Pei Chang Chung M.D.cc: Chung, Pei Chang MD; Gaudreault, Rachel N. PA-C; Suthan***, Nanthini MD~this was entered in error, as I already completed a history and physicalHistory of Present IllnessConsult detailsConsult date: 05/08/24Reason for consult: abdominal painPMFSHPast Medical HistoryMedical History (Reviewed 05/07/24 @ 21:08 by Rachel N. Gaudreault, PA-C)Colon cancerIron deficiency anemia (Unknown)Mass of colon (~12/2021)ObesitySurgical HistorySurgical History (Reviewed 05/07/24 @ 21:08 by Rachel N. Gaudreault, PA-C)History of colon resection 12/29/2021 - hand assisted laparoscopic sigmoid colectomy with mobilization of the splenic flexureHistory of partial thyroidectomyFamily HistoryFamily History (Updated 05/08/24 @ 02:31 by Abby E. Scanzoni, RN)Father Hypertension Malignant neoplasm of prostateMother Deceased COPD (chronic obstructive pulmonary disease)Social HistorySocial History (Reviewed 05/07/24 @ 21:08 by Rachel N. Gaudreault, PA-C)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: LIVES WITH SIGNIFICANT OTHER Spiritual care concerns: No MedsHome Medications and Allergies Home Medications Medication Instructions Recorded Confirmed Typecholecalciferol (vitamin D3) 25 25 mcg PO DAILY 01/12/24 05/08/24 Historymcg (1,000 unit) tablet (Vitamin D3) levothyroxine 100 mcg tablet 100 mcg PO DAILY 01/12/24 05/08/24 Historymultivitamin with minerals-folic 1 tablet PO DAILY 01/12/24 05/08/24 Historyacid 200 mcg chewable tablet (Adult Multivitamin Gummies) AllergiesAllergy/AdvReac Type Severity Reaction Status Date / TimeNo Known Allergies Allergy Verified 05/08/24 02:36Vital Signs Vital Signs - 24 hr 05/07/2420:12 05/07/2420:12 05/07/2422:58Temperature 37.1 C 37.1 C Pulse Rate 72 76 61Respiratory Rate 17 19 18Blood Pressure 143/76 H 143/76 H 123/68Pulse Oximetry 100 100 98Oxygen Delivery Room Air 05/08/2401:00 05/08/2402:26 05/08/2406:00Temperature 36.4 C 36.4 CPulse Rate 66 62 70Respiratory Rate 18 16 16Blood Pressure 137/76 149/80 H 132/72Pulse Oximetry 100 98 100Oxygen Delivery 05/08/2408:25Temperature Pulse Rate Respiratory Rate Blood Pressure Pulse Oximetry Oxygen Delivery Room AirResultsLabs 05/07/24 21:05 05/07/24 21:05 Labs: Abnormal lab results 05/07/24 Range/Units 21:05 RBC 4.38 L (4.6-6.20) M/mm3Hgb 11.5 L (14.0-18.0) g/dLHct 35.5 L (42.0-52.0) %MPV 10.8 H (7.4-10.4) flCarbon Dioxide 20 L (22-30) mmol/LBUN 25 H (9-20) mg/dLUr Specific Gravity 1.092 H (1.001-1.035) Urine Ketones 1+ H (Negative) mg/dL Diabetes panel 05/07/24 Range/Units 21:05 Sodium 139 (137-145) mmol/LPotassium 3.6 (3.4-5.0) mmol/LChloride 107 (98-107) mmol/LCarbon Dioxide 20 L (22-30) mmol/LBUN 25 H (9-20) mg/dLCreatinine 1.30 (0.7-1.3) mg/dLGlucose 93 (65-110) mg/dLCalcium 9.2 (8.4-10.2) mg/dLAST 24 (17-59) U/LALT 15 (6-50) U/LAlkaline Phosphatase 85 (38-126) U/LTotal Protein 8.0 (6.3-8.2) g/dLAlbumin 4.7 (3.5-5.1) g/dL Calcium panel 05/07/24 Range/Units 21:05 Calcium 9.2 (8.4-10.2) mg/dLAlbumin 4.7 (3.5-5.1) g/dL Pituitary panel 05/07/24 Range/Units 21:05 Sodium 139 (137-145) mmol/LPotassium 3.6 (3.4-5.0) mmol/LChloride 107 (98-107) mmol/LCarbon Dioxide 20 L (22-30) mmol/LBUN 25 H (9-20) mg/dLCreatinine 1.30 (0.7-1.3) mg/dLGlucose 93 (65-110) mg/dLCalcium 9.2 (8.4-10.2) mg/dL Adrenal panel 05/07/24 Range/Units 21:05 Sodium 139 (137-145) mmol/LPotassium 3.6 (3.4-5.0) mmol/LChloride 107 (98-107) mmol/LCarbon Dioxide 20 L (22-30) mmol/LBUN 25 H (9-20) mg/dLCreatinine 1.30 (0.7-1.3) mg/dLGlucose 93 (65-110) mg/dLCalcium 9.2 (8.4-10.2) mg/dLTotal Bilirubin 0.5 (0.2-1.3) mg/dLAST 24 (17-59) U/LALT 15 (6-50) U/LAlkaline Phosphatase 85 (38-126) U/LTotal Protein 8.0 (6.3-8.2) g/dLAlbumin 4.7 (3.5-5.1) g/dLAll other labs normal.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: Chung, Pei Chang MD 05/08/24 / 1212Electronically signed by: Chung, Pei Chang MD 05/09/24 0958

Mallory Hubbard, PA - 05/15/2025 8:55 AM CDTFormatting of this note is different from the original.Inpatient Discharge SummaryBRIEF OVERVIEWAdmitting Provider: William Cavanaugh Chapman, MDDischarge Provider: Chapman, William Cavanaugh, MDPrimary Care Physician at Discharge: Beard, Kelsey Michelle, NP 618-463-0689 Admission Date: 5/14/2025 Discharge Date: 5/15/2025Admission Location: Barnes Jewish HospitalHospital Problems/Diagnoses:Principal Problem: Metastatic colon cancer to liver (HCC)Active Problems: Metastasis to liver (HCC)Resolved Problems:No resolved hospital problems.DETAILS OF HOSPITAL STAYPresenting Problem/History of Present Illness:Mr. Alexander R Towell is a 49 y.o. male with history of metastatic colorectal cancer the liver. Presenting for surgical consultation accompanied by his girlfriend, Kimberly. He was diagnosed with sigmoid colon cancer status post laparoscopic sigmoid colectomy in 12/29/2021. He was recurrence free until three years later, his recurrence was in the terminal ileum status post right hemicolectomy in 7/1/2024, pathology notable for ileal adenocarcinoma. Last colonoscopy was 2 months ago which was normal. He was first seen in our clinic and reviewed at liver multidisciplinary conference in 10/2024. > Findings: PET (july)- 4 areas of FDG uptake in the liver, very focal. 2 in left hemiliver 1 near segment 7 + 1 near the dome. MRI (aug)- treatment response with smaller lesions, only see 3 lesions. Pelvic disease is treated. >

Plan: Consider left lateral resection versus ablationHospital Course:The patient was taken to the OR on 5/14 for a robotic segment 2 resection (small wedge). For details of the operation, please see the OP note in Epic.Surgeons and Role: * Chapman, William Cavanaugh, MD - Primary>Post operative pain controlled with PO pain mediations.>Foley catheter was removed without incident.>No surgical drain utilized. PT/OT evaluated while inpatient and recommend home.The patient was discharged home in stable condition on 5/15.Scripts: Oxycodone 5mg #15, robaxinFollow-up:No future appointments. > surgical follow up in 2 weeks, appointment has been requestedTest Results Pending at Discharge:Pending Labs Order Current Status Surgical pathology In process Operative Procedures Performed:Procedure(s):XI LIVER RESECTION - LAPAROSCOPIC ROBOTIC ASSISTED, TAP BlockDischarge DetailsPhysical Exam at Discharge:Discharge Condition: goodPulse: 60Resp: 17BP: 121/80Temp: 36.5 °C (97.7 °F)Weight: 97.9 kg (215 lb 14.4 oz)Pertinent Exam Findings at Discharge: dermabond CDIDischarge Disposition:Patient will be discharged to:home Code Status at Discharge: FULLDischarge Instructions:Instructions For Hepatobiliary Surgery Patients: Call 911 or go to your local emergency room if: You have bleeding from your incision that worries you. You have chest pain. You feel like you can’t catch your breath. You faint or pass out. Call Your Doctor If: You have a fever of 101.5 F degrees or higher. It is hard for you to urinate. You have nausea, vomiting or diarrhea. If you have bright red blood or bad smelling drainage from your incision sites. You have any questions about your medications. You have belly pain that is getting worse. Your incision is red or swollen. Your eyes appear yellow; you have clay-colored stool, dark urine, and/or persistent itching. These can be a signs of a problem with your liver. If you are sent home with a drain, call if there is a sudden change in your abdominal drain output or color. If you need to talk with a doctor after regular hours or on weekends; please call your doctor’s office. The voicemail will give you directions on how to reach the on call doctor for an emergency. Do NOT leave a message on the voice mail. These messages will not be heard until the next business day. Office of Dr. Chapman: (314) 362-2538Diet:Regular Diet as toleratedActivity:You may perform activities as you feel up to it. Do NOT lift anything over 10 pounds for 6 weeks. This includes babies and pets.Do NOT drive while taking narcotic pain medicine. It is very important to stay active. Take several short walks each day.Care Instructions:You may take showers. Pat wounds dry. Do not rub.Keep your incision site dry and clean. Do NOT take tub baths, go swimming or use a hot tub until approved by your doctor. It is normal to feel very tired for several weeks after surgery. It’s ok to rest as needed.Follow Up:You will need to follow up with your Primary Care Doctor in 1-2 weeks. It is VERY important to let your doctor know if any changes were made to your medications while you were in the hospital.Discharge Medications:Current Medications TAKE these medications acetaminophen 500 mg capsuleTake 2 capsules (1,000 mg total) by mouth every 6 (six) hours as needed for painFor: painaspirin 325 mgTake 1 tablet (325 mg total) by mouth every 6 (six) hours as needed for pain or headachesFor: paincyanocobalamin 100 mcg tabletTake 1 tablet (100 mcg total) by mouth early morning before breakfastFor: prevention of vitamin B12 deficiencyCommonly known as: Vitamin B-12docusate sodium 100 mg capsuleTake 1 capsule (100 mg total) by mouth 2 (two) times a day as needed for constipationFor: constipationCommonly known as: COLACEfluticasone propionate 50 mcg/actuation nasal sprayAdminister 1 spray into each nostril daily as needed for rhinitisFor: inflammation of the nose due to an allergyCommonly known as: FLONASEiron bisgly,ps-FA-B-C#12-succ 65 mg-65 mg -1,000 mcg (24) tabletTake 1 tablet by mouth 3 (three) times a weekFor: anemia from inadequate ironlevothyroxine 112 mcg tabletTake 1 tablet (112 mcg total) by mouth early morning before breakfastFor: a condition with low thyroid hormone levelsCommonly known as: SYNTHROIDloperamide 2 mg tabletTake 1 tablet (2 mg total) by mouth 4 (four) times a day as needed for diarrheaFor: diarrhea caused by chemotherapyCommonly known as: IMODIUM A-DLORazepam 0.5 mg tabletTake 1 tablet (0.5 mg total) by mouth every 8 (eight) hours as needed for anxietyFor: anxiousCommonly known as: ATIVANmethocarbamoL 500 mg tabletTake 1 tablet (500 mg total) by mouth 3 (three) times a day as needed for muscle spasmsCommonly known as: ROBAXINmultivitamin with minerals tabletTake 1 tablet by mouth daily with dinnerFor: treatment to prevent mineral deficiency, treatment to prevent vitamin deficiencyomega-3 fatty acids-fish oil 300-1,000 mg capsuleTake 2 capsules (2 g total) by mouth daily with dinnerFor: supplementSUMAtriptan 50 mg tabletTake 1 tablet (50 mg total) by mouth once as needed for migraineFor: a migraine headacheCommonly known as: IMITREXzolpidem 5 mg tabletTake 1 tablet (5 mg total) by mouth nightly as needed for sleepFor: difficulty falling asleepCommonly known as: AMBIENOutpatient Follow-Up:Cosigned by William Chapman, MD at 05/15/2025 12:23 PM CDTElectronically signed by Mallory Hubbard, PA at 05/15/2025 8:56 AM CDTElectronically signed by William Chapman, MD at 05/15/2025 12:23 PM CDTdocumented in this encounter

Michael Bryant, NP - 12/19/2025 9:36 AM CSTFormatting of this note is different from the original.Inpatient Discharge SummaryBRIEF OVERVIEWAdmitting Provider: William Cavanaugh Chapman, MDDischarge Provider: No att. providers foundPrimary Care Physician at Discharge: Beard, Kelsey Michelle, NP 618-258-0485 Admission Date: 12/18/2025 Discharge Date: 12/19/2025Admission Location: Barnes Jewish HospitalHospital Problems/Diagnoses:Principal Problem: Metastatic colon cancer to liverResolved Problems:No resolved hospital problems.DETAILS OF HOSPITAL STAYPresenting Problem/History 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. Hospital Course:The patient was taken to the OR for a Procedure(s) (LRB):XI LIVER RESECTION - LAPAROSCOPIC ROBOTIC ASSISTED SEGMENT 5 8 and 4B, INTRAOPERATIVE ULTRASOUND and TAP BLOCK (N/A) on 12/18/2025. For details of the operation, please see the OP note in Epic. * Chapman, William Cavanaugh - Primary * Godfrey, Caroline Marie - Fellow>Post operative pain controlled with PO pain mediations.>Foley catheter was removed without incident.>Patient diet was advanced as tolerated on POD 1 passing gas, no BM. >A post-operative visit with the office of Dr. Chapman has been scheduled for 12/29. The patient was discharged to home in stable condition on 12/19, no need for home health skilled services.Scripts: Oxycodone #10, Gabapentin for 14 days, Robaxin for 14 days, OTC; Acetaminophen, Lidocaine patches, senna-docusate, Follow-up:Future Appointments Date Time Provider Department Center 12/29/2025 9:30 AM Martens, Gregory, MD PhD TXP CAM 12B SU Test Results Pending at Discharge:Pending Labs Order Current Status Surgical pathology Collected (12/18/25 1454) Operative Procedures Performed:Procedure(s):XI LIVER RESECTION - LAPAROSCOPIC ROBOTIC ASSISTED SEGMENT 5 8 and 4B, INTRAOPERATIVE ULTRASOUND and TAP BLOCKDischarge DetailsPhysical Exam at Discharge:Discharge Condition: goodPulse: 50Resp: 18BP: 108/59Temp: 36.6 °C (97.8 °F)Weight: 102.1 kg (225 lb)Pertinent Exam Findings at Discharge: Patient discharged with robotic surgical sites approximated with derma bond C/D/I. Implanted Port de-accessed at Discharge. Discharge Disposition:Patient will be discharged to:home Code Status at Discharge: FULL CODEDischarge Instructions:Instructions For Hepatobiliary Surgery Patients: Call 911 or go to your local emergency room if: You have bleeding from your incision that worries you. You have chest pain. You feel like you can’t catch your breath. You faint or pass out. Call Your Doctor If: You have a fever of 101.5 F degrees or higher. It is hard for you to urinate. You have nausea, vomiting or diarrhea. If you have bright red blood or bad smelling drainage from your incision sites. You have any questions about your medications. You have belly pain that is getting worse. Your incision is red or swollen. Your eyes appear yellow; you have clay-colored stool, dark urine, and/or persistent itching. These can be a signs of a problem with your liver. If you are sent home with a drain, call if there is a sudden change in your abdominal drain output or color. If you need to talk with a doctor after regular hours or on weekends; please call your doctor’s office. The voicemail will give you directions on how to reach the on call doctor for an emergency. Do NOT leave a message on the voice mail. These messages will not be heard until the next business day. Office of Dr. Chapman: (314) 362-2538Diet:Regular Diet as toleratedActivity:You may perform activities as you feel up to it. Do NOT lift anything over 10 pounds for 6 weeks. This includes babies and pets.Do NOT drive while taking narcotic pain medicine. It is very important to stay active. Take several short walks each day.Care Instructions:You may take showers. Pat wounds dry. Do not rub.Keep your incision site dry and clean. Do NOT take tub baths, go swimming or use a hot tub until approved by your doctor. It is normal to feel very tired for several weeks after surgery. It’s ok to rest as needed.Follow Up:You will need to follow up with your Primary Care Doctor in 1-2 weeks. It is VERY important to let your doctor know if any changes were made to your medications while you were in the hospital.Discharge Medications:Current Medications PAUSE taking these medications loperamide 2 mg tabletWait to take this until your doctor or other care provider tells you to start again.Take 1 tablet (2 mg total) by mouth 4 (four) times a day as needed for diarrheaFor: diarrhea caused by chemotherapyCommonly known as: IMODIUM A-Dprochlorperazine 10 mg tabletWait to take this until your doctor or other care provider tells you to start again.Defer to prescriber. Take 1 tablet (10 mg total) by mouth 3 (three) times a day as needed for nauseaFor: nausea and vomiting caused by cancer drugsCommonly known as: COMPAZINEzolpidem 5 mg tabletWait to take this until your doctor or other care provider tells you to start again.Do not take while taking narcotic pain medication. Take 1 tablet (5 mg total) by mouth nightly as needed for sleepFor: difficulty falling asleepCommonly known as: AMBIENTAKE these medications acetaminophen 500 mg capsuleTake 2 capsules (1,000 mg total) by mouth every 6 (six) hoursFor: paincetirizine 10 mg tabletTake 1 tablet (10 mg total) by mouth daily as needed for allergies or rhinitisCommonly known as: ZyrTECdocusate sodium 100 mg capsuleTake 1 capsule (100 mg total) by mouth 2 (two) times a day as needed for constipationCommonly known as: COLACEgabapentin 100 mg capsuleTake 1 capsule (100 mg total) by mouth 2 (two) times a dayCommonly known as: NEURONTINlevothyroxine 125 mcg tabletTake 1 tablet (125 mcg total) by mouth early morning before breakfastFor: a condition with low thyroid hormone levelsCommonly known as: SYNTHROIDlidocaine 5 %Place 1 patch on the skin daily for 12 hours Remove & discard patch(es) within 12 hours or as directed by MDCommonly known as: LIDODERMLORazepam 0.5 mg tabletTake 1 tablet (0.5 mg total) by mouth every 8 (eight) hours as needed for anxietyCommonly known as: ATIVANmethocarbamoL 500 mg tabletTake 2 tablets (1,000 mg total) by mouth 3 (three) times a day for 14 daysCommonly known as: ROBAXINmultivitamin with minerals tabletTake 1 tablet by mouth early morning before breakfastoxyCODONE 5 mg immediate release tabletTake 1 tablet (5 mg total) by mouth every 6 (six) hours as needed for painFor: painCommonly known as: ROXICODONEpropranoloL 20 mg tabletTake 1 tablet (20 mg total) by mouth early morning before breakfastCommonly known as: INDERALsenna-docusate 8.6-50 mgTake 1 tablet by mouth daily as needed for constipationCommonly known as: PERICOLACEOutpatient Follow-Up:Future Appointments Date Time Provider Department Center 12/29/2025 9:30 AM Martens, Gregory, MD PhD TXP CAM 12B SU Cosigned by William Chapman, MD at 12/19/2025 3:55 PM CSTElectronically signed by Michael Bryant, NP at 12/19/2025 11:17 AM CSTElectronically signed by William Chapman, MD at 12/19/2025 3:55 PM CSTdocumented in this encounter

Author Pei ChungAnderson HealthcareMay 9th, 2024 9:57am

Note Date/Time May 9th, 2024 9:57am

Anderson Hospital 6800 State Route 162 Maryville, IL 62062 Discharge Summary SignedPatient: Towell,Alexander R MR#: M000499848 DOB: 08/04/1975 Acct:V00003663948Age: 48 ADM Date: 05/08/24 Loc: ANH3MEDSUR 327-01 Attending Dr: Pei Chang Chung M.D.cc: Chung, Pei Chang MD; Gaudreault, Rachel N. PA-C; Suthan***, Nanthini MD~DS: Admitting DiagnosisDischarge Date5/9/2024Admitting Diagnosis Small-bowel obstructionDS: Discharge DiagnosisDischarge Diagnosis(1) Small bowel obstruction: Code(s):K56.609 - Unspecified intestinal obstruction, unspecified as to partial versus complete obstruction Status: Acute Assessment and

Plan: resolved, small-bowel series normal, tolerating diet, exam benign, follow-up 2 weeks post discharge(2) History of colon cancer: Code(s):Z85.038 - Personal history of other malignant neoplasm of large intestine Status: Acute Assessment and

Plan: status post sigmoid colectomy and adjuvant chemotherapy, doing well, follow-up with OncologyDS: SummaryHospital CourseReason for hospitalization: small-bowel obstructionHospital Course: The patient is a 48-year-old male presenting from an outside hospital with a small-bowel obstruction. CT from outside hospital was significant for small bowel obstruction with transition point in the right lower quadrant. The patient was transferred to Anderson Hospital and admitted to the surgical service. Upon evaluation, conservative management with bowel rest and NG decompression was initiated. On hospital day 1., a small bowel series was ordered with water-soluble contrast through the NG tube. The small bowel serieswas noted to be unremarkable with noted passage within 15 minutes to the colon. Given these findings, the NG tube was clamped and subsequently removed. The patient was started on a clear liquid diet. On hospital day 2. , the patient was tolerating a clear liquid diet and his abdominal exam was benign. The patient reported multiple bowel movements after the small-bowel series. His diet was then advanced to a regular diet. He was able to tolerate a regular diet without issue and will now be discharged home. He will follow up with me in 2 weeks.Status at DischargeFunctional status at discharge: independent ambulationOverall status at discharge: patient is back to baselineTime Spent with PatientTime attestation: Total time spent providing and/or coordinating discharge services:Time spent: Less than 30 minutesExamConst: General: cooperative, comfortable and no acute distress Resp: Auscultation: clear to auscultation bilaterally Cardio: Rate: regular rate Rhythm: regular rhythm GI: Inspection: normal to inspection and non-distended GI Palp: No abdominal tenderness, Yes Soft to palpation and No Tenderness to palpation present (GI) Discharge PlanDischargeAttending physician on discharge: Chung,Pei Chang Consulting providers: Gaudreault,Rachel N.Discharging Clinician: Chung,Pei Chang Anticipated Discharge Date/Time: 05/09/24 14:00Patient Disposition: Home, Self-CareActivity: as toleratedDiet: as toleratedPatient Instructions: Antibiotic FormStand Alone Forms: General Discharge InformationFollow-up/Referrals:Chung,Pei Chang, MD [Physician] - 2 WeeksDischarge Medications:Continued levothyroxine 100 mcg tablet 100 mcg PO DAILY multivit with min-folic acid [Adult Multivitamin Gummies] 200 mcg Tablet,Chewable 1 tablet PO DAILY cholecalciferol (vitamin D3) [Vitamin D3] 25 mcg (1,000 unit) Tablet 25 mcg PO DAILY Date of admission: 05/08/24 09:11Primary Care Provider: Suthan***,NanthiniAdmitting Provider: Chung,Pei ChangAttending physician on admission: Chung,Pei ChangCondition: StableThis 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: Chung, Pei Chang MD 05/09/24 / 0957Electronically signed by: Chung, Pei Chang MD 05/09/24 0957

Author Kelsy WasmuthAnderson HealthcareJuly 3rd, 2024 4:37pm

Note Date/Time July 3rd, 2024 4:26pm

Anderson Hospital 6800 State Route 162 Maryville, IL 62062 Discharge Summary SignedPatient: Towell,Alexnder R MR#: M000499848 DOB: 08/04/1975 Acct:V00003676858Age: 48 ADM Date: 07/01/24 Loc: ANH3MEDSUR 303-01 Attending Dr: Pei Chang Chung M.D.cc: Chung, Pei Chang MD; Suthan***, Nanthini MD~DS: Admitting DiagnosisDischarge Date07/03/2024Admitting DiagnosisIleal mass, adenocarcinomaStatus post partial colectomyAnemiaHistory of colon cancerDS: Discharge DiagnosisDischarge Diagnosis(1) Colon cancer: Code(s):C18.9 - Malignant neoplasm of colon, unspecified Status: Acute(2) Status post partial resection of colon: Code(s):Z90.49 - Acquired absence of other specified parts of digestive tract Status: Acute(3) History of colon cancer: Code(s):Z85.038 - Personal history of other malignant neoplasm of large intestine Status: Acute(4) Anemia: Qualifiers: Anemia type: unspecified type Qualified Code(s): D64.9 - Anemia, unspecified Code(s):D64.9 - Anemia, unspecified Status: AcuteDS: SummaryHospital CourseReason for hospitalization: This is a 48-year-old man who has a history of colon cancer status post hand assisted laparoscopic sigmoid colectomy in 2021. He underwent chemotherapy following surgery. Recently, in May of 2024, he was found to have a small-bowel obstruction on a CT scan. He then had a colonoscopy on 05/29/2024 with pathology coming back as moderately differentiated adenocarcinoma from a possible ileal mass. He was seen as an outpatient by Dr. Chung and decision wasmade to proceed with a hand assisted laparoscopic right colectomy. He presentedfor surgery on 07/01/2024.Hospital Course: He underwent hand assisted laparoscopic right colectomy with mobilization of hepatic flexure by Dr. Chung the on 07/01/2024. During surgery he was found to have a palpable mass in the terminal ileum with noted masses in the mesentery consistent with lymph node spread. He was admitted for monitoring and management postoperatively. His diet has slowly been advanced. He is tolerating a solid diet today. No nausea or vomiting. He is tolerating activity. Postoperative pain has been well controlled. Labs monitored postop day 1 and appeared stable. He was voiding independently without any issues. After discussing with Dr. Chung, the patient is stable for discharge postop day 2.Status at DischargeFunctional status at discharge: independent ambulationOverall status at discharge: patient is progressing back to baselineTime Spent with PatientTime attestation: Total time spent providing and/or coordinating discharge services:Time spent: Less than 30 minutesExamConst: General: comfortable and no acute distress Resp: Effort & Inspection: normal respiratory effort Auscultation: clear toauscultation bilaterally Cardio: Rate: regular rate Rhythm: regular rhythm GI: Inspection: non-distended and incision (incisions dry and intact) GI Palp: Yes Soft to palpation, Yes Tenderness to palpation present (GI) (incisional) and No Guarding due to palpation present (GI) Auscultation: normal bowel sounds Neuro: General: moves all extremities and no focal motor deficits Extrem: General: no calf tenderness and no edema Psych: Mental Status: mental status grossly normal Insight: Good insight present (Psych) DS: DataData Completed and PendingCompleted studies during hospitalization: Pending at discharge07/01/24 14:38Surgical [PTH] Routine Procedures/Treatments: Procedures Operation Date: 07/01/24 12:00Actual Procedure Side Surgeonp Hand Assisted Laparoscopic Right Colectomy Right Pei Chang Chung, MDImagingRadiologist’s impression: ITS ImpressionsAbdomen X-Ray 07/01/24 15:32

IMPRESSION: No foreign body detected.Discharge PlanDischargeAttending physician on discharge: Chung,Pei Chang Discharging Clinician: Wasmuth,Kelsy B. Anticipated Discharge Date/Time: 07/03/24 16:33Patient Disposition: Home, Self-CareActivity: may shower and other - see discharge instructionsDiet: as tolerated and regularWound Care Instructions: incision open to airDischarge Instructions: DISCHARGE INSTRUCTION SHEET FOR DR. CHUNG1. May shower in 24 hours, no soaking in bath x 2weeks.2. Call office for:* Wound increasingly painful or bleeding* Vomiting* Fever of greater than 101 degrees3. No heavy lifting > 10-15 pounds x 6 weeks4. No driving for 1 week5. Up walking 10-30 minutes three times per day.6. Follow-up 10-14 days in office for wound check or as previously scheduled. (288-3616)7. Oral pain medications prescription has been sent electronically to the pharmacy.Take Tylenol 500mg every 6 hours and Ibuprofen 600mg every 6 hours for the first 2 days, then as needed. Patient Instructions: Antibiotic FormStand Alone Forms: General Discharge InformationFollow-up/Referrals:Chung,Pei Chang, MD [Physician] - Keep Reg. Scheduled Appt.Discharge Medications:New hydrocodone-acetaminophen 5-325 mg Tablet 1 tablet PO Q4-6H PRN (Reason: Pain Rated 4-6) Qty: 20 0RFContinued Fish Oil Capsule 1,000 mg PO DAILY ferrous sulfate 325 mg (65 mg iron) Tablet 650 mg PO DAILY levothyroxine 100 mcg tablet 100 mcg PO DAILY multivit with min-folic acid [Adult Multivitamin Gummies] 200 mcg Tablet,Chewable 1 tablet PO DAILY cholecalciferol (vitamin D3) [Vitamin D3] 25 mcg (1,000 unit) Tablet 25 mcg PO DAILY Discontinued ciprofloxacin HCl 500 mg tablet 500 mg PO .COMPLEX Qty: 1 0RF Rx Instructions: 500 mg orally at 2:00pm the day before your surgery.; metronidazole 500 mg tablet 500 mg PO .COMPLEX Qty: 3 0RF Rx Instructions: 500 mg orally at 1:00pm, 2:00pm, and 11:00pm the day before your surgery.; Date of admission: 07/01/24 15:35Primary Care Provider: Suthan***,NanthiniAdmitting Provider: Chung,Pei ChangAttending physician on admission: Chung,Pei ChangCondition: StableQualityVTE ProphylaxisVTE prophylaxis: mechanical ordered and pharmacologic orderedThis 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: Wasmuth, Kelsy B. APN 07/03/24 / 1626Electronically signed by: Wasmuth, Kelsy B. APN 07/03/24 1637

Deshka Foster, MD - 05/14/2025 10:37 AM CDTFormatting 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 ASSISTEDDeshka Foster, MD, PhDSurgery FellowCosigned by William Chapman, MD at 05/14/2025 11:14 AM CDTElectronically signed by Deshka Foster, MD at 05/14/2025 10:38 AM CDTElectronically signed by William Chapman, MD at 05/14/2025 11:14 AM CDTAssociated attestation - William Chapman, MD - 05/14/2025 11:14 AM CDTFormatting of this note might be different from the original.49 year old man with left lateral segment CRC metastasis, here for robotic liver resection. The patient and his family seem to understand the issues and agree with the plans.Source Note - Mallory Hubbard, PA - 04/30/2025 9:30 AM CDTFormatting of this note might be different from the original.Transplant/ Hepatobiliary Surgery Outpatient Clinic NoteChief Complaint: metastatic colorectal cancer to the liverReferred by: Benjamin R. Tan, MDHPI: Mr. Alexander R Towell is a 49 y.o. male with history of metastatic colorectal cancer the liver. Presenting for surgical consultation accompanied by his girlfriend, Kimberly. He was diagnosed with sigmoid colon cancer status post laparoscopic sigmoid colectomy in 12/29/2021. He was recurrence free until three years later, his recurrence was in the terminal ileum status post right hemicolectomy in 7/1/2024, pathology notable for ileal adenocarcinoma. Last colonoscopy was 2 months ago which was normal. He was first seen in our clinic and reviewed at liver multidisciplinary conference in 10/2024. > Findings: PET (july)- 4 areas of FDG uptake in the liver, very focal. 2 in left hemiliver 1 near segment 7 + 1 near the dome. MRI (aug)- treatment response with smaller lesions, only see 3 lesions. Pelvic disease is treated. >

Plan: Consider left lateral resection versus ablationPast Medical

History: has a past medical history of Anemia, Cancer (HCC), Peripheral neuropathy, and Thyroid disease. Past Surgical

History: has a past surgical history that includes Colon surgery (12/30/2021) and Small Bowel Resection (07/01/2024).Social

History: Alcohol use: none Tobacco use: noneOccupation: previous research assistant at SIUEECOG status: ECOG: 0 - Fully active, able to carry on all pre-disease performance without restrictionAllergies: No Known AllergiesFamily

History:family history includes Prostate cancer (age of onset: 69) in his father.Medications: HOME MEDICATIONS : cyanocobalamin (Vitamin B-12) 100 mcg tablet iron bisgly,ps-FA-B-C#12-succ 65 mg-65 mg -1,000 mcg (24) tablet levothyroxine (SYNTHROID) 100 mcg tablet multivitamin with minerals tablet omega-3 fatty acids-fish oil 300-1,000 mg capsuleReview of Systems: Reports: noneDenies any abdominal pain, nausea, vomiting, constipation, diarrhea, dark urine, light stools, fevers, chills, loss of appetite, weight loss, jaundice or pruritis. Physical Exam: Blood pressure 130/84, pulse 54, temperature 36.3 °C (97.3 °F), height 182.9 cm (6’), weight 96.6 kg (213 lb).Constitutional: Ambulatory, No acute distressHead: Normocephalic, non traumaticEyes:Bilateral sclera anicteric ENT: Normal hearing, no obvious deformitiesLungs: Non- labored breathing, on room airCV: Well perfused, no JVDAbdomen: Soft, not distended, non tender. No hernia. Well healed incision. Skin: No rashes or jaundiceExtremities: Warm, no pitting pedal edemaNeuro: No gross neurological deficitsPysch: Mood appropriate, A+Ox3Labs: > none to review Pathology: Consult material received from Anderson Hospital, Maryville, IL (OSC: AS21-7173; 11/22/2021) A. Stomach, biopsy - Normal oxyntic mucosa - No H. pylori organisms are identified by H&E examination B. Small bowel, biopsy - Normal duodenal mucosa C. Large bowel, descending colon mass, biopsy - Ulcerated invasive adenocarcinoma Consult material received from Anderson Hospital, Maryville, IL (OSC: AS21-7988; 12/29/2021) A. Large bowel, sigmoid, left hemicolectomy - Moderately differentiated colonic adenocarcinoma invading the visceral peritoneum (pT4a) - Tumor arises in the sigmoid colon and measures 6.0 cm in greatest dimension, per report - Surgical margins are negative for tumor - Negative for perineural or lymphovascular invasion - Metastatic adenocarcinoma in one of twenty-three lymph nodes(1/23; pN1a) Consult material received from Anderson Hospital, Maryville, IL (OSC: AS24-3099; 05/29/2024) A. Small bowel, terminal ileum ulcerated lesion, biopsy - Invasive adenocarcinoma, moderately-differentiated - Intact nuclear expression of mismatch repair proteins (MLH1, PMS2, MSH2, and MSH6) by immunostains Consult material received from Anderson Hospital, Maryville, IL (OSC: AS24-3810; 07/01/2024) A. Large bowel, right colon and ileum, right hemicolectomy - Moderately differentiated adenocarcinoma involving the perienteric soft tissue, muscularis propria, submucosa, and mucosa (see comment) - No precursor lesion identified in the ileal mucosa - Per report, deep/radial margin positive for tumor - Distal and proximal margins negative for tumor - Positive for perineural invasion - Negative for definitive lymphovascular invasion - Five tumor deposits identified - Metastatic adenocarcinoma in four of fourteen lymph nodes (4/14) - Normal appendix Imaging: MRI 4/30/2025: 1. Unchanged hepatic segment 2 lesion consistent with continuedtreatment response. No evidence of progressive or new metastaticdisease in the abdomen.2. Near complete resolution of the wedge shaped lesion in hepaticsegment 8, which was previously thought to represent focal hepatictoxicity related to oxaliplatin.

Assessment: Mr. Towell is a 49 y.o. male with history of metastatic colorectal adenocarcinoma to the liver presenting to clinic for surgical consultation.

Plan: - Preliminary imaging review shows resectable metastatic disease in the liver. The patient is a good candidate for surgery. We will discuss the patient’s imaging at our liver multidisciplinary conference on Thursday morning prior to making final recommendations. All questions were answered in clinic. The patient will be updated with findings and recommendations following review at conference. - We discussed with them the risks, benefits, and alternatives to proceeding with a robotic liver resection. We explained a brief description of the operative procedure and expected convalescence. They express understanding and would like to proceed with surgery; therefore surgical consent was obtained today. - CPAP is scheduled on 5/1. - Dr. Chapman to discuss with medical oncologist Dr. Arshad. Disposition: We will follow-up with the patient after reviewing the patient’s case at conference. They know to call the office with any questions or concerns in the interim. ADDENDUM: This patient’s case was reviewed at our liver multidisciplinary imaging conference on 5/1> Findings: Marked treatment response over time. Areas of seg 2 disease shriveling away. No correlate currently for prior seg 8 disease. Remaining: one visible high seg 2 metastasis–partially treated, measures up to 7mm. >

Plan: Consider resecting seg 2 lesion, vs L lateral? Watch the R, could ablate if needed We will proceed with a robotic liver resection. Patient has been notified of findings and agrees with plan. Mallory E. Hubbard, PAPatient Care Team:Suthan, Nanthini, MD as PCP - GeneralArshad, 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 05/02/2025 9:31 AM CDTElectronically signed by Mallory Hubbard, PA at 04/30/2025 8:18 PM CDTElectronically signed by Mallory Hubbard, PA at 05/01/2025 3:39 PM CDTElectronically signed by William Chapman, MD at 05/02/2025 9:31 AM CDTdocumented in this encounter

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

Author Pei ChungAnderson HealthcareMay 8th, 2024 12:20pm

Note Date/Time May 8th, 2024 12:16pm

Anderson Hospital 6800 State Route 162 Maryville, IL 62062 History & Physical Report SignedPatient: Towell,Alexander R MR#: M000499848 DOB: 08/04/1975 Acct:V00003663948Age: 48 ADM Date: 05/08/24 Loc: ANH3MEDSUR 327-01 Attending Dr: Pei Chang Chung M.D.cc: Chung, Pei Chang MD; Gaudreault, Rachel N. PA-C; Suthan***, Nanthini MD~H&P: HPIHistory of Present IllnessDate/Time: 05/08/24 12:12Chief Complaint: abdominal pain

Narrative: The patient is a 48-year-old male well known to my service from previous sigmoidcolectomy secondary to metastatic sigmoid colon cancer. The patient presents complaining of crampy abdominal pain, nausea, constipation over the last month. The patient reports the symptoms have been progressively worsening. Workup, including imaging, is significant for small bowel obstruction. The patient has been admitted to my service and made NPO, NG tube decompression has been initiated. The patient reports he did have some diarrhea yesterday after takingsome laxatives.Review of SystemsReview of Systems: All systems reviewed & are unremarkable except as noted in HPI and below PMFSHPast Medical HistoryMedical History (Reviewed 05/08/24 @ 12:14 by Pei Chang Chung, MD)Colon cancerIron deficiency anemia (Unknown)Mass of colon (~12/2021)ObesitySurgical HistorySurgical History (Reviewed 05/08/24 @ 12:14 by Pei Chang Chung, 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 05/08/24 @ 12:14 by Pei Chang Chung, MD)Father Hypertension Malignant neoplasm of prostateMother Deceased COPD (chronic obstructive pulmonary disease)Social HistorySocial History (Reviewed 05/08/24 @ 12:14 by Pei Chang Chung, 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: LIVES WITH SIGNIFICANT OTHER Spiritual care concerns: No MedsHome Medications and Allergies Home Medications Medication Instructions Recorded Confirmed Typecholecalciferol (vitamin D3) 25 25 mcg PO DAILY 01/12/24 05/08/24 Historymcg (1,000 unit) tablet (Vitamin D3) levothyroxine 100 mcg tablet 100 mcg PO DAILY 01/12/24 05/08/24 Historymultivitamin with minerals-folic 1 tablet PO DAILY 01/12/24 05/08/24 Historyacid 200 mcg chewable tablet (Adult Multivitamin Gummies) AllergiesAllergy/AdvReac Type Severity Reaction Status Date / TimeNo Known Allergies Allergy Verified 05/08/24 02:36Vital Signs Vital Signs - 24 hr 05/07/2420:12 05/07/2420:12 05/07/2422:58Temperature 37.1 C 37.1 C Pulse Rate 72 76 61Respiratory Rate 17 19 18Blood Pressure 143/76 H 143/76 H 123/68Pulse Oximetry 100 100 98Oxygen Delivery Room Air 05/08/2401:00 05/08/2402:26 05/08/2406:00Temperature 36.4 C 36.4 CPulse Rate 66 62 70Respiratory Rate 18 16 16Blood Pressure 137/76 149/80 H 132/72Pulse Oximetry 100 98 100Oxygen Delivery 05/08/2408:25Temperature Pulse Rate Respiratory Rate Blood Pressure Pulse Oximetry Oxygen Delivery Room AirExamConst: General: cooperative, comfortable and no acute distress HENMT: Head: normal to inspection, normocephalic and atraumatic Eyes: General: appearance normal, both eyes and all related structures Neck: Neck: normal visual inspection, full ROM and no lymphadenopathy Resp: Auscultation: clear to auscultation bilaterally Cardio: Rate: regular rate Rhythm: regular rhythm GI: Inspection: normal to inspection, distended and incision GI Palp: No abdominal tenderness, Yes Soft to palpation, No Tenderness to palpation present (GI), No Guarding due to palpation present (GI) and No Rigid due to palpation Skin: General skin exam: normal color and no rashes or lesions noted Neuro: General: patient oriented x3 and CN’s II-XI intact bilaterally Extrem: General: normal to inspection and full ROM Psych: Appearance: grossly normal H&P: ResultsLabsLabs: Short CBC 05/07/24 Range/Units 21:05 WBC 4.9 (4.5-10.0) K/mm3Hgb 11.5 L (14.0-18.0) g/dLHct 35.5 L (42.0-52.0) %Plt Count 240 (150-375) k/mm3 BMP 05/07/24 21:05Sodium 139Potassium 3.6Chloride 107Carbon Dioxide 20 LBUN 25 HCreatinine 1.30Glucose 93Calcium 9.2 Liver Function 05/07/24 Range/Units 21:05 Total Bilirubin 0.5 (0.2-1.3) mg/dLAST 24 (17-59) U/LALT 15 (6-50) U/LAlkaline Phosphatase 85 (38-126) U/LAlbumin 4.7 (3.5-5.1) g/dL Urine 05/07/24 Range/Units 21:05 Urine Color Yellow (Yellow) Urine Appearance Clear (Clear) Urine pH 5.0 (5.0-9.0) Ur Specific Gravity 1.092 H (1.001-1.035) Urine Protein Negative (Negative) mg/dLUrine Glucose (UA) Negative (Negative) mg/dLAssessment and PlanAssessment and plan(1) Small bowel obstruction: Code(s):K56.609 - Unspecified intestinal obstruction, unspecified as to partial versus complete obstruction Status: Acute Assessment and

Plan: exam benign, cont conservative mgmt c NPO, NG decompression, will get SBS for further evalThis 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: Chung, Pei Chang MD 05/08/24 / 1216Electronically signed by: Chung, Pei Chang MD 05/08/24 1220

Author Pei ChungAnderson HealthcareJuly 1st, 2024 11:33am

Note Date/Time July 1st, 2024 11:33am

Anderson Hospital 6800 State Route 162 Maryville, IL 62062 History & Physical Update SignedPatient: Towell,Alexnder R MR#: M000499848 DOB: 08/04/1975 Acct:V00003676858Age: 48 ADM Date: 07/01/24 Loc: ANHSURGERY Attending Dr: Pei Chang Chung M.D.cc: ~History and Physical UpdateUpdateDate/Time: 07/01/24 11:33History and Physical has been reviewed, including an updated exam of the patient. There are NO changes in the patient’s condition.Risks, benefits, and alternatives have been discussed and questions answered. Patient agrees to proceed with procedure.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: Chung, Pei Chang MD 07/01/24 / 1133Electronically signed by: Chung, Pei Chang MD 07/01/24 1133

Author Pei ChungAnderson HealthcareJuly 22nd, 2024 12:21pm

Note Date/Time July 22nd, 2024 12:21pm

Anderson Hospital 6800 State Route 162 Maryville, IL 62062 History & Physical Update 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: ~History and Physical UpdateUpdateDate/Time: 07/22/24 12:21History and Physical has been reviewed, including an updated exam of the patient. There are NO changes in the patient’s condition.Risks, benefits, and alternatives have been discussed and questions answered. Patient agrees to proceed with procedure.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: Chung, Pei Chang MD 07/22/24 / 1221Electronically signed by: Chung, Pei Chang MD 07/22/24 1221

Additional Discharge Instructions DISCHARGE INSTRUCTION SHEET FOR LAPAROSCOPIC SURGERIES DR. JOHNSON/CHUNG

PATIENT TO TAKE HOME

1. May shower the day after surgery over incisions. Do not submerge in water x 2weeks.

2. Call office for: Wound increasingly painful or bleeding Vomiting Fever of greater than 101 degrees

3. Expect some blood on dressing and old blood on skin.

4. If no bowel movement for two days, take 1 oz. (30 ml) Milk of Magnesia, if no results, take Fleets enema. May take an over the counter stool softener daily.

5. No heavy lifting > 20-25 pounds x 6 weeks for Hand-assisted laparoscopic colectomy.

6. No driving for 3 days or while taking narcotic pain medications.

7. Up walking 10-30 minutes three times per day.

8. Call the office to schedule a follow-up appointment for 2 weeks after your OR.

9. Oral pain medications prescription to be sent to pharmacy. May transition to Tylenol 500mg by mouth every 6 hours as needed for pain once your pain becomes mild and is not requiring the narcotics.

10. NUTRITION: Start out by drinking fluids and increase your diet as tolerated. If you experience nausea, try dry toast, crackers, and 7-UP. If nausea or vomiting persists, contact your surgeon�s office.

Instruction/Education Provided Antibiotic Form Hydrocodone/Acetaminophen (By mouth) Colectomy (DC)

Additional Instructions Discharge Instruction Sheet for Portacath Placement Dr. Lane, Dr. Wikiera, Dr. Johnson, Dr. Chung General and Laparoscopic Surgical Associates 6812 State Route 162 Suite 121 Maryville, IL. 62062 618-288-3616 1.) May shower in 24 hours. 2.) Rest today, then may resume normal light activity tomorrow. 3.) No strenuous activity with upper extremity on the side of the port for 1 week. 4.) Tylenol or ibuprofen over the counter as needed for pain. 5.) Call office for any wound concerns or increasing pain. 6.) Follow up with oncologist as scheduled. You were given TORADOL 15MG (IBUPROFEN) today at 1:00 PM. Do not repeat this medication for 3 hours from time given.

Additional Instructions DISCHARGE INSTRUCTION SHEET FOR DR. CHUNG

1. May shower in 24 hours, no soaking in bath x 2weeks.
2. Call office for: Wound increasingly painful or bleeding Vomiting Fever of greater than 101 degrees
3. No heavy lifting > 10-15 pounds x 6 weeks
4. No driving for 1 week
5. Up walking 10-30 minutes three times per day.
6. Follow-up 10-14 days in office for wound check or as previously scheduled. (288-3616)
7. Oral pain medications prescription has been sent electronically to the pharmacy. Take Tylenol 500mg every 6 hours and Ibuprofen 600mg every 6 hours for the first 2 days, then as needed.

Additional Instructions Discharge Instruction Sheet for Portacath Placement Dr. Lane, Dr. Wikiera, Dr. Johnson, Dr. Chung General and Laparoscopic Surgical Associates 6812 State Route 162 Suite 121 Maryville, IL. 62062 618-288-3616 1.) May shower in 24 hours. 2.) Rest today, then may resume normal light activity tomorrow. 3.) No strenuous activity with upper extremity on the side of the port for 1 week. 4.) Tylenol or ibuprofen over the counter as needed for pain. 5.) Call office for any wound concerns or increasing pain. 6.) Follow up with oncologist as scheduled.

Telephone Encounter - Brittni C - 08/09/2023 10:49 AM CDTFormatting of this note might be different from the original.Received a referral for patient to be seen for right wrist, I tried to call both numbers and left a voicemail for her to give us a call back and schedule.Electronically signed by Brittni C at 08/09/2023 10:50 AM CDTdocumented in this encounter

Telephone Encounter - Nurse Kimberly B - 08/12/2024 4:17 PM CDTFormatting of this note might be different from the original.Called pt about amb referral placed on 8/1. No appt has been scheduled with mws onx. Gave phone number to department and asked pt to call at convenient time.Electronically signed by Nurse Kimberly B at 08/12/2024 4:22 PM CDTdocumented in this encounter

Telephone Encounter - Benjamin Tan, MD - 09/06/2024 11:35 AM CDTFormatting of this note might be different from the original.Left Vm for him to call back to discuss tumor board consensus.Left VM also with Dr. Arshad, pt’s local oncologist.and left VM about possible candidacy for resection. Electronically signed by Benjamin Tan, MD at 09/06/2024 11:45 AM CDTdocumented in this encounter

Telephone Encounter - Ciaran M - 09/11/2024 2:53 PM CDTFormatting of this note is different from the original.Patient Query:Was an attempt to transfer to the assigned clinical staff or backline? “Yes”, Reason for call?: Ellen Sweatt is calling from Dr.Tan’s office requesting scheduling for patient. The referral has not been fully reviewed yet and informed Ellen of this and informed her that I would notify Dr. Field’s office.Who is the caller: Ellen SweattWhat is the best number for them to contact for a call back: 3143624113 Electronically signed by Ciaran M at 09/11/2024 2:59 PM CDTdocumented in this encounter

Telephone Encounter - Benjamin Tan, MD - 09/17/2024 11:58 AM CDTFormatting of this note might be different from the original.Called paeint about his scan results as well as tumor board recommendations. Will need a sooner appt than what was given for the patient to discuss suitability of resection vs transplnation vs systemic therapy alone vs HAIP. As such will refer the patient to see Dr. Chapman/Doyle/Khan for discussion.Electronically signed by Benjamin Tan, MD at 09/17/2024 12:00 PM CDTdocumented in this encounter

Telephone Encounter - Matthew H - 10/03/2024 11:24 AM CDTFormatting of this note might be different from the original.Called to schedule. Pt will need to callback to set up visit d/t infusion conflict. Electronically signed by Matthew H at 10/03/2024 11:25 AM CDTdocumented in this encounter

Telephone Encounter - Matthew H - 11/01/2024 1:23 PM CDTFormatting of this note might be different from the original.Images from the original note were not included.Pt girlfriend called to inquire about treatment process. She stated that MRI that was scheduled by Dr. Fields office was canceled, then rescheudled; however, she is unsure if this MRI is valid. MA is going to place new orders for MRI and schedule. Pt girlfriend would like to know what the plan is for after MRI if any. Electronically signed by Matthew H at 11/01/2024 1:25 PM CDTdocumented in this encounter

Telephone Encounter - Matthew H - 11/14/2024 8:30 AM CSTFormatting of this note might be different from the original.—– Message from Stephanie S sent at 11/13/2024 3:29 PM CST —–Hi,This has been approved by insurance. The referral has been updated to reflect this. They should be good to go.Thanks!Stephanie S—– Message —–From: Hunter, Matthew, EMTSent: 11/12/2024 2:34 PM CSTTo: Wu Su Abd Transplant Precert PoolI am not sure if I have requested a Pre-Auth for this patient or not. If not can we start one.Electronically signed by Matthew H at 11/14/2024 8:30 AM CSTdocumented in this encounter

Telephone Encounter - Elizabeth N - 01/06/2025 2:11 PM CSTFormatting of this note might be different from the original.Patient’s wife, Kim, called. She said Dr. Chapman Jr called them recently and they have not been able to connect with him. They are aware that Dr. Chapman Sr will be reaching out to them with regards to further treatment for Mr. Towell. They would like a general idea of what the test results ordered by Dr Chapman Jr indicated. I gave the message to Dr Chapman Jr and he reached out to the patient.Electronically signed by Elizabeth N at 01/06/2025 2:14 PM CSTdocumented in this encounter

Initial Assessments - Nurse Kelli M - 05/15/2025 7:31 AM CDTFormatting of this note might be different from the original.CM Initial Assessment Interview NoteInformation Obtained From: Patient(05/14/25 1630)Admission Source: Non Health Care Facility Point of OriginImpression: Patient admitted for robotic liver resection s/p colorectal cancer and hepatic metastasis. Patient lives at home with his significant other, Kimberly and is IADL’s at baseline.Plan Includes: Patient anticipated discharge home when medically stable. Patient may have home health care needs pending PT/OT recs. Patient does not have a preference for a home health agency and a list of agencies can/will be provided if needed. Patient has family for home support and transportation. Case Management will continue to follow for anticipated discharge needs. Additional Information: Role of CM explained to patient. CM verified address, phone number, insurance and emergency contact from facesheet with patient/family. Primary Source of Transportation: KimberlyDoes the patient need discharge transport arranged?: No(05/14/25 1630)Health Insurance Coverage: MolinaPrescription Coverage: yesPharmacy:Walmart Pharmacy 1071 - Wood River, IL - 610 WESLEY DRIVE610 WESLEY DRIVEWood River IL 62095Phone: 618-259-0293 Fax: 618-259-8757Primary Care Provider: Kelsey Beard, NPSuthan, Nanthini, MDPrior to Admission:Functional Status: Independent with ADLsPrimary Caregiver: SelfSupport System: Spouse/Significant OtherHome Care Services: NoOutpatient Services: NoDurable Medical Equipment: NoneLiving Arrangements: Spouse/significant otherType of Residence: Private residenceSteps in home?: Yes, Outside of home, Yes, Inside homeNumber of steps inside: 10 stepsNumber of steps outside: 4 stepsMedication management: Independent(05/14/25 1630)SDOH:Transportation:Financial Resource:Housing:Utilities:Social Connections:Food Insecurity:Behavioral Health Services:Behavioral Health Services: No(05/14/25 1630)Anticipated Level of Care:Anticipated discharge level of care: Private residencePt/Family agrees with Anticipated Level of Care: Yes(05/14/25 1630)Patient expects to be Discharged to:Private residence, (05/14/25 1630)Patient’s Identified Problem/GoalProblem: Ensure acute medical needs are met and that patient has a safe discharge plan.Goal: Secure a discharge plan that patient/family are agreeable with and ensure patient has continuum of care.Case management will follow for discharge planning and send referrals as needed. Kelli Marie Macomber, RNElectronically signed by Nurse Kelli M at 05/15/2025 7:37 AM CDTPlan of Care - Nurse Caden C - 05/14/2025 9:34 PM CDTFormatting of this note might be different from the original.Goals: monitor I&Os, monitor vital signs, pain management, foley catheter discontinued, fall preventionSummary: Problem: Discharge PlanningGoal: Understanding discharge needs will improveOutcome: ProgressingProblem: ActivityGoal: Risk for activity intolerance and fatigue will decreaseOutcome: ProgressingGoal: Ability to tolerate increased activity will improveOutcome: ProgressingGoal: Ability to avoid complications of mobility impairment will improveOutcome: ProgressingProblem: Communication ImpairmentGoal: Ability to express needs and understand communicationOutcome: ProgressingProblem: General Patient EducationGoal: Knowledge of disease process, condition or treatment will be improvedOutcome: ProgressingProblem: Health BehaviorGoal: Ability to state signs and symptoms to report to health care provider will improveOutcome: ProgressingGoal: Ability to identify and alter actions that are detrimental to health will improveOutcome: ProgressingGoal: Ability to identify and utilize available resources and services will improveOutcome: ProgressingGoal: Compliance with prescribed regimen will improveOutcome: ProgressingProblem: Physical RegulationGoal: Will remain free from infectionOutcome: ProgressingGoal: Ability to maintain clinical measurements within normal limits will improveOutcome: ProgressingGoal: Ability to maintain body temperature in the normal range will improveOutcome: ProgressingProblem: SafetyGoal: Free from injury or harmOutcome: ProgressingGoal: Ability to maintain safety and efficiency with swallowing without signs of aspiration will improveOutcome: ProgressingElectronically signed by Nurse Caden C at 05/14/2025 9:36 PM CDTPlan of Care - Nurse Amber T - 05/14/2025 3:34 PM CDTFormatting of this note might be different from the original.Goals: Monitor vital signs, intake and output, pain management, comfort, admission questionsSummary: Problem: Discharge PlanningGoal: Understanding discharge needs will improveOutcome: ProgressingElectronically signed by Nurse Amber T at 05/14/2025 3:35 PM CDTBrief Op Note - William Chapman, MD - 05/14/2025 1:08 PM CDTFormatting of this note is different from the original.Operative Progress NoteSurgical Team: Surgeons and Role: * Chapman, William Cavanaugh, MD - PrimaryAnesthesiologist: Zoller, Jonathan Kramer, MDAnesthesia Resident: Lewis, Bradley Mitchell, DOCirculator: St. Pierre, Grace Marguerite, RNScrub: Sullivan, Ryan W., STRNFA: Scherer, Meranda Della, RNFLOAT: Berlage, Julia Newman, RN; Boehmer, Natalie Nicole, RNDATE OF SURGERY :5/14/2025Preoperative

Diagnosis: Pre-op Diagnosis * Metastatic colon cancer to liver (HCC) [C18.9, C78.7]Postoperative

Diagnosis: Post-op Diagnosis * Metastatic colon cancer to liver (HCC) [C18.9, C78.7]Procedure(s):Procedure(s) (LRB):XI LIVER RESECTION - LAPAROSCOPIC ROBOTIC ASSISTED, TAP Block (N/A)Operative Findings:Single nodule in segment 2Estimated Blood Loss:No blood loss documented.Intraoperative Fluids:600 mls crystalloidSpecimens:ID Type Source Tests Collected by Time A : Segment 2 Excision Tissue Liver, Partial Resection SURGICAL PATHOLOGY Chapman, William Cavanaugh, MD 5/14/2025 1401 Implants:Nothing was implanted during the procedureBlood/Blood Products Transfused:noneComplications:NoneCondition on Discharge from the operating room was stableWilliam Cavanaugh Chapman, MDDate: 5/14/2025 Time: 2:03 PMElectronically signed by William Chapman, MD at 05/14/2025 2:04 PM CDTOp Note - William Chapman, MD - 05/14/2025 12:00 AM CDTFormatting of this note might be different from the original.PREOPERATIVE DIAGNOSISMetastatic colorectal cancer to the liver.POSTOPERATIVE DIAGNOSISMetastatic colorectal cancer to the liver.PROCEDURERobotic segment 2 liver resection.SURGEONWilliam Chapman, MD.1ST ASSISTANTJessica Foster, MD.2ND ASSISTANTMeranda Scherer, RNFA.I was present during the operative procedure from the time of incision until the time of closure and immediately available for all remaining portions of the procedure. The patient was given Ancef within 30 minutes of the skin incision and written for less than 24 hours postoperative antibiotics. Sequential compression device stockings were placed on lower extremities for DVT prophylaxis.INDICATIONS FOR OPERATIONThis patient is a 49-year-old man who previously had a colorectal cancer and developed hepatic metastases. His primary tumor was resected after initiation of chemotherapy and his 3 hepatic metastases have essentially disappeared with exception of a segment 2 site which is 7 mm in size. He and his medical oncology team wished to have this resected to make him NED. He is brought to the operating room at this time for planned segment 2 liver resection.OPERATIVE FINDINGSThe patient had a small nodule easily available in segment 2 near the left hemidiaphragm. This was resected circumferentially and no other metastatic sites were identified.OPERATIVE PROCEDUREAfter placing the patient on the operating table in supine position, general endotracheal anesthesia was induced. Monitoring lines were placed by anesthesia. Initially, a Veress needle was used to gain access to the peritoneal cavity, which was insufflated with CO2. Initially, a 5 mm trocar was placed in the left upper quadrant with a forward viewing laparoscope in the trocar for direct visualization. The abdomen was entered without difficulty. The underlying bowel were examined and there was no evidence of bowel injury. At this point, 4 additional 8 mm trocars were placed for robotic resection. The robot was docked and attention was directed at the planned liver resection. The falciform ligament was ligated and divided with the LigaSure device. The left lateral segment was then mobilized by dividing the left triangular ligament under direct visualization. The left lower segment was elevated and a punctate metastatic site identified in segment 2. At this point, a nonanatomic circumferential resection was performed using combination of electrocautery circumferentially. After complete removal of the specimen the liver parenchyma was inspected. There was no evidence of bile leakage and the resection sites appeared watertight. The liver resection was placed in an EndoCatch bag and exited through the umbilical site. The trocars were removed and the robot was undocked. The skin incisions of the previously placed trocars were then closed using 4-0 Dexon subcuticular suture. Dermabond was placed. Patient was awakened, extubated, and taken to the recovery room in stable condition. Final sponge and instrument counts correct x2.ESTIMATED BLOOD LOSSMinimal.IV FLUIDS1400 mL crystalloid.SPECIMENSSegment 2 liver resection.CONDITION ON DISCHARGEStable.Job ID/Internal Job ID: 018311/1061817811Electronically signed by William Chapman, MD at 05/15/2025 5:06 PM CDTdocumented in this encounter

Telephone Encounter - Jeannette K - 11/21/2025 9:55 AM CSTFormatting of this note might be different from the original.Per Mallory, schedule pt to be seen by Dr. Chapman next Wed, 11/26. Also schedule pt for CPAP for the same day. Procedure should be robotic liver resection.Spoke with pt and he is scheduled for 11/26 at 9 AM. I also put a prep for case in and spoke to CPAP. Pt is scheduled for CPAP on 11/26 at 10AM. Pt is aware of all of the above and voiced understanding. Electronically signed by Jeannette K at 11/21/2025 9:59 AM CSTdocumented in this encounter

Plan of Care - Nurse Jayla W - 12/19/2025 9:09 AM CSTFormatting of this note might be different from the original.Goals: Clinical Goals for the Shift: ambulation, vital signsSummary: Problem: ActivityGoal: Patient’s tolerance of increased activity will improveOutcome: ProgressingGoal: Patient will maintain or regain ADL functionOutcome: ProgressingProblem: NutritionGoal: Patient’s nutritional status will improveOutcome: ProgressingGoal: Patient’s ability to achieve adequate nutrition will improveOutcome: ProgressingElectronically signed by Nurse Jayla W at 12/19/2025 9:09 AM CSTPlan of Care - Nurse Danee C - 12/19/2025 6:11 AM CSTFormatting of this note might be different from the original.Shift Summary: Pain controlled with current regimen. Patient ambulated independently in hallway. Problem: NutritionGoal: Patient’s nutritional status will improveOutcome: OngoingFlowsheets (Taken 12/19/2025 0610)Patient’s nutritional status will improve: Provide postoperative nutritional progressionProblem: Physical RegulationGoal: Gastrointestinal status for postoperative course will improveOutcome: OngoingFlowsheets (Taken 12/19/2025 0610)Gastrointestinal status for postoperative course will improve: Monitor gastrointestinal status Perform actions to prevent or reduce the incidence of constipationProblem: ActivityGoal: Patient’s tolerance of increased activity will improveOutcome: ProgressingFlowsheets (Taken 12/19/2025 0610)Patient’s tolerance of increased activity will improve: Implement and manage activity progression plan Encourage out of bed for meals Encourage energy conservation techniquesProblem: Lack of KnowledgeGoal: Ability to develop a pain control plan will improveOutcome: ProgressingFlowsheets (Taken 12/19/2025 0609)Ability to develop a pain control plan will improve: Explain causes of pain and how long pain can be expected to last Teach information regarding pain management Educate pain scale for assessing level of painProblem: MedicationGoal: Satisfaction with pain management medication regimen will improveOutcome: ProgressingFlowsheets (Taken 12/19/2025 0609)Satisfaction with pain management medication regimen will improve: Assess satisfaction with pain management regimenElectronically signed by Nurse Danee C at 12/19/2025 6:12 AM CSTBrief Op Note - William Chapman, MD - 12/18/2025 2:05 PM CSTFormatting of this note is different from the original.Operative Progress NoteSurgical Team: * Chapman, William Cavanaugh - Primary * Godfrey, Caroline Marie - FellowAnesthesiologist: King, Christopher R., MD PhDCRNA: Maxey, Lucas Aaron, CRNACirculator: Boehmer, Natalie Nicole, RNScrub: Sullivan, Ryan W., STSurgical Assistant: Matson, Sarah Christine, PAOrientee Circulator: Thomason, Andy Keith, RNDATE OF SURGERY :12/18/2025Preoperative

Diagnosis: Pre-op Diagnosis * Metastatic colon cancer to liver [C18.9, C78.7]Postoperative

Diagnosis: Post-op Diagnosis * Metastatic colon cancer to liver [C18.9, C78.7]Procedure(s):Procedure(s) (LRB):XI LIVER RESECTION - LAPAROSCOPIC ROBOTIC ASSISTED SEGMENT 5 8 and 4B, INTRAOPERATIVE ULTRASOUND and TAP BLOCK (N/A)Operative Findings:Superficial tumor in seg 5/8 and 4BEstimated Blood Loss:minimalIntraoperative Fluids:14000 mlsSpecimens:ID Type Source Tests Collected by Time A : Sement 5/8 Liver Resection Tissue Liver, Partial Resection SURGICAL PATHOLOGY Chapman, William Cavanaugh, MD 12/18/2025 1452 B : Segment 4B Liver Resection Tissue Liver, Partial Resection SURGICAL PATHOLOGY Chapman, William Cavanaugh, MD 12/18/2025 1453 Implants:Nothing was implanted during the procedureBlood/Blood Products Transfused:1400 mls crystalloidComplications:NoneCondition on Discharge from the operating room was stableWilliam Cavanaugh Chapman, MDDate: 12/18/2025 Time: 3:20 PMElectronically signed by William Chapman, MD at 12/18/2025 3:21 PM CSTOp Note - William Chapman, MD - 12/18/2025 12:00 AM CSTFormatting of this note might be different from the original.SURGEONWilliam Chapman, MD.FIRST ASSISTANTAaron Delman, MDI was present during the operative procedure from after the time of incision until the time of closure and immediately available for all remaining portions of the procedure. Dr. Delman acted as 1st assistant since no suitable resident was available. He was present for the entire procedure including the initial exploration, intraoperative ultrasonography, and liver resection.PREOPERATIVE DIAGNOSISMetastatic colorectal cancer to 2 sites in the liver.POSTOP DIAGNOSISMetastatic colorectal cancer to 2 sites in the liver.PROCEDUREResection of 2 sites of hepatic metastasis from colorectal cancer prior, intraoperative ultrasonography, tap block.OPERATIVE FINDINGSThe patient had a normal-appearing background liver. Two surface-based tumors were easily identified and as anticipated with 1 in segment 4B and a second tumor site in segments 5 and 8. Nonanatomic excisional resection was performed of both tumor sites. There was no evidence of bile leakage and no significant bleeding at the time of the resection.OPERATIVE PROCEDUREAfter placing the patient on the operating table supine position, general endotracheal anesthesia was induced. The abdomen was prepped and draped in the usual sterile fashion. Using a knife, a 1.5 cm incision was made on the supraumbilical location incorporating the patient’s previous incision. This was extended through the subcutaneous tissue and fascia with electrocautery. Peritoneum was carefully entered to avoid injury to the underlying bowel. Following entry in the peritoneal cavity, a fixed table Hassan check cannula was placed and laparoscopy and robotic imaging were both examined. So the was no evidence of bowel adhesion to the anterior abdominal wall. The liver was normal in appearance. Overall, this appeared to be suitable for resection. A 1.5 cm tumor site was noted in segment 4B and an approximately 1 cm tumor site noted in segments 5 and 8. These were resected with wedge excision with no difficulty and no significant blood loss at the time of the procedure. Final sponge and instrument counts correct x2.ESTIMATED BLOOD LOSSMinimal.IV FLUIDS800 mL crystalloidJob ID/Internal Job ID: 259270/1079574445Electronically signed by William Chapman, MD at 12/19/2025 4:00 PM CSTdocumented in this encounter

Date Note Type Note Provider Name and Address Organization Details Recorded Time

09/27/2021

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Rash/Skin Lesion Reported by Patient HPI For quality, patient reports multiple (two) but reports not painful . For location, patient reports chest (two lumps) . For duration, patient reports has noted for >3 months (5 yrs) . For associated symptoms, patient reports no fever .

New pt is here to establish pcp. pt said he had on and off episodes of lightheadedness , denied chest pain or palpitations . Pt admits he has anxiety with some panic symptoms , declined med , he could manage without med per pt

Nanthini Suthan, MD

Attn: Accounting,2041 GOOSE LAKE RD, East Saint Louis, IL, 62206-2822, US

IL - SIHF 09/27/2021 15:15:47

10/12/2021

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Anemia Reported by Patient HPI For context, patient reports previous hemoglobin: (7.1) and low iron . For associated symptoms, patient reports blood in stool but reports no shortness of breath and no chest pain . For severity, patient reports microcytic (mcv<80) . For modifying factors, patient reports otc medication (nsaid) .

Rash/Skin Lesion Reported by Patient HPI For quality, patient reports multiple (two) but reports not painful . For location, patient reports chest (two lumps) . For duration, patient reports has noted for >3 months (5 yrs) . For associated symptoms, patient reports no fever .

Us showed lipoma .

pt is here for f/u and labs pt said he had on and off episodes of lightheadedness , denied chest pain or palpitations . Pt admits he has anxiety with some panic symptoms , declined med , he could manage without med per pt

Nanthini Suthan, MD

Attn: Accounting,2041 GOOSE LAKE RD, East Saint Louis, IL, 62206-2822, US

IL - SIHF 10/12/2021 15:51:44

11/12/2021

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Rash/Skin Lesion Reported by Patient HPI For quality, patient reports multiple (two) but reports not painful . For location, patient reports chest (two lumps) . For duration, patient reports has noted for >3 months (5 yrs) . For associated symptoms, patient reports no fever .

Us showed lipoma .

Anemia Reported by Patient HPI For context, patient reports previous hemoglobin: (8.0) and low iron . For associated symptoms, patient reports blood in stool but reports no shortness of breath and no chest pain . For severity, patient reports microcytic (mcv<80) . For modifying factors, patient reports otc medication (nsaid) .

pt was seen by GI yesterday and awaiting for colonoscopy/egd

pt is here for f/u and labs

Nanthini Suthan, MD

Attn: Accounting,2041 GOOSE LAKE RD, East Saint Louis, IL, 62206-2822, US

IL - SIHF 11/12/2021 15:52:37

03/01/2022

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Anemia Reported by Patient HPI For context, patient reports previous hemoglobin: (8.0) and low iron . For associated symptoms, patient reports blood in stool (due to colon cancer) but reports no shortness of breath and no chest pain . For severity, patient reports microcytic (mcv<80) . For timing, patient reports better . For modifying factors, patient reports otc medication (nsaid) . For prior tests, patient reports upper endoscopy (and colonoscopy) .

pt is here for f/u and labs pt was recently diagnosed with colon cancer -s/p lap colectomy 12/2021 -seeing onco

Nanthini Suthan, MD

Attn: Accounting,2041 GOOSE LAKE RD, East Saint Louis, IL, 62206-2822, US

IL - SIHF 03/01/2022 11:48:31

07/12/2022

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Anemia Reported by Patient HPI For context, patient reports previous hemoglobin: (8.0- improved) and low iron (pt is on chemo for colon cancer). For severity, patient reports microcytic (mcv<80) . For timing, patient reports better . For modifying factors, patient reports otc medication (nsaid) . For associated symptoms, patient reports no shortness of breath and no chest pain . For prior tests, patient reports upper endoscopy (and colonoscopy) .

pt is here for f/u and labs pt was recently diagnosed with colon cancer -s/p lap colectomy 12/2021 -seeing onco

Nanthini Suthan, MD

Attn: Accounting,2041 GOOSE LAKE RD, East Saint Louis, IL, 62206-2822, US

IL - SIHF 07/13/2022 16:18:08

01/18/2023

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Thyroid Reported by Patient HPI For context, patient reports history of hypothyroidism . For associated symptoms, patient reports constipation but reports no weight loss , no palpitations , no depression , and no fatigue . For duration, patient reports started: (partial thyroidectomy 9/2022) . For onset/timing, patient reports better . For modifying factors, patient reports medication (thyroid pill- taking med as prescribed.) .

pt is here for f/u pt has noticed cyst on L/foot , 2 months ago , not painful pt was recently diagnosed with colon cancer -s/p lap colectomy 12/2021 -seeing onco

Nanthini Suthan, MD

Attn: Accounting,2041 GOOSE LAKE RD, East Saint Louis, IL, 62206-2822, US

IL - SIHF 01/18/2023 15:54:30

07/25/2023

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Thyroid Reported by Patient HPI For context, patient reports history of hypothyroidism . For associated symptoms, patient reports constipation but reports no weight loss , no palpitations , no depression , and no fatigue . For duration, patient reports started: (partial thyroidectomy 9/2022) . For onset/timing, patient reports better . For modifying factors, patient reports medication (thyroid pill- taking med as prescribed.) .

Wrist/Hand Reported by Patient HPI For hand dominance, patient reports right . For location, patient reports right and ulnar . For severity, patient reports mild . For duration, patient reports 6 months . For associated symptoms, patient reports no weakness and no swelling .

pt is here for f/u

pt was diagnosed with colon cancer -s/p lap colectomy 12/2021 -seeing onco

pt is complaining of less hearing for a while , denied ear pain

Nanthini Suthan, MD

Attn: Accounting,2041 GOOSE LAKE RD, East Saint Louis, IL, 62206-2822, US

IL - SIHF 07/25/2023 14:03:55

11/30/2023

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Thyroid Reported by Patient HPI For context, patient reports history of hypothyroidism . For associated symptoms, patient reports constipation but reports no weight loss , no palpitations , no depression , and no fatigue . For duration, patient reports started: (partial thyroidectomy 9/2022) . For onset/timing, patient reports better . For modifying factors, patient reports medication (thyroid pill- taking med as prescribed.) .

pt is here for f/u

pt was diagnosed with colon cancer -s/p lap colectomy 12/2021 -seeing onco

Nanthini Suthan, MD

Attn: Accounting,2041 GOOSE LAKE RD, East Saint Louis, IL, 62206-2822, US

IL - SIHF 11/30/2023 09:50:11

05/02/2024

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pt is here for change in bowel habit with constipation /feeling tired and also recent lab showed anemia as well /denied abdominal pain -but has noticed dark color stool

pt was diagnosed with colon cancer -s/p lap colectomy 12/2021 -seeing onco

Nanthini Suthan, MD

Attn: Accounting,2041 GOOSE LAKE RD, East Saint Louis, IL, 62206-2822, US

IL - SIHF 05/02/2024 11:35:13

02/10/2025

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Patient presents to the clinic with acute complaint of a cough. Patient was established with Dr. Nan for primary care. Patient’s past medical history includes: hypothyroidism, adenocarcinoma of descending colon, OSA, thyroid nodule, ileal ulcer, anemia, GERD, asthma, and lobectomy of thyroid gland. Other providers: Oncologist: Dr. Arshad at mercy

Cough -Patient reports he started feeling unwell last Tuesday -Patient reports experiencing symptoms of fever, headache, chills, diarrhea, body aches, sinus congestion, productive cough-green/bloody sputum, and increased fatigue -Denies experiencing symptoms of nausea/vomiting -Patient reports he was around his father and nephew who were also sick. -Patient reports taking sudafed, aspirin, tylenol and vitamins for symptom management.

KELSEY BEARD, FNP-BC

Attn: Accounting,2041 GOOSE LAKE RD, East Saint Louis, IL, 62206-2822, US

IL - SIHF 03/08/2025 23:57:59

04/01/2025

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Patient presents to the clinic to establish care. Patient was previously established with Dr. Nan for primary care. Other providers: Dr. Arshad-oncology Dr. Tae-endocrinology

-Medical Hx/Surgical Hx: Hypothyroidism, adenocarcinoma of descending colon, sleep apnea, thyroid nodule, LDL ulcer, anemia, CKD, thrombocytopenic disorder, anxiety, GERD, asthma, lobectomy of thyroid gland, and small bowel resection.

-Family hx: Mother:deceased-chronic obstructive pulmonary disease Father: living-hypertensive disorder Maternal Grandmother: deceased-old age, DMII Maternal Grandfather: deceased-unknown Paternal Grandmother: deceased-unknown Paternal Grandfather: deceased-unknown

-Tobacco/Drug/Alcohol Use: Patient denies history of tobacco or drug use. Reports history of alcohol use socially, but quit using alcohol in 2015.

Chicken pox: unsure

Marital status: in a long term relationship 16+ yrs

Sexually active: yes

Occupation: SIUE

Highest level of education: Masters

Other habits: Exercise- occasionally Diet- Reg

Allergies: NKDA

KELSEY BEARD, FNP-BC

Attn: Accounting,2041 GOOSE LAKE RD, East Saint Louis, IL, 62206-2822, US

IL - SIHF 04/20/2025 13:00:49

06/10/2025

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Patient presents to the clinic with acute concerns for migraines. Patient’s past medical history includes: Hypothyroidism, adenocarcinoma of descending colon, sleep apnea, thyroid nodule, LDL ulcer, anemia, CKD, thrombocytopenic disorder, anxiety, GERD, asthma, lobectomy of thyroid gland, and small bowel resection. Other providers: Dr. Arshad-oncology Dr. Tae-endocrinology

-Patient reports his migraines have improved since his chemo was paused, but he is worried they will worsen as his chemo is restarting. -Patient reports sumatriptan does help -Negative brain MRI -Patient has been having daily migraines. He has had to use some pain medication to provide relief. -Patient reports daily sudafed use, drinking 6 cups of coffee daily, taking ibuprofen/tylenol frequently

KELSEY BEARD, FNP-BC

Attn: Accounting,2041 GOOSE LAKE RD, East Saint Louis, IL, 62206-2822, US

IL - SIHF 06/10/2025 17:22:51

10/08/2025

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Patient is a 50 year old Caucasian male presenting to the clinic with for migraine follow up. Patient’s past medical history includes: Hypothyroidism, adenocarcinoma of descending colon, sleep apnea, thyroid nodule, LDL ulcer, anemia, CKD, thrombocytopenic disorder, anxiety, GERD, asthma, lobectomy of thyroid gland, and small bowel resection. Other providers: Dr. Arshad-oncology Dr. Tae-endocrinology

-Patient reports he decreased caffeine intake -Migraines have improved with propranolol -Patient reports he still has frequent headaches, but not as severe -He is taking propranolol 1.5 times per day. He does not take twice a day regularly -Patient reports chemo is going well, he has no new cancer growth. He is taking a trip to New York in December.

KELSEY BEARD, FNP-BC

Attn: Accounting,2041 GOOSE LAKE RD, East Saint Louis, IL, 62206-2822, US

IL - SIHF 10/08/2025 16:00:32

10/27/2025

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ROS as noted in the HPI

CHIEF COMPLAINT/ PRESENTING CONCERNS

Medication management

HISTORY OF PRESENT ILLNESS (Bold symptoms that meet DSM-5 Diagnostic Criteria)

PSYCHIATRIC HISTORY

MSE: (chronological development of symptoms - onset, duration, severity, triggers, modifying factors, associated symptoms):

Patient presents to clinic for medication management. 1.5 years ago was diagnosed with stage 4 cancer and given 1 year to live. Was rx. Lorazepam and Ambien by oncology. States medications work well to ease anxiety and sleep disturbance.

Patient in bouts of insomnia. Not as needed as Lorazepam, but very helpful.

Anxiety

Onset: has been dealing with cancer for 5 years. Was in remission for 1 year, then had a reoccurrence at stage 4. He was given a year to live at the time.

Characteristics: has anxiety going in to chemo. Effects him mentally. Questions about mortality and existential thoughts, he obsesses over this. He is still doing research for his PhD.

Triggers: physical pains (mouth sores, diarrhea, inflammation), approaching chemo. Illness, thinking may be worse than what he thought. Questioning mortality.

Insomnia

Occurs every once in a while, previously slept with no issue. When doing research will have trouble going to bed. Will stay up until 6am and wake at 9am. Ambien helps him maintain sleep schedule.

Past diagnoses: anxiety not formally diagnosed

AVH: denies

Mood: feeling fine

How are you doing today (0-10)

Current Medications: has been using for a year without incident

• Zolpidem 5mg has over 15 left

• Lorazepam 0.5mg has 6 left

Past Medications: none

Past psychiatrists: denies

Hospitalizations: denies

Counseling/Therapy: denies

MEDICAL HISTORY

Illness/Injuries/Surgeries: Stage 4 colon cancer. Anemia. Hypothyroidism. Renal impairment. Speech impediment as a child.

Allergies/Seizures/Head injuries: seasonal/denies/denies

PCP: Kelsey Beard

ROS (constitution, vision, hearing, scent, mouth, cardiac, pulmonary, gastro, urinary, skin, musculoskeletal, neurological)

• night sweats, fevers: denies

• vision, hearing, sinus changes, issues with teeth, throat, gums: wears glasses. Mouth sores.

• cardiac - chest pain, palpitation, racing heart: denies

• pulmonary – difficulty breathing, coughing: hx. of sleep apnea

• gastro – upset stomach, diarrhea, constipation, reflux: lifelong constipation. Reflux mild. Diarrhea

• urinary – pain, urgency, difficulty, retention: denies

• skin issues: various d/t chemotherapy

• musculoskeletal – muscle, bone, joint pain, or discomfort: nothing out of ordinary

• neuro – weakness, numbness, dizziness, headache, tremors: denies

FAMILY PSYCHIATRIC/MEDICAL HISTORY

Mother:

Father:

Siblings:

Grandmother:

Grandfather:

DEVELOPMENTAL SOCIAL HISTORY

Childhood: Had a regular childhood. 2 sisters, 1 passed away from cardiac event. Recently reconnected with other and they get along. Mother passed away. Father is still living. He lives with patient. Father is going across country on his motorcycle.

Relationship: partner living together for 15 years and been together 18 years. Feels safe

Work/ Educational

History: Did carpentry for 10 years prior. Master’s degree in computer science and mathematics and going for PhD in computer science.

Adverse life events: denies

SUBSTANCE USE/ABUSE

Alcohol: denies remission since 2015, quit cold turkey as he did not make best decisions on it.

Tobacco/vape: denies; denies

Marijuana: denies; denies

Caffeine: endorses tea now and then, in the past overused, but stopped d/t headaches.

Others: no

RISK ASSESSMENT

In the past month

1. Have you wished you were dead or wished you could go to sleep and not wake up? Denies has too many things he wants to do before he dies.

2. Have you actually had any thoughts of killing yourself? denies

3. Have you ever done anything, started to do anything, or prepared to do anything to end your life? denies

4. Self-harm behaviors:

Homicidal ideations: denies

Weapons: denies

Legal/Arrests/DUI:

ACTIVITIES OF DAILY LIVING

Sleep concerns: intermittent difficulty sleeping; difficulty falling and staying asleep. Occurs when he gets involved with his research and stays up too long and can’t go to bed and this interferes with his week.

Change in appetite: appetite has returned now that he is on reduce chemo.

SEXUALITY ASSESSMENT

LMP and Contraception:

Sexually active:

Assigned gender at birth:

Pronouns:

Nicole Bennett, NP

Attn: Accounting,2041 GOOSE LAKE RD, East Saint Louis, IL, 62206-2822, US

IL - SIHF 10/29/2025 22:52:30

11/25/2025

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ROS as noted in the HPI

11/25/25 - Mood: pretty good Cc: denies Spotted some lesions in his liver. Meeting with surgeon tomorrow. Colon and bowels have been clean since.

SIHISIB: denies AVH: denies New or increased use of substance of abuse: denies Sleep: sleeping more this past week, d/t anxiety from news of spot on liver Appetite: no changes

CHIEF COMPLAINT/ PRESENTING CONCERNS Medication management

HISTORY OF PRESENT ILLNESS (Bold symptoms that meet DSM-5 Diagnostic Criteria) PSYCHIATRIC HISTORY MSE: (chronological development of symptoms - onset, duration, severity, triggers, modifying factors, associated symptoms): Patient presents to clinic for medication management. 1.5 years ago was diagnosed with stage 4 cancer and given 1 year to live. Was rx. Lorazepam and Ambien by oncology. States medications work well to ease anxiety and sleep disturbance. Patient in bouts of insomnia. Not as needed as Lorazepam, but very helpful.

Anxiety Onset: has been dealing with cancer for 5 years. Was in remission for 1 year, then had a reoccurrence at stage 4. He was given a year to live at the time. Characteristics: has anxiety going in to chemo. Effects him mentally. Questions about mortality and existential thoughts, he obsesses over this. He is still doing research for his PhD. Triggers: physical pains (mouth sores, diarrhea, inflammation), approaching chemo. Illness, thinking may be worse than what he thought. Questioning mortality.

Insomnia Occurs every once in a while, previously slept with no issue. When doing research will have trouble going to bed. Will stay up until 6am and wake at 9am. Ambien helps him maintain sleep schedule.

Past diagnoses: anxiety not formally diagnosed AVH: denies Mood: feeling fine How are you doing today (0-10)

Current Medications: has been using for a year without incident

• Zolpidem 5mg has over 15 left
• Lorazepam 0.5mg has 6 left Past Medications: none

Past psychiatrists: denies Hospitalizations: denies Counseling/Therapy: denies

MEDICAL HISTORY Illness/Injuries/Surgeries: Stage 4 colon cancer. Anemia. Hypothyroidism. Renal impairment. Speech impediment as a child. Allergies/Seizures/Head injuries: seasonal/denies/denies PCP: Kelsey Beard

ROS (constitution, vision, hearing, scent, mouth, cardiac, pulmonary, gastro, urinary, skin, musculoskeletal, neurological)

• night sweats, fevers: denies
• vision, hearing, sinus changes, issues with teeth, throat, gums: wears glasses. Mouth sores.
• cardiac - chest pain, palpitation, racing heart: denies
• pulmonary – difficulty breathing, coughing: hx. of sleep apnea
• gastro – upset stomach, diarrhea, constipation, reflux: lifelong constipation. Reflux mild. Diarrhea
• urinary – pain, urgency, difficulty, retention: denies
• skin issues: various d/t chemotherapy
• musculoskeletal – muscle, bone, joint pain, or discomfort: nothing out of ordinary
• neuro – weakness, numbness, dizziness, headache, tremors: denies

FAMILY PSYCHIATRIC/MEDICAL HISTORY Mother: Father: Siblings: Grandmother: Grandfather:

DEVELOPMENTAL SOCIAL HISTORY Childhood: Had a regular childhood. 2 sisters, 1 passed away from cardiac event. Recently reconnected with other and they get along. Mother passed away. Father is still living. He lives with patient. Father is going across country on his motorcycle. Relationship: partner living together for 15 years and been together 18 years. Feels safe Work/ Educational

History: Did carpentry for 10 years prior. Master’s degree in computer science and mathematics and going for PhD in computer science. Adverse life events: denies

SUBSTANCE USE/ABUSE Alcohol: denies remission since 2015, quit cold turkey as he did not make best decisions on it. Tobacco/vape: denies; denies Marijuana: denies; denies Caffeine: endorses tea now and then, in the past overused, but stopped d/t headaches. Others: no

RISK ASSESSMENT In the past month

1. Have you wished you were dead or wished you could go to sleep and not wake up? Denies has too many things he wants to do before he dies.
2. Have you actually had any thoughts of killing yourself? denies
3. Have you ever done anything, started to do anything, or prepared to do anything to end your life? denies
4. Self-harm behaviors: Homicidal ideations: denies Weapons: denies Legal/Arrests/DUI:

ACTIVITIES OF DAILY LIVING Sleep concerns: intermittent difficulty sleeping; difficulty falling and staying asleep. Occurs when he gets involved with his research and stays up too long and can’t go to bed and this interferes with his week. Change in appetite: appetite has returned now that he is on reduce chemo.

SEXUALITY ASSESSMENT LMP and Contraception: Sexually active: Assigned gender at birth: Pronouns:

Nicole Bennett, NP

Attn: Accounting,2041 GOOSE LAKE RD, East Saint Louis, IL, 62206-2822, US

IL - SIHF 11/25/2025 16:01:43

01/26/2026

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ROS as noted in the HPI

1/26 - Mood: good Cc: going into more intense chemo for a while. Had surgery 12/18 - recovered

SIHISIB: denies AVH: denies New or increased use of substance of abuse: denies Sleep: ok Appetite: off chemo for past 2 month, so eating quite a bit.

11/25/25 - Mood: pretty good Cc: denies Spotted some lesions in his liver. Meeting with surgeon tomorrow. Colon and bowels have been clean since.

SIHISIB: denies AVH: denies New or increased use of substance of abuse: denies Sleep: sleeping more this past week, d/t anxiety from news of spot on liver Appetite: no changes

CHIEF COMPLAINT/ PRESENTING CONCERNS Medication management

HISTORY OF PRESENT ILLNESS (Bold symptoms that meet DSM-5 Diagnostic Criteria) PSYCHIATRIC HISTORY MSE: (chronological development of symptoms - onset, duration, severity, triggers, modifying factors, associated symptoms): Patient presents to clinic for medication management. 1.5 years ago was diagnosed with stage 4 cancer and given 1 year to live. Was rx. Lorazepam and Ambien by oncology. States medications work well to ease anxiety and sleep disturbance. Patient in bouts of insomnia. Not as needed as Lorazepam, but very helpful.

Anxiety Onset: has been dealing with cancer for 5 years. Was in remission for 1 year, then had a reoccurrence at stage 4. He was given a year to live at the time. Characteristics: has anxiety going in to chemo. Effects him mentally. Questions about mortality and existential thoughts, he obsesses over this. He is still doing research for his PhD. Triggers: physical pains (mouth sores, diarrhea, inflammation), approaching chemo. Illness, thinking may be worse than what he thought. Questioning mortality.

Insomnia Occurs every once in a while, previously slept with no issue. When doing research will have trouble going to bed. Will stay up until 6am and wake at 9am. Ambien helps him maintain sleep schedule.

Past diagnoses: anxiety not formally diagnosed AVH: denies Mood: feeling fine How are you doing today (0-10)

Current Medications: has been using for a year without incident

• Zolpidem 5mg has over 15 left
• Lorazepam 0.5mg has 6 left Past Medications: none

Past psychiatrists: denies Hospitalizations: denies Counseling/Therapy: denies

MEDICAL HISTORY Illness/Injuries/Surgeries: Stage 4 colon cancer. Anemia. Hypothyroidism. Renal impairment. Speech impediment as a child. Allergies/Seizures/Head injuries: seasonal/denies/denies PCP: Kelsey Beard

ROS (constitution, vision, hearing, scent, mouth, cardiac, pulmonary, gastro, urinary, skin, musculoskeletal, neurological)

• night sweats, fevers: denies
• vision, hearing, sinus changes, issues with teeth, throat, gums: wears glasses. Mouth sores.
• cardiac - chest pain, palpitation, racing heart: denies
• pulmonary – difficulty breathing, coughing: hx. of sleep apnea
• gastro – upset stomach, diarrhea, constipation, reflux: lifelong constipation. Reflux mild. Diarrhea
• urinary – pain, urgency, difficulty, retention: denies
• skin issues: various d/t chemotherapy
• musculoskeletal – muscle, bone, joint pain, or discomfort: nothing out of ordinary
• neuro – weakness, numbness, dizziness, headache, tremors: denies

FAMILY PSYCHIATRIC/MEDICAL HISTORY Mother: Father: Siblings: Grandmother: Grandfather:

DEVELOPMENTAL SOCIAL HISTORY Childhood: Had a regular childhood. 2 sisters, 1 passed away from cardiac event. Recently reconnected with other and they get along. Mother passed away. Father is still living. He lives with patient. Father is going across country on his motorcycle. Relationship: partner living together for 15 years and been together 18 years. Feels safe Work/ Educational

History: Did carpentry for 10 years prior. Master’s degree in computer science and mathematics and going for PhD in computer science. Adverse life events: denies

SUBSTANCE USE/ABUSE Alcohol: denies remission since 2015, quit cold turkey as he did not make best decisions on it. Tobacco/vape: denies; denies Marijuana: denies; denies Caffeine: endorses tea now and then, in the past overused, but stopped d/t headaches. Others: no

RISK ASSESSMENT In the past month

1. Have you wished you were dead or wished you could go to sleep and not wake up? Denies has too many things he wants to do before he dies.
2. Have you actually had any thoughts of killing yourself? denies
3. Have you ever done anything, started to do anything, or prepared to do anything to end your life? denies
4. Self-harm behaviors: Homicidal ideations: denies Weapons: denies Legal/Arrests/DUI:

ACTIVITIES OF DAILY LIVING Sleep concerns: intermittent difficulty sleeping; difficulty falling and staying asleep. Occurs when he gets involved with his research and stays up too long and can’t go to bed and this interferes with his week. Change in appetite: appetite has returned now that he is on reduce chemo.

SEXUALITY ASSESSMENT LMP and Contraception: Sexually active: Assigned gender at birth: Pronouns:

Nicole Bennett, NP

Attn: Accounting,2041 GOOSE LAKE RD, East Saint Louis, IL, 62206-2822, US

IL - SIHF 01/27/2026 14:00:09

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

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

Instructions

Antibiotic Form Hydrocodone/Acetaminophen (By mouth) Colectomy (DC)

Reminders

Order Date Submit Date Provider Name Organization Details Last Modified By Last Modified Time Details

Appointments

PHONE VISIT 15

03/30/2026 10:45AM

Nicole Bennett, NP Not available Not available Not available

ANY 15

04/09/2026 01:30PM

KELSEY BEARD, FNP-BC Not available Not available Not available

Lab

drug screen, urine

10/28/2025 12:45:49

10/28/2025

Nicole Bennett, NP

Bethalto HC (BH)

2 Terminal Dr Ste 8, EAST ALTON, IL, 62024-2294, Ph (618) 259-0365

Nicole Bennett, NP 10/28/2025 12:45:51

TSH + free T4, serum

04/01/2025 11:29:25

04/01/2025

KELSEY BEARD, FNP-BC

LABCORP

102 Rottingham,Ste 2, Edwardsville, IL, 62025, Ph (618) 659-8692

Darla Turner, MA 04/22/2025 17:07:37

CBC w/ auto diff

04/01/2025 11:29:25

04/01/2025

KELSEY BEARD, FNP-BC

LABCORP

102 Rottingham,Ste 2, Edwardsville, IL, 62025, Ph (618) 659-8692

Not Available 05/02/2025 09:14:39

CMP, serum or plasma

04/01/2025 11:29:25

04/01/2025

KELSEY BEARD, FNP-BC

LABCORP

102 Rottingham,Ste 2, Edwardsville, IL, 62025, Ph (618) 659-8692

Not Available 05/02/2025 09:14:36

HbA1c (hemoglobin A1c), blood

04/01/2025 11:29:25

04/01/2025

KELSEY BEARD, FNP-BC

LABCORP

102 Rottingham,Ste 2, Edwardsville, IL, 62025, Ph (618) 659-8692

Not Available 05/02/2025 09:14:37

lipid panel, serum

04/01/2025 11:29:25

04/01/2025

KELSEY BEARD, FNP-BC

LABCORP

102 Rottingham,Ste 2, Edwardsville, IL, 62025, Ph (618) 659-8692

Not Available 05/02/2025 09:14:34

influenza virus A + B + SARS-CoV-2 (COVID19) Ag panel, rapid IA, upper respiratory specimen

02/10/2025 13:10:29

02/10/2025

KELSEY BEARD, FNP-BC

Bethalto HC (Adult Med)

2 Terminal Dr Ste 8, EAST ALTON, IL, 62024-2294, Ph (618) 258-0485

Not Available 02/10/2025 16:13:43

lipid panel, serum

11/30/2023 09:42:49

11/30/2023

Nanthini Suthan, MD

LABCORP

102 Rottingham,Ste 2, Edwardsville, IL, 62025, Ph (618) 659-8692

Not Available 12/13/2023 03:08:26

CMP, serum or plasma

11/30/2023 09:42:49

11/30/2023

Nanthini Suthan, MD

LABCORP

102 Rottingham,Ste 2, Edwardsville, IL, 62025, Ph (618) 659-8692

Not Available 12/13/2023 03:08:27

albumin/creatinine, mass ratio, urine

11/30/2023 09:42:48

11/30/2023

Nanthini Suthan, MD

LABCORP

102 Rottingham,Ste 2, Edwardsville, IL, 62025, Ph (618) 659-8692

Not Available 12/13/2023 07:15:15

CBC w/ auto diff

11/30/2023 09:42:48

11/30/2023

Nanthini Suthan, MD

LABCORP

102 Rottingham,Ste 2, Edwardsville, IL, 62025, Ph (618) 659-8692

Not Available 12/13/2023 03:08:28

CMP, serum or plasma

01/18/2023 14:59:46

01/18/2023

Nanthini Suthan, MD

LABCORP

102 Rottingham,Ste 2, Edwardsville, IL, 62025, Ph (618) 659-8692

Not Available 01/19/2023 03:14:14

lipid panel, serum

01/18/2023 14:59:46

01/18/2023

Nanthini Suthan, MD

LABCORP

102 Rottingham,Ste 2, Edwardsville, IL, 62025, Ph (618) 659-8692

Not Available 01/19/2023 03:14:14

HbA1c (hemoglobin A1c), blood

01/18/2023 14:59:46

01/18/2023

Nanthini Suthan, MD

LABCORP

102 Rottingham,Ste 2, Edwardsville, IL, 62025, Ph (618) 659-8692

Not Available 01/19/2023 04:08:05

CBC w/ auto diff

01/18/2023 14:59:45

01/18/2023

Nanthini Suthan, MD

LABCORP

102 Rottingham,Ste 2, Edwardsville, IL, 62025, Ph (618) 659-8692

Not Available 01/19/2023 03:14:15

TSH + free T4, serum

03/01/2022 09:58:21

03/01/2022

Nanthini Suthan, MD

LABCORP

102 Rottingham,Ste 2, Edwardsville, IL, 62025, Ph (618) 659-8692

Not Available 03/23/2022 08:23:52

ferritin, serum or plasma

11/12/2021 15:49:11

11/12/2021

Nanthini Suthan, MD

LABCORP

102 Rottingham,Ste 2, Edwardsville, IL, 62025, Ph (618) 659-8692

Not Available 01/06/2022 16:11:18

vitamin B12 + folate, serum or blood

11/12/2021 15:49:11

11/12/2021

Nanthini Suthan, MD

LABCORP

102 Rottingham,Ste 2, Edwardsville, IL, 62025, Ph (618) 659-8692

Not Available 01/06/2022 16:11:16

parietal cell Ab, serum

11/12/2021 15:49:11

11/12/2021

Nanthini Suthan, MD

LABCORP

102 Rottingham,Ste 2, Edwardsville, IL, 62025, Ph (618) 659-8692

Not Available 01/06/2022 16:11:16

ANA (antinuclear antibodies) screen, serum

11/12/2021 15:49:11

11/12/2021

Nanthini Suthan, MD

LABCORP

102 Rottingham,Ste 2, Edwardsville, IL, 62025, Ph (618) 659-8692

Not Available 01/06/2022 16:11:17

CBC w/ auto diff

11/12/2021 15:49:10

11/12/2021

Nanthini Suthan, MD

LABCORP

102 Rottingham,Ste 2, Edwardsville, IL, 62025, Ph (618) 659-8692

Not Available 01/06/2022 16:11:15

thyroid peroxidase (tpo) Ab, serum

10/12/2021 15:46:51

10/12/2021

Nanthini Suthan, MD

LABCORP

102 Rottingham,Ste 2, Edwardsville, IL, 62025, Ph (618) 659-8692

Not Available 11/06/2021 04:08:33

hemoglobin + hematocrit, blood

10/12/2021 11:25:25

10/12/2021

Nanthini Suthan, MD

LABCORP

102 Rottingham,Ste 2, Edwardsville, IL, 62025, Ph (618) 659-8692

Not Available 11/06/2021 04:08:32

TSH, ultra-sensitive, serum

10/12/2021 11:25:25

10/12/2021

Nanthini Suthan, MD

LABCORP

102 Rottingham,Ste 2, Edwardsville, IL, 62025, Ph (618) 659-8692

Not Available 11/06/2021 04:08:33

CBC w/ auto diff

09/27/2021 10:39:42

09/27/2021

Nanthini Suthan, MD

LABCORP

102 Rottingham,Ste 2, Edwardsville, IL, 62025, Ph (618) 659-8692

Not Available 10/02/2021 06:12:43

lipid panel, serum

09/27/2021 10:39:42

09/27/2021

Nanthini Suthan, MD

LABCORP

102 Rottingham,Ste 2, Edwardsville, IL, 62025, Ph (618) 659-8692

Not Available 10/02/2021 06:12:44

TSH, ultra-sensitive, serum

09/27/2021 10:39:42

09/27/2021

Nanthini Suthan, MD

LABCORP

102 Rottingham,Ste 2, Edwardsville, IL, 62025, Ph (618) 659-8692

Not Available 10/02/2021 06:12:46

HbA1c (hemoglobin A1c), blood

09/27/2021 10:39:42

09/27/2021

Nanthini Suthan, MD

LABCORP

102 Rottingham,Ste 2, Edwardsville, IL, 62025, Ph (618) 659-8692

Not Available 10/02/2021 06:12:45

CMP, serum or plasma

09/27/2021 10:39:41

09/27/2021

Nanthini Suthan, MD

LABCORP

102 Rottingham,Ste 2, Edwardsville, IL, 62025, Ph (618) 659-8692

Not Available 10/02/2021 06:12:44

Referral

sleep medicine referral

07/25/2023 09:32:15

07/25/2023

Nanthini Suthan, MD Not available Not Available 09/11/2023 15:40:44

gastroenterologist referral

10/12/2021 11:24:01

10/12/2021

Nanthini Suthan, MD Not available Not Available 12/22/2021 17:00:47

sleep medicine referral

09/27/2021 10:43:38

09/27/2021

Nanthini Suthan, MD

Gateway Regional Pulmonary Rehab

2100 Madison Ave, Granite City, IL, 62040, Ph (618) 798-3659

Not Available 03/02/2022 15:24:28

Procedures

psychiatrist referral

10/08/2025 15:28:32

10/08/2025

KELSEY BEARD, FNP-BC

Bethalto Hc (BH)

2 Terminal Dr, East Alton, IL, 62024-2060, Ph (618) 259-0365

Josie Schulte, RMA 11/05/2025 09:14:54

Surgeries

None recorded.

Imaging

CT, abdomen + pelvis, w/wo contrast

05/02/2024 11:14:50

05/02/2024

Nanthini Suthan, MD

Osf (Saint Anthony’s) Scheduling

2 Saint Anthonys Way, Alton, IL, 62002, Ph (618) 474-4606

Not Available 05/07/2024 20:16:47

XR, wrist

07/25/2023 09:32:15

07/25/2023

Nanthini Suthan, MD

Osf (Saint Anthony’s) Scheduling

2 Saint Anthonys Way, Alton, IL, 62002, Ph (618) 474-4606

Not Available 07/28/2023 12:11:54

US, thyroid

03/01/2022 09:58:21

03/01/2022

Nanthini Suthan, MD

Alton Memorial (Radiology)

1 Memorial Dr, Alton, IL, 62002, Ph (618) 463-7311

Not Available 03/11/2022 08:24:54

US, chest wall

09/27/2021 10:39:41

09/27/2021

Nanthini Suthan, MD

Osf (Saint Anthony’s) Scheduling

2 Saint Anthonys Way, Alton, IL, 62002, Ph (618) 474-4606

Rebecca Reiter, MA 03/11/2022 12:21:27

electrocardiogram

09/27/2021 10:39:41

09/27/2021

Nanthini Suthan, MD

Osf (Saint Anthony’s) Scheduling

2 Saint Anthonys Way, Alton, IL, 62002, Ph (618) 474-4606

Not Available 10/11/2021 16:45:02

MedicationOrders

lorazepam 0.5 mg tablet

01/26/2026 12:08:44

Walmart Pharmacy 1071

610 Wesley Drive, Wood River, 62095, Ph 6182590293

Not Available Not available 01/26/2026 12:11:01

Take 1 tablet every day by oral route as needed for 30 days, for Anxiety.

zolpidem 5 mg tablet

01/26/2026 12:08:36

Walmart Pharmacy 1071

610 Wesley Drive, Wood River, 62095, Ph 6182590293

Not Available Not available 01/26/2026 12:11:01

Take 1 tablet every day by oral route as needed for 30 days.

propranolol 20 mg tablet

10/08/2025 15:23:16

Walmart Pharmacy 1071

610 Wesley Drive, Wood River, 62095, Ph 6182590293

Nicole Bennett, NP Not available 11/25/2025 09:26:38

Take 1 tablet twice a day by oral route for 90 days.

VaccineOrders

None recorded.

Patient Targets No targets recorded.

Patient Instructions

Encounter Date Encounter Id Patient Instructions Last Modified By Organization Details Last Modified Time

10/08/2025 6194971

migraine aura without a headache: care instructions

KELSEY BEARD, FNP-BC Not available 10/08/2025 15:24:23

Plan of care has been discussed with patient including expected therapeutic benefits and potential side effects of prescribed medication and treatments. Patient verbalizes understanding and is in agreement with the plan of care. Patient was instructed to keep all scheduled appointments and contact the clinic for any additional problems.

Health Maintenance: - CRC screening (45-75): colonoscopy 2024 - Osteoporosis screening: Due at 65. - Lipid screening (>45 unless additional risk factors): 4/1/25 - HIV : declined - HepC: declined -Eye exam: 2024 -Dental Exam: unknown, scheduled - Immunizations: - Influenza: Due. Patient obtained - Prevnar 20: Due at 65. - Tdap/Td (q10years): 7/25/23 - Zoster (>60):Due at 60. - COVID-19: 10/25/23, 6/6/22, 11/30/21, 5/15/21, 4/21/21 - AAA screening (65-75): Due at 65. - Prostate ca screening (>50 or >45 if AA, +FH; d/w patient): Due at 50. -Labs ordered this visit: n/a

kbeard52 Not available 10/08/2025 15:31:50

06/10/2025 5989947

migraine aura without a headache: care instructions

KELSEY BEARD, FNP-BC Not available 06/10/2025 16:38:16

Plan of care has been discussed with patient including expected therapeutic benefits and potential side effects of prescribed medication and treatments. Patient verbalizes understanding and is in agreement with the plan of care. Patient was instructed to keep all scheduled appointments and contact the clinic for any additional problems.

Health Maintenance: - CRC screening (45-75): colonoscopy 2024 - Osteoporosis screening: Due at 65. - Lipid screening (>45 unless additional risk factors): ordered - HIV : declined - HepC: declined -Eye exam: 2024 -Dental Exam: unknown, scheduled - Immunizations: - Influenza: Due. Patient obtained - Prevnar 20: Due at 65. - Tdap/Td (q10years): 7/25/23 - Zoster (>60):Due at 60. - COVID-19: 10/25/23, 6/6/22, 11/30/21, 5/15/21, 4/21/21 - AAA screening (65-75): Due at 65. - Prostate ca screening (>50 or >45 if AA, +FH; d/w patient): Due at 50. -Labs ordered this visit: n/a

kbeard52 Not available 06/10/2025 16:39:23

04/01/2025 5869965

A healthy lifestyle: care instructions

KELSEY BEARD, FNP-BC Not available 04/01/2025 11:24:31

Plan of care has been discussed with patient including expected therapeutic benefits and potential side effects of prescribed medication and treatments. Patient verbalizes understanding and is in agreement with the plan of care. Patient was instructed to keep all scheduled appointments and contact the clinic for any additional problems.

Health Maintenance: - CRC screening (45-75): colonoscopy 2024 - Osteoporosis screening: Due at 65. - Lipid screening (>45 unless additional risk factors): ordered - HIV : declined - HepC: declined -Eye exam: 2024 -Dental Exam: unknown, scheduled - Immunizations: - Influenza: Due. Patient obtained - Prevnar 20: Due at 65. - Tdap/Td (q10years): 7/25/23 - Zoster (>60):Due at 60. - COVID-19: 10/25/23, 6/6/22, 11/30/21, 5/15/21, 4/21/21 - AAA screening (65-75): Due at 65. - Prostate ca screening (>50 or >45 if AA, +FH; d/w patient): Due at 50. -Labs ordered this visit: annual labs ordered

kbeard52 Not available 04/20/2025 12:58:54

02/10/2025 5782407

upper respiratory infection (cold): care instructions

KELSEY BEARD, FNP-BC Not available 02/10/2025 13:09:37

Plan of care has been discussed with patient including expected therapeutic benefits and potential side effects of prescribed medication and treatments. Patient verbalizes understanding and is in agreement with the plan of care. Patient was instructed to keep all scheduled appointments and contact the clinic for any additional problems.

kbeard52 Not available 03/08/2025 23:57:22

05/02/2024 5311546

keep f/u

nsuthan Not available 05/02/2024 11:16:04

11/30/2023 5068146

eating healthy foods: care instructions

Nanthini Suthan, MD Not available 11/30/2023 09:42:49

f/u in 6month

nsuthan Not available 11/30/2023 09:41:54

07/25/2023 4873977

eating healthy foods: care instructions

Nanthini Suthan, MD Not available 07/25/2023 09:32:16

A healthy lifestyle: care instructions

Nanthini Suthan, MD Not available 07/25/2023 09:32:16

ear irrigation/tdap/diet /f/u in 4 month

nsuthan Not available 07/25/2023 09:39:58

01/18/2023 4587183

A healthy lifestyle: care instructions

Nanthini Suthan, MD Not available 01/18/2023 14:41:49

ganglions: care instructions

Nanthini Suthan, MD Not available 01/18/2023 14:59:47

constipation: care instructions

Nanthini Suthan, MD Not available 01/18/2023 15:54:00

labs/f/u in 6 month

nsuthan Not available 01/18/2023 15:00:10

07/12/2022 4316469

A healthy lifestyle: care instructions

Nanthini Suthan, MD Not available 07/12/2022 11:19:47

f/u in 6 month

nsuthan Not available 07/12/2022 11:19:47

03/01/2022 4136950

f/u in 4month

nsuthan Not available 03/01/2022 10:02:43

11/12/2021 3991640

f/u in 2month

nsuthan Not available 11/12/2021 10:55:17

10/12/2021 3941637

f/u in 1month with labs

nsuthan Not available 10/12/2021 11:33:40

09/27/2021 3916671

A healthy lifestyle: care instructions

Nanthini Suthan, MD Not available 09/27/2021 10:39:42

f/u in 2 wks

nsuthan Not available 09/27/2021 10:38:23

I have reviewed Dr. Arshad’s office note, colonoscopy report and pathology prior to today’s visit. I discussed the pathology finding with the patient. I have recommended proceeding with HAL right colectomy under general anesthesia as an AM admit. Procedure risks, benefits, and expected outcomes were discussed in detail. Explained this is a hand assisted technique. Discussed the usual length of operation time, need for bowel prep with antibiotics, usual placement of incision and trocars, typical 6-8 week recovery, as well as the length of time spent in the hospital. Potential complications were also discussed in detail which includes conversion to open surgery, bleeding, infection, anastomotic leak, and return to surgery. All questions were answered. Patient would like to proceed. Follow-up 2 weeks postoperatively.

1. Personal Hx of colon cancer/ SBO/ ileum ulcer/chronic constipation/weight loss/appetite loss: Patient had an outpatient CT at St. Anthony’s which showed SBO and patient then presented to Anderson ER 5/07/2024 at which time he was seen by surgery ( Dr. Chung) and NG decompression recommended and there was no indication for surgery at that time. S/P partial sigmoid bowel resection for adenocarcinoma in the sigmoid colon on 12/29/2021, patient completed chemotherapy but did not require radiation. Colonoscopy performed by Dr. Rodriguez 05/29/2024 which revealed a ulcer at the ileum. Unfortunately, bx were consistent with moderately differentiated adenocarcinoma. patient has been taking Dulcolax daily to avoid any slowing of his bowels. Following his hospitalization beginning of May he was doing well until about 12 days ago when he started to experience abdominal cramping and nausea. At that time he may dietary adjustments and switch to more of a liquid based diet that has been slowly advancing his diet and yesterday was able to tolerate solid foods. Today in the office he denied any GI complaints other than appetite loss and weight loss. Patient advised to contact his oncologist Dr. Arshad to discuss his treatment/surgical options He will continue to adjust his diet based on symptoms and ok to continue laxatives at this time as he feels he is dependent on them Patient advised to avoid hard to digest foods such as meats recommended supplemental nutrition such as boost or Ensure to help increase caloric intake
2. IDA: Labs earlier this month showed Hgb 12, Hct 36, MCV 81, platelets 240, iron 35, TIBC 451, iron sat 8% and ferritin 5. patient denies any signs of active GI bleeding at this time. Patient to follow up with Hematology/Oncology for management The patient will follow up in the office on an as-needed basis. 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. Future Tests Future scheduled test information is unavailable

Pending Tests Pending diagnostic test information is unavailable

Future Visits Future appointment information is unavailable

Referrals to Other ProvidersReason for ReferralReferral Start DateProviderProvider Contact InformationProvider AddressPei Chang Chung , MDWork Phone: +1(618)288-36166810 State Route 162Suite 100MARYVILLE IL 62062As needed.Nanthini Suthan*** , MDWork Phone: +1(618)258-0485TWO TERMINAL DRIVESUITE 8EAST ALTON IL 62024Primary Care Physician SuthanWork Phone: +1(618)258-0485Pei Chang Chung , MDWork Phone: +1(618)288-36166810 State Route 162Suite 100MARYVILLE IL 62062Future ProceduresProcedure NameOrdered DateScheduled DateOutpatient Surgery DischargeMay 29th, 2024 11:46amMay 29th, 2024 12:00amAdmit as InpatientJuly 1st, 2024 3:35pmJuly 1st, 2024 3:35pmDischarge OrderJuly 3rd, 2024 4:36pmJuly 3rd, 2024 4:36pmUrinary Catheter, Place INTRAOPERATIVEJuly 1st, 2024 2:08pmJuly 1st, 2024 2:15pmOutpatient Surgery DischargeJanuary 17th, 2024 1:01pmJanuary 17th, 2024 1:00amOutside images CTMay 7th, 2024 10:15pmMay 7th, 2024 12:00amDischarge OrderMay 9th, 2024 9:50amMay 9th, 2024 9:50amPlacement to ObservationMay 7th, 2024 11:56pmMay 7th, 2024 11:56pmChange Status to InpatientMay 8th, 2024 9:11amMay 8th, 2024 9:11amFuture Medications Future medication information is unavailable

Patient InstructionsAntibiotic FormAnemia (AC)Anemia (AC)Hydrocodone/Acetaminophen (By mouth)Colectomy (DC)

? etiology. denies any overt blood. Recent H&H 7.1/27.3, iron saturation of 3, TIBC of 13 and ferritin <1. continue oral iron Will schedule EGD and colonoscopy. Never had EGD. last colonoscopy was over 20 years ago. He believes his father was dx with colon cancer in his 70’s. Future Tests Future scheduled test information is unavailable

Pending Tests Pending diagnostic test information is unavailable

Future Visits Future appointment information is unavailable

Referrals to Other ProvidersReason for ReferralReferral Start DateProviderProvider Contact InformationProvider AddressK63.89 - Other specified diseases of intestine,D50.9 - Iron deficiency anemia, unspecifiedNovember 22nd, 2021Richard H. Wikiera , DOWork Phone: +1(618)288-36166810 State Route 100Suite 100MARYVILLE IL 62062Pei Chang Chung , MDWork Phone: +1(618)288-36166810 State Route 162Suite 100MARYVILLE IL 62062Future Procedures Future procedure information is unavailable

Future Medications Future medication information is unavailable

Patient InstructionsAnemia (AC)Anemia (AC)Antibiotic FormHydrocodone/Acetaminophen (By mouth)Colectomy (DC)

? etiology. denies any overt blood. Recent H&H 7.1/27.3, iron saturation of 3, TIBC of 13 and ferritin <1. continue oral iron Will schedule EGD and colonoscopy. Never had EGD. last colonoscopy was over 20 years ago. He believes his father was dx with colon cancer in his 70’s. Future Tests Future scheduled test information is unavailable

Pending Tests Pending diagnostic test information is unavailable

Future Visits Future appointment information is unavailable

Referrals to Other ProvidersReason for ReferralReferral Start DateProviderProvider Contact InformationProvider AddressK63.89 - Other specified diseases of intestine,D50.9 - Iron deficiency anemia, unspecifiedNovember 22nd, 2021Richard H. Wikiera , DOWork Phone: +1(618)288-36166810 State Route 100Suite 100MARYVILLE IL 62062Pei Chang Chung , MDWork Phone: +1(618)288-36166810 State Route 162Suite 100MARYVILLE IL 62062Future Procedures Future procedure information is unavailable

Future Medications Future medication information is unavailable

Patient InstructionsAnemia (AC)Anemia (AC)Antibiotic FormHydrocodone/Acetaminophen (By mouth)Colectomy (DC)

? etiology. denies any overt blood. Recent H&H 7.1/27.3, iron saturation of 3, TIBC of 13 and ferritin <1. continue oral iron Will schedule EGD and colonoscopy. Never had EGD. last colonoscopy was over 20 years ago. He believes his father was dx with colon cancer in his 70’s. Future Tests Future scheduled test information is unavailable

Pending Tests Pending diagnostic test information is unavailable

Future Visits Future appointment information is unavailable

Referrals to Other ProvidersReason for ReferralReferral Start DateProviderProvider Contact InformationProvider AddressK63.89 - Other specified diseases of intestine,D50.9 - Iron deficiency anemia, unspecifiedNovember 22nd, 2021Richard H. Wikiera , DOWork Phone: +1(618)288-36166810 State Route 100Suite 100MARYVILLE IL 62062Pei Chang Chung , MDWork Phone: +1(618)288-36166810 State Route 162Suite 100MARYVILLE IL 62062Future Procedures Future procedure information is unavailable

Future Medications Future medication information is unavailable

Patient InstructionsAnemia (AC)Anemia (AC)Antibiotic FormHydrocodone/Acetaminophen (By mouth)Colectomy (DC)

? etiology. denies any overt blood. Recent H&H 7.1/27.3, iron saturation of 3, TIBC of 13 and ferritin <1. continue oral iron Will schedule EGD and colonoscopy. Never had EGD. last colonoscopy was over 20 years ago. He believes his father was dx with colon cancer in his 70’s. Future Tests Future scheduled test information is unavailable

Pending Tests Pending diagnostic test information is unavailable

Future Visits Future appointment information is unavailable

Referrals to Other ProvidersReason for ReferralReferral Start DateProviderProvider Contact InformationProvider AddressK63.89 - Other specified diseases of intestine,D50.9 - Iron deficiency anemia, unspecifiedNovember 22nd, 2021Richard H. Wikiera , DOWork Phone: +1(618)288-36166810 State Route 100Suite 100MARYVILLE IL 62062Pei Chang Chung , MDWork Phone: +1(618)288-36166810 State Route 162Suite 100MARYVILLE IL 62062Pei Chang Chung , MDWork Phone: +1(618)288-36166810 State Route 162Suite 100MARYVILLE IL 62062Future Procedures Future procedure information is unavailable

Future Medications Future medication information is unavailable

Patient InstructionsAnemia (AC)Anemia (AC)Antibiotic FormHydrocodone/Acetaminophen (By mouth)Colectomy (DC)

Future Tests Future scheduled test information is unavailable

Pending Tests Pending diagnostic test information is unavailable

Future Visits Future appointment information is unavailable

Referrals to Other ProvidersReason for ReferralReferral Start DateProviderProvider Contact InformationProvider AddressK63.89 - Other specified diseases of intestine,D50.9 - Iron deficiency anemia, unspecifiedNovember 22nd, 2021Richard H. Wikiera , DOWork Phone: +1(618)288-36166810 State Route 100Suite 100MARYVILLE IL 62062Pei Chang Chung , MDWork Phone: +1(618)288-36166810 State Route 162Suite 100MARYVILLE IL 62062Pei Chang Chung , MDWork Phone: +1(618)288-36166810 State Route 162Suite 100MARYVILLE IL 62062Future Procedures Future procedure information is unavailable

Future Medications Future medication information is unavailable

Patient InstructionsAnemia (AC)Anemia (AC)Antibiotic FormHydrocodone/Acetaminophen (By mouth)Colectomy (DC)

Future Tests Future scheduled test information is unavailable

Pending Tests Pending diagnostic test information is unavailable

Future Visits Future appointment information is unavailable

Referrals to Other ProvidersReason for ReferralReferral Start DateProviderProvider Contact InformationProvider AddressK63.89 - Other specified diseases of intestine,D50.9 - Iron deficiency anemia, unspecifiedNovember 22nd, 2021Richard H. Wikiera , DOWork Phone: +1(618)288-36166810 State Route 100Suite 100MARYVILLE IL 62062Pei Chang Chung , MDWork Phone: +1(618)288-36166810 State Route 162Suite 100MARYVILLE IL 62062Syed M. Arshad , MDWork Phone: +1(618)288-11402227 Vadalabene Dr.Suite 200MARYVILLE IL 62062Pei Chang Chung , MDWork Phone: +1(618)288-36166810 State Route 162Suite 100MARYVILLE IL 62062Future Procedures Future procedure information is unavailable

Future Medications Future medication information is unavailable

Patient InstructionsAnemia (AC)Antibiotic FormHydrocodone/Acetaminophen (By mouth)Colectomy (DC)Acute Diarrhea (ED)

Future Tests Future scheduled test information is unavailable

Pending Tests Pending diagnostic test information is unavailable

Future Visits Future appointment information is unavailable

Referrals to Other ProvidersReason for ReferralReferral Start DateProviderProvider Contact InformationProvider AddressAs needed.Nanthini Suthan*** , MDWork Phone: +1(618)258-0485TWO TERMINAL DRIVESUITE 8EAST ALTON IL 62024Primary Care Physician SuthanWork Phone: +1(618)258-0485Pei Chang Chung , MDWork Phone: +1(618)288-36166810 State Route 162Suite 100MARYVILLE IL 62062Future ProceduresProcedure NameOrdered DateScheduled DateOutpatient Surgery DischargeJanuary 17th, 2024 1:01pmJanuary 17th, 2024 1:00amOutside images CTMay 7th, 2024 10:15pmMay 7th, 2024 12:00amDischarge OrderMay 9th, 2024 9:50amMay 9th, 2024 9:50amPlacement to ObservationMay 7th, 2024 11:56pmMay 7th, 2024 11:56pmChange Status to InpatientMay 8th, 2024 9:11amMay 8th, 2024 9:11amFuture Medications Future medication information is unavailable

Patient InstructionsAntibiotic Form

AuthorHannah MorrisonAnderson HealthcareAuthoredJune 12th, 2024 10:08amI have reviewed Dr. Arshad’s office note, colonoscopy report and pathology prior to today’s visit. I discussed the pathology finding with the patient. I have recommended proceeding with HAL right colectomy under general anesthesia as an AM admit. Procedure risks, benefits, and expected outcomes were discussed in detail. Explained this is a hand assisted technique. Discussed the usual length of operation time, need for bowel prep with antibiotics, usual placement of incision and trocars, typical 6-8 week recovery, as well as the length of time spent in the hospital. Potential complications were also discussed in detail which includes conversion to open surgery, bleeding, infection, anastomotic leak, and return to surgery. All questions were answered. Patient would like to proceed. Follow-up 2 weeks postoperatively.AuthorSheena EslingerAnderson HealthcareAuthoredMay 31st, 2024 12:52pm1) Personal Hx of colon cancer/ SBO/ ileum ulcer/chronic constipation/weight loss/appetite loss: Patient had an outpatient CT at St. Anthony’s which showed SBO and patient then presented to Anderson ER 5/07/2024 at which time he was seen by surgery ( Dr. Chung) and NG decompression recommended and there was no indication for surgery at that time. S/P partial sigmoid bowel resection for adenocarcinoma in the sigmoid colon on 12/29/2021, patient completed chemotherapy but did not require radiation. Colonoscopy performed by Dr. Rodriguez 05/29/2024 which revealed a ulcer at the ileum. Unfortunately, bx were consistent with moderately differentiated adenocarcinoma. patient has been taking Dulcolax daily to avoid any slowing of his bowels. Following his hospitalization beginning of May he was doing well until about 12 days ago when he started to experience abdominal cramping and nausea. At that time he may dietary adjustments and switch to more of a liquid based diet that has been slowly advancing his diet and yesterday was able to tolerate solid foods. Today in the office he denied any GI complaints other than appetite loss and weight loss. Patient advised to contact his oncologist Dr. Arshad to discuss his treatment/surgical options He will continue to adjust his diet based on symptoms and ok to continue laxatives at this time as he feels he is dependent on them Patient advised to avoid hard to digest foods such as meats recommended supplemental nutrition such as boost or Ensure to help increase caloric intake 2) IDA: Labs earlier this month showed Hgb 12, Hct 36, MCV 81, platelets 240, iron 35, TIBC 451, iron sat 8% and ferritin 5. patient denies any signs of active GI bleeding at this time. Patient to follow up with Hematology/Oncology for management The patient will follow up in the office on an as-needed basis. 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.Future Tests Future scheduled test information is unavailable

Pending Tests Pending diagnostic test information is unavailable

Future Visits Future appointment information is unavailable

Referrals to Other ProvidersReason for ReferralReferral Start DateProviderProvider Contact InformationProvider AddressPei Chang Chung , MDWork Phone: +1(618)288-36166810 State Route 162Suite 100MARYVILLE IL 62062As needed.Nanthini Suthan*** , MDWork Phone: +1(618)258-0485TWO TERMINAL DRIVESUITE 8EAST ALTON IL 62024Primary Care Physician SuthanWork Phone: +1(618)258-0485Pei Chang Chung , MDWork Phone: +1(618)288-36166810 State Route 162Suite 100MARYVILLE IL 62062Future ProceduresProcedure NameOrdered DateScheduled DateOutpatient Surgery DischargeMay 29th, 2024 11:46amMay 29th, 2024 12:00amAdmit as InpatientJuly 1st, 2024 3:35pmJuly 1st, 2024 3:35pmDischarge OrderJuly 3rd, 2024 4:36pmJuly 3rd, 2024 4:36pmUrinary Catheter, Place INTRAOPERATIVEJuly 1st, 2024 2:08pmJuly 1st, 2024 2:15pmOutpatient Surgery DischargeJanuary 17th, 2024 1:01pmJanuary 17th, 2024 1:00amOutside images CTMay 7th, 2024 10:15pmMay 7th, 2024 12:00amDischarge OrderMay 9th, 2024 9:50amMay 9th, 2024 9:50amPlacement to ObservationMay 7th, 2024 11:56pmMay 7th, 2024 11:56pmChange Status to InpatientMay 8th, 2024 9:11amMay 8th, 2024 9:11amFuture Medications Future medication information is unavailable

Patient InstructionsAntibiotic FormAnemia (AC)Anemia (AC)Hydrocodone/Acetaminophen (By mouth)Colectomy (DC)

AuthorHannah MorrisonAnderson HealthcareAuthoredJune 12th, 2024 10:08amI have reviewed Dr. Arshad’s office note, colonoscopy report and pathology prior to today’s visit. I discussed the pathology finding with the patient. I have recommended proceeding with HAL right colectomy under general anesthesia as an AM admit. Procedure risks, benefits, and expected outcomes were discussed in detail. Explained this is a hand assisted technique. Discussed the usual length of operation time, need for bowel prep with antibiotics, usual placement of incision and trocars, typical 6-8 week recovery, as well as the length of time spent in the hospital. Potential complications were also discussed in detail which includes conversion to open surgery, bleeding, infection, anastomotic leak, and return to surgery. All questions were answered. Patient would like to proceed. Follow-up 2 weeks postoperatively.AuthorSheena EslingerAnderson HealthcareAuthoredMay 31st, 2024 12:52pm1) Personal Hx of colon cancer/ SBO/ ileum ulcer/chronic constipation/weight loss/appetite loss: Patient had an outpatient CT at St. Anthony’s which showed SBO and patient then presented to Anderson ER 5/07/2024 at which time he was seen by surgery ( Dr. Chung) and NG decompression recommended and there was no indication for surgery at that time. S/P partial sigmoid bowel resection for adenocarcinoma in the sigmoid colon on 12/29/2021, patient completed chemotherapy but did not require radiation. Colonoscopy performed by Dr. Rodriguez 05/29/2024 which revealed a ulcer at the ileum. Unfortunately, bx were consistent with moderately differentiated adenocarcinoma. patient has been taking Dulcolax daily to avoid any slowing of his bowels. Following his hospitalization beginning of May he was doing well until about 12 days ago when he started to experience abdominal cramping and nausea. At that time he may dietary adjustments and switch to more of a liquid based diet that has been slowly advancing his diet and yesterday was able to tolerate solid foods. Today in the office he denied any GI complaints other than appetite loss and weight loss. Patient advised to contact his oncologist Dr. Arshad to discuss his treatment/surgical options He will continue to adjust his diet based on symptoms and ok to continue laxatives at this time as he feels he is dependent on them Patient advised to avoid hard to digest foods such as meats recommended supplemental nutrition such as boost or Ensure to help increase caloric intake 2) IDA: Labs earlier this month showed Hgb 12, Hct 36, MCV 81, platelets 240, iron 35, TIBC 451, iron sat 8% and ferritin 5. patient denies any signs of active GI bleeding at this time. Patient to follow up with Hematology/Oncology for management The patient will follow up in the office on an as-needed basis. 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.Future Tests Future scheduled test information is unavailable

Pending Tests Pending diagnostic test information is unavailable

Future Visits Future appointment information is unavailable

Referrals to Other ProvidersReason for ReferralReferral Start DateProviderProvider Contact InformationProvider AddressPei Chang Chung , MDWork Phone: +1(618)288-36166810 State Route 162Suite 100MARYVILLE IL 62062Primary Care Physician SuthanWork Phone: +1(618)258-0485Pei Chang Chung , MDWork Phone: +1(618)288-36166810 State Route 162Suite 100MARYVILLE IL 62062Pei Chang Chung , MDWork Phone: +1(618)288-36166810 State Route 162Suite 100MARYVILLE IL 62062Future ProceduresProcedure NameOrdered DateScheduled DateOutpatient Surgery DischargeMay 29th, 2024 11:46amMay 29th, 2024 12:00amAdmit as InpatientJuly 1st, 2024 3:35pmJuly 1st, 2024 3:35pmDischarge OrderJuly 3rd, 2024 4:36pmJuly 3rd, 2024 4:36pmUrinary Catheter, Place INTRAOPERATIVEJuly 1st, 2024 2:08pmJuly 1st, 2024 2:15pmOutside images CTMay 7th, 2024 10:15pmMay 7th, 2024 12:00amDischarge OrderMay 9th, 2024 9:50amMay 9th, 2024 9:50amPlacement to ObservationMay 7th, 2024 11:56pmMay 7th, 2024 11:56pmChange Status to InpatientMay 8th, 2024 9:11amMay 8th, 2024 9:11amOutpatient Surgery DischargeJuly 22nd, 2024 3:55pmJuly 22nd, 2024 12:00amFuture Medications Future medication information is unavailable

Patient InstructionsAntibiotic FormAnemia (AC)Anemia (AC)Hydrocodone/Acetaminophen (By mouth)Colectomy (DC)

Author Anthony ZychAnderson HealthcareMay 8th, 2024 7:04pm

Note Date/Time May 7th, 2024 9:04pm

Anderson Hospital 6800 State Route 162 Maryville, IL 62062 Emergency Room Visit Note SignedPatient: Towell,Alexander R MR#: M000499848 DOB: 08/04/1975 Acct:V00003663948Age: 48 ADM Date: 05/08/24 Loc: ANH3MEDSUR 327-01 Attending Dr: Pei Chang Chung M.D.cc: Gaudreault, Rachel N. PA-C; Suthan***, Nanthini MD; Zych, Anthony H. MD~HPI - Abdominal PainGeneralChief Complaint: Abdominal PainStated Complaint: bowel obstruction; CT scan earlier todayTime Seen by Provider: 05/07/24 20:19Source: patient and old records reviewedMode of arrival: ambulatoryLimitations: no limitationsHistory of Present IllnessHPI narrative: Patient is a 48-year-old male who presents the ED with report of bowel obstruction. Patient has history of partial colectomy in 2019 for colon cancer,performed by Dr. Chung. He has since underwent chemotherapy under Dr. Arshad. He states a history of chronic constipation, but states over the last 1 month, he has had increased difficulty with constipation. He has required taking laxatives frequently to have a bowel movement. He does note his stools have been dark in color over the last few weeks. He had blood work done recently andwas noted to be newly anemic. Following with Dr. Arshad for this. He is not onany blood thinners. Denies BRBPR. Has been having intermittent abdominal pain,mostly throughout his upper abdomen over the last 1 week, with intermittent nausea and vomiting. He underwent outpatient CT scan today at Saint Anthony’s Hospital in Alton which showed a partial small-bowel obstruction. He was then sent to the ED for further evaluation. Patient denies fevers.Related Data Home Medications Medication Instructions Recorded Confirmedcholecalciferol (vitamin D3) 25 25 mcg PO DAILY 01/12/24 01/12/24mcg (1,000 unit) tablet (Vitamin D3) levothyroxine 100 mcg tablet 100 mcg PO DAILY 01/12/24 01/12/24multivitamin with minerals-folic 1 tablet PO DAILY 01/12/24 01/12/24acid 200 mcg chewable tablet (Adult Multivitamin Gummies) AllergiesAllergy/AdvReac Type Severity Reaction Status Date / TimeNo Known Allergies Allergy Verified 05/07/24 20:16Review of SystemsReview of Systems: CONSTITUTIONAL: Denies fever, chills, or sweats.GASTROINTESTINAL: See HPI.GENITOURINARY: Denies dysuria or hematuria.MUSCULOSKELETAL: Denies back pain, extremity pain, myalgia.NEUROLOGIC: Denies headache, dizziness, numbness, or weakness. All systems reviewed & are unremarkable except as noted in HPI and below PMFSHPast Medical HistoryMedical History (Reviewed 05/07/24 @ 21:08 by Rachel N. Gaudreault, PA-C)Colon cancerIron deficiency anemia (Unknown)Mass of colon (~12/2021)ObesitySurgical HistorySurgical History (Reviewed 05/07/24 @ 21:08 by Rachel N. Gaudreault, PA-C)History of colon resection 12/29/2021 - hand assisted laparoscopic sigmoid colectomy with mobilization of the splenic flexureHistory of partial thyroidectomyFamily HistoryFamily History (Reviewed 05/07/24 @ 21:08 by Rachel N. Gaudreault, PA-C)Father Carcinoma of colon HypertensionMother Deceased COPD (chronic obstructive pulmonary disease)Social HistorySocial History (Reviewed 05/07/24 @ 21:08 by Rachel N. Gaudreault, PA-C)Smoking status: Never smoker Second hand tobacco smoke exposure: No Alcohol intake: former Drinks per week: 1 Alcohol use details: LAST DRINK 2015 Substance use: never Substance use type: does not use Living arrangements: with family Additional living arrangements comments: LIVES WITH SIGNIFICANT OTHER Spiritual care concerns: No Exam

Narrative: GENERAL: Well appearing, well-nourished, non-toxic, in no acute distress.HEAD: Normocephalic, atraumatic.RESPIRATORY: Airway patent, respirations nonlabored. Clear to auscultation bilaterally, no rales, rhonchi, wheezing.CARDIOVASCULAR: Regular rate and rhythm without murmurs, rubs, or gallops.ABDOMINAL: Soft, diffuse tenderness throughout upper abdomen, worst throughout epigastric region, nondistended. Normoactive BS. MUSCULOSKELETAL: Moves all extremities. No gross deformities.SKIN: Warm, dry, normal color.NEURO: A&O X3. Speech clear. Cranial nerves II-XII grossly intact. Steady gait. No ataxic movements. PSYCHIATRIC: Appropriate mood and affect. Normal interaction.CourseVital SignsVital signs: Vital SignsTemperature 98.7 F 05/07/24 20:12Pulse Rate 72 05/07/24 20:12Respiratory Rate 17 05/07/24 20:12Blood Pressure 143/76 H 05/07/24 20:12Pulse Oximetry 100 05/07/24 20:12Oxygen Delivery Room Air 05/07/24 20:12Temperature 98.7 F 05/07/24 20:12Pulse Rate 61 05/07/24 22:58Respiratory Rate 18 05/07/24 22:58Blood Pressure 123/68 05/07/24 22:58Pulse Oximetry 98 05/07/24 22:58Oxygen Delivery Room Air 05/07/24 20:12MDM - Abdominal PainMDM NarrativeMedical decision making narrative: Patient presented to ED with abnormal outpatient CT scan of his abdomen which showed SBO. History of colon cancer with partial resection. Has had issues with constipation, dark stools over the last few weeks. Vital signs are stable upon arrival. DRE performed in the ED with brown stool, guaiac negative. Cbc without leukocytosis. Hemoglobin 11.5, increasing from recent records. Normal platelets. CMP unremarkable. Lactic acid within normal limits at 0.7. Urinalysis with evidence of dehydration, no signs of infection. Fluids ongoing. CTreport was faxed from outside hospital, shows dilated loops of small bowel with transition zone in right lower abdomen, consistent with SBO. Discussed case with Dr. Chung, general surgery, agreed with plan for NG tube, will admit primarily. Patient has remained stable throughout ED stay. Denies current painor nausea. Keep NPO.Discussed case with Dr. Hopen, hospitalist, regarding comorbidity of hypothyroidism - on levothyroxine therapy. Patient does not have any other significant past medical history. She advised to given patient 1/2 his normal home dose of levothyroxine in the IV formulation while patient is NPO. She did not feel his workup otherwise warranted a medicine consult at this time. Will defer official consult for now. Will be happy to consult if other acute medicalissues developed during hospitalization.Medical RecordsAttestation: I reviewed the patient’s medical records.Lab DataAttestation: I reviewed the patient’s lab results. 05/07/24 21:05 05/07/24 21:05 Labs: Lab Results 05/07/24 Range/Units 21:05 WBC 4.9 (4.5-10.0) K/mm3RBC 4.38 L (4.6-6.20) M/mm3Hgb 11.5 L (14.0-18.0) g/dLHct 35.5 L (42.0-52.0) %MCV 81.1 (80-100) flMCH 26.3 (26-34) pgMCHC 32.4 (32-36) g/dlRDW 12.6 (11.5-14.5) %Plt Count 240 (150-375) k/mm3MPV 10.8 H (7.4-10.4) flImmature Gran % (Auto) 0.4 (0-0.5) %Neut % (Auto) 66.6 (45.5-73.1) %Lymph % (Auto) 22.0 (18.3-44.2) %Mono % (Auto) 8.4 (2.6-8.5) %Eos % (Auto) 2.2 (0-4.4) %Baso % (Auto) 0.4 (0.2-1.2) %Lymph # (Auto) 1.08 (0.9-3.2) K/mm3Mono # (Auto) 0.4 (0.1-0.6) K/mm3Eos # (Auto) 0.1 (0-0.3) K/mm3Baso # (Auto) 0.0 (0.0-0.1) K/mm3Abs Immat Gran (auto) 0.02 (0.00-0.031) K/mm3Absolute Neuts (auto) 3.3 (1.3-6.7) K/mm3Absolute Nucleated RBC 0.000 (0.0-0.012) K/mm3Nucleated RBC % 0.0 (0.0-0.2) %Sodium 139 (137-145) mmol/LPotassium 3.6 (3.4-5.0) mmol/LChloride 107 (98-107) mmol/LCarbon Dioxide 20 L (22-30) mmol/LAnion Gap 12 (4-12) mmol/LBUN 25 H (9-20) mg/dLCreatinine 1.30 (0.7-1.3) mg/dLEstim Creat Clear Calc 70 ml/minEstimated GFR 59 (59 - ) Glucose 93 (65-110) mg/dLLactic Acid 0.7 (0.7-2.0) mmol/LCalcium 9.2 (8.4-10.2) mg/dLTotal Bilirubin 0.5 (0.2-1.3) mg/dLAST 24 (17-59) U/LALT 15 (6-50) U/LAlkaline Phosphatase 85 (38-126) U/LTotal Protein 8.0 (6.3-8.2) g/dLAlbumin 4.7 (3.5-5.1) g/dLLipase 71 (23-300) U/LUrine Color Yellow (Yellow) Urine Appearance Clear (Clear) Urine pH 5.0 (5.0-9.0) Ur Specific Gravity 1.092 H (1.001-1.035) Urine Protein Negative (Negative) mg/dLUrine Glucose (UA) Negative (Negative) mg/dLUrine Ketones 1+ H (Negative) mg/dLUr Blood (Man) Negative (Negative) Urine Nitrate Negative (Negative) Urine Bilirubin Negative (Negative) Urine Urobilinogen 0.2 (<2.0) mg/dLLeukocyte Esterase Rfl Negative (Negative) LEU/ULImaging DataAttestation: I personally reviewed and interpreted this imaging study as follows:Radiologist’s impression: CT ABD/pelvis: Impression: There are dilated loops of small bowel measuring upto 3.5 cm with fecalization of bowel contents and transition zone within the right lower abdomen where there is twirling of a short-segment loop of small bowel with abnormal wall thickening, and surrounding engorged vessels/fat stranding. Findings are suspicious for acute small bowel obstruction, possibly partial. Further evaluation with endoscopy to exclude underlying neoplasm due to prior history of colon cancer. Prominent enlarged abdominal lymph nodes. These may be reactive or neoplastic given history of prior malignancy. Comparison to prior studies and attention on follow-up. Sclerotic focus in the left iliac bone, nonspecific given history of malignancy. Comparison with priorstudies were stability or evaluation with MRI or bone scan if clinically indicated. Status post colonic resection and anastomosis without suspicious findings around the anastomosis. Small free fluid in the pelvis.Discharge PlanDischargeClinical Impression: Small bowel obstruction, History of colon cancer, Status post partial resectionof colon, AnemiaPatient Disposition: Still a PatientCondition: StablePrescriptions:No Action levothyroxine 100 mcg tablet 100 mcg PO DAILY Adult Multivitamin Gummies 200 mcg Tablet,Chewable 1 tablet PO DAILY cholecalciferol (vitamin D3) [Vitamin D3] 25 mcg (1,000 unit) Tablet 25 mcg PO DAILY tramadol 50 mg tablet 50 mg PO Q6H PRN (Reason: pain) Qty: 7 0RFFollow-up/Referrals:Suthan***,Nanthini, MD [Primary Care Provider] - 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: Gaudreault, Rachel N. PA-C 05/07/24 / 2104Electronically signed by: Gaudreault, Rachel N. PA-C 05/08/24 0041 Zych, Anthony H. MD 05/08/24 1904

Author Pei ChungAnderson HealthcareJuly 2nd, 2024 2:47pm

Note Date/Time July 2nd, 2024 2:47pm

Anderson Hospital 6800 State Route 162 Maryville, IL 62062 General Surgery Progress Note SignedPatient: Towell,Alexnder R MR#: M000499848 DOB: 08/04/1975 Acct:V00003676858Age: 48 ADM Date: 07/01/24 Loc: ANH3MEDSUR 303-01 Attending Dr: Pei Chang Chung M.D.cc: ~Progress Note: A&PAssessment and Plan(1) Adenocarcinoma of small bowel: Code(s):C17.9 - Malignant neoplasm of small intestine, unspecified Status: Acute Assessment and

Plan: doing well, await path, ADAT, cont encourage OOB/ISSubjectiveSubjectiveDate/Time Seen: 07/02/24 14:46Interval history: feels pretty good, up and ambulating s issue, no bowel fxn, tol clearsReview of SystemsReview of Systems: All systems reviewed & are unremarkable except as noted in HPI and below ExamConst: General: cooperative, comfortable and no acute distress GI: Inspection: normal to inspection, non-distended and incision GI Palp: Yes abdominal tenderness, Yes Soft to palpation, Yes Tenderness to palpation present (GI), No Guarding due to palpation present (GI) and No Rigid due to palpation Objective DataVital SignsVital Signs: Vital Signs - 24 hr 07/01/2415:49 07/01/2416:00 07/01/2416:15Temperature 36.5 C Pulse Rate 55 L 61 56 LRespiratory Rate 14 18 16Blood Pressure 117/62 113/58 L 126/66Pulse Oximetry 100 100 98Oxygen Delivery Simple FaceMask Simple FaceMask Room AirOxygen Flow Rate 8 8 07/01/2416:30 07/01/2416:45 07/01/2417:00Temperature Pulse Rate 66 70 77Respiratory Rate 18 16 18Blood Pressure 119/60 123/74 123/70Pulse Oximetry 96 100 100Oxygen Delivery Room Air Room Air Room AirOxygen Flow Rate 07/01/2417:20 07/01/2417:35 07/01/2418:05Temperature 36.0 C L 36.0 C L 36.0 C LPulse Rate 71 74 60Respiratory Rate 18 16 18Blood Pressure 139/56 L 150/58 H 141/58 HPulse Oximetry 97 99 98Oxygen Delivery Oxygen Flow Rate 07/01/2419:07 07/01/2420:00 07/01/2420:00Temperature 36.3 C L 36.3 C LPulse Rate 57 L 68Respiratory Rate 18 17Blood Pressure 132/55 L 122/64Pulse Oximetry 98 100 100Oxygen Delivery Room Air Oxygen Flow Rate 07/01/2423:57 07/02/2404:00 07/02/2408:00Temperature 36.9 C 36.6 C 36.0 C LPulse Rate 63 72 50 LRespiratory Rate 18 16 16Blood Pressure 113/62 123/63 125/65Pulse Oximetry 99 99 100Oxygen Delivery Oxygen Flow Rate 07/02/2408:00 07/02/2411:48Temperature 36.1 C LPulse Rate 58 LRespiratory Rate 16Blood Pressure 127/70Pulse Oximetry 99Oxygen Delivery Room Air Oxygen Flow Rate Intake/OutputIntake/Output: Intake & Output 06/29/24 06/30/24 07/01/24 07/02/24 23:59 23:59 23:59 23:59Intake Total 300 1050Output Total 550Balance 300 500Meds/ResultsMedications: Active MedicationsGeneric Name Dose Route Start Last Admin Trade Name Freq PRN Reason Stop Dose AdminHydrocodone Bitart/Acetaminophen 1 tab 07/01/24 15:35 07/02/24 06:21 Hydrocodone/Acetaminophen (*Crx) 5-325 Mg Tablet PO 1 tab Q4H PRN Administration Pain Rated 4-6 Enoxaparin Sodium 40 mg 07/02/24 09:00 07/02/24 08:05 Enoxaparin 40 Mg/0.4 Ml Syringe SUB-Q 40 mg DAILY SCH AdministrationFamotidine 20 mg 07/01/24 21:00 07/02/24 08:05 Famotidine 20 Mg/2 Ml Vial IV PUSH 20 mg Q12HR SCH AdministrationFentanyl Citrate 25 mcg 07/01/24 16:00 Fentanyl Citrate Inj (*Crx) 100 Mcg/2 Ml Vial IV PUSH Q2M PRN Pain Hydromorphone HCl 1 mg 07/01/24 17:16 Hydromorphone Hcl Inj (*Crx) 1 Mg/Ml Syr IV PUSH Q2H PRN Breakthrough Pain Rated 7-10 or NPO Hydromorphone HCl 0.5 mg 07/01/24 15:35 Hydromorphone Hcl Inj (*Crx) 1 Mg/Ml Syr IV PUSH Q2H PRN Breakthrough Pain Rated 4-6 or NPO Lactated Ringer’s 1,000 mls @ 100 mls/hr 07/01/24 15:35 07/02/24 10:18 Lr - Lactated Ringers Iv IV CONT 100 mls/hr .Q10H SCH AdministrationIbuprofen 800 mg in 200 mls @ 400 mls/hr 07/01/24 15:35 Caldolor 800 Mg/200 Ml IVPB Q6H PRN Breakthrough Pain Rated 1-3 or NPO Levothyroxine Sodium 100 mcg 07/02/24 06:30 07/02/24 05:17 Levothyroxine Sodium 100 Mcg Tablet PO 100 mcg DAILY@0630 SCH AdministrationNaloxone HCl 0.1 mg 07/01/24 15:35 Naloxone Hcl 0.4 Mg/Ml Vial IV PUSH Q2M PRN Opiate Reversal Ondansetron HCl 4 mg 07/01/24 15:35 Ondansetron Inj 4 Mg/2 Ml Vial IV PUSH Q4H PRN Nausea And Vomiting Radiology Results: ITS ImpressionsAbdomen X-Ray 07/01/24 15:32

IMPRESSION: No foreign body detected.LabsLabs: Laboratory Results - last 24 hr 07/02/24 06:04WBC 10.5 HRBC 4.37 LHgb 12.3 LHct 38.7 LMCV 88.6MCH 28.1MCHC 31.8 LRDW 17.1 HPlt Count 216MPV 11.0 HSodium 139Potassium 3.9Chloride 105Carbon Dioxide 23Anion Gap 11BUN 11 DCreatinine 1.00Estim Creat Clear Calc 90Estimated GFR > 60Glucose 113 HCalcium 9.2This 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: Chung, Pei Chang MD 07/02/24 / 1447Electronically signed by: Chung, Pei Chang MD 07/02/24 1447

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

Mary Stuart, PA - 08/23/2023 9:00 AM CDTFormatting of this note is different from the original.Images from the original note were not included.NEW PATIENT VISITSubjective CHIEF COMPLAINTHe had concerns including Pain of the Right Wrist.HISTORY OF PRESENT ILLINESSPatient here with complaints of right wrist pain. He reports a fall 8 months ago. He was playing with his niece and this was an accidental fall. Symptoms initially got better slowly with time, however he is continued to experience ongoing ulnar-sided pain. It limits him with rotation and extension type activities. Symptoms are exacerbated by use. They improve with rest. A constant dull aching sensation. He states history of chemo induced neuropathy of the right wrist and hand, which is stablePain AssessmentPain

Assessment: 0-10Pain Score: 2PAST MEDICAL HISTORYHe has a past medical history of Anemia, Cancer (CMS/HCC) (HCC), and Peripheral neuropathy.PAST SURGICAL HISTORYHe has a past surgical history that includes Colon surgery.MEDICATIONSHe has a current medication list which includes the following prescription(s): levothyroxine.ALLERGIESHe has No Known Allergies.SOCIAL HISTORYHe No alcohol history on file.FAMILY HISTORYHistory reviewed. No pertinent family history.REVIEW OF SYSTEMSReview of Systems Constitutional: Negative for chills, fatigue and fever. Eyes: Negative for pain and visual disturbance. Respiratory: Negative for chest tightness and shortness of breath. Cardiovascular: Negative for chest pain and leg swelling. Gastrointestinal: Negative for abdominal pain, constipation, diarrhea and vomiting. Genitourinary: Negative for dysuria, frequency and urgency. Musculoskeletal: Negative for myalgias. Skin: Negative for rash and wound. Neurological: Negative for dizziness, weakness and light-headedness. Hematological: Does not bruise/bleed easily. Psychiatric/Behavioral: Negative for confusion and hallucinations. Objective PHYSICAL EXAMBP 141/89 | Pulse 62 | Ht 182.9 cm (6’) | Wt 100.2 kg (221 lb) | BMI 29.97 kg/m² Right hand/wristInspectionErythema: absentEffusion: absentEdema: presentSurgical scar/wound: absent. PalpationTenderness: present. The tenderness is located in the ulnar forveal, ulnar triquetral and DRUJ.Range of motionThe patient has reduced range of motion of the right wrist.The patient has pain with range of motion of the right wrist.Strength Thumb extension: 5/5Thumb flexion: 5/5Thumb opposition: 5/5Wrist extension: 4/5Wrist flexion: 5/5Interossei: 3/5Grip: 4/5NeurovascularThe patient has normal vascular on the right side of their body.The patient has normal sensation with exceptions as noted below.Median: paresthesiasRadial: paresthesiasUlnar: paresthesiasTestTinel’s sign: negativeUlnar Impaction sign: positiveLeft hand/wristThe patient has normal inspection, palpation, range of motion, strength, and stability of the left hand and wrist.REVIEW OF X-RAYS/STUDIES/LABSXR Wrist Right 3 or More Views Radiographs of the right wrist reviewed, interpreted, and compared with earlier views obtained at an outside facility. No acute fractures are seen. On tunnel view, there subacute changes at the trapezial process, likely reflective of prior injury or subacute fracture. No bony entrapment is present upon carpal tunnel. Positive ulnar variance appreciatedFriedman, Michael, MD - 07/28/2023Formatting of this note might be different from the original.EXAM DESCRIPTION: XR WRIST LIMITED 2 VIEW RIGHTREASON FOR STUDY: Two views submitted without comparison.

FINDINGS: Two views submitted without comparison.No acute fractures are identified. Ulnar positive variance ispresent. The joint spaces are normal. There is no dorsal wristsoft tissue swelling.THIS IS AN ELECTRONICALLY VERIFIED FINAL REPORT7/28/2023 11:06 AM- Electronically signed by Michael Friedman M.D.Michael Friedman M.D.MF: MFD: 7/28/2023 11:06 AMT: 7/28/2023 11:06 AMReport ID: 3444913Reading Location: FRIEDMANDXLT-19

IMPRESSION: Right ulnar positive variance.Exam End: 07/26/23 16:09 Specimen Collected: 07/28/23 11:06 Last Resulted: 07/28/23 11:09 Received From: OSF Healthcare Result Received: 08/23/23 08:56 Assessment/Plan Alexander was seen today for pain.Diagnoses and all orders for this visit:TFCC (triangular fibrocartilage complex) injury, right, initial encounter- XR Wrist Right 3 or More Views- Ambulatory referral order to Occupational Therapy -; FutureClosed displaced fracture of trapezium of right wrist, sequela- Ambulatory referral order to Occupational Therapy -; FutureCongenital positive ulnar variance of right wrist- Ambulatory referral order to Occupational Therapy -; FuturePeripheral neuropathy due to chemotherapy (HCC)Plan We discussed and reviewed his complaints, clinical findings, and images today. We discussed conservative versus surgical management of his above diagnoses.We discussed the benefits of hand therapy, including further reduction in pain, inflammation, and correction of mechanical/strength deficits. Patient elected to proceed and order placed. Splinting per discretion of OT. Follow up in 6-8 weeks, if symptoms persist. If he he fails OT may further benefit from injection. Further conservative measures including ice/heat, avoidance of aggravating activities, OTC NSAIDs/analgesics p.r.n. (if able to take), OTC analgesic creams reviewed with him today.All questions were answered. Patient expressed full understanding and agreement of plan. This note was partially completed using M*Modal Fluency Direct speaking software, therefore, occasional wrong-word or ‘sound-a-like’ substitutions may have occurred. Read the chart carefully and recognize, using context, where substitutions have occurred. Mary Katherine Stuart, PAElectronically signed by Mary Stuart, PA at 09/12/2023 10:34 AM CDTdocumented in this encounter

Benjamin Tan, MD - 08/15/2024 3:15 PM CDTFormatting of this note is different from the original.Images from the original note were not included.Oncology Medicine History and PhysicalAlexander R TowellDOB:8/4/1975 DATE OF VISIT:8/15/2024Referring Provider: Syed M. Arshad, MD Cancer Staging No matching staging information was found for the patient.Oncology History Overview Note DIAGNOSIS:Sigmoid Adenocarcinoma Stage IIIMetastaticTerminal Ileum Adenocarcinoma, MSS, RAS WT, with liver metastasesGENOMIC DATA:1. TEMPUS XT for small bowel adenocarcinoma2. TEMPUS XF- ONCOLOGIC HISTORY:presented with anemia with tiredness, constipation, abdominal pain and fatigue back in 2021. He required blood transfusions- 11/22/2021 Colonoscopy showed malignant appearing mas in descending colon with ulceration and partial obstruction- 11/23/2021 labs notes wbc 3.8, Hb 9.4, platelets 310K, creatinine 1.8, bilirubin 0.3, CEA 1.4- 12/09/2021 CT scan showed exophytic sigmoid colon mass (2.6 cm) with Lymph nodes suspicious for metastatic disease and sclerotic focus in the left iliac bone.- 12/10/2021 Consultation with Dr. Syed (Oncology)- 12/29/2021 laparsocopic sigmoid colectomy pathology showed moderately differentiated colon adenocarcinoma 1 of 23 LN +, MSS, RAS WT- stage IIIB pT4N1M0- 02/16/2022 to 08/29/2022 adjuvant FOLFOX x 12 cycles with dose reduction. Toxicities include neuropathy and diarrhea, fatigue- 01/01/2023 CT scans showed no recurrence- 01/09/2023 Colonoscopy showed normal findings- 12/29/2023 CT showed no metastases- 05/29/2024 Colonoscopy showed large ulcerated mass in the terminal ileum, biopsy confirmed moderately differentiated adenocarcinoma- 07/01/2024 right hemicolectomy - showed 4 of 14 LN +, PNI+, no LVI, RAS WT, MSS- 07/11/2024 Tempus XF - 07/25/2024 PET scan done showed liver lesions. Started chemotherapy with Cycle 1 FOLFIRI- 08/12/2024 Cycle 2 FOLFIRI/bevacizumab: has diarrhea treated with immodium- 08/15/2024 Consultation with medical oncology (tan) to discuss HAI pump therapyTREATMENT HISTORY: laparsocopic sigmoid colectomy 12/29/2021Adjuvant FOLFOX x 12 cycles 2/16/2022- 8/2022Right hemicolectomy 7/1/2024FRONTLINE FOLFIRI/Bevacizumab- 07/25/2024 Cycle 1 FOLFIRI- 08/12/2024 Cycle 2 FOLFIRI/BevacizumabMalignant neoplasm metastatic to liver (HCC) 8/16/2024 Initial Diagnosis Malignant neoplasm metastatic to liver (HCC)Active Treatment & Therapy Plans for Towell, Alexander R Towell, Alexander R does not have any active plans of the following types: Oncology Chemotherapy Treatment, Oncology Treatment (2), Oncology Treatment (3), Oncology Supportive Care, Specialty Infusion Treatment, Blood Products, BMT, HematologySubjective Mr. Alexander R Towell is a 49 y.o. Non-Hispanic male who comes to the Gastrointestinal Oncology Clinic at Washington University for second opinion for his metastatic colon cancer.In brief, Mr. Alexander R Towell presented with anemia with tiredness, constipation, abdominal pain and fatigue back in 2021. He required blood transfusions- 11/22/2021 Colonoscopy showed malignant appearing mas in descending colon with ulceration and partial obstruction- 11/23/2021 labs notes wbc 3.8, Hb 9.4, platelets 310K, creatinine 1.8, bilirubin 0.3, CEA 1.4- 12/09/2021 CT scan showed exophytic sigmoid colon mass (2.6 cm) with Lymph nodes suspicious for metastatic disease and sclerotic focus in the left iliac bone.- 12/10/2021 Consultation with Dr. Syed (Oncology)- 12/29/2021 laparsocopic sigmoid colectomy pathology showed moderately differentiated colon adenocarcinoma 1 of 23 LN +, MSS, RAS WT- stage IIIB pT4N1M0- 02/16/2022 to 08/29/2022 adjuvant FOLFOX x 12 cycles with dose reduction. Toxicities include neuropathy and diarrhea, fatigue- 01/01/2023 CT scans showed no recurrence- 01/09/2023 Colonoscopy showed normal findings- 12/29/2023 CT showed no metastases- 05/29/2024 Colonoscopy showed large ulcerated mass in the terminal ileum, biopsy confirmed moderately differentiated adenocarcinoma- 07/01/2024 right hemicolectomy - showed 4 of 14 LN +, PNI+, no LVI, RAS WT, MSS- 07/11/2024 Tempus XF - 07/25/2024 PET scan done showed liver lesions. Started chemotherapy with Cycle 1 FOLFIRI- 08/12/2024 Cycle 2 FOLFIRI/bevacizumab: has diarrhea treated with immodium- 08/15/2024 Consultation with medical oncology (tan) to discuss HAI pump therapyToday, he comes and noted :- feeling well- mild loose stools- no fever, chills- no nausea, vomiting- no abdominal pain- no chest pain, SOBPast Medical

History: Diagnosis Date Anemia Cancer (CMS/HCC) (HCC) Peripheral neuropathy Thyroid disease Past Surgical

History: Procedure Laterality Date COLON SURGERY 12/30/2021 SMALL BOWEL RESECTION 07/01/2024 Prior to Admission medications Medication Sig Start Date End Date Taking? Authorizing Provider levothyroxine (SYNTHROID) 88 mcg tablet Take 1 tablet (88 mcg total) by mouth daily 3/23/23 Provider, Historical, MD No Known AllergiesSocial History Tobacco Use Smoking status: Never Smokeless tobacco: None Substance and Sexual Activity Drug use: None Sexual activity: None Alcohol Use: Not on file Family History Problem Relation Age of Onset Prostate cancer Father 69 Review of SystemsReview of Systems Constitutional: Negative. HENT: Negative. Eyes: Negative. Respiratory: Negative. Cardiovascular: Negative. Gastrointestinal: Negative. Endocrine: Negative. Genitourinary: Negative. Musculoskeletal: Negative. Skin: Negative. Neurological: Negative. Hematological: Negative. Psychiatric/Behavioral: Negative. Pain: negative.Review of SystemsObjective Vitals:BP: 127/83Temp: 36.3 °C (97.4 °F)Temp src: OralPulse: 68Resp: 16SpO2: 97 %Height: 184.2 cm (6’ 0.52")Weight: 88.2 kg (194 lb 6.4 oz)ECOG:0PHYSICAL EXAMINATIONPhysical ExamVitals reviewed. Constitutional: General: He is not in acute distress. Appearance: Normal appearance. HENT: Head: Normocephalic and atraumatic. Nose: Nose normal. Eyes: General: No scleral icterus. Conjunctiva/sclera: Conjunctivae normal. Cardiovascular: Rate and Rhythm: Normal rate and regular rhythm. Pulses: Normal pulses. Heart sounds: Normal heart sounds. Pulmonary: Effort: Pulmonary effort is normal. Breath sounds: Normal breath sounds. No wheezing or rales. Abdominal: General: Abdomen is flat. Bowel sounds are normal. There is no distension. Palpations: Abdomen is soft. There is no mass. Tenderness: There is no abdominal tenderness. Musculoskeletal: General: Normal range of motion. Cervical back: Normal range of motion. Right lower leg: No edema. Left lower leg: No edema. Lymphadenopathy: Cervical: No cervical adenopathy. Skin: General: Skin is warm and dry. Coloration: Skin is not jaundiced. Neurological: General: No focal deficit present. Mental Status: He is alert and oriented to person, place, and time. Psychiatric: Mood and Affect: Mood normal. Behavior: Behavior normal. Thought Content: Thought content normal. Judgment: Judgment normal. Lab/Radiology/Diagnostic Review:No results found for this or any previous visit (from the past 24 hour(s)). PATHOLOGY REVIEW:7/1/20245/29/202411/22/20219/20/2022THYROID, RIGHT LOBE, RIGHT LOBECTOMY:- NODULAR HYPERPLASIA (NODULAR GOITER)-ADDITIONAL PATHOLOGIC FINDINGS - ONE (1) LYMPH NODE NEGATIVE FOR METASTASIS (0/1).- LYMPHOCYTIC THYROIDITIS:- PARATHYROID GLAND(S): ONE PRESENT IN THE LOWER POLE, WITHOUT HISTOLOGIC ABNORMALITIES.7/29/2022THYROID LOBE, RIGHT, ULTRASOUND GUIDED NEEDLE BIOPSY:- ADEQUATE FOR INTERPRETATION. - SUSPICIOUS FOR FOLLICULAR NEOPLASM. BETHESDA CLASS IV. 5/11/2022A. THYROID LOBE, RIGHT, (1ST NODULE), ULTRASOUND-GUIDED NEEDLE BIOPSY; - ADEQUATE FOR INTERPRETATION.- BENIGN, CONSISTENT WITH BENIGN FOLLICULAR NODULE (INCLUDES ADENOMATOID NODULE, COLLOID NODULE, ETC.). BETHESDA CLASS II.B. THYROID LOBE, RIGHT (2ND NODULE), ULTRASOUND-GUIDED NEEDLE BIOPSY: - ADEQUATE FOR INTERPRETATION.- ATYPIA OF ON DETERMINE SIGNIFICANCE. FOLLICULAR CELLS WITH MILD FOCAL ARCHITECTURAL ATYPIA. BETHESDA CLASS IIIctDNA7/11/2024RADIOLOGY REVIEW:PET OSH 7/25/2024 CONSULT1. At least four hypermetabolic liver lesions involving segment II,VII and VIII compatible with metastatic disease.2. Two intensely hypermetabolic soft tissue nodule deposits in therectovesical pouch are compatible with metastatic diseaseThe findings, conclusions and recommendations within this report donot replace the initial findings, conclusions and recommendationsmade at the facility where the study was performed based upon theimaging and clinical condition at that time. Comparison with theprior report and clinical history is necessary. The provided imagesmay or may not represent the native source data set and thus maycontain changes that may lower the accuracy of this second-opinioninterpretation..SURGERY 7/1/2024Colonoscopy 5/29/2024Bone scan 5/22/2024CT AP OSH 5/7/2024CT AP 12/28/2023ASSESSMENT AND PLAN:Alexander R Towell is a 49 y.o. Non-Hispanic male with metastatic small bowel adenocarcinoma with liver and pelvis metastases who presents for second opinionMetastatic Terminal Ileum Adenocarcinoma, MSS, RAS WT, with liver and pelvic metastases- I reviewed available records per epic prior to the visit- I also reviewed records sent by patient through the portal after the visit and summarized and outlined as above- I have reviewed the PET scan images noting at least 4 liver lesions and also uptake in the rectovesical region of the pelvis concerning for extrahepatic disease- I have reviewed his TEMPUS XT and XF noting no RASS alterations, MSS and a TP53 alteration also seen in the tumor and blood- With the limited data during the visit, we recommended proceeding with an MRI abdomen and Pelvis to assess fully these liver lesions. We also had his PET scan from outside consulted as above.- Unclear if HAI pump therapy appropriate for him as he has pelvis disease. I would like to review his MRI imaging once available and refer him to our colorectal surgeons and hepatobiliary/transplant surgeons to assess resection of both pelvis disease as well as liver disease, as well as options for possible locoregional therapies to the liver, including ablation, Y90, TARE, SBRT.- At this point, he is to continue his current systemic therapy locally.All of his questions were answered. He understands and was in agreement with the plan of care. He knows to call the office in the interim with any symptoms, questions, or concerns.Benjamin R. Tan, MD My total encounter time on 8/15/2024 was 66 minutes which was spent in the activities documented in the note. This includes time spent prior to the visit and after the visit in direct care of the patient. This time does not include time spent in any separately reportable services. Electronically signed by Benjamin Tan, MD at 08/16/2024 9:21 PM CDTdocumented in this encounter

Ellen S - 09/11/2024 3:06 PM CDTFormatting of this note might be different from the original.Called Dr.Field’s office to attempt to get this pt scheduled and was unsuccessful after a 20 minute call that was not helpful. Called Dr.Field’s office back because of concerns this appt will not get scheduled and was told Megan the NP will get back with me.Electronically signed by Ellen S at 09/11/2024 3:14 PM CDTdocumented in this encounter

Lauren Lutz, NP - 10/23/2024 10:30 AM CDTFormatting of this note is different from the original.Transplant/ Hepatobiliary Surgery Outpatient Clinic NoteChief Complaint: mCRC to the liverReferred by: Nanthini Suthan, MDHPI: Mr. Alexander R Towell is a 49 y.o. male with a history of metastatic CRC diagnosed via colonoscopy done for constipation in 2021. Pt then underwent laparoscopic sigmoid colectomy 12/29/21 (1/23 lymph nodes +; negative for K-ras mutation). Complete chemotherapy with FOLFOX 2/16-12/22/22. Per patient report, things were stable for ~1 year, when he began experiencing constipation again. Pt underwent repeat colonoscopy 5/29/24 which demonstrated a large ulcerated lesion with bleeding in the terminal ileum. He is now s/p R sided hemicolectomy 7/1/24 (small bowel +invasive adenocarcinoma, perineural invasion present, 4/14 lymph nodes +; no lymphovascular invasion; K-ras negative). Pt started back on chemotherapy with FOLFIRI/Avastin 7/25/24 with Dr. Arshad (Mercy), and has also been seen by Dr. Tan at WashU for a second opinion. Per patient report he underwent a CT scan last week at Anderson hospital, those results are not available at the time of this visit. Of note, pt initially planned to be seen by Dr. Fields who scheduled a repeat MRI 11/1/24, pt was able to get into see Dr. Chapman sooner. Advised pt to keep appointment for repeat MRI. Past Medical

History: has a past medical history of Anemia, Cancer (CMS/HCC) (HCC), Peripheral neuropathy, and Thyroid disease. Past Surgical

History: has a past surgical history that includes Colon surgery (12/30/2021) and Small Bowel Resection (07/01/2024).Social

History: Alcohol: deniesTobacco: deniesMarijuana: deniesOccupation: not currently, previous research assistant at SIUEPresents to clinic with partner. Allergies: No Known AllergiesFamily

History:family history includes Prostate cancer (age of onset: 69) in his father.Medications: HOME MEDICATIONS : cyanocobalamin (Vitamin B-12) 100 mcg tablet iron bisgly,ps-FA-B-C#12-succ 65 mg-65 mg -1,000 mcg (24) tablet levothyroxine (SYNTHROID) 100 mcg tablet multivitamin with minerals tablet omega-3 fatty acids-fish oil 300-1,000 mg capsuleReview of Systems: Reports: overall tolerating chemo ok, some fatigue, N better managed on current regimenDenies any abdominal pain, vomiting, constipation, diarrhea, dark urine, light stools, fevers, chills, loss of appetite, weight loss, jaundice or pruritis. Physical Exam: Blood pressure 143/79, pulse 85, temperature 36.6 °C (97.8 °F), height 182.9 cm (6’), weight 89.5 kg (197 lb 6.4 oz).Constitutional: AmbulatoryHead: Normocephalic, non traumaticEyes:Bilateral sclera anicteric ENT: Normal hearing, no obvious deformitiesLungs: Non- labored breathing, on room airCV: Well perfused, no JVDAbdomen: Soft, not distended, non tenderSkin: No rashes or jaundiceExtremities: Warm, no pitting pedal edemaNeuro: No gross neurological deficitsPysch: Mood appropriate, A+Ox3Labs: No results found for: “WBC”, “HGB”, “HCT”, “MCV"Lab Results Component Value Date CREATININE 1.4 (H) 08/28/2024 Pathology: Taken: 8/20/2024 Received: 8/20/2024 Accessioned: 8/20/2024 Reported: 8/22/2024 Physician(s): Benjamin Tan, M.D. Anderson Hospital Department of Pathology 6800 State Route 162 Maryville, IL 62062 P: 618-391-6765 F: 618-288-6541 Histology: 618-391-6774

Diagnosis: Consult material received from Anderson Hospital, Maryville, IL (OSC: AS21-7173; 11/22/2021) A. Stomach, biopsy - Normal oxyntic mucosa - No H. pylori organisms are identified by H&E examination B. Small bowel, biopsy - Normal duodenal mucosa C. Large bowel, descending colon mass, biopsy - Ulcerated invasive adenocarcinoma Consult material received from Anderson Hospital, Maryville, IL (OSC: AS21-7988; 12/29/2021) A. Large bowel, sigmoid, left hemicolectomy - Moderately differentiated colonic adenocarcinoma invading the visceral peritoneum (pT4a) - Tumor arises in the sigmoid colon and measures 6.0 cm in greatest dimension, per report - Surgical margins are negative for tumor - Negative for perineural or lymphovascular invasion - Metastatic adenocarcinoma in one of twenty-three lymph nodes(1/23; pN1a) Consult material received from Anderson Hospital, Maryville, IL (OSC: AS24-3099; 05/29/2024) A. Small bowel, terminal ileum ulcerated lesion, biopsy - Invasive adenocarcinoma, moderately-differentiated - Intact nuclear expression of mismatch repair proteins (MLH1, PMS2, MSH2, and MSH6) by immunostains Consult material received from Anderson Hospital, Maryville, IL (OSC: AS24-3810; 07/01/2024) A. Large bowel, right colon and ileum, right hemicolectomy - Moderately differentiated adenocarcinoma involving the perienteric soft tissue, muscularis propria, submucosa, and mucosa (see comment) - No precursor lesion identified in the ileal mucosa - Per report, deep/radial margin positive for tumor - Distal and proximal margins negative for tumor - Positive for perineural invasion - Negative for definitive lymphovascular invasion - Five tumor deposits identified - Metastatic adenocarcinoma in four of fourteen lymph nodes (4/14) - Normal appendix Imaging: MRI Liver 8/28/24

FINDINGS: Liver: No surface nodularity. No steatosis or iron deposition.- Bile ducts: No biliary ductal dilation.- Focal liver lesions: No arterial enhancing liver lesion. A 2.3 cmhepatobiliary phase hypointense lesion is seen in segment 2 (series34, image 35 and series 38, image 20). Additional 1.3 cmhepatobiliary phase hypointense lesion in segment 4A (series 38,image 23 and series 34, image 34). A vague hepatobiliary phasehypointense lesion is seen in segment 7 measuring 5 mm (series 38,image 25) and series 34, image 33). Peripheral wedge-shaped area of hepatobiliary phase hypointensity inhepatic segment 8 (series 38, image 26), without a correlate on othersequences.- Vasculature: Patent. Conventional hepatic arterial anatomy.Gallbladder: NormalPancreas: Normal. No pancreatic ductal dilation.Spleen: NormalAdrenals: NormalKidneys: Normal no hydronephrosis.Bladder: Normal.Reproductive organs: Prostate is not enlarged.Other Findings: Small volume ascites. No bowel obstruction. Postsurgical changes of sigmoid colectomy and right hemicolectomy. No bowel obstruction. No suspicious osseous lesion. Colonicdiverticulosis. Small right hydrocele. Residual linear T2 hypointensity is seen in the rectovesicular pouch(series 12, image 28 and series 27, image 52), corresponding totreated pelvic metastases. No associated enhancement or diffusionrestriction.

IMPRESSION:1. Vague hepatobiliary phase hypointense lesions in segment 2, 4Aand 7, corresponding to FDG avid lesions on PET/CT 07/25/2024. Thevague appearance of these lesions likely indicates treatmentresponse. Previously described lesion in the liver dome in segment 8on PET/CT is not seen on the current examination.2. Treated rectovesicular pouch lesions without evidence of residualmetastatic disease in the pelvis.3. Conventional hepatic arterial anatomy.4. Peripheral wedge-shaped area of hepatobiliary phase hypointensityin segment 8 without a correlate on other sequences is nonspecific,but is unlikely to represent metastatic disease.

Assessment: Mr. Towell is a 49 y.o. male with mCRC to the liver presenting to clinic for surgical consultation.

Plan: - We will discuss the patient’s imaging at our liver multidisciplinary conference on Thursday morning prior to making further recommendations. All questions were answered in clinic. The patient will be updated with findings and recommendations following review at conference. - Will obtain OSH imaging performed last week at Anderson Hospital for review. - Advised pt to keep appointment for MRI at this point, can further discuss after reviewing at imaging conference. Disposition: We will follow-up with the patient after reviewing the patient’s case at conference. . They know to call the office with any questions or concerns in the interim. Lauren Michelle Lutz, NPPatient Care Team:Suthan, Nanthini, MD as PCP - GeneralArshad, Syed M., MD as Referring Physician (Hematology)Tan, Benjamin R., MD as Medical Oncologist/Hematologist (Medical Oncology) Cosigned by William Chapman, MD at 10/26/2024 6:07 AM CDTElectronically signed by Lauren Lutz, NP at 10/24/2024 8:49 AM CDTElectronically signed by William Chapman, MD at 10/26/2024 6:07 AM CDTdocumented in this encounter

William Chapman, MD - 11/14/2024 1:00 PM CSTFormatting of this note is different from the original.Images from the original note were not included.WASHINGTON UNIVERSITY SCHOOL OF MEDICINE SECTION OF COLON RECTAL SURGERY HISTORY AND PHYSICALName: Alexander R TowellMRN: 104670153Date of birth: 8/4/1975Date of visit: 11/14/2024 Referring Provider: Benjamin R. Tan, MDPCP: Suthan, Nanthini, MDOncologist:Tan, Benjamin R., MD Reason for visit: Evaluate question of peritoneal metastasis from small bowel adenocarcinoma. HPI: Mr. Towell is a 49 y.o. male who presents for evaluation of a questionable peritoneal metastasis from his known primary small bowel adenocarcinoma. In brief, this is a 49-year-old male who in 2021 was diagnosed with a sigmoid colon cancer and underwent primary resection with anastomosis. He subsequently received a complete course of adjuvant therapy and was otherwise without evidence of residual disease until July 20, 2024. At that time, he presented with symptoms and underwent axial imaging which showed bowel obstruction with a presumed mass in the terminal ileum. He then underwent laparoscopic right hemicolectomy, with an operative note that reports no evidence of peritoneal disease. His pathology returned with a primary diagnosis of ileal adenocarcinoma with positive lymph nodes. There was no mention of exploration of the pelvis, but notably the surgeon did not see any evidence of peritoneal metastasis at that time. In August, 2024, he then underwent PET imaging prior to initiating adjuvant chemotherapy and was found to have evidence of disease within the liver as well as several foci of PET avidity in the pelvis in the retrovesical pouch. At that time, he was initiated on medical treatment and referred to the hepatobiliary Surgical Service as well as myself for further evaluation. He has since seen the liver surgery team, and they have ordered an MRI of the abdomen to better characterize his amount of residual liver disease after adjuvant therapy.Today, he presents to me for evaluation of this questionable pelvic metastasis. He has no abdominal pain at this time and is otherwise without symptoms. He is having regular bowel function and tolerating a diet. His weight is stable. He continues on chemotherapy, with approximately 8 weeks left prior to completing his course of FOLFIRI. He is up-to-date with his colonoscopy, having undergone 1 earlier this year which was unremarkable. He has also had genetic testing, which he notes showed no evidence of any germline mutations.His past surgical history is notable for a laparoscopic anterior resection in 2021 and a laparoscopic right hemicolectomy in 2024. He has no notable family history of colon or rectal cancer.Pertinent Past Medical

History:Intestinal cancerAnticoagulation:NonePertinent Past Surgical

History:07/01/2024-Last Colonoscopy:05/29/2024-Pathology/Histology:07/01/2024-Recent Imaging Impressions:08/15/2024- PET CT SKULL TO THIGH-

IMPRESSION:1. At least four hypermetabolic liver lesions involving segment II,VII and VIII compatible with metastatic disease.2. Two intensely hypermetabolic soft tissue nodule deposits in therectovesical pouch are compatible with metastatic disease08/28/2024- MRI ABD PELVIS-

IMPRESSION:1. Vague hepatobiliary phase hypointense lesions in segment 2, 4Aand 7, corresponding to FDG avid lesions on PET/CT 07/25/2024. Thevague appearance of these lesions likely indicates treatmentresponse. Previously described lesion in the liver dome in segment 8on PET/CT is not seen on the current examination.2. Treated rectovesicular pouch lesions without evidence of residualmetastatic disease in the pelvis.3. Conventional hepatic arterial anatomy.4. Peripheral wedge-shaped area of hepatobiliary phase hypointensityin segment 8 without a correlate on other sequences is nonspecific,but is unlikely to represent metastatic disease.Tumor markers:His CEAs have always been normal per patient.Past Medical

History:Past Medical

History: Diagnosis Date Anemia Cancer (CMS/HCC) (HCC) Peripheral neuropathy Thyroid disease Past Surgical

History:Past Surgical

History: Procedure Laterality Date COLON SURGERY 12/30/2021 SMALL BOWEL RESECTION 07/01/2024 Allergies: Patient has no known allergies.Medications: Current Outpatient Medications: cyanocobalamin (Vitamin B-12) 100 mcg tablet, Take 1 tablet (100 mcg total) by mouth daily, Disp: , Rfl: iron bisgly,ps-FA-B-C#12-succ 65 mg-65 mg -1,000 mcg (24) tablet, Take by mouth 2 (two) times a day, Disp: , Rfl: levothyroxine (SYNTHROID) 100 mcg tablet, Take 112 mcg by mouth daily, Disp: , Rfl: multivitamin with minerals tablet, Take 1 tablet by mouth daily, Disp: , Rfl: omega-3 fatty acids-fish oil 300-1,000 mg capsule, Take 2 capsules (2 g total) by mouth daily, Disp: , Rfl: Social

History:Social History Tobacco Use Smoking Status Never Smokeless Tobacco Never Alcohol Use: Not on file Lives in WOOD RIVER IL 62095-1144. The patient is accompanied today by his significant other.Family history: Family History Problem Relation Age of Onset Prostate cancer Father 69 Review of Systems:A comprehensive review of systems was performed and positive and pertinent negative responses are scanned into the medical record. All pertinent positives are included in the HPI.Physical Exam:VITAL SIGNS: Weight - 87.9 kg (193 lb 12.8 oz) pounds, Blood pressure - 129/90, Heart rate - 85 bpm, Temperature - 36.2 °C (97.1 °F) (Transdermal) °F.GENERAL: Alert and oriented x 3 in no apparent distress. Well nourished. HEENT: Conjunctivae clear. No scleral icterus. Mucous membranes moist. No masses or lymphadenopathy. Trachea midline without stridorCHEST: Bilateral chest rise, nonlabored breathing. No audible rales, rhonchi. HEART: Regular rate and rhythm. Radial pulse 2+ ABDOMEN: Soft, nontender, nondistended with no masses or hernias. No peritonitis, rebound or guarding. His prior surgical scars are well healed.ANORECTAL: DeferredEXTREMITIES: Warm and well perfused. 2+ distal pulses. NEUROLOGIC: Normal facies, spontaneous equal movement in all 4 extremities. SKIN: No skin lesions. No cervical, supraclavicular, axillary, or inguinal adenopathy. PSYCHIATRIC: Within normal limits. Chaperone was present for entirety of exam. Review of Laboratory and Imaging Studies: Laboratory review: None to review I personally reviewed his most recent PET August, 2024, which shows several foci of PET avidity between the bladder and rectosigmoid colon. On CT scan, there is minimal associated mass located in these areas. It is unclear if this is due to a true area of malignancy versus some sort of postoperative change causing an inflammatory response in this area.I have also reviewed his abdominal and pelvic MRI from September, 2024, which does not show any focal masslike lesion in this region. There is some haziness, however, and it is unclear how to interpret this.

Assessment: 49 y.o. male who presented with a history of prior sigmoid adenocarcinoma now presenting for evaluation after discovery of a terminal ileal adenocarcinoma that was resected and then subsequently found to have some PET avidity within the pelvis prior to initiation of adjuvant therapy. His genetic testing has been negative. His colonoscopy was negative for any colon related lesions. Given the the PET scan was performed proximally 1 month after his resection and that there was no evidence of peritoneal disease at the time of his exploration in July, it is unclear exactly what the source of the PET avidity in the pelvis may be. He has an upcoming MRI scheduled to better interrogate the lesions within his liver, and I recommend also performing a repeat PET scan to again evaluate what is happening in the pelvis. There is a possibility that the previously noted hypermetabolic activity was related to some other process, and in fact there was no malignancy within the peritoneum. However, we also discussed the potential for an indeterminate result from the PET scan that may ultimately require a diagnostic laparoscopy in order to fully rule out disease. Given his multiple prior operations, including 1 just in the past 4 months, I am hesitant to proceed directly with the laparoscopy as I think it may be difficult to expose the pelvis a mammography the expected adhesions, particularly given that there is significant adhesiolysis that needed to be performed at his last operation.

Plan: I discussed all this with the patient including unclear picture given the testing we have not failed. He agrees with the plan to proceed with a PET scan in addition to his upcoming abdominal MRI, and we will then proceed with a possible laparoscopy given the results of the PET scan. However, if there was no evidence of hypermetabolic activity in the pelvis on the PET, I think it would be reasonable to go straight to any indicated liver directed therapy and presumed his peritoneum free of disease.As a result of this visit, he needs:Imaging:PETLabs:NoneEndoscopy:None Pelvic Floor Evaluation:NoneReferrals to:NoneWill Chapman, Jr MDAssistant Professor, Colon and Rectal SurgeryWashington University School of Medicinep: (314) 454 - 7177CC: Patient Care Team:Suthan, Nanthini, MD as PCP - GeneralArshad, 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 C. Jr., MD as Consulting Physician (Colon and Rectal Surgery)Chapman, William Cavanaugh, MD as Consulting Physician (Transplant Surgery)Transcription completed by M*Modal Software. Transcription variances may occur. Electronically signed by William Chapman, MD at 11/17/2024 2:56 PM CSTdocumented in this encounter

Maureen Mercier, NP - 12/10/2024 10:25 AM CSTFormatting of this note might be different from the original.To call patient regarding MRI findings and plan for interval imaging.Electronically signed by Maureen Mercier, NP at 12/10/2024 10:27 AM CSTdocumented in this encounter

Maureen Mercier, NP - 12/30/2024 1:04 PM CSTFormatting of this note might be different from the original.Attempted to call wife regarding questions regarding MRI. No answer. VM left.Electronically signed by Maureen Mercier, NP at 12/30/2024 1:04 PM CSTdocumented in this encounter

Mallory Hubbard, PA - 04/30/2025 9:30 AM CDTFormatting of this note might be different from the original.Transplant/ Hepatobiliary Surgery Outpatient Clinic NoteChief Complaint: metastatic colorectal cancer to the liverReferred by: Benjamin R. Tan, MDHPI: Mr. Alexander R Towell is a 49 y.o. male with history of metastatic colorectal cancer the liver. Presenting for surgical consultation accompanied by his girlfriend, Kimberly. He was diagnosed with sigmoid colon cancer status post laparoscopic sigmoid colectomy in 12/29/2021. He was recurrence free until three years later, his recurrence was in the terminal ileum status post right hemicolectomy in 7/1/2024, pathology notable for ileal adenocarcinoma. Last colonoscopy was 2 months ago which was normal. He was first seen in our clinic and reviewed at liver multidisciplinary conference in 10/2024. > Findings: PET (july)- 4 areas of FDG uptake in the liver, very focal. 2 in left hemiliver 1 near segment 7 + 1 near the dome. MRI (aug)- treatment response with smaller lesions, only see 3 lesions. Pelvic disease is treated. >

Plan: Consider left lateral resection versus ablationPast Medical

History: has a past medical history of Anemia, Cancer (HCC), Peripheral neuropathy, and Thyroid disease. Past Surgical

History: has a past surgical history that includes Colon surgery (12/30/2021) and Small Bowel Resection (07/01/2024).Social

History: Alcohol use: none Tobacco use: noneOccupation: previous research assistant at SIUEECOG status: ECOG: 0 - Fully active, able to carry on all pre-disease performance without restrictionAllergies: No Known AllergiesFamily

History:family history includes Prostate cancer (age of onset: 69) in his father.Medications: HOME MEDICATIONS : cyanocobalamin (Vitamin B-12) 100 mcg tablet iron bisgly,ps-FA-B-C#12-succ 65 mg-65 mg -1,000 mcg (24) tablet levothyroxine (SYNTHROID) 100 mcg tablet multivitamin with minerals tablet omega-3 fatty acids-fish oil 300-1,000 mg capsuleReview of Systems: Reports: noneDenies any abdominal pain, nausea, vomiting, constipation, diarrhea, dark urine, light stools, fevers, chills, loss of appetite, weight loss, jaundice or pruritis. Physical Exam: Blood pressure 130/84, pulse 54, temperature 36.3 °C (97.3 °F), height 182.9 cm (6’), weight 96.6 kg (213 lb).Constitutional: Ambulatory, No acute distressHead: Normocephalic, non traumaticEyes:Bilateral sclera anicteric ENT: Normal hearing, no obvious deformitiesLungs: Non- labored breathing, on room airCV: Well perfused, no JVDAbdomen: Soft, not distended, non tender. No hernia. Well healed incision. Skin: No rashes or jaundiceExtremities: Warm, no pitting pedal edemaNeuro: No gross neurological deficitsPysch: Mood appropriate, A+Ox3Labs: > none to review Pathology: Consult material received from Anderson Hospital, Maryville, IL (OSC: AS21-7173; 11/22/2021) A. Stomach, biopsy - Normal oxyntic mucosa - No H. pylori organisms are identified by H&E examination B. Small bowel, biopsy - Normal duodenal mucosa C. Large bowel, descending colon mass, biopsy - Ulcerated invasive adenocarcinoma Consult material received from Anderson Hospital, Maryville, IL (OSC: AS21-7988; 12/29/2021) A. Large bowel, sigmoid, left hemicolectomy - Moderately differentiated colonic adenocarcinoma invading the visceral peritoneum (pT4a) - Tumor arises in the sigmoid colon and measures 6.0 cm in greatest dimension, per report - Surgical margins are negative for tumor - Negative for perineural or lymphovascular invasion - Metastatic adenocarcinoma in one of twenty-three lymph nodes(1/23; pN1a) Consult material received from Anderson Hospital, Maryville, IL (OSC: AS24-3099; 05/29/2024) A. Small bowel, terminal ileum ulcerated lesion, biopsy - Invasive adenocarcinoma, moderately-differentiated - Intact nuclear expression of mismatch repair proteins (MLH1, PMS2, MSH2, and MSH6) by immunostains Consult material received from Anderson Hospital, Maryville, IL (OSC: AS24-3810; 07/01/2024) A. Large bowel, right colon and ileum, right hemicolectomy - Moderately differentiated adenocarcinoma involving the perienteric soft tissue, muscularis propria, submucosa, and mucosa (see comment) - No precursor lesion identified in the ileal mucosa - Per report, deep/radial margin positive for tumor - Distal and proximal margins negative for tumor - Positive for perineural invasion - Negative for definitive lymphovascular invasion - Five tumor deposits identified - Metastatic adenocarcinoma in four of fourteen lymph nodes (4/14) - Normal appendix Imaging: MRI 4/30/2025: 1. Unchanged hepatic segment 2 lesion consistent with continuedtreatment response. No evidence of progressive or new metastaticdisease in the abdomen.2. Near complete resolution of the wedge shaped lesion in hepaticsegment 8, which was previously thought to represent focal hepatictoxicity related to oxaliplatin.

Assessment: Mr. Towell is a 49 y.o. male with history of metastatic colorectal adenocarcinoma to the liver presenting to clinic for surgical consultation.

Plan: - Preliminary imaging review shows resectable metastatic disease in the liver. The patient is a good candidate for surgery. We will discuss the patient’s imaging at our liver multidisciplinary conference on Thursday morning prior to making final recommendations. All questions were answered in clinic. The patient will be updated with findings and recommendations following review at conference. - We discussed with them the risks, benefits, and alternatives to proceeding with a robotic liver resection. We explained a brief description of the operative procedure and expected convalescence. They express understanding and would like to proceed with surgery; therefore surgical consent was obtained today. - CPAP is scheduled on 5/1. - Dr. Chapman to discuss with medical oncologist Dr. Arshad. Disposition: We will follow-up with the patient after reviewing the patient’s case at conference. They know to call the office with any questions or concerns in the interim. ADDENDUM: This patient’s case was reviewed at our liver multidisciplinary imaging conference on 5/1> Findings: Marked treatment response over time. Areas of seg 2 disease shriveling away. No correlate currently for prior seg 8 disease. Remaining: one visible high seg 2 metastasis–partially treated, measures up to 7mm. >

Plan: Consider resecting seg 2 lesion, vs L lateral? Watch the R, could ablate if needed We will proceed with a robotic liver resection. Patient has been notified of findings and agrees with plan. Mallory E. Hubbard, PAPatient Care Team:Suthan, Nanthini, MD as PCP - GeneralArshad, 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 05/02/2025 9:31 AM CDTElectronically signed by Mallory Hubbard, PA at 04/30/2025 8:18 PM CDTElectronically signed by Mallory Hubbard, PA at 05/01/2025 3:39 PM CDTElectronically signed by William Chapman, MD at 05/02/2025 9:31 AM CDTdocumented in this encounter

Maureen Mercier, NP - 05/28/2025 9:15 AM CDTFormatting of this note is different from the original.Abdominal Transplant/HPB Post-Op Clinic NoteChief Complaint: Postoperative visit.HPI: Mr. Alexander R Towell is a 49 y.o. male with a history of metastatic colorectal cancer to the liver s/p XI LIVER RESECTION - LAPAROSCOPIC ROBOTIC ASSISTED, TAP Block on 05/14/2025 with Dr. Chapman. The postoperative course was unremarkable. Doing well today. Minimal complaints upon Ros. Feeling well. He denies abdominal pain, nausea, vomiting, constipation, diarrhea, fevers or chills. He reports a healthy appetite. Past Medical

History: has a past medical history of Anemia, Cancer (HCC), Peripheral neuropathy, Sleep apnea, and Thyroid disease.He has no past medical history of Acute respiratory failure requiring reintubation (HCC), Awareness under anesthesia, Delayed emergence from general anesthesia, Hard to intubate, Malignant hyperthermia, Motion sickness, PONV (postoperative nausea and vomiting), Postoperative delirium, or Pseudocholinesterase deficiency. Past Surgical

History: has a past surgical history that includes Colon surgery (12/30/2021); Small Bowel Resection (07/01/2024); and Thyroidectomy, partial (Right, 2022).Social

History: reports that he has never smoked. He has never used smokeless tobacco. He reports that he does not use drugs. Patient denies consuming alcoholic drinks. Allergies: No Known AllergiesFamily

History: family history includes Prostate cancer (age of onset: 69) in his father.Medications: HOME MEDICATIONS : cyanocobalamin (Vitamin B-12) 100 mcg tablet docusate sodium (COLACE) 100 mg capsule 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 prochlorperazine (COMPAZINE) 10 mg tablet propranoloL (INDERAL) 20 mg tablet zolpidem (AMBIEN) 5 mg tabletVitalsBP 132/86 Pulse 93 Temp 36.4 °C (97.6 °F) Ht 182.9 cm (6’) Wt 98.7 kg (217 lb 9.6 oz) SpO2 97% BMI 29.51 kg/m² Review of Systems: Review of Systems All other systems reviewed and are negative.Physical Exam: Physical ExamConstitutional: General: He is not in acute distress. Appearance: Normal appearance. He is not ill-appearing, toxic-appearing or diaphoretic. HENT: Head: Normocephalic and atraumatic. Right Ear: External ear normal. Left Ear: External ear normal. Eyes: Conjunctiva/sclera: Conjunctivae normal. Cardiovascular: Rate and Rhythm: Normal rate. Pulses: Normal pulses. Pulmonary: Effort: Pulmonary effort is normal. No respiratory distress. Abdominal: General: Abdomen is flat. There is no distension. Palpations: Abdomen is soft. There is no mass. Tenderness: There is no abdominal tenderness. There is no guarding. Hernia: No hernia is present. Comments: Incision healing well Musculoskeletal: Comments: Independently moves extremities Skin: General: Skin is warm and dry. Coloration: Skin is not pale. Findings: No erythema or rash. Neurological: Mental Status: He is alert and oriented to person, place, and time. Psychiatric: Mood and Affect: Mood normal. Behavior: Behavior normal. Thought Content: Thought content normal. Judgment: Judgment normal. Surgical Pathology:URGICAL PATHOLOGY REPORT FINAL WITH ADDENDUM Patient Name: TOWELL, ALEXANDER R. Accession #: S25-23061 Gender: M DOB: 8/4/1975 (Age: 49) Address: 304 PICKER AVE, WOOD RIVER, IL 62095-1144 MRN: 104670153 Hospital #: 2272813559 Taken:5/14/2025 Received:5/14/2025 Accessioned:5/14/2025 Reported: 5/19/2025 Patient Type: BJH Inpatient Service: Surgery Location: BJH 0164 Physician(s): William C. Chapman, M.D. Nanthini Suthan, MD Benjamin Tan, M.D.

Diagnosis: A. Liver, segment 2, resection - Metastatic adenocarcinoma morphologically compatible with the patient’s colorectal primary. - Adenocarcinoma present at cauterized resection margin. - Perineural invasion identified. laha/5/19/2025 07:49 By this signature, I attest that the above diagnosis is based upon my personal examination of the slides(and/or other material indicated in the diagnosis). Adam L. Booth, M.D. Report Electronically Reviewed and Signed Out By Adam L. Booth, M.D. 5/19/2025 11:46:56 Diagnosis Comment Previous case (W24-7828) was reviewed and is morphologically identical to current specimen. Larry Ha, M.D.

History: Patient is a 49-year-old man with a metastatic colon cancer to the liver. Operative Procedure: Liver resection, laparoscopic robotic assisted Specimen(s) Received: A: Segment 2 excision

Gross Description: Received in formalin labeled with patient identifiers and “segment 2 excision” is a wedge shaped piece of liver parenchyma (1.5 x 1.4 x 1.2 cm). The resection margin is shaggy purple-black with extensive thermal artifact. There is an area of white pallor on the capsular surface measuring 0.7 cm in greatest dimension. The resection margin is inked black and the capsular surface is inked blue. Serial sections show a firm white nodule below the previously described area on the capsular surface measuring up to 1.0 x 1.0 x 0.8 cm. The lesion abuts the capsular surface and comes to within 0.1 cm of the closest resection margin. The specimen is submitted entirely in cassettes A1 and A 2. Jar 1 bao2/5/15/2025 10:44 PA(s): Beth Ann Obertino-Norwood, PA (ASCP)CM By this signature, I attest that the above diagnosis is based upon my personal examination of the slides(and/or other material). Addenda/Procedures Addendum Ordered:7/10/2025Status:Signed OutAddendum Complete:7/10/2025By:Samuel J. Ballentine, M.D.Addendum Signed Out:7/11/2025 Addendum Comment A request for Molecular Archived Tissue Testing was received, which is to be performed on tissue from the attached case. The report, slides and blocks for the case were retrieved from archives. The pathologist whose signature appears below reviewed the original pathology report, examined H&E slides, and selected the blocks appropriate to the specifications of the ordered molecular analysis. Materials were forwarded to Tempus where the Tempus xT test will be performed. An addendum report will be issued when the results of this molecular test are available. By this signature, I attest that the above diagnosis is based upon my personal examination of the slides(and/or other material indicated in the diagnosis). Samuel J. Ballentine, M.D.Report Electronically Reviewed and Signed Out By Samuel J. Ballentine, M.D. 7/11/2025 09:25:42 The xT 595 test was performed at Tempus, 600 West Chicago Ave, Suite 775, Chicago, IL 60654. The performance characteristics of some immunohistochemical stains, fluorescence in-situ hybridization tests and immunophenotyping by flow cytometry cited in this report (if any) were determined by the Surgical Pathology and Flow Cytometry Departments at Barnes-Jewish Hospital as part of an ongoing quality assurance program and in compliance with federally mandated regulations drawn from the Clinical Laboratory Improvement Act of 1988 (CLIA ‘88). Some of these tests rely on the use of “analyte specific reagents” and are subject to specific labeling requirements by the US Food and Drug Administration. Such diagnostic tests may only be performed in a facility that is certified by the Department of Health and Human Services as a high complexity laboratory under CLIA ‘88. The FDA has determined that such clearance or approval is not necessary. This test is used for clinical purposes. It should not be regarded as investigational or for research. Nevertheless, federal rules concerning the medical use of analyte specific reagents require that the following disclaimer be attached to the report: This test was developed and its performance characteristics determined by the Surgical Pathology and Flow Cytometry Departments of Barnes-Jewish Hospital. It has not been cleared or approved by the U. S. Food and Drug Administration. IMAGES AND SCANNED DOCUMENTS, IF INCLUDED, ONLY VIEWABLE IN PDF VERSION OF REPORT Assessment and

Plan: Mr. Towell is a 49 y.o. with a history of metastatic colorectal cancer the liver s/p XI LIVER RESECTION - LAPAROSCOPIC ROBOTIC ASSISTED, TAP Block. Presents for postoperative visit. Surgical pathology was discussed with the patient today. All of their questions were answered in detail.Continue weight lifting restrictions of <10lbs for another 4 weeks.Stay hydrated and continue to drink plenty of fluids throughout the day. Eat a well balanced diet, and continue nutrition supplement shakes as needed.As the surgical glue begins to flake off, it is ok to peel the glue off. Follow up with Dr. Tan as scheduled. Dr. Chapman to discs with oncology (Arshad and Tan).Follow-up: We will see the patient in clinic as needed. The patient knows to call the office with any questions or concerns in the interim. Maureen Mercier, NPPatient 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 08/01/2025 1:53 PM CDTElectronically signed by Maureen Mercier, NP at 08/01/2025 10:37 AM CDTElectronically signed by William Chapman, MD at 08/01/2025 1:53 PM CDTdocumented in this encounter

Benjamin Tan, MD - 07/08/2025 11:45 AM CDTFormatting of this note is different from the original.Images from the original note were not included. Oncology Return/Follow Up VisitAlexander R TowellDOB:8/4/1975 DATE OF VISIT:7/8/2025 Cancer Staging No matching staging information was found for the patient.Oncology History Overview Note DIAGNOSIS:Sigmoid Adenocarcinoma Stage IIIMetastaticTerminal Ileum Adenocarcinoma, MSS, RAS WT, with liver metastasesGENOMIC DATA:1. TEMPUS XT for small bowel adenocarcinoma2. TEMPUS XF- ONCOLOGIC HISTORY:presented with anemia with tiredness, constipation, abdominal pain and fatigue back in 2021. He required blood transfusions- 11/22/2021 Colonoscopy showed malignant appearing mas in descending colon with ulceration and partial obstruction- 11/23/2021 labs notes wbc 3.8, Hb 9.4, platelets 310K, creatinine 1.8, bilirubin 0.3, CEA 1.4- 12/09/2021 CT scan showed exophytic sigmoid colon mass (2.6 cm) with Lymph nodes suspicious for metastatic disease and sclerotic focus in the left iliac bone.- 12/10/2021 Consultation with Dr. Syed (Oncology)- 12/29/2021 laparsocopic sigmoid colectomy pathology showed moderately differentiated colon adenocarcinoma 1 of 23 LN +, MSS, RAS WT- stage IIIB pT4N1M0- 02/16/2022 to 08/29/2022 adjuvant FOLFOX x 12 cycles with dose reduction. Toxicities include neuropathy and diarrhea, fatigue- 01/01/2023 CT scans showed no recurrence- 01/09/2023 Colonoscopy showed normal findings- 12/29/2023 CT showed no metastases- 05/29/2024 Colonoscopy showed large ulcerated mass in the terminal ileum, biopsy confirmed moderately differentiated adenocarcinoma- 07/01/2024 right hemicolectomy - showed 4 of 14 LN +, PNI+, no LVI, RAS WT, MSS- 07/11/2024 Tempus XF - 07/25/2024 PET scan done showed liver lesions. Started chemotherapy with Cycle 1 FOLFIRI- 08/12/2024 Cycle 2 FOLFIRI/bevacizumab: has diarrhea treated with immodium- 08/15/2024 Consultation with medical oncology (tan) to discuss HAI pump therapyTREATMENT HISTORY: laparsocopic sigmoid colectomy 12/29/2021Adjuvant FOLFOX x 12 cycles 2/16/2022- 8/2022Right hemicolectomy 7/1/2024FRONTLINE FOLFIRI/Bevacizumab- 07/25/2024 Cycle 1 FOLFIRI- 08/12/2024 Cycle 2 FOLFIRI/Bevacizumab- 02/12/2025 Maintenance 5FU/bevacizumab- 04/16/2025 Maintenance 5FU/Bev (last dose prior to surgery)5. Robotic Segment 2 resection (Chapman) 5/14/2025Malignant neoplasm metastatic to liver (HCC) 8/16/2024 Initial Diagnosis Malignant neoplasm metastatic to liver (HCC)Active Treatment & Therapy Plans for Towell, Alexander R Towell, Alexander R does not have any active plans of the following types: Oncology Chemotherapy Treatment, Oncology Treatment (2), Oncology Treatment (3), Oncology Supportive Care Therapy Plan, Specialty Infusion Treatment, Blood Products, BMT, Hematology, Radiopharmaceutical Treatment, Pediatric Infusion Treatment, Pediatric Infusion Treatment #3, Pediatric Infusion Treatment #2, Transplant Therapy Plan, PHERESIS, DIALYSIS, Interventional Psychiatry, Line Care , Dialysis Therapy Plan 2, BMT/ONC IP BLOOD PRODUCTS, Specialty Infusion Treatment 2, Specialty Infusion Treatment 3, Specialty Infusion Treatment 4, Oncology Supportive Care Treatment Plan, Oncology Treatment (4)Subjective Mr. Alexander R Towell is a 49 y.o. Non-Hispanic male who comes to the Gastrointestinal Oncology Clinic at Washington University for a follow up oncology visit.Since his last visit with us, he continued with his treatments locally. His last scans done 4/30/2025 showed He then underwent a robotic segment 2 resection by Dr. Chapman on 5/14/2025. Operative findings notes no other metasattic site except for the segment 2 lesion which was small. Pathology showed metatatic adenocarcinoma but also at the cauterized margin with PNI.Today, he comes with his wife and notes- feeling well- surgical scars well healed- no diarrhea- no fever, chills- no nausea, vomiting- no abdominal pain- no chest pain, SOBPast 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 Prior to Admission medications Medication Sig Start Date End Date Taking? Authorizing Provider levothyroxine (SYNTHROID) 88 mcg tablet Take 1 tablet (88 mcg total) by mouth daily 3/23/23 Provider, Historical, MD No Known AllergiesSocial History Tobacco Use Smoking status: Never Smokeless tobacco: Never Substance and Sexual Activity Drug use: Never Sexual activity: Defer Alcohol Use: Not At Risk (5/14/2025) AUDIT-C Frequency of Alcohol Consumption: Never Average Number of Drinks: Patient does not drink Frequency of Binge Drinking: Never Family History Problem Relation Age of Onset Prostate cancer Father 69 Review of SystemsReview of Systems Constitutional: Negative. HENT: Negative. Eyes: Negative. Respiratory: Negative. Cardiovascular: Negative. Gastrointestinal: Negative. Endocrine: Negative. Genitourinary: Negative. Musculoskeletal: Negative. Skin: Negative. Neurological: Negative. Hematological: Negative. Psychiatric/Behavioral: Negative. Pain: negative.Review of SystemsObjective Vitals:No data recordedECOG:0PHYSICAL EXAMINATIONPhysical ExamVitals reviewed. Constitutional: General: He is not in acute distress. Appearance: Normal appearance. HENT: Head: Normocephalic and atraumatic. Nose: Nose normal. Eyes: General: No scleral icterus. Conjunctiva/sclera: Conjunctivae normal. Cardiovascular: Rate and Rhythm: Normal rate and regular rhythm. Pulses: Normal pulses. Heart sounds: Normal heart sounds. Pulmonary: Effort: Pulmonary effort is normal. Breath sounds: Normal breath sounds. No wheezing or rales. Abdominal: General: Abdomen is flat. Bowel sounds are normal. There is no distension. Palpations: Abdomen is soft. There is no mass. Tenderness: There is no abdominal tenderness. Comments: Surgical scars healed well Musculoskeletal: General: Normal range of motion. Cervical back: Normal range of motion. Right lower leg: No edema. Left lower leg: No edema. Lymphadenopathy: Cervical: No cervical adenopathy. Skin: General: Skin is warm and dry. Coloration: Skin is not jaundiced. Neurological: General: No focal deficit present. Mental Status: He is alert and oriented to person, place, and time. Psychiatric: Mood and Affect: Mood normal. Behavior: Behavior normal. Thought Content: Thought content normal. Judgment: Judgment normal. Lab/Radiology/Diagnostic Review:No results found for this or any previous visit (from the past 24 hours). Hematology Lab History Latest Ref Rng & Units 5/1/2025 08:41 5/14/2025 14:38 5/15/2025 05:38 Labs - Hematology WBC 3.80 - 9.90 K/cumm 3.73 3.71 7.76 Total Hb, POC 13.0 - 17.5 g/dL 15.6 14.4 14.6 Hct 38.9 - 50.3 % 44.3 41.2 42.4 Plt 150 - 400 K/cumm 138 148 150 Neutrophil abs 1.50 - 6.50 K/cumm 1.55 Lymphocytes, abs 0.80 - 3.30 K/cumm 1.56 Chem/LFT Lab History Latest Ref Rng & Units 8/28/2024 17:09 5/1/2025 08:41 5/14/2025 14:38 5/15/2025 05:38 Labs-Chem/LFT Sodium 135 - 145 mmol/L 140 142 141 Creatinine 0.80 - 1.30 mg/dL 1.00 1.16 1.03 Bilirubin, total 0.1 - 1.2 mg/dL 0.5 0.8 0.7 AST 10 - 50 Units/L 34 60 67 ALT 7 - 55 Units/L 35 63 78 Alk phos 40 - 130 Units/L 63 65 61 CrCl- Actual Body Weight (Cockcroft-Gault) 81.9 122.3 101.3 120.2 PATHOLOGY REVIEW:5/14/2025 A. Liver, segment 2, resection - Metastatic adenocarcinoma morphologically compatible with the patient’s colorectal primary. - Adenocarcinoma present at cauterized resection margin. - Perineural invasion identified. 7/1/20245/29/202411/22/20219/20/2022THYROID, RIGHT LOBE, RIGHT LOBECTOMY:- NODULAR HYPERPLASIA (NODULAR GOITER)-ADDITIONAL PATHOLOGIC FINDINGS - ONE (1) LYMPH NODE NEGATIVE FOR METASTASIS (0/1).- LYMPHOCYTIC THYROIDITIS:- PARATHYROID GLAND(S): ONE PRESENT IN THE LOWER POLE, WITHOUT HISTOLOGIC ABNORMALITIES.7/29/2022THYROID LOBE, RIGHT, ULTRASOUND GUIDED NEEDLE BIOPSY:- ADEQUATE FOR INTERPRETATION. - SUSPICIOUS FOR FOLLICULAR NEOPLASM. BETHESDA CLASS IV. 5/11/2022A. THYROID LOBE, RIGHT, (1ST NODULE), ULTRASOUND-GUIDED NEEDLE BIOPSY; - ADEQUATE FOR INTERPRETATION.- BENIGN, CONSISTENT WITH BENIGN FOLLICULAR NODULE (INCLUDES ADENOMATOID NODULE, COLLOID NODULE, ETC.). BETHESDA CLASS II.B. THYROID LOBE, RIGHT (2ND NODULE), ULTRASOUND-GUIDED NEEDLE BIOPSY: - ADEQUATE FOR INTERPRETATION.- ATYPIA OF ON DETERMINE SIGNIFICANCE. FOLLICULAR CELLS WITH MILD FOCAL ARCHITECTURAL ATYPIA. BETHESDA CLASS IIIctDNA7/11/2024RADIOLOGY REVIEW:MRI Abdomen wwo 4/30/20251. Unchanged hepatic segment 2 lesion consistent with continuedtreatment response. No evidence of progressive or new metastaticdisease in the abdomen.2. Near complete resolution of the wedge shaped lesion in hepaticsegment 8, which was previously thought to represent focal hepatictoxicity related to oxaliplatin. Focal liver lesions: Unchanged hepatic segment 2 lesion measuringup to 7 mm, likely representing treated metastatic disease (series 26image 22), previously 2.3 cm on 08/20/2024. The reported corticalirregularity within hepatic segment 7 seen on prior study is not seenon today’s exam. Interval near complete resolution of theill-defined wedge-shaped hypoenhancement hepatic segment 8.MRI Abdomen Liver wwo 11/29/20241. Posttreatment changes related to previously seen hepatic lesionswith decrease in size compared to the prior study consistent withtreatment response. No new lesions identified.2. Ill-defined wedge shaped decreased uptake in hepatic segment 8has also decreased in size compared to prior study which could berelated to a no focal hepatic toxicity related to oxaliplatin.PET/CT 11/21/20241. Interval resolution of the previously seen four hypermetabolic liver lesions and hepatic segments 2, 7, and 8. Of note, small hepatic lesions are difficult to characterize with PET/CT accurately and would be better evaluated with MRI if there is clinical concern. 2. Interval resolution of the hypermetabolic soft tissue nodules in the rectovesicular pouch.3. Persistent activity in the right hilar region, which is indeterminate.CT Body Consult 10/15/20241. The lesions seen on hepatobiliary phase of the prior MRI are much smaller on this exam. It is not certain whether this representsresponse to therapy or differences in technique, particularly given that the lesions could not be seen on portal venous phase of theprior MRI as well. Adequate comparison would require a repeat MRI examination 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 right hilar lymph node which measures at the upper limits of normal for size was hypermetabolic and could represent a metastasis.3. Small stable 7 mm groundglass nodule left lower lobe.MRI Abdomen Pelvis wwo 8/28/20241. Vague hepatobiliary phase hypointense lesions in segment 2, 4A and 7, corresponding to FDG avid lesions on PET/CT 07/25/2024. Thevague appearance of these lesions likely indicates treatment response. Previously described lesion in the liver dome in segment 8 on PET/CT is not seen on the current examination.2. Treated rectovesicular pouch lesions without evidence of residualmetastatic disease in the pelvis.3. Conventional hepatic arterial anatomy.4. Peripheral wedge-shaped area of hepatobiliary phase hypointensity in segment 8 without a correlate on other sequences is nonspecific,but is unlikely to represent metastatic disease.PET OSH 7/25/2024 CONSULT1. At least four hypermetabolic liver lesions involving segment II, VII and VIII compatible with metastatic disease.2. Two intensely hypermetabolic soft tissue nodule deposits in the rectovesical pouch are compatible with metastatic disease.SURGERY 7/1/2024Colonoscopy 5/29/2024Bone scan 5/22/2024CT AP OSH 5/7/2024CT AP 12/28/2023ASSESSMENT AND PLAN:Alexander R Towell is a 49 y.o. Non-Hispanic male with metastatic small bowel adenocarcinoma with liver and pelvis metastases who presents for second opinionMetastatic Terminal Ileum Adenocarcinoma, MSS, RAS WT, with liver and pelvic ? metastases- I reviewed with him and his wife his pathology report noting metastatic left liver adenocarcinoma compatible with colon primary. We also reviewed high risk features such as PNI and positive margin- I reviewed his prior scans noting that he had at least 4 liver lesions previously and only the left liver lesion is measurable on his last scan which was resected. We discussed that despite disappearance in scans, there is still likelihood that residual cancer cells remain viable and may become apparent with later imaging scans.- We discussed obtaining a post op baseline MRI abdomen with PET FDG given the he had prior pelvic lesions with FDG avidity and to confrim if there is truly residual disease.- We also discussed TEMPUS XT NGS as well as a ctDNA post op to assess for MRD.- I reviewed his labs noting elevated creatinine at 1.31 and normal CEA- I discussed that I am in favor of continuing systemic therapy in light of the positive margin and the multiple liver lesions seen prior.- duration of therapy unclear, but will need to reassess with scans, CEA and ctDNA serially- I have encouraged continued treatment with his oncologist- Pt and wife states that they would like to be treated at South County. He had been treated with FOLFIRI/bev and we plan to continue this regimen.-RTC after his scansAll of his questions were answered. He understands and was in agreement with the plan of care. He knows to call the office in the interim with any symptoms, questions, or concerns.Benjamin R. Tan, MD Electronically signed by Benjamin Tan, MD at 07/09/2025 4:04 PM CDTdocumented in this encounter

Crystal Wolf, PA - 07/31/2025 10:20 AM CDTFormatting of this note is different from the original.Images from the original note were not included. Oncology Return/Follow Up VisitAlexander R TowellDOB:8/4/1975 DATE OF VISIT:7/31/2025 Cancer Staging No matching staging information was found for the patient.Oncology History Overview Note DIAGNOSIS:Sigmoid Adenocarcinoma Stage IIIMetastaticTerminal Ileum Adenocarcinoma, MSS, RAS WT, with liver metastasesGENOMIC DATA:1. TEMPUS XT for small bowel adenocarcinoma2. TEMPUS XF- ONCOLOGIC HISTORY:presented with anemia with tiredness, constipation, abdominal pain and fatigue back in 2021. He required blood transfusions- 11/22/2021 Colonoscopy showed malignant appearing mas in descending colon with ulceration and partial obstruction- 11/23/2021 labs notes wbc 3.8, Hb 9.4, platelets 310K, creatinine 1.8, bilirubin 0.3, CEA 1.4- 12/09/2021 CT scan showed exophytic sigmoid colon mass (2.6 cm) with Lymph nodes suspicious for metastatic disease and sclerotic focus in the left iliac bone.- 12/10/2021 Consultation with Dr. Syed (Oncology)- 12/29/2021 laparsocopic sigmoid colectomy pathology showed moderately differentiated colon adenocarcinoma 1 of 23 LN +, MSS, RAS WT- stage IIIB pT4N1M0- 02/16/2022 to 08/29/2022 adjuvant FOLFOX x 12 cycles with dose reduction. Toxicities include neuropathy and diarrhea, fatigue- 01/01/2023 CT scans showed no recurrence- 01/09/2023 Colonoscopy showed normal findings- 12/29/2023 CT showed no metastases- 05/29/2024 Colonoscopy showed large ulcerated mass in the terminal ileum, biopsy confirmed moderately differentiated adenocarcinoma- 07/01/2024 right hemicolectomy - showed 4 of 14 LN +, PNI+, no LVI, RAS WT, MSS- 07/11/2024 Tempus XF - 07/25/2024 PET scan done showed liver lesions. Started chemotherapy with Cycle 1 FOLFIRI- 08/12/2024 Cycle 2 FOLFIRI/bevacizumab: has diarrhea treated with immodium- 08/15/2024 Consultation with medical oncology (tan) to discuss HAI pump therapyTREATMENT HISTORY: laparsocopic sigmoid colectomy 12/29/2021Adjuvant FOLFOX x 12 cycles 2/16/2022- 8/2022Right hemicolectomy 7/1/2024FRONTLINE FOLFIRI/Bevacizumab- 07/25/2024 Cycle 1 FOLFIRI- 08/12/2024 Cycle 2 FOLFIRI/Bevacizumab- 02/12/2025 Maintenance 5FU/bevacizumab- 04/16/2025 Maintenance 5FU/Bev (last dose prior to surgery)5. Robotic Segment 2 resection (Chapman) 5/14/2025Malignant neoplasm metastatic to liver (HCC) 8/16/2024 Initial Diagnosis Malignant neoplasm metastatic to liver (HCC)Active Treatment Plans for Towell, Alexander R Oncology Chemotherapy Treatment: FOLFIRI+Bev: (Fluorouracil / Leucovorin / Irinotecan / Bevacizumab) 14 Day Cycles - Colon/Rectum Current day: Day 1, Cycle 1 (Planned for 7/31/2025) Following planned day: Day 1, Cycle 2 (Planned for 8/14/2025) Subjective Mr. Alexander R Towell is a 49 y.o. Non-Hispanic male who comes to the Gastrointestinal Oncology Clinic at Washington University for a follow up oncology visit.He was last seen here on 7/8/2025. His pathology from his liver resection 5/14/2025 was discussed and planned to continue FOLFIRI/Bev. Patient wanted to transfer his treatments to SOCO. Today is cycle 1 of FOLFIRI/Bev. He presents to clinic today accompanied by his wife. He has been tolerating treatment well and his only complaints are fatigue and nausea. His nausea is well controlled with Compazine. Since hepatic resection in May, he has been on maintenance therapy. He uses Propranolol for migraines. He is eating well with a healthy appetite. He has normal bowel and urinary function. He denies abdominal pain, vomiting, diarrhea, constipation, fevers, chills,or chest pain. 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 Prior to Admission medications Medication Sig Start Date End Date Taking? Authorizing Provider levothyroxine (SYNTHROID) 88 mcg tablet Take 1 tablet (88 mcg total) by mouth daily 3/23/23 Provider, Historical, MD No Known AllergiesSocial History Tobacco Use Smoking status: Never Smokeless tobacco: Never Substance and Sexual Activity Drug use: Never Sexual activity: Defer Alcohol Use: Not At Risk (5/14/2025) AUDIT-C Frequency of Alcohol Consumption: Never Average Number of Drinks: Patient does not drink Frequency of Binge Drinking: Never Family History Problem Relation Age of Onset Prostate cancer Father 69 Review of SystemsReview of Systems Constitutional: Negative. HENT: Negative. Eyes: Negative. Respiratory: Negative. Cardiovascular: Negative. Gastrointestinal: Negative. Endocrine: Negative. Genitourinary: Negative. Musculoskeletal: Negative. Skin: Negative. Neurological: Negative. Hematological: Negative. Psychiatric/Behavioral: Negative. Pain: negative.Review of SystemsObjective Vitals:No data recordedECOG:0PHYSICAL EXAMINATIONPhysical ExamVitals reviewed. Constitutional: General: He is not in acute distress. Appearance: Normal appearance. HENT: Head: Normocephalic and atraumatic. Nose: Nose normal. Eyes: General: No scleral icterus. Conjunctiva/sclera: Conjunctivae normal. Cardiovascular: Rate and Rhythm: Normal rate and regular rhythm. Pulses: Normal pulses. Heart sounds: Normal heart sounds. Pulmonary: Effort: Pulmonary effort is normal. Breath sounds: Normal breath sounds. No wheezing or rales. Abdominal: General: Abdomen is flat. Bowel sounds are normal. There is no distension. Palpations: Abdomen is soft. There is no mass. Tenderness: There is no abdominal tenderness. Comments: Surgical scars healed well Musculoskeletal: General: Normal range of motion. Cervical back: Normal range of motion. Right lower leg: No edema. Left lower leg: No edema. Lymphadenopathy: Cervical: No cervical adenopathy. Skin: General: Skin is warm and dry. Coloration: Skin is not jaundiced. Neurological: General: No focal deficit present. Mental Status: He is alert and oriented to person, place, and time. Psychiatric: Mood and Affect: Mood normal. Behavior: Behavior normal. Thought Content: Thought content normal. Judgment: Judgment normal. Lab/Radiology/Diagnostic Review:No results found for this or any previous visit (from the past 24 hours). Hematology Lab History Latest Ref Rng & Units 5/1/2025 08:41 5/14/2025 14:38 5/15/2025 05:38 7/8/2025 11:50 Labs - Hematology WBC 3.80 - 9.90 K/cumm 3.73 3.71 7.76 4.36 Total Hb, POC 13.0 - 17.5 g/dL 15.6 14.4 14.6 16.0 Hct 38.9 - 50.3 % 44.3 41.2 42.4 46.8 Plt 150 - 400 K/cumm 138 148 150 213 Neutrophil abs 1.50 - 6.50 K/cumm 1.55 1.70 Lymphocytes, abs 0.80 - 3.30 K/cumm 1.56 1.86 Chem/LFT Lab History Latest Ref Rng & Units 5/1/2025 08:41 5/14/2025 14:38 5/15/2025 05:38 7/8/2025 11:50 Labs-Chem/LFT Sodium 135 - 145 mmol/L 140 142 141 139 Creatinine 0.80 - 1.30 mg/dL 1.00 1.16 1.03 1.31 Bilirubin, total 0.1 - 1.2 mg/dL 0.5 0.8 0.7 0.8 AST 10 - 50 Units/L 34 60 67 25 ALT 7 - 55 Units/L 35 63 78 29 Alk phos 40 - 130 Units/L 63 65 61 79 CrCl- Actual Body Weight (Cockcroft-Gault) 122.3 101.3 120.2 97.1 Tumor Marker History Latest Ref Rng & Units 7/8/2025 11:50 Tumor Markers CEA <=5.0 ng/mL 4.7 PATHOLOGY REVIEW:5/14/2025 A. Liver, segment 2, resection - Metastatic adenocarcinoma morphologically compatible with the patient’s colorectal primary. - Adenocarcinoma present at cauterized resection margin. - Perineural invasion identified. 7/1/20245/29/202411/22/20219/20/2022THYROID, RIGHT LOBE, RIGHT LOBECTOMY:- NODULAR HYPERPLASIA (NODULAR GOITER)-ADDITIONAL PATHOLOGIC FINDINGS - ONE (1) LYMPH NODE NEGATIVE FOR METASTASIS (0/1).- LYMPHOCYTIC THYROIDITIS:- PARATHYROID GLAND(S): ONE PRESENT IN THE LOWER POLE, WITHOUT HISTOLOGIC ABNORMALITIES.7/29/2022THYROID LOBE, RIGHT, ULTRASOUND GUIDED NEEDLE BIOPSY:- ADEQUATE FOR INTERPRETATION. - SUSPICIOUS FOR FOLLICULAR NEOPLASM. BETHESDA CLASS IV. 5/11/2022A. THYROID LOBE, RIGHT, (1ST NODULE), ULTRASOUND-GUIDED NEEDLE BIOPSY; - ADEQUATE FOR INTERPRETATION.- BENIGN, CONSISTENT WITH BENIGN FOLLICULAR NODULE (INCLUDES ADENOMATOID NODULE, COLLOID NODULE, ETC.). BETHESDA CLASS II.B. THYROID LOBE, RIGHT (2ND NODULE), ULTRASOUND-GUIDED NEEDLE BIOPSY: - ADEQUATE FOR INTERPRETATION.- ATYPIA OF ON DETERMINE SIGNIFICANCE. FOLLICULAR CELLS WITH MILD FOCAL ARCHITECTURAL ATYPIA. BETHESDA CLASS IIIctDNA7/11/2024RADIOLOGY REVIEW:MRI Abdomen 4/30/2025:Unchanged hepatic segment 2 lesion consistent with continued treatment response. No evidence of progressive or new metastatic disease in the abdomen. Near complete resolution of the wedge shaped lesion in hepaticsegment 8, which was previously thought to represent focal hepatictoxicity related to oxaliplatin. Focal liver lesions: Unchanged hepatic segment 2 lesion measuring up to 7 mm, likely representing treated metastatic disease (series 26 image 22), previously 2.3 cm on 08/20/2024. The reported cortical irregularity within hepatic segment 7 seen on prior study is not seen on today’s exam. Interval near complete resolution of the ill-defined wedge-shaped hypoenhancement hepatic segment 8.MRI Abdomen Liver 11/29/2024:Posttreatment changes related to previously seen hepatic lesions with decrease in size compared to the prior study consistent with treatment response. No new lesions identified. Ill-defined wedge shaped decreased uptake in hepatic segment 8 has also decreased in size compared to prior study which could be related to a no focal hepatic toxicity related to oxaliplatin.PET/CT 11/21/2024:Interval resolution of the previously seen four hypermetabolic liver lesions and hepatic segments 2, 7, and 8. Of note, small hepatic lesions are difficult to characterize with PET/CT accurately and would be better evaluated with MRI if there is clinical concern. Interval resolution of the hypermetabolic soft tissue nodules in the rectovesicular pouch.Persistent activity in the right hilar region, which is indeterminate.CT Body Consult 10/15/2024:The lesions seen on hepatobiliary phase of the prior MRI are much smaller on this exam. It is not certain whether this represents response to therapy or differences in technique, particularly given that the lesions could not be seen on portal venous phase of the prior MRI as well. Adequate comparison would require a repeat MRI examination with hepatobiliary phase. Stable indeterminate 8 mm solid nodule in the right lower lobe. This was not hypermetabolic on the prior CT examination, but a right hilar lymph node which measures at the upper limits of normal for size was hypermetabolic and could represent a metastasis. Small stable 7 mm groundglass nodule left lower lobe.MRI Abdomen Pelvis 8/28/2024:Vague hepatobiliary phase hypointense lesions in segment 2, 4A and 7, corresponding to FDG avid lesions on PET/CT 07/25/2024. The vague appearance of these lesions likely indicates treatment response. Previously described lesion in the liver dome in segment 8 on PET/CT is not seen on the current examination. Treated rectovesicular pouch lesions without evidence of residualmetastatic disease in the pelvis. Conventional hepatic arterial anatomy. Peripheral wedge-shaped area of hepatobiliary phase hypointensity in segment 8 without a correlate on other sequences is nonspecific, but is unlikely to represent metastatic disease.PET OSH 7/25/2024 CONSULTAt least four hypermetabolic liver lesions involving segment II, VII and VIII compatible with metastatic disease. Two intensely hypermetabolic soft tissue nodule deposits in the rectovesical pouch are compatible with metastatic diseaseSURGERY 7/1/2024Colonoscopy 5/29/2024Bone scan 5/22/2024CT AP OSH 5/7/2024CT AP 12/28/2023ASSESSMENT AND PLAN:Alexander R Towell is a 49 y.o. Non-Hispanic male with metastatic small bowel adenocarcinoma with liver and pelvis metastases who presents for second opinionMetastatic Terminal Ileum Adenocarcinoma, MSS, RAS WT, with liver and pelvic ? metastases- I reviewed with him and his wife his pathology report noting metastatic left liver adenocarcinoma compatible with colon primary. We also reviewed high risk features such as PNI and positive margin- I reviewed his prior scans noting that he had at least 4 liver lesions previously and only the left liver lesion is measurable on his last scan which was resected. We discussed that despite disappearance in scans, there is still likelihood that residual cancer cells remain viable and may become apparent with later imaging scans.- We discussed obtaining a post op baseline MRI abdomen with PET FDG given the he had prior pelvic lesions with FDG avidity and to confrim if there is truly residual disease.- We also discussed TEMPUS XT NGS as well as a ctDNA post op to assess for MRD.- I discussed that I am in favor of continuing systemic therapy in light of the positive margin and the multiple liver lesions seen prior.- duration of therapy unclear, but will need to reassess with scans, CEA and ctDNA serially- Today is cycle 1 as maintenance 5-FU. - He will return to clinic in 2 weeks for cycle 2 with restaging FDG PET/CT and MR abdomen/pelvisAll of his questions were answered. He understands and was in agreement with the plan of care. He knows to call the office in the interim with any symptoms, questions, or concerns.Crystal Wolf, PA-CWashington University School of Medicine Division of Medical OncologyIn collaboration with Dr. Benjamin TanCosigned by Benjamin Tan, MD at 08/13/2025 4:56 PM CDTElectronically signed by Crystal Wolf, PA at 08/12/2025 8:25 PM CDTElectronically signed by Benjamin Tan, MD at 08/13/2025 4:56 PM CDTdocumented in this encounter

Benjamin Tan, MD - 08/14/2025 11:00 AM CDTFormatting of this note is different from the original.Images from the original note were not included. Oncology Return/Follow Up VisitAlexander R TowellDOB:8/4/1975 DATE OF VISIT:8/14/2025 Cancer Staging No matching staging information was found for the patient.Oncology History Overview Note DIAGNOSIS:Sigmoid Adenocarcinoma Stage IIIMetastaticTerminal Ileum Adenocarcinoma, MSS, RAS WT, with liver metastasesGENOMIC DATA:- DYPD normal1. TEMPUS XT for small bowel adenocarcinoma2. TEMPUS XT on Liver specimen 5/14/20253. TEMPUS XF- 07/08/2025ONCOLOGIC HISTORY:presented with anemia with tiredness, constipation, abdominal pain and fatigue back in 2021. He required blood transfusions- 11/22/2021 Colonoscopy showed malignant appearing mas in descending colon with ulceration and partial obstruction- 11/23/2021 labs notes wbc 3.8, Hb 9.4, platelets 310K, creatinine 1.8, bilirubin 0.3, CEA 1.4- 12/09/2021 CT scan showed exophytic sigmoid colon mass (2.6 cm) with Lymph nodes suspicious for metastatic disease and sclerotic focus in the left iliac bone.- 12/10/2021 Consultation with Dr. Syed (Oncology)- 12/29/2021 laparsocopic sigmoid colectomy pathology showed moderately differentiated colon adenocarcinoma 1 of 23 LN +, MSS, RAS WT- stage IIIB pT4N1M0- 02/16/2022 to 08/29/2022 adjuvant FOLFOX x 12 cycles with dose reduction. Toxicities include neuropathy and diarrhea, fatigue- 01/01/2023 CT scans showed no recurrence- 01/09/2023 Colonoscopy showed normal findings- 12/29/2023 CT showed no metastases- 05/29/2024 Colonoscopy showed large ulcerated mass in the terminal ileum, biopsy confirmed moderately differentiated adenocarcinoma- 07/01/2024 right hemicolectomy - showed 4 of 14 LN +, PNI+, no LVI, RAS WT, MSS- 07/11/2024 Tempus XF - 07/25/2024 PET scan done showed liver lesions. Started chemotherapy with Cycle 1 FOLFIRI- 08/12/2024 Cycle 2 FOLFIRI/bevacizumab: has diarrhea treated with immodium- 08/15/2024 Consultation with medical oncology (tan) to discuss HAI pump therapyTREATMENT HISTORY: laparoscopic sigmoid colectomy 12/29/2021Adjuvant FOLFOX x 12 cycles 2/16/2022- 8/2022Right hemicolectomy 7/1/2024FRONTLINE FOLFIRI/Bevacizumab- 07/25/2024 Cycle 1 FOLFIRI- 08/12/2024 Cycle 2 FOLFIRI/Bevacizumab- 02/12/2025 Maintenance 5FU/bevacizumab- 04/16/2025 Maintenance 5FU/Bev (last dose prior to surgery)5. Robotic Segment 2 resection (Chapman) 5/14/20255. Resumption of 5FU +/- bev- 07/31/2025 Cycle 1 5FU 2400 CIVI- MRI/PET no evidence of recurrenceMalignant neoplasm metastatic to liver (HCC) 8/16/2024 Initial Diagnosis Malignant neoplasm metastatic to liver (HCC)Active Treatment & Therapy Plans for Towell, Alexander R Oncology Chemotherapy Treatment: FOLFIRI+Bev: (Fluorouracil / Leucovorin / Irinotecan / Bevacizumab) 14 Day Cycles - Colon/Rectum Current day: Day 1, Cycle 1 (Started on 7/31/2025; Originally planned for 7/31/2025) Following planned day: Day 1, Cycle 2 (Planned for 8/14/2025) Line Care : IV Maintenance Therapy Plan Current treatment: Treatment 1 (Planned for 8/14/2025) Subjective Mr. Alexander R Towell is a 50 y.o. Non-Hispanic male who comes to the Gastrointestinal Oncology Clinic at Washington University for a follow up oncology visit.He resumed 5FU alone 7/31/2025.He had restaging scans done with MRI and PET 8/13/2025 which showed no evidence of disease. His CTDNA was negative and his CEA 4.6 7/31/2025He comes today and notes:- feeling well- no abdominal pain- no nausea, vomiting- no fever, chills- no diarrhea, constipationPast 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 Prior to Admission medications Medication Sig Start Date End Date Taking? Authorizing Provider levothyroxine (SYNTHROID) 88 mcg tablet Take 1 tablet (88 mcg total) by mouth daily 3/23/23 Provider, Historical, MD No Known AllergiesSocial History Tobacco Use Smoking status: Never Smokeless tobacco: Never Substance and Sexual Activity Drug use: Never Sexual activity: Defer Alcohol Use: Not At Risk (5/14/2025) AUDIT-C Frequency of Alcohol Consumption: Never Average Number of Drinks: Patient does not drink Frequency of Binge Drinking: Never Family History Problem Relation Age of Onset Prostate cancer Father 69 Review of SystemsReview of Systems Constitutional: Negative. HENT: Negative. Eyes: Negative. Respiratory: Negative. Cardiovascular: Negative. Gastrointestinal: Negative. Endocrine: Negative. Genitourinary: Negative. Musculoskeletal: Negative. Skin: Negative. Neurological: Negative. Hematological: Negative. Psychiatric/Behavioral: Negative. Pain: negative.Review of SystemsObjective Vitals:BP: 118/81Temp: 36.7 °C (98.1 °F)Temp src: OralPulse: 51Resp: 16SpO2: 95 %Weight: 99.2 kg (218 lb 9.6 oz)ECOG:0PHYSICAL EXAMINATIONPhysical ExamVitals reviewed. Constitutional: General: He is not in acute distress. Appearance: Normal appearance. HENT: Head: Normocephalic and atraumatic. Nose: Nose normal. Eyes: General: No scleral icterus. Conjunctiva/sclera: Conjunctivae normal. Cardiovascular: Rate and Rhythm: Normal rate and regular rhythm. Pulses: Normal pulses. Heart sounds: Normal heart sounds. Pulmonary: Effort: Pulmonary effort is normal. Breath sounds: Normal breath sounds. No wheezing or rales. Abdominal: General: Abdomen is flat. Bowel sounds are normal. There is no distension. Palpations: Abdomen is soft. There is no mass. Tenderness: There is no abdominal tenderness. Comments: Surgical scars healed well Musculoskeletal: General: Normal range of motion. Cervical back: Normal range of motion. Right lower leg: No edema. Left lower leg: No edema. Lymphadenopathy: Cervical: No cervical adenopathy. Skin: General: Skin is warm and dry. Coloration: Skin is not jaundiced. Neurological: General: No focal deficit present. Mental Status: He is alert and oriented to person, place, and time. Psychiatric: Mood and Affect: Mood normal. Behavior: Behavior normal. Thought Content: Thought content normal. Judgment: Judgment normal. Lab/Radiology/Diagnostic Review:Recent Results (from the past 24 hours) Comprehensive metabolic panel Collection Time: 08/14/25 10:44 AM Result Value Ref Range Sodium 140 135 - 145 mmol/L Potassium, pl 4.3 3.3 - 4.9 mmol/L Chloride 107 97 - 110 mmol/L CO2 26 22 - 32 mmol/L Anion gap 7 2 - 15 mmol/L BUN 18 6 - 25 mg/dL Creatinine 0.96 0.80 - 1.30 mg/dL Glucose 112 70 - 199 mg/dL Calcium 8.9 8.5 - 10.3 mg/dL Bilirubin, total 0.4 0.1 - 1.2 mg/dL Protein, pl 7.1 6.5 - 8.5 g/dL Albumin 4.4 3.5 - 5.0 g/dL Alk phos 70 40 - 130 Units/L ALT 21 7 - 55 Units/L AST 20 10 - 50 Units/L CBC with auto differential Collection Time: 08/14/25 10:44 AM Result Value Ref Range WBC 4.27 3.80 - 9.90 K/cumm Hgb 15.5 13.0 - 17.5 g/dL Hct 43.9 38.9 - 50.3 % Plt 152 150 - 400 K/cumm MPV 10.3 9.1 - 12.3 fL RBC 4.85 4.30 - 5.80 M/cumm MCV 90.5 81.3 - 96.4 fL MCH 32.0 27.1 - 33.3 pg MCHC 35.3 32.3 - 35.7 g/dL RDW CV 14.9 11.1 - 14.9 % RDW SD 48.3 (H) 35.7 - 48.1 fL NRBC abs 0.00 0.00 - 0.01 K/cumm ANC Prelim 2.37 1.50 - 6.50 K/cumm Differential, auto Collection Time: 08/14/25 10:44 AM Result Value Ref Range Neutrophil abs 2.37 1.50 - 6.50 K/cumm Imm gran abs 0.02 0.00 - 0.10 K/cumm Lymphocyte abs 1.27 0.80 - 3.30 K/cumm Monocyte abs 0.50 0.20 - 0.80 K/cumm Eosinophil abs 0.08 0.00 - 0.50 K/cumm Basophil abs 0.03 0.00 - 0.10 K/cumm Neutrophil pct 55.5 % Imm gran pct 0.5 % Lymphocyte pct 29.7 % Monocyte pct 11.7 % Eosinophil pct 1.9 % Basophil pct 0.7 % eGFR Collection Time: 08/14/25 10:44 AM Result Value Ref Range eGFR >90 >=60 mL/min/1.73 m2 Hematology Lab History Latest Ref Rng & Units 5/15/2025 05:38 7/8/2025 11:50 7/31/2025 09:59 8/14/2025 10:44 Labs - Hematology WBC 3.80 - 9.90 K/cumm 7.76 4.36 3.31 4.27 Total Hb, POC 13.0 - 17.5 g/dL 14.6 16.0 14.8 15.5 Hct 38.9 - 50.3 % 42.4 46.8 42.9 43.9 Plt 150 - 400 K/cumm 150 213 183 152 Neutrophil abs 1.50 - 6.50 K/cumm 1.70 1.11 2.37 Lymphocytes, abs 0.80 - 3.30 K/cumm 1.86 1.45 1.27 Chem/LFT Lab History Latest Ref Rng & Units 5/15/2025 05:38 7/8/2025 11:50 7/31/2025 09:59 8/14/2025 10:44 Labs-Chem/LFT Sodium 135 - 145 mmol/L 141 139 141 140 Creatinine 0.80 - 1.30 mg/dL 1.03 1.31 1.03 0.96 Bilirubin, total 0.1 - 1.2 mg/dL 0.7 0.8 0.6 0.4 AST 10 - 50 Units/L 67 25 28 20 ALT 7 - 55 Units/L 78 29 34 21 Alk phos 40 - 130 Units/L 61 79 75 70 CrCl- Actual Body Weight (Cockcroft-Gault) 120.2 97.1 124.1 129.1 Tumor Marker History Latest Ref Rng & Units 7/8/2025 11:50 7/31/2025 09:59 Tumor Markers CEA <=5.0 ng/mL 4.7 4.6 PATHOLOGY REVIEW:5/14/2025 A. Liver, segment 2, resection - Metastatic adenocarcinoma morphologically compatible with the patient’s colorectal primary. - Adenocarcinoma present at cauterized resection margin. - Perineural invasion identified. 7/1/20245/29/202411/22/20219/20/2022THYROID, RIGHT LOBE, RIGHT LOBECTOMY:- NODULAR HYPERPLASIA (NODULAR GOITER)-ADDITIONAL PATHOLOGIC FINDINGS - ONE (1) LYMPH NODE NEGATIVE FOR METASTASIS (0/1).- LYMPHOCYTIC THYROIDITIS:- PARATHYROID GLAND(S): ONE PRESENT IN THE LOWER POLE, WITHOUT HISTOLOGIC ABNORMALITIES.7/29/2022THYROID LOBE, RIGHT, ULTRASOUND GUIDED NEEDLE BIOPSY:- ADEQUATE FOR INTERPRETATION. - SUSPICIOUS FOR FOLLICULAR NEOPLASM. BETHESDA CLASS IV. 5/11/2022A. THYROID LOBE, RIGHT, (1ST NODULE), ULTRASOUND-GUIDED NEEDLE BIOPSY; - ADEQUATE FOR INTERPRETATION.- BENIGN, CONSISTENT WITH BENIGN FOLLICULAR NODULE (INCLUDES ADENOMATOID NODULE, COLLOID NODULE, ETC.). BETHESDA CLASS II.B. THYROID LOBE, RIGHT (2ND NODULE), ULTRASOUND-GUIDED NEEDLE BIOPSY: - ADEQUATE FOR INTERPRETATION.- ATYPIA OF ON DETERMINE SIGNIFICANCE. FOLLICULAR CELLS WITH MILD FOCAL ARCHITECTURAL ATYPIA. BETHESDA CLASS IIIctDNA7/11/2024RADIOLOGY REVIEW:MRI Abdomen/PET/CT 8/13/2025Posttreatment changes to hepatic segment 2. No evidence of recurrentor metastatic disease in the abdomen or pelvis. 1. No PET/CT evidence of residual/recurrent locoregional or distantmetastatic disease.2. The right suprahilar lymph node is favored to be reactive, giventhe stable size and FDG avidity.3. The bilateral lung lower lobe nodules, are favored to be benign,given the lack of FDG uptake and stable size, dating back to CT inDecember 2024.4. Diffuse persistent left hemithyroid activity. Recommendevaluation with thyroid function tests. MRI Abdomen 4/30/2025:Unchanged hepatic segment 2 lesion consistent with continued treatment response. No evidence of progressive or new metastatic disease in the abdomen. Near complete resolution of the wedge shaped lesion in hepaticsegment 8, which was previously thought to represent focal hepatictoxicity related to oxaliplatin. Focal liver lesions: Unchanged hepatic segment 2 lesion measuring up to 7 mm, likely representing treated metastatic disease (series 26 image 22), previously 2.3 cm on 08/20/2024. The reported cortical irregularity within hepatic segment 7 seen on prior study is not seen on today’s exam. Interval near complete resolution of the ill-defined wedge-shaped hypoenhancement hepatic segment 8.MRI Abdomen Liver 11/29/2024:Posttreatment changes related to previously seen hepatic lesions with decrease in size compared to the prior study consistent with treatment response. No new lesions identified. Ill-defined wedge shaped decreased uptake in hepatic segment 8 has also decreased in size compared to prior study which could be related to a no focal hepatic toxicity related to oxaliplatin.PET/CT 11/21/2024:Interval resolution of the previously seen four hypermetabolic liver lesions and hepatic segments 2, 7, and 8. Of note, small hepatic lesions are difficult to characterize with PET/CT accurately and would be better evaluated with MRI if there is clinical concern. Interval resolution of the hypermetabolic soft tissue nodules in the rectovesicular pouch.Persistent activity in the right hilar region, which is indeterminate.CT Body Consult 10/15/2024:The lesions seen on hepatobiliary phase of the prior MRI are much smaller on this exam. It is not certain whether this represents response to therapy or differences in technique, particularly given that the lesions could not be seen on portal venous phase of the prior MRI as well. Adequate comparison would require a repeat MRI examination with hepatobiliary phase. Stable indeterminate 8 mm solid nodule in the right lower lobe. This was not hypermetabolic on the prior CT examination, but a right hilar lymph node which measures at the upper limits of normal for size was hypermetabolic and could represent a metastasis. Small stable 7 mm groundglass nodule left lower lobe.MRI Abdomen Pelvis 8/28/2024:Vague hepatobiliary phase hypointense lesions in segment 2, 4A and 7, corresponding to FDG avid lesions on PET/CT 07/25/2024. The vague appearance of these lesions likely indicates treatment response. Previously described lesion in the liver dome in segment 8 on PET/CT is not seen on the current examination. Treated rectovesicular pouch lesions without evidence of residualmetastatic disease in the pelvis. Conventional hepatic arterial anatomy. Peripheral wedge-shaped area of hepatobiliary phase hypointensity in segment 8 without a correlate on other sequences is nonspecific, but is unlikely to represent metastatic disease.PET OSH 7/25/2024 CONSULTAt least four hypermetabolic liver lesions involving segment II, VII and VIII compatible with metastatic disease. Two intensely hypermetabolic soft tissue nodule deposits in the rectovesical pouch are compatible with metastatic diseaseSURGERY 7/1/2024Colonoscopy 5/29/2024Bone scan 5/22/2024CT AP OSH 5/7/2024CT AP 12/28/2023ASSESSMENT AND PLAN:Alexander R Towell is a 50 y.o. Non-Hispanic male with metastatic small bowel adenocarcinoma with liver and pelvis metastases who presents for second opinionMetastatic Terminal Ileum Adenocarcinoma, MSS, RAS WT, with liver and pelvic ? Metastases- I reviewed his PET scan and MRI report and images with him and his wife noting no evidence of radiologic recurrence- I reviewed with him his ctDNA which showed no alteration and his CEA is normal- we again reviewed that although scans and labs show no clear recurrence, unclear if there is true residual disease. Options to continue adjuvant 5FU vs surveillance discussed. Pros and cons reviewed.- At this point, he is agreeable to proceed with chemotherapy. Will keep him on 5FU for now, possible addition of iri and bev should there be any progression.- RTC in 2 weeks for treatment and in 4 weeks with a visit.All of his questions were answered. He understands and was in agreement with the plan of care. He knows to call the office in the interim with any symptoms, questions, or concerns. Benjamin Tan MDElectronically signed by Benjamin Tan, MD at 08/14/2025 2:08 PM CDTdocumented in this encounter

Amy Ngo, NP - 09/11/2025 8:15 AM CDTFormatting of this note is different from the original.Images from the original note were not included.Oncology Return/Follow Up VisitAlexander R TowellDOB:8/4/1975 DATE OF VISIT:9/11/2025 Oncology History Overview Note DIAGNOSIS:Sigmoid Adenocarcinoma Stage IIIMetastaticTerminal Ileum Adenocarcinoma, MSS, RAS WT, with liver metastasesGENOMIC DATA:- DYPD normal1. TEMPUS XT for small bowel adenocarcinoma2. TEMPUS XT on Liver specimen 5/14/20253. TEMPUS XF- 07/08/2025ONCOLOGIC HISTORY:presented with anemia with tiredness, constipation, abdominal pain and fatigue back in 2021. He required blood transfusions- 11/22/2021 Colonoscopy showed malignant appearing mas in descending colon with ulceration and partial obstruction- 11/23/2021 labs notes wbc 3.8, Hb 9.4, platelets 310K, creatinine 1.8, bilirubin 0.3, CEA 1.4- 12/09/2021 CT scan showed exophytic sigmoid colon mass (2.6 cm) with Lymph nodes suspicious for metastatic disease and sclerotic focus in the left iliac bone.- 12/10/2021 Consultation with Dr. Syed (Oncology)- 12/29/2021 laparsocopic sigmoid colectomy pathology showed moderately differentiated colon adenocarcinoma 1 of 23 LN +, MSS, RAS WT- stage IIIB pT4N1M0- 02/16/2022 to 08/29/2022 adjuvant FOLFOX x 12 cycles with dose reduction. Toxicities include neuropathy and diarrhea, fatigue- 01/01/2023 CT scans showed no recurrence- 01/09/2023 Colonoscopy showed normal findings- 12/29/2023 CT showed no metastases- 05/29/2024 Colonoscopy showed large ulcerated mass in the terminal ileum, biopsy confirmed moderately differentiated adenocarcinoma- 07/01/2024 right hemicolectomy - showed 4 of 14 LN +, PNI+, no LVI, RAS WT, MSS- 07/11/2024 Tempus XF - 07/25/2024 PET scan done showed liver lesions. Started chemotherapy with Cycle 1 FOLFIRI- 08/12/2024 Cycle 2 FOLFIRI/bevacizumab: has diarrhea treated with immodium- 08/15/2024 Consultation with medical oncology (tan) to discuss HAI pump therapyTREATMENT HISTORY: laparoscopic sigmoid colectomy 12/29/2021Adjuvant FOLFOX x 12 cycles 2/16/2022- 8/2022Right hemicolectomy 7/1/2024FRONTLINE FOLFIRI/Bevacizumab- 07/25/2024 Cycle 1 FOLFIRI- 08/12/2024 Cycle 2 FOLFIRI/Bevacizumab- 02/12/2025 Maintenance 5FU/bevacizumab- 04/16/2025 Maintenance 5FU/Bev (last dose prior to surgery)5. Robotic Segment 2 resection (Chapman) 5/14/20255. Resumption of 5FU +/- bev- 07/31/2025 Cycle 1 5FU 2400 CIVI- MRI/PET no evidence of recurrence- 08/14/2025 Cycle 2 5FU 2400 CIVI- 08/28/2025 Cycle 3 5FU 2400 CIVIMalignant neoplasm metastatic to liver (HCC) 8/16/2024 Initial Diagnosis Malignant neoplasm metastatic to liver (HCC)Active Treatment & Therapy Plans for Towell, Alexander R “Alex” Oncology Chemotherapy Treatment: FOLFIRI+Bev: (Fluorouracil / Leucovorin / Irinotecan / Bevacizumab) 14 Day Cycles - Colon/Rectum Current day: Day 1, Cycle 4 (Planned for 9/11/2025) Following planned day: Day 1, Cycle 5 (Planned for 9/25/2025) Line Care : IV Maintenance Therapy Plan Current treatment: Treatment 1 (Planned for 8/14/2025) Subjective Mr. Alexander R Towell is a 50 y.o. Non-Hispanic male who comes to the Gastrointestinal Oncology Clinic at Washington University for a follow up oncology visit.He resumed 5FU alone 7/31/2025. His CTDNA was negative and his CEA 4.6 7/31/2025. He had restaging scans done with MRI and PET 8/13/2025 which showed no evidence of disease.He comes today with his SO and notes:- feeling well with no complaints- tolerating 5FU pump well- eating and drinking well- bowels are moving without issues or change, at baselinePast 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 Prior to Admission medications Medication Sig Start Date End Date Taking? Authorizing Provider levothyroxine (SYNTHROID) 88 mcg tablet Take 1 tablet (88 mcg total) by mouth daily 3/23/23 Provider, Historical, MD No Known AllergiesSocial History Tobacco Use Smoking status: Never Smokeless tobacco: Never Substance and Sexual Activity Drug use: Never Sexual activity: Defer Alcohol Use: Not At Risk (5/14/2025) AUDIT-C Frequency of Alcohol Consumption: Never Average Number of Drinks: Patient does not drink Frequency of Binge Drinking: Never Family History Problem Relation Age of Onset Prostate cancer Father 69 Review of SystemsReview of Systems Constitutional: Negative. Negative for chills and fever. HENT: Negative. Eyes: Negative. Respiratory: Negative. Negative for cough and shortness of breath. Cardiovascular: Negative. Negative for chest pain. Gastrointestinal: Negative. Negative for abdominal pain, blood in stool, nausea and vomiting. Endocrine: Negative. Genitourinary: Negative. Musculoskeletal: Negative. Skin: Negative. Neurological: Negative. Hematological: Negative. Psychiatric/Behavioral: The patient is nervous/anxious. Pain: negative.Negative for: new onset pain.Objective Vitals:BP: 131/74Temp: 36.4 °C (97.6 °F)Temp src: OralPulse: 55Resp: 16SpO2: 99 %Weight: 102.2 kg (225 lb 3.2 oz)ECOG: 0PHYSICAL EXAMINATIONPhysical ExamVitals reviewed. Constitutional: Appearance: Normal appearance. HENT: Head: Normocephalic and atraumatic. Nose: Nose normal. Eyes: General: No scleral icterus. Conjunctiva/sclera: Conjunctivae normal. Cardiovascular: Rate and Rhythm: Normal rate and regular rhythm. Heart sounds: Normal heart sounds. Pulmonary: Effort: Pulmonary effort is normal. No respiratory distress. Breath sounds: Normal breath sounds. Abdominal: General: Bowel sounds are normal. There is no distension. Palpations: Abdomen is soft. Tenderness: There is no abdominal tenderness. Musculoskeletal: General: Normal range of motion. Cervical back: Normal range of motion. Right lower leg: No edema. Left lower leg: No edema. Lymphadenopathy: Cervical: No cervical adenopathy. Skin: General: Skin is warm and dry. Coloration: Skin is not jaundiced. Neurological: General: No focal deficit present. Mental Status: He is alert and oriented to person, place, and time. Psychiatric: Mood and Affect: Mood normal. Behavior: Behavior normal. Thought Content: Thought content normal. Judgment: Judgment normal. Lab/Radiology/Diagnostic Review:Recent Results (from the past 24 hours) Comprehensive metabolic panel Collection Time: 09/11/25 7:49 AM Result Value Ref Range Sodium 141 135 - 145 mmol/L Potassium, pl 4.3 3.3 - 4.9 mmol/L Chloride 106 97 - 110 mmol/L CO2 27 22 - 32 mmol/L Anion gap 8 2 - 15 mmol/L BUN 23 6 - 25 mg/dL Creatinine 1.06 0.80 - 1.30 mg/dL Glucose 99 70 - 199 mg/dL Calcium 9.2 8.5 - 10.3 mg/dL Bilirubin, total 0.7 0.1 - 1.2 mg/dL Protein, pl 7.1 6.5 - 8.5 g/dL Albumin 4.3 3.5 - 5.0 g/dL Alk phos 73 40 - 130 Units/L ALT 29 7 - 55 Units/L AST 22 10 - 50 Units/L CBC with auto differential Collection Time: 09/11/25 7:49 AM Result Value Ref Range WBC 4.91 3.80 - 9.90 K/cumm Hgb 15.2 13.0 - 17.5 g/dL Hct 44.2 38.9 - 50.3 % Plt 155 150 - 400 K/cumm MPV 9.8 9.1 - 12.3 fL RBC 4.69 4.30 - 5.80 M/cumm MCV 94.2 81.3 - 96.4 fL MCH 32.4 27.1 - 33.3 pg MCHC 34.4 32.3 - 35.7 g/dL RDW CV 15.0 (H) 11.1 - 14.9 % RDW SD 50.8 (H) 35.7 - 48.1 fL NRBC abs 0.00 0.00 - 0.01 K/cumm ANC Prelim 2.35 1.50 - 6.50 K/cumm Differential, auto Collection Time: 09/11/25 7:49 AM Result Value Ref Range Neutrophil abs 2.35 1.50 - 6.50 K/cumm Imm gran abs 0.02 0.00 - 0.10 K/cumm Lymphocyte abs 1.72 0.80 - 3.30 K/cumm Monocyte abs 0.62 0.20 - 0.80 K/cumm Eosinophil abs 0.16 0.00 - 0.50 K/cumm Basophil abs 0.04 0.00 - 0.10 K/cumm Neutrophil pct 47.9 % Imm gran pct 0.4 % Lymphocyte pct 35.0 % Monocyte pct 12.6 % Eosinophil pct 3.3 % Basophil pct 0.8 % eGFR Collection Time: 09/11/25 7:49 AM Result Value Ref Range eGFR 86 >=60 mL/min/1.73 m2 Hematology Lab History Latest Ref Rng & Units 7/31/2025 09:59 8/14/2025 10:44 8/28/2025 08:37 9/11/2025 07:49 Labs - Hematology WBC 3.80 - 9.90 K/cumm 3.31 4.27 5.08 4.91 Total Hb, POC 13.0 - 17.5 g/dL 14.8 15.5 14.9 15.2 Hct 38.9 - 50.3 % 42.9 43.9 43.0 44.2 Plt 150 - 400 K/cumm 183 152 147 155 Neutrophil abs 1.50 - 6.50 K/cumm 1.11 2.37 2.38 2.35 Lymphocytes, abs 0.80 - 3.30 K/cumm 1.45 1.27 1.88 1.72 Chem/LFT Lab History Latest Ref Rng & Units 7/31/2025 09:59 8/14/2025 10:44 8/28/2025 08:37 9/11/2025 07:49 Labs-Chem/LFT Sodium 135 - 145 mmol/L 141 140 140 141 Creatinine 0.80 - 1.30 mg/dL 1.03 0.96 1.01 1.06 Bilirubin, total 0.1 - 1.2 mg/dL 0.6 0.4 0.6 0.7 AST 10 - 50 Units/L 28 20 48 22 ALT 7 - 55 Units/L 34 21 67 29 Alk phos 40 - 130 Units/L 75 70 72 73 CrCl- Actual Body Weight (Cockcroft-Gault) 124.1 129.1 126.3 120.5 Tumor Marker History Latest Ref Rng & Units 7/8/2025 11:50 7/31/2025 09:59 8/14/2025 10:44 8/28/2025 08:37 Tumor Markers CEA <=5.0 ng/mL 4.7 4.6 3.9 4.1 PATHOLOGY REVIEW:5/14/2025 A. Liver, segment 2, resection - Metastatic adenocarcinoma morphologically compatible with the patient’s colorectal primary. - Adenocarcinoma present at cauterized resection margin. - Perineural invasion identified. 7/1/20245/29/202411/22/20219/20/2022THYROID, RIGHT LOBE, RIGHT LOBECTOMY:- NODULAR HYPERPLASIA (NODULAR GOITER)-ADDITIONAL PATHOLOGIC FINDINGS - ONE (1) LYMPH NODE NEGATIVE FOR METASTASIS (0/1).- LYMPHOCYTIC THYROIDITIS:- PARATHYROID GLAND(S): ONE PRESENT IN THE LOWER POLE, WITHOUT HISTOLOGIC ABNORMALITIES.7/29/2022THYROID LOBE, RIGHT, ULTRASOUND GUIDED NEEDLE BIOPSY:- ADEQUATE FOR INTERPRETATION. - SUSPICIOUS FOR FOLLICULAR NEOPLASM. BETHESDA CLASS IV. 5/11/2022A. THYROID LOBE, RIGHT, (1ST NODULE), ULTRASOUND-GUIDED NEEDLE BIOPSY; - ADEQUATE FOR INTERPRETATION.- BENIGN, CONSISTENT WITH BENIGN FOLLICULAR NODULE (INCLUDES ADENOMATOID NODULE, COLLOID NODULE, ETC.). BETHESDA CLASS II.B. THYROID LOBE, RIGHT (2ND NODULE), ULTRASOUND-GUIDED NEEDLE BIOPSY: - ADEQUATE FOR INTERPRETATION.- ATYPIA OF ON DETERMINE SIGNIFICANCE. FOLLICULAR CELLS WITH MILD FOCAL ARCHITECTURAL ATYPIA. BETHESDA CLASS IIIctDNA7/11/2024RADIOLOGY REVIEW:MRI Abdomen/PET/CT 8/13/2025Posttreatment changes to hepatic segment 2. No evidence of recurrentor metastatic disease in the abdomen or pelvis. 1. No PET/CT evidence of residual/recurrent locoregional or distantmetastatic disease.2. The right suprahilar lymph node is favored to be reactive, giventhe stable size and FDG avidity.3. The bilateral lung lower lobe nodules, are favored to be benign,given the lack of FDG uptake and stable size, dating back to CT inDecember 2024.4. Diffuse persistent left hemithyroid activity. Recommendevaluation with thyroid function tests. MRI Abdomen 4/30/2025:Unchanged hepatic segment 2 lesion consistent with continued treatment response. No evidence of progressive or new metastatic disease in the abdomen. Near complete resolution of the wedge shaped lesion in hepaticsegment 8, which was previously thought to represent focal hepatictoxicity related to oxaliplatin. Focal liver lesions: Unchanged hepatic segment 2 lesion measuring up to 7 mm, likely representing treated metastatic disease (series 26 image 22), previously 2.3 cm on 08/20/2024. The reported cortical irregularity within hepatic segment 7 seen on prior study is not seen on today’s exam. Interval near complete resolution of the ill-defined wedge-shaped hypoenhancement hepatic segment 8.MRI Abdomen Liver 11/29/2024:Posttreatment changes related to previously seen hepatic lesions with decrease in size compared to the prior study consistent with treatment response. No new lesions identified. Ill-defined wedge shaped decreased uptake in hepatic segment 8 has also decreased in size compared to prior study which could be related to a no focal hepatic toxicity related to oxaliplatin.PET/CT 11/21/2024:Interval resolution of the previously seen four hypermetabolic liver lesions and hepatic segments 2, 7, and 8. Of note, small hepatic lesions are difficult to characterize with PET/CT accurately and would be better evaluated with MRI if there is clinical concern. Interval resolution of the hypermetabolic soft tissue nodules in the rectovesicular pouch.Persistent activity in the right hilar region, which is indeterminate.CT Body Consult 10/15/2024:The lesions seen on hepatobiliary phase of the prior MRI are much smaller on this exam. It is not certain whether this represents response to therapy or differences in technique, particularly given that the lesions could not be seen on portal venous phase of the prior MRI as well. Adequate comparison would require a repeat MRI examination with hepatobiliary phase. Stable indeterminate 8 mm solid nodule in the right lower lobe. This was not hypermetabolic on the prior CT examination, but a right hilar lymph node which measures at the upper limits of normal for size was hypermetabolic and could represent a metastasis. Small stable 7 mm groundglass nodule left lower lobe.MRI Abdomen Pelvis 8/28/2024:Vague hepatobiliary phase hypointense lesions in segment 2, 4A and 7, corresponding to FDG avid lesions on PET/CT 07/25/2024. The vague appearance of these lesions likely indicates treatment response. Previously described lesion in the liver dome in segment 8 on PET/CT is not seen on the current examination. Treated rectovesicular pouch lesions without evidence of residualmetastatic disease in the pelvis. Conventional hepatic arterial anatomy. Peripheral wedge-shaped area of hepatobiliary phase hypointensity in segment 8 without a correlate on other sequences is nonspecific, but is unlikely to represent metastatic disease.PET OSH 7/25/2024 CONSULTAt least four hypermetabolic liver lesions involving segment II, VII and VIII compatible with metastatic disease. Two intensely hypermetabolic soft tissue nodule deposits in the rectovesical pouch are compatible with metastatic diseaseSURGERY 7/1/2024Colonoscopy 5/29/2024Bone scan 5/22/2024CT AP OSH 5/7/2024CT AP 12/28/2023Assessment/Plan Alexander R Towell is a 50 y.o. Non-Hispanic male with metastatic small bowel adenocarcinoma with liver and pelvis metastases who presents for follow up. Metastatic Terminal Ileum Adenocarcinoma, MSS, RAS WT, with liver and pelvic ? Metastases- Patient has been resumed on maintenance 5-FU and is tolerating this well. - We reviewed labs today which were notable for normal CMP and CBC. - At this point, he is agreeable to proceed with chemotherapy. Will keep him on 5FU for now, possible addition of iri and bev should there be any progression.- RTC in 2 weeks for treatment and in 4 weeks with ROV.- Will plan for scans around time of 11/6 visit. Amy Ngo, NPIn collaboration with Dr. TanCosigned by Benjamin Tan, MD at 09/11/2025 9:59 AM CDTElectronically signed by Amy Ngo, NP at 09/11/2025 8:30 AM CDTElectronically signed by Benjamin Tan, MD at 09/11/2025 9:59 AM CDTdocumented in this encounter

Benjamin Tan, MD - 10/09/2025 8:15 AM CDTFormatting of this note is different from the original.Images from the original note were not included.Oncology Return/Follow Up VisitAlexander R TowellDOB:8/4/1975 DATE OF VISIT:10/9/2025 Oncology History Overview Note DIAGNOSIS:Sigmoid Adenocarcinoma Stage IIIMetastaticTerminal Ileum Adenocarcinoma, MSS, RAS WT, with liver metastasesGENOMIC DATA:- DYPD normal1. TEMPUS XT for small bowel adenocarcinoma2. TEMPUS XT on Liver specimen 5/14/20253. TEMPUS XF- 07/08/2025ONCOLOGIC HISTORY:presented with anemia with tiredness, constipation, abdominal pain and fatigue back in 2021. He required blood transfusions- 11/22/2021 Colonoscopy showed malignant appearing mas in descending colon with ulceration and partial obstruction- 11/23/2021 labs notes wbc 3.8, Hb 9.4, platelets 310K, creatinine 1.8, bilirubin 0.3, CEA 1.4- 12/09/2021 CT scan showed exophytic sigmoid colon mass (2.6 cm) with Lymph nodes suspicious for metastatic disease and sclerotic focus in the left iliac bone.- 12/10/2021 Consultation with Dr. Syed (Oncology)- 12/29/2021 laparsocopic sigmoid colectomy pathology showed moderately differentiated colon adenocarcinoma 1 of 23 LN +, MSS, RAS WT- stage IIIB pT4N1M0- 02/16/2022 to 08/29/2022 adjuvant FOLFOX x 12 cycles with dose reduction. Toxicities include neuropathy and diarrhea, fatigue- 01/01/2023 CT scans showed no recurrence- 01/09/2023 Colonoscopy showed normal findings- 12/29/2023 CT showed no metastases- 05/29/2024 Colonoscopy showed large ulcerated mass in the terminal ileum, biopsy confirmed moderately differentiated adenocarcinoma- 07/01/2024 right hemicolectomy - showed 4 of 14 LN +, PNI+, no LVI, RAS WT, MSS- 07/11/2024 Tempus XF - 07/25/2024 PET scan done showed liver lesions. Started chemotherapy with Cycle 1 FOLFIRI- 08/12/2024 Cycle 2 FOLFIRI/bevacizumab: has diarrhea treated with immodium- 08/15/2024 Consultation with medical oncology (tan) to discuss HAI pump therapyTREATMENT HISTORY: laparoscopic sigmoid colectomy 12/29/2021Adjuvant FOLFOX x 12 cycles 2/16/2022- 8/2022Right hemicolectomy 7/1/2024FRONTLINE FOLFIRI/Bevacizumab- 07/25/2024 Cycle 1 FOLFIRI- 08/12/2024 Cycle 2 FOLFIRI/Bevacizumab- 02/12/2025 Maintenance 5FU/bevacizumab- 04/16/2025 Maintenance 5FU/Bev (last dose prior to surgery)5. Robotic Segment 2 resection (Chapman) 5/14/20255. Resumption of 5FU +/- bev- 07/31/2025 Cycle 1 5FU 2400 CIVI- MRI/PET no evidence of recurrence- 08/14/2025 Cycle 2 5FU 2400 CIVI- 08/28/2025 Cycle 3 5FU 2400 CIVIMalignant neoplasm metastatic to liver (HCC) 8/16/2024 Initial Diagnosis Malignant neoplasm metastatic to liver (HCC)Active Treatment & Therapy Plans for Towell, Alexander R “Alex” Oncology Chemotherapy Treatment: FOLFIRI+Bev: (Fluorouracil / Leucovorin / Irinotecan / Bevacizumab) 14 Day Cycles - Colon/Rectum Current day: Day 1, Cycle 6 (Planned for 10/9/2025) Following planned day: Day 1, Cycle 7 (Planned for 10/23/2025) Line Care : IV Maintenance Therapy Plan Current treatment: Treatment 1 (Planned for 8/14/2025) Subjective Mr. Alexander R Towell is a 50 y.o. Non-Hispanic male who comes to the Gastrointestinal Oncology Clinic at Washington University for a follow up oncology visit.He had his last treatment with 5FU on 9/25/2025 and tolerated this well.He comes today with his SO and notes:- feeling well with no complaints- tolerating 5FU pump well- no abdominal pain, nausea, vomiting, mucositis- bleeding, jaundice, painPast 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 Prior to Admission medications Medication Sig Start Date End Date Taking? Authorizing Provider levothyroxine (SYNTHROID) 88 mcg tablet Take 1 tablet (88 mcg total) by mouth daily 3/23/23 Provider, Historical, MD No Known AllergiesSocial History Tobacco Use Smoking status: Never Smokeless tobacco: Never Substance and Sexual Activity Drug use: Never Sexual activity: Defer Alcohol Use: Not At Risk (5/14/2025) AUDIT-C Frequency of Alcohol Consumption: Never Average Number of Drinks: Patient does not drink Frequency of Binge Drinking: Never Family History Problem Relation Age of Onset Prostate cancer Father 69 Review of SystemsReview of Systems Constitutional: Negative. Negative for chills and fever. HENT: Negative. Eyes: Negative. Respiratory: Negative. Negative for cough and shortness of breath. Cardiovascular: Negative. Negative for chest pain. Gastrointestinal: Negative. Negative for abdominal pain, blood in stool, nausea and vomiting. Endocrine: Negative. Genitourinary: Negative. Musculoskeletal: Negative. Skin: Negative. Neurological: Negative. Hematological: Negative. Psychiatric/Behavioral: Positive for sleep disturbance. Pain: negative.Negative for: new onset pain.Objective Vitals:BP: 117/76Temp: 36.4 °C (97.6 °F)Temp src: OralPulse: 54Resp: 16SpO2: 97 %Weight: 103.5 kg (228 lb 3.2 oz)ECOG: 0PHYSICAL EXAMINATIONPhysical ExamVitals reviewed. Constitutional: Appearance: Normal appearance. HENT: Head: Normocephalic and atraumatic. Nose: Nose normal. Eyes: General: No scleral icterus. Conjunctiva/sclera: Conjunctivae normal. Cardiovascular: Rate and Rhythm: Normal rate and regular rhythm. Heart sounds: Normal heart sounds. Pulmonary: Effort: Pulmonary effort is normal. No respiratory distress. Breath sounds: Normal breath sounds. Abdominal: General: Bowel sounds are normal. There is no distension. Palpations: Abdomen is soft. Tenderness: There is no abdominal tenderness. Musculoskeletal: General: Normal range of motion. Cervical back: Normal range of motion. Right lower leg: No edema. Left lower leg: No edema. Lymphadenopathy: Cervical: No cervical adenopathy. Skin: General: Skin is warm and dry. Coloration: Skin is not jaundiced. Neurological: General: No focal deficit present. Mental Status: He is alert and oriented to person, place, and time. Psychiatric: Mood and Affect: Mood normal. Behavior: Behavior normal. Thought Content: Thought content normal. Judgment: Judgment normal. Lab/Radiology/Diagnostic Review:Recent Results (from the past 24 hours) Comprehensive metabolic panel Collection Time: 10/09/25 7:55 AM Result Value Ref Range Sodium 141 135 - 145 mmol/L Potassium, pl 4.3 3.3 - 4.9 mmol/L Chloride 108 97 - 110 mmol/L CO2 25 22 - 32 mmol/L Anion gap 8 2 - 15 mmol/L BUN 20 6 - 25 mg/dL Creatinine 1.11 0.80 - 1.30 mg/dL Glucose 105 70 - 199 mg/dL Calcium 8.6 8.5 - 10.3 mg/dL Bilirubin, total 0.7 0.1 - 1.2 mg/dL Protein, pl 7.0 6.5 - 8.5 g/dL Albumin 4.4 3.5 - 5.0 g/dL Alk phos 65 40 - 130 Units/L ALT 31 7 - 55 Units/L AST 24 10 - 50 Units/L CBC with auto differential Collection Time: 10/09/25 7:55 AM Result Value Ref Range WBC 4.81 3.80 - 9.90 K/cumm Hgb 15.0 13.0 - 17.5 g/dL Hct 43.5 38.9 - 50.3 % Plt 150 150 - 400 K/cumm MPV 10.1 9.1 - 12.3 fL RBC 4.54 4.30 - 5.80 M/cumm MCV 95.8 81.3 - 96.4 fL MCH 33.0 27.1 - 33.3 pg MCHC 34.5 32.3 - 35.7 g/dL RDW CV 14.7 11.1 - 14.9 % RDW SD 51.5 (H) 35.7 - 48.1 fL NRBC abs 0.00 0.00 - 0.01 K/cumm ANC Prelim 2.50 1.50 - 6.50 K/cumm Differential, auto Collection Time: 10/09/25 7:55 AM Result Value Ref Range Neutrophil abs 2.50 1.50 - 6.50 K/cumm Imm gran abs 0.02 0.00 - 0.10 K/cumm Lymphocyte abs 1.54 0.80 - 3.30 K/cumm Monocyte abs 0.57 0.20 - 0.80 K/cumm Eosinophil abs 0.15 0.00 - 0.50 K/cumm Basophil abs 0.03 0.00 - 0.10 K/cumm Neutrophil pct 52.0 % Imm gran pct 0.4 % Lymphocyte pct 32.0 % Monocyte pct 11.9 % Eosinophil pct 3.1 % Basophil pct 0.6 % eGFR Collection Time: 10/09/25 7:55 AM Result Value Ref Range eGFR 81 >=60 mL/min/1.73 m2 Hematology Lab History Latest Ref Rng & Units 8/28/2025 08:37 9/11/2025 07:49 9/25/2025 08:41 10/9/2025 07:55 Labs - Hematology WBC 3.80 - 9.90 K/cumm 5.08 4.91 5.20 4.81 Total Hb, POC 13.0 - 17.5 g/dL 14.9 15.2 15.2 15.0 Hct 38.9 - 50.3 % 43.0 44.2 44.7 43.5 Plt 150 - 400 K/cumm 147 155 146 150 Neutrophil abs 1.50 - 6.50 K/cumm 2.38 2.35 2.94 2.50 Lymphocytes, abs 0.80 - 3.30 K/cumm 1.88 1.72 1.49 1.54 Chem/LFT Lab History Latest Ref Rng & Units 8/28/2025 08:37 9/11/2025 07:49 9/25/2025 08:41 10/9/2025 07:55 Labs-Chem/LFT Sodium 135 - 145 mmol/L 140 141 141 141 Creatinine 0.80 - 1.30 mg/dL 1.01 1.06 1.11 1.11 Bilirubin, total 0.1 - 1.2 mg/dL 0.6 0.7 0.6 0.7 AST 10 - 50 Units/L 48 22 33 24 ALT 7 - 55 Units/L 67 29 62 31 Alk phos 40 - 130 Units/L 72 73 74 65 CrCl- Actual Body Weight (Cockcroft-Gault) 126.3 120.5 116.8 116.6 Tumor Marker History Latest Ref Rng & Units 8/14/2025 10:44 8/28/2025 08:37 9/11/2025 07:49 9/25/2025 08:41 Tumor Markers CEA <=5.0 ng/mL 3.9 4.1 4.0 3.8 PATHOLOGY REVIEW:5/14/2025 A. Liver, segment 2, resection - Metastatic adenocarcinoma morphologically compatible with the patient’s colorectal primary. - Adenocarcinoma present at cauterized resection margin. - Perineural invasion identified. 7/1/20245/29/202411/22/20219/20/2022THYROID, RIGHT LOBE, RIGHT LOBECTOMY:- NODULAR HYPERPLASIA (NODULAR GOITER)-ADDITIONAL PATHOLOGIC FINDINGS - ONE (1) LYMPH NODE NEGATIVE FOR METASTASIS (0/1).- LYMPHOCYTIC THYROIDITIS:- PARATHYROID GLAND(S): ONE PRESENT IN THE LOWER POLE, WITHOUT HISTOLOGIC ABNORMALITIES.7/29/2022THYROID LOBE, RIGHT, ULTRASOUND GUIDED NEEDLE BIOPSY:- ADEQUATE FOR INTERPRETATION. - SUSPICIOUS FOR FOLLICULAR NEOPLASM. BETHESDA CLASS IV. 5/11/2022A. THYROID LOBE, RIGHT, (1ST NODULE), ULTRASOUND-GUIDED NEEDLE BIOPSY; - ADEQUATE FOR INTERPRETATION.- BENIGN, CONSISTENT WITH BENIGN FOLLICULAR NODULE (INCLUDES ADENOMATOID NODULE, COLLOID NODULE, ETC.). BETHESDA CLASS II.B. THYROID LOBE, RIGHT (2ND NODULE), ULTRASOUND-GUIDED NEEDLE BIOPSY: - ADEQUATE FOR INTERPRETATION.- ATYPIA OF ON DETERMINE SIGNIFICANCE. FOLLICULAR CELLS WITH MILD FOCAL ARCHITECTURAL ATYPIA. BETHESDA CLASS IIIctDNA7/11/2024RADIOLOGY REVIEW:MRI Abdomen/PET/CT 8/13/2025Posttreatment changes to hepatic segment 2. No evidence of recurrentor metastatic disease in the abdomen or pelvis. 1. No PET/CT evidence of residual/recurrent locoregional or distantmetastatic disease.2. The right suprahilar lymph node is favored to be reactive, giventhe stable size and FDG avidity.3. The bilateral lung lower lobe nodules, are favored to be benign,given the lack of FDG uptake and stable size, dating back to CT inDecember 2024.4. Diffuse persistent left hemithyroid activity. Recommendevaluation with thyroid function tests. MRI Abdomen 4/30/2025:Unchanged hepatic segment 2 lesion consistent with continued treatment response. No evidence of progressive or new metastatic disease in the abdomen. Near complete resolution of the wedge shaped lesion in hepaticsegment 8, which was previously thought to represent focal hepatictoxicity related to oxaliplatin. Focal liver lesions: Unchanged hepatic segment 2 lesion measuring up to 7 mm, likely representing treated metastatic disease (series 26 image 22), previously 2.3 cm on 08/20/2024. The reported cortical irregularity within hepatic segment 7 seen on prior study is not seen on today’s exam. Interval near complete resolution of the ill-defined wedge-shaped hypoenhancement hepatic segment 8.MRI Abdomen Liver 11/29/2024:Posttreatment changes related to previously seen hepatic lesions with decrease in size compared to the prior study consistent with treatment response. No new lesions identified. Ill-defined wedge shaped decreased uptake in hepatic segment 8 has also decreased in size compared to prior study which could be related to a no focal hepatic toxicity related to oxaliplatin.PET/CT 11/21/2024:Interval resolution of the previously seen four hypermetabolic liver lesions and hepatic segments 2, 7, and 8. Of note, small hepatic lesions are difficult to characterize with PET/CT accurately and would be better evaluated with MRI if there is clinical concern. Interval resolution of the hypermetabolic soft tissue nodules in the rectovesicular pouch.Persistent activity in the right hilar region, which is indeterminate.CT Body Consult 10/15/2024:The lesions seen on hepatobiliary phase of the prior MRI are much smaller on this exam. It is not certain whether this represents response to therapy or differences in technique, particularly given that the lesions could not be seen on portal venous phase of the prior MRI as well. Adequate comparison would require a repeat MRI examination with hepatobiliary phase. Stable indeterminate 8 mm solid nodule in the right lower lobe. This was not hypermetabolic on the prior CT examination, but a right hilar lymph node which measures at the upper limits of normal for size was hypermetabolic and could represent a metastasis. Small stable 7 mm groundglass nodule left lower lobe.MRI Abdomen Pelvis 8/28/2024:Vague hepatobiliary phase hypointense lesions in segment 2, 4A and 7, corresponding to FDG avid lesions on PET/CT 07/25/2024. The vague appearance of these lesions likely indicates treatment response. Previously described lesion in the liver dome in segment 8 on PET/CT is not seen on the current examination. Treated rectovesicular pouch lesions without evidence of residualmetastatic disease in the pelvis. Conventional hepatic arterial anatomy. Peripheral wedge-shaped area of hepatobiliary phase hypointensity in segment 8 without a correlate on other sequences is nonspecific, but is unlikely to represent metastatic disease.PET OSH 7/25/2024 CONSULTAt least four hypermetabolic liver lesions involving segment II, VII and VIII compatible with metastatic disease. Two intensely hypermetabolic soft tissue nodule deposits in the rectovesical pouch are compatible with metastatic diseaseSURGERY 7/1/2024Colonoscopy 5/29/2024Bone scan 5/22/2024CT AP OSH 5/7/2024CT AP 12/28/2023Assessment/Plan Alexander R Towell is a 50 y.o. Non-Hispanic male with metastatic small bowel adenocarcinoma with liver and pelvis metastases who presents for follow up. Metastatic Terminal Ileum Adenocarcinoma, MSS, RAS WT, with liver and pelvic ? Metastases- Patient has been resumed on maintenance 5-FU and is tolerating this well. - We reviewed labs today which were notable for normal CMP and CBC. CEA had been normal - At this point, he is agreeable to proceed with chemotherapy with 5FU , discussed addition of iri and bev should there be any progression.- RTC in 2 weeks for treatment and in 4 weeks with ROV.- Will plan for scans around time of 11/6 visit. Benjamin R. Tan, MDElectronically signed by Benjamin Tan, MD at 10/09/2025 8:49 AM CDTdocumented in this encounter

Amy Ngo, NP - 11/06/2025 11:20 AM CSTFormatting of this note is different from the original.Images from the original note were not included.Oncology Return/Follow Up VisitAlexander R TowellDOB:8/4/1975 DATE OF VISIT:11/6/2025 Oncology History Overview Note DIAGNOSIS:Sigmoid Adenocarcinoma Stage IIIMetastaticTerminal Ileum Adenocarcinoma, MSS, RAS WT, with liver metastasesGENOMIC DATA:- DYPD normal1. TEMPUS XT for small bowel adenocarcinoma2. TEMPUS XT on Liver specimen 5/14/20253. TEMPUS XF- 07/08/2025ONCOLOGIC HISTORY:presented with anemia with tiredness, constipation, abdominal pain and fatigue back in 2021. He required blood transfusions- 11/22/2021 Colonoscopy showed malignant appearing mas in descending colon with ulceration and partial obstruction- 11/23/2021 labs notes wbc 3.8, Hb 9.4, platelets 310K, creatinine 1.8, bilirubin 0.3, CEA 1.4- 12/09/2021 CT scan showed exophytic sigmoid colon mass (2.6 cm) with Lymph nodes suspicious for metastatic disease and sclerotic focus in the left iliac bone.- 12/10/2021 Consultation with Dr. Syed (Oncology)- 12/29/2021 laparsocopic sigmoid colectomy pathology showed moderately differentiated colon adenocarcinoma 1 of 23 LN +, MSS, RAS WT- stage IIIB pT4N1M0- 02/16/2022 to 08/29/2022 adjuvant FOLFOX x 12 cycles with dose reduction. Toxicities include neuropathy and diarrhea, fatigue- 01/01/2023 CT scans showed no recurrence- 01/09/2023 Colonoscopy showed normal findings- 12/29/2023 CT showed no metastases- 05/29/2024 Colonoscopy showed large ulcerated mass in the terminal ileum, biopsy confirmed moderately differentiated adenocarcinoma- 07/01/2024 right hemicolectomy - showed 4 of 14 LN +, PNI+, no LVI, RAS WT, MSS- 07/11/2024 Tempus XF - 07/25/2024 PET scan done showed liver lesions. Started chemotherapy with Cycle 1 FOLFIRI- 08/12/2024 Cycle 2 FOLFIRI/bevacizumab: has diarrhea treated with immodium- 08/15/2024 Consultation with medical oncology (tan) to discuss HAI pump therapyTREATMENT HISTORY: laparoscopic sigmoid colectomy 12/29/2021Adjuvant FOLFOX x 12 cycles 2/16/2022- 8/2022Right hemicolectomy 7/1/2024FRONTLINE FOLFIRI/Bevacizumab- 07/25/2024 Cycle 1 FOLFIRI- 08/12/2024 Cycle 2 FOLFIRI/Bevacizumab- 02/12/2025 Maintenance 5FU/bevacizumab- 04/16/2025 Maintenance 5FU/Bev (last dose prior to surgery)5. Robotic Segment 2 resection (Chapman) 5/14/20255. Resumption of 5FU +/- bev- 07/31/2025 Cycle 1 5FU 2400 CIVI- 08/13/2025 MRI/PET no evidence of recurrence- 08/14/2025 Cycle 2 5FU 2400 CIVI- 08/28/2025 Cycle 3 5FU 2400 CIVI- 09/11/2025 Cycle 4 5FU 2400 CIVI- 09/25/2025 Cycle 5 5FU 2400 CIVI- 10/09/2025 Cycle 6 5FU 2400 CIVI- 10/23/2025 Cycle 7 5FU 2400 CIVI- 11/16/2025 Cycle 8 5FU 2400 CIVIMalignant neoplasm metastatic to liver (HCC) 8/16/2024 Initial Diagnosis Malignant neoplasm metastatic to liver (HCC)Active Treatment & Therapy Plans for Towell, Alexander R “Alex” Oncology Chemotherapy Treatment: FOLFIRI+Bev: (Fluorouracil / Leucovorin / Irinotecan / Bevacizumab) 14 Day Cycles - Colon/Rectum Current day: Day 1, Cycle 8 (Planned for 11/6/2025) Following planned day: Day 1, Cycle 9 (Planned for 11/20/2025) Line Care : IV Maintenance Therapy Plan Current treatment: Treatment 1 (Planned for 8/14/2025) Subjective Mr. Alexander R Towell is a 50 y.o. Non-Hispanic male who comes to the Gastrointestinal Oncology Clinic at Washington University for a follow up oncology visit.He was last seen 10/9/2025 and continued on 5FU. He last received 5FU on 10/23/2025. He underwent CT today which showed stable lung nodules. His MRI is still pending insurance approval. He comes today with his SO and notes:- may have had a 24h bug, felt drained, HA, vomited. Feeling better now. - no fevers, chills- no other complaints including abdominal pain, SOB, cough, chest painPast 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 Prior to Admission medications Medication Sig Start Date End Date Taking? Authorizing Provider levothyroxine (SYNTHROID) 88 mcg tablet Take 1 tablet (88 mcg total) by mouth daily 3/23/23 Provider, Historical, MD No Known AllergiesSocial History Tobacco Use Smoking status: Never Smokeless tobacco: Never Substance and Sexual Activity Drug use: Never Sexual activity: Defer Alcohol Use: Not At Risk (5/14/2025) AUDIT-C Frequency of Alcohol Consumption: Never Average Number of Drinks: Patient does not drink Frequency of Binge Drinking: Never Family History Problem Relation Age of Onset Prostate cancer Father 69 Review of SystemsReview of Systems Constitutional: Negative. Negative for chills and fever. HENT: Negative. Eyes: Negative. Respiratory: Negative. Negative for cough and shortness of breath. Cardiovascular: Negative. Negative for chest pain. Gastrointestinal: Negative. Negative for abdominal pain, blood in stool, nausea and vomiting. Endocrine: Negative. Genitourinary: Negative. Musculoskeletal: Negative. Skin: Negative. Neurological: Negative. Hematological: Negative. Psychiatric/Behavioral: Positive for sleep disturbance. Pain: negative.Negative for: new onset pain.Objective Vitals:BP: 120/78Temp: 36.5 °C (97.7 °F)Temp src: OralPulse: 63Resp: 16SpO2: 95 %Weight: 104.1 kg (229 lb 9.6 oz)ECOG: 0PHYSICAL EXAMINATIONPhysical ExamVitals reviewed. Constitutional: Appearance: Normal appearance. HENT: Head: Normocephalic and atraumatic. Nose: Nose normal. Eyes: General: No scleral icterus. Conjunctiva/sclera: Conjunctivae normal. Cardiovascular: Rate and Rhythm: Normal rate and regular rhythm. Heart sounds: Normal heart sounds. Pulmonary: Effort: Pulmonary effort is normal. No respiratory distress. Breath sounds: Normal breath sounds. Abdominal: General: Bowel sounds are normal. There is no distension. Palpations: Abdomen is soft. Tenderness: There is no abdominal tenderness. Musculoskeletal: General: Normal range of motion. Cervical back: Normal range of motion. Right lower leg: No edema. Left lower leg: No edema. Skin: General: Skin is warm and dry. Coloration: Skin is not jaundiced. Neurological: General: No focal deficit present. Mental Status: He is alert and oriented to person, place, and time. Mental status is at baseline. Psychiatric: Mood and Affect: Mood normal. Behavior: Behavior normal. Thought Content: Thought content normal. Lab/Radiology/Diagnostic Review:Recent Results (from the past 24 hours) Comprehensive metabolic panel Collection Time: 11/06/25 9:13 AM Result Value Ref Range Sodium 137 135 - 145 mmol/L Potassium, pl 4.2 3.3 - 4.9 mmol/L Chloride 104 97 - 110 mmol/L CO2 27 22 - 32 mmol/L Anion gap 6 2 - 15 mmol/L BUN 18 6 - 25 mg/dL Creatinine 1.07 0.80 - 1.30 mg/dL Glucose 100 70 - 199 mg/dL Calcium 9.2 8.5 - 10.3 mg/dL Bilirubin, total 0.7 0.1 - 1.2 mg/dL Protein, pl 7.3 6.5 - 8.5 g/dL Albumin 4.4 3.5 - 5.0 g/dL Alk phos 71 40 - 130 Units/L ALT 29 7 - 55 Units/L AST 23 10 - 50 Units/L CBC with auto differential Collection Time: 11/06/25 9:13 AM Result Value Ref Range WBC 5.69 3.80 - 9.90 K/cumm Hgb 15.5 13.0 - 17.5 g/dL Hct 44.5 38.9 - 50.3 % Plt 160 150 - 400 K/cumm MPV 10.1 9.1 - 12.3 fL RBC 4.72 4.30 - 5.80 M/cumm MCV 94.3 81.3 - 96.4 fL MCH 32.8 27.1 - 33.3 pg MCHC 34.8 32.3 - 35.7 g/dL RDW CV 13.7 11.1 - 14.9 % RDW SD 46.8 35.7 - 48.1 fL NRBC abs 0.00 0.00 - 0.01 K/cumm ANC Prelim 3.35 1.50 - 6.50 K/cumm CEA Collection Time: 11/06/25 9:13 AM Result Value Ref Range CEA 2.9 <=5.0 ng/mL Differential, auto Collection Time: 11/06/25 9:13 AM Result Value Ref Range Neutrophil abs 3.35 1.50 - 6.50 K/cumm Imm gran abs 0.03 0.00 - 0.10 K/cumm Lymphocyte abs 1.56 0.80 - 3.30 K/cumm Monocyte abs 0.59 0.20 - 0.80 K/cumm Eosinophil abs 0.14 0.00 - 0.50 K/cumm Basophil abs 0.02 0.00 - 0.10 K/cumm Neutrophil pct 58.8 % Imm gran pct 0.5 % Lymphocyte pct 27.4 % Monocyte pct 10.4 % Eosinophil pct 2.5 % Basophil pct 0.4 % eGFR Collection Time: 11/06/25 9:13 AM Result Value Ref Range eGFR 85 >=60 mL/min/1.73 m2 Hematology Lab History Latest Ref Rng & Units 9/25/2025 08:41 10/9/2025 07:55 10/23/2025 12:31 11/6/2025 09:13 Labs - Hematology WBC 3.80 - 9.90 K/cumm 5.20 4.81 6.55 5.69 Total Hb, POC 13.0 - 17.5 g/dL 15.2 15.0 15.3 15.5 Hct 38.9 - 50.3 % 44.7 43.5 44.9 44.5 Plt 150 - 400 K/cumm 146 150 170 160 Neutrophil abs 1.50 - 6.50 K/cumm 2.94 2.50 4.04 3.35 Lymphocytes, abs 0.80 - 3.30 K/cumm 1.49 1.54 1.66 1.56 Chem/LFT Lab History Latest Ref Rng & Units 9/25/2025 08:41 10/9/2025 07:55 10/23/2025 12:31 11/6/2025 09:13 Labs-Chem/LFT Sodium 135 - 145 mmol/L 141 141 141 137 Creatinine 0.80 - 1.30 mg/dL 1.11 1.11 1.05 1.07 Bilirubin, total 0.1 - 1.2 mg/dL 0.6 0.7 0.6 0.7 AST 10 - 50 Units/L 33 24 24 23 ALT 7 - 55 Units/L 62 31 36 29 Alk phos 40 - 130 Units/L 74 65 68 71 CrCl- Actual Body Weight (Cockcroft-Gault) 116.8 116.6 123.1 121.7 Tumor Marker History Latest Ref Rng & Units 9/25/2025 08:41 10/9/2025 07:55 10/23/2025 12:31 11/6/2025 09:13 Tumor Markers CEA <=5.0 ng/mL 3.8 3.3 4.1 2.9 PATHOLOGY REVIEW:5/14/2025 A. Liver, segment 2, resection - Metastatic adenocarcinoma morphologically compatible with the patient’s colorectal primary. - Adenocarcinoma present at cauterized resection margin. - Perineural invasion identified. 7/1/20245/29/202411/22/20219/20/2022THYROID, RIGHT LOBE, RIGHT LOBECTOMY:- NODULAR HYPERPLASIA (NODULAR GOITER)-ADDITIONAL PATHOLOGIC FINDINGS - ONE (1) LYMPH NODE NEGATIVE FOR METASTASIS (0/1).- LYMPHOCYTIC THYROIDITIS:- PARATHYROID GLAND(S): ONE PRESENT IN THE LOWER POLE, WITHOUT HISTOLOGIC ABNORMALITIES.7/29/2022THYROID LOBE, RIGHT, ULTRASOUND GUIDED NEEDLE BIOPSY:- ADEQUATE FOR INTERPRETATION. - SUSPICIOUS FOR FOLLICULAR NEOPLASM. BETHESDA CLASS IV. 5/11/2022A. THYROID LOBE, RIGHT, (1ST NODULE), ULTRASOUND-GUIDED NEEDLE BIOPSY; - ADEQUATE FOR INTERPRETATION.- BENIGN, CONSISTENT WITH BENIGN FOLLICULAR NODULE (INCLUDES ADENOMATOID NODULE, COLLOID NODULE, ETC.). BETHESDA CLASS II.B. THYROID LOBE, RIGHT (2ND NODULE), ULTRASOUND-GUIDED NEEDLE BIOPSY: - ADEQUATE FOR INTERPRETATION.- ATYPIA OF ON DETERMINE SIGNIFICANCE. FOLLICULAR CELLS WITH MILD FOCAL ARCHITECTURAL ATYPIA. BETHESDA CLASS IIIctDNA7/11/2024RADIOLOGY REVIEW:MRI Abdomen/PET/CT 8/13/2025Posttreatment changes to hepatic segment 2. No evidence of recurrentor metastatic disease in the abdomen or pelvis. 1. No PET/CT evidence of residual/recurrent locoregional or distantmetastatic disease.2. The right suprahilar lymph node is favored to be reactive, giventhe stable size and FDG avidity.3. The bilateral lung lower lobe nodules, are favored to be benign,given the lack of FDG uptake and stable size, dating back to CT inDecember 2024.4. Diffuse persistent left hemithyroid activity. Recommendevaluation with thyroid function tests. MRI Abdomen 4/30/2025:Unchanged hepatic segment 2 lesion consistent with continued treatment response. No evidence of progressive or new metastatic disease in the abdomen. Near complete resolution of the wedge shaped lesion in hepaticsegment 8, which was previously thought to represent focal hepatictoxicity related to oxaliplatin. Focal liver lesions: Unchanged hepatic segment 2 lesion measuring up to 7 mm, likely representing treated metastatic disease (series 26 image 22), previously 2.3 cm on 08/20/2024. The reported cortical irregularity within hepatic segment 7 seen on prior study is not seen on today’s exam. Interval near complete resolution of the ill-defined wedge-shaped hypoenhancement hepatic segment 8.MRI Abdomen Liver 11/29/2024:Posttreatment changes related to previously seen hepatic lesions with decrease in size compared to the prior study consistent with treatment response. No new lesions identified. Ill-defined wedge shaped decreased uptake in hepatic segment 8 has also decreased in size compared to prior study which could be related to a no focal hepatic toxicity related to oxaliplatin.PET/CT 11/21/2024:Interval resolution of the previously seen four hypermetabolic liver lesions and hepatic segments 2, 7, and 8. Of note, small hepatic lesions are difficult to characterize with PET/CT accurately and would be better evaluated with MRI if there is clinical concern. Interval resolution of the hypermetabolic soft tissue nodules in the rectovesicular pouch.Persistent activity in the right hilar region, which is indeterminate.CT Body Consult 10/15/2024:The lesions seen on hepatobiliary phase of the prior MRI are much smaller on this exam. It is not certain whether this represents response to therapy or differences in technique, particularly given that the lesions could not be seen on portal venous phase of the prior MRI as well. Adequate comparison would require a repeat MRI examination with hepatobiliary phase. Stable indeterminate 8 mm solid nodule in the right lower lobe. This was not hypermetabolic on the prior CT examination, but a right hilar lymph node which measures at the upper limits of normal for size was hypermetabolic and could represent a metastasis. Small stable 7 mm groundglass nodule left lower lobe.MRI Abdomen Pelvis 8/28/2024:Vague hepatobiliary phase hypointense lesions in segment 2, 4A and 7, corresponding to FDG avid lesions on PET/CT 07/25/2024. The vague appearance of these lesions likely indicates treatment response. Previously described lesion in the liver dome in segment 8 on PET/CT is not seen on the current examination. Treated rectovesicular pouch lesions without evidence of residualmetastatic disease in the pelvis. Conventional hepatic arterial anatomy. Peripheral wedge-shaped area of hepatobiliary phase hypointensity in segment 8 without a correlate on other sequences is nonspecific, but is unlikely to represent metastatic disease.PET OSH 7/25/2024 CONSULTAt least four hypermetabolic liver lesions involving segment II, VII and VIII compatible with metastatic disease. Two intensely hypermetabolic soft tissue nodule deposits in the rectovesical pouch are compatible with metastatic diseaseSURGERY 7/1/2024Colonoscopy 5/29/2024Bone scan 5/22/2024CT AP OSH 5/7/2024CT AP 12/28/2023Assessment/Plan Alexander R Towell is a 50 y.o. Non-Hispanic male with metastatic small bowel adenocarcinoma with liver and pelvis metastases who presents for follow up. Metastatic Terminal Ileum Adenocarcinoma, MSS, RAS WT, with liver and pelvic ? Metastases- Patient has been resumed on maintenance 5-FU and is tolerating this well. - We reviewed his CT chest which showed stable indeterminate RLL nodule and LLL nodule. MRI to be obtained once insurance is approved. - We reviewed labs today which were notable for normal CMP and CBC. CEA 2.9. - At this point, he is agreeable to proceed with chemotherapy with 5FU. Dr. Tan had previously discussed addition of iri and bev should there be any progression.- RTC in 2 weeks for treatment and in 4 weeks with ROV.Amy Ngo, NPIn collaboration with Dr. TanCosigned by Benjamin Tan, MD at 11/12/2025 5:15 PM CSTElectronically signed by Amy Ngo, NP at 11/12/2025 12:31 PM CSTElectronically signed by Benjamin Tan, MD at 11/12/2025 5:15 PM CSTdocumented in this encounter

Amy Ngo, NP - 11/12/2025 5:20 PM CSTFormatting of this note might be different from the original.Called patient and informed him of MRI results showing two new liver lesions concerning for metastatic disease. Will plan for PET/CT, tumor board review and possible referral to HPB surgery.Pt voiced understanding and agreement. Electronically signed by Amy Ngo, NP at 11/12/2025 5:21 PM CSTdocumented in this encounter

Benjamin Tan, MD - 11/20/2025 8:15 AM CSTFormatting of this note is different from the original.Images from the original note were not included.Oncology Return/Follow Up VisitAlexander R TowellDOB:8/4/1975 DATE OF VISIT:11/20/2025 Oncology History Overview Note DIAGNOSIS:Sigmoid Adenocarcinoma Stage IIIMetastaticTerminal Ileum Adenocarcinoma, MSS, RAS WT, with liver metastasesGENOMIC DATA:- DYPD normal1. TEMPUS XT for small bowel adenocarcinoma2. TEMPUS XT on Liver specimen 5/14/20253. TEMPUS XF- 07/08/2025ONCOLOGIC HISTORY:presented with anemia with tiredness, constipation, abdominal pain and fatigue back in 2021. He required blood transfusions- 11/22/2021 Colonoscopy showed malignant appearing mas in descending colon with ulceration and partial obstruction- 11/23/2021 labs notes wbc 3.8, Hb 9.4, platelets 310K, creatinine 1.8, bilirubin 0.3, CEA 1.4- 12/09/2021 CT scan showed exophytic sigmoid colon mass (2.6 cm) with Lymph nodes suspicious for metastatic disease and sclerotic focus in the left iliac bone.- 12/10/2021 Consultation with Dr. Syed (Oncology)- 12/29/2021 laparsocopic sigmoid colectomy pathology showed moderately differentiated colon adenocarcinoma 1 of 23 LN +, MSS, RAS WT- stage IIIB pT4N1M0- 02/16/2022 to 08/29/2022 adjuvant FOLFOX x 12 cycles with dose reduction. Toxicities include neuropathy and diarrhea, fatigue- 01/01/2023 CT scans showed no recurrence- 01/09/2023 Colonoscopy showed normal findings- 12/29/2023 CT showed no metastases- 05/29/2024 Colonoscopy showed large ulcerated mass in the terminal ileum, biopsy confirmed moderately differentiated adenocarcinoma- 07/01/2024 right hemicolectomy - showed 4 of 14 LN +, PNI+, no LVI, RAS WT, MSS- 07/11/2024 Tempus XF - 07/25/2024 PET scan done showed liver lesions. Started chemotherapy with Cycle 1 FOLFIRI- 08/12/2024 Cycle 2 FOLFIRI/bevacizumab: has diarrhea treated with immodium- 08/15/2024 Consultation with medical oncology (tan) to discuss HAI pump therapyTREATMENT HISTORY: laparoscopic sigmoid colectomy 12/29/2021Adjuvant FOLFOX x 12 cycles 2/16/2022- 8/2022Right hemicolectomy 7/1/2024FRONTLINE FOLFIRI/Bevacizumab- 07/25/2024 Cycle 1 FOLFIRI- 08/12/2024 Cycle 2 FOLFIRI/Bevacizumab- 02/12/2025 Maintenance 5FU/bevacizumab- 04/16/2025 Maintenance 5FU/Bev (last dose prior to surgery)5. Robotic Segment 2 resection (Chapman) 5/14/20255. Resumption of 5FU +/- bev- 07/31/2025 Cycle 1 5FU 2400 CIVI- 08/13/2025 MRI/PET no evidence of recurrence- 08/14/2025 Cycle 2 5FU 2400 CIVI- 08/28/2025 Cycle 3 5FU 2400 CIVI- 09/11/2025 Cycle 4 5FU 2400 CIVI- 09/25/2025 Cycle 5 5FU 2400 CIVI- 10/09/2025 Cycle 6 5FU 2400 CIVI- 10/23/2025 Cycle 7 5FU 2400 CIVI- 11/06/2025 Cycle 8 5FU 2400 CIVI (CEA 2.9)- 11/06/2025 CT Chest stable lung lesions- 11/09/2025 MRI abdomen with 2 new liver lesions- 11/19/2025 PET/FDGMalignant neoplasm metastatic to liver (HCC) 8/16/2024 Initial Diagnosis Malignant neoplasm metastatic to liver (HCC)Active Treatment & Therapy Plans for Towell, Alexander R “Alex” Oncology Chemotherapy Treatment: FOLFIRI+Bev: (Fluorouracil / Leucovorin / Irinotecan / Bevacizumab) 14 Day Cycles - Colon/Rectum Current day: Day 1, Cycle 9 (Planned for 11/20/2025) Following planned day: Day 1, Cycle 10 (Planned for 12/4/2025) Line Care : IV Maintenance Therapy Plan Current treatment: Treatment 1 (Planned for 8/14/2025) Subjective Mr. Alexander R Towell is a 50 y.o. Non-Hispanic male who comes to the Gastrointestinal Oncology Clinic at Washington University for a follow up oncology visit.He was last seen 11/6/2025 and continued on 5FU. He last received cycle 8 5FU on 11/6/2025. He underwent CT chest 11/6/2025 which showed stable lung nodules. His MRI done 11/9/2025 showed development of 2 liver lesions suspicious for metastatic disease. He had a PET/FDG done 11/19/2025 which showed minimal uptake in one of the liver lesions but could not differentiate between recurrence vs physiologic change.His case was reviewed at Tumor board this morning and consensus is to refer back to dr. Chapman to discussed possible wedge resections for these two peripheral liver lesions and confirm if indeed recurrent vs benign. He comes today with his SO and notes:- feeling well- no abdominal pain- no jaundice- no nausea, vomitingPast 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 Prior to Admission medications Medication Sig Start Date End Date Taking? Authorizing Provider levothyroxine (SYNTHROID) 88 mcg tablet Take 1 tablet (88 mcg total) by mouth daily 3/23/23 Provider, Historical, MD No Known AllergiesSocial History Tobacco Use Smoking status: Never Smokeless tobacco: Never Substance and Sexual Activity Drug use: Never Sexual activity: Defer Alcohol Use: Not At Risk (5/14/2025) AUDIT-C Frequency of Alcohol Consumption: Never Average Number of Drinks: Patient does not drink Frequency of Binge Drinking: Never Family History Problem Relation Age of Onset Prostate cancer Father 69 Review of SystemsReview of Systems Constitutional: Negative. Negative for chills and fever. HENT: Negative. Eyes: Negative. Respiratory: Negative. Negative for cough and shortness of breath. Cardiovascular: Negative. Negative for chest pain. Gastrointestinal: Negative. Negative for abdominal pain, blood in stool, nausea and vomiting. Endocrine: Negative. Genitourinary: Negative. Musculoskeletal: Negative. Skin: Negative. Neurological: Negative. Hematological: Negative. Psychiatric/Behavioral: Positive for sleep disturbance. Pain: negative.Negative for: new onset pain.Objective Vitals:BP: 117/79Temp: 37 °C (98.6 °F)Temp src: OralPulse: 59Resp: 16SpO2: 97 %Weight: 103.9 kg (229 lb)ECOG: 0PHYSICAL EXAMINATIONPhysical ExamVitals reviewed. Constitutional: Appearance: Normal appearance. HENT: Head: Normocephalic and atraumatic. Nose: Nose normal. Eyes: General: No scleral icterus. Conjunctiva/sclera: Conjunctivae normal. Cardiovascular: Rate and Rhythm: Normal rate and regular rhythm. Heart sounds: Normal heart sounds. Pulmonary: Effort: Pulmonary effort is normal. No respiratory distress. Breath sounds: Normal breath sounds. Abdominal: General: Bowel sounds are normal. There is no distension. Palpations: Abdomen is soft. Tenderness: There is no abdominal tenderness. Musculoskeletal: General: Normal range of motion. Cervical back: Normal range of motion. Right lower leg: No edema. Left lower leg: No edema. Skin: General: Skin is warm and dry. Coloration: Skin is not jaundiced. Neurological: General: No focal deficit present. Mental Status: He is alert and oriented to person, place, and time. Mental status is at baseline. Psychiatric: Mood and Affect: Mood normal. Behavior: Behavior normal. Thought Content: Thought content normal. Lab/Radiology/Diagnostic Review:Recent Results (from the past 24 hours) Comprehensive metabolic panel Collection Time: 11/20/25 7:58 AM Result Value Ref Range Sodium 140 135 - 145 mmol/L Potassium, pl 4.0 3.3 - 4.9 mmol/L Chloride 106 97 - 110 mmol/L CO2 27 22 - 32 mmol/L Anion gap 8 2 - 15 mmol/L BUN 23 6 - 25 mg/dL Creatinine 1.11 0.80 - 1.30 mg/dL Glucose 105 70 - 199 mg/dL Calcium 9.0 8.5 - 10.3 mg/dL Bilirubin, total 0.9 0.1 - 1.2 mg/dL Protein, pl 7.3 6.5 - 8.5 g/dL Albumin 4.3 3.5 - 5.0 g/dL Alk phos 80 40 - 130 Units/L ALT 46 7 - 55 Units/L AST 28 10 - 50 Units/L CBC with auto differential Collection Time: 11/20/25 7:58 AM Result Value Ref Range WBC 4.35 3.80 - 9.90 K/cumm Hgb 15.3 13.0 - 17.5 g/dL Hct 43.9 38.9 - 50.3 % Plt 131 (L) 150 - 400 K/cumm MPV 9.8 9.1 - 12.3 fL RBC 4.70 4.30 - 5.80 M/cumm MCV 93.4 81.3 - 96.4 fL MCH 32.6 27.1 - 33.3 pg MCHC 34.9 32.3 - 35.7 g/dL RDW CV 14.1 11.1 - 14.9 % RDW SD 48.0 35.7 - 48.1 fL NRBC abs 0.00 0.00 - 0.01 K/cumm ANC Prelim 2.66 1.50 - 6.50 K/cumm CEA Collection Time: 11/20/25 7:58 AM Result Value Ref Range CEA 2.6 <=5.0 ng/mL Differential, auto Collection Time: 11/20/25 7:58 AM Result Value Ref Range Neutrophil abs 2.66 1.50 - 6.50 K/cumm Imm gran abs 0.02 0.00 - 0.10 K/cumm Lymphocyte abs 0.95 0.80 - 3.30 K/cumm Monocyte abs 0.60 0.20 - 0.80 K/cumm Eosinophil abs 0.10 0.00 - 0.50 K/cumm Basophil abs 0.02 0.00 - 0.10 K/cumm Neutrophil pct 61.1 % Imm gran pct 0.5 % Lymphocyte pct 21.8 % Monocyte pct 13.8 % Eosinophil pct 2.3 % Basophil pct 0.5 % eGFR Collection Time: 11/20/25 7:58 AM Result Value Ref Range eGFR 81 >=60 mL/min/1.73 m2 Hematology Lab History Latest Ref Rng & Units 10/9/2025 07:55 10/23/2025 12:31 11/6/2025 09:13 11/20/2025 07:58 Labs - Hematology WBC 3.80 - 9.90 K/cumm 4.81 6.55 5.69 4.35 Total Hb, POC 13.0 - 17.5 g/dL 15.0 15.3 15.5 15.3 Hct 38.9 - 50.3 % 43.5 44.9 44.5 43.9 Plt 150 - 400 K/cumm 150 170 160 131 Neutrophil abs 1.50 - 6.50 K/cumm 2.50 4.04 3.35 2.66 Lymphocytes, abs 0.80 - 3.30 K/cumm 1.54 1.66 1.56 0.95 Chem/LFT Lab History Latest Ref Rng & Units 10/9/2025 07:55 10/23/2025 12:31 11/6/2025 09:13 11/20/2025 07:58 Labs-Chem/LFT Sodium 135 - 145 mmol/L 141 141 137 140 Creatinine 0.80 - 1.30 mg/dL 1.11 1.05 1.07 1.11 Bilirubin, total 0.1 - 1.2 mg/dL 0.7 0.6 0.7 0.9 AST 10 - 50 Units/L 24 24 23 28 ALT 7 - 55 Units/L 31 36 29 46 Alk phos 40 - 130 Units/L 65 68 71 80 CrCl- Actual Body Weight (Cockcroft-Gault) 116.6 123.1 121.7 117 Tumor Marker History Latest Ref Rng & Units 10/9/2025 07:55 10/23/2025 12:31 11/6/2025 09:13 11/20/2025 07:58 Tumor Markers CEA <=5.0 ng/mL 3.3 4.1 2.9 2.6 PATHOLOGY REVIEW:5/14/2025 A. Liver, segment 2, resection - Metastatic adenocarcinoma morphologically compatible with the patient’s colorectal primary. - Adenocarcinoma present at cauterized resection margin. - Perineural invasion identified. 7/1/20245/29/202411/22/20219/20/2022THYROID, RIGHT LOBE, RIGHT LOBECTOMY:- NODULAR HYPERPLASIA (NODULAR GOITER)-ADDITIONAL PATHOLOGIC FINDINGS - ONE (1) LYMPH NODE NEGATIVE FOR METASTASIS (0/1).- LYMPHOCYTIC THYROIDITIS:- PARATHYROID GLAND(S): ONE PRESENT IN THE LOWER POLE, WITHOUT HISTOLOGIC ABNORMALITIES.7/29/2022THYROID LOBE, RIGHT, ULTRASOUND GUIDED NEEDLE BIOPSY:- ADEQUATE FOR INTERPRETATION. - SUSPICIOUS FOR FOLLICULAR NEOPLASM. BETHESDA CLASS IV. 5/11/2022A. THYROID LOBE, RIGHT, (1ST NODULE), ULTRASOUND-GUIDED NEEDLE BIOPSY; - ADEQUATE FOR INTERPRETATION.- BENIGN, CONSISTENT WITH BENIGN FOLLICULAR NODULE (INCLUDES ADENOMATOID NODULE, COLLOID NODULE, ETC.). BETHESDA CLASS II.B. THYROID LOBE, RIGHT (2ND NODULE), ULTRASOUND-GUIDED NEEDLE BIOPSY: - ADEQUATE FOR INTERPRETATION.- ATYPIA OF ON DETERMINE SIGNIFICANCE. FOLLICULAR CELLS WITH MILD FOCAL ARCHITECTURAL ATYPIA. BETHESDA CLASS IIIctDNA7/11/2024RADIOLOGY REVIEW:PET/FDG 11/19/2025Suggestion 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.MRI Abdomen Pelvis 11/09/2025Interval development of two hepatic segment 4A/8 lesions, suspiciousfor metastatic disease. - 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.Chest CT 11/6/20251. Stable right lower lobe indeterminate pulmonary nodule. 2. Stable groundglass nodule in the left lower lobe. 3. No disease progression in the chest.MRI Abdomen/PET/CT 8/13/2025Posttreatment changes to hepatic segment 2. No evidence of recurrentor metastatic disease in the abdomen or pelvis. 1. No PET/CT evidence of residual/recurrent locoregional or distantmetastatic disease.2. The right suprahilar lymph node is favored to be reactive, giventhe stable size and FDG avidity.3. The bilateral lung lower lobe nodules, are favored to be benign,given the lack of FDG uptake and stable size, dating back to CT inDecember 2024.4. Diffuse persistent left hemithyroid activity. Recommendevaluation with thyroid function tests. MRI Abdomen 4/30/2025:Unchanged hepatic segment 2 lesion consistent with continued treatment response. No evidence of progressive or new metastatic disease in the abdomen. Near complete resolution of the wedge shaped lesion in hepaticsegment 8, which was previously thought to represent focal hepatictoxicity related to oxaliplatin. Focal liver lesions: Unchanged hepatic segment 2 lesion measuring up to 7 mm, likely representing treated metastatic disease (series 26 image 22), previously 2.3 cm on 08/20/2024. The reported cortical irregularity within hepatic segment 7 seen on prior study is not seen on today’s exam. Interval near complete resolution of the ill-defined wedge-shaped hypoenhancement hepatic segment 8.MRI Abdomen Liver 11/29/2024:Posttreatment changes related to previously seen hepatic lesions with decrease in size compared to the prior study consistent with treatment response. No new lesions identified. Ill-defined wedge shaped decreased uptake in hepatic segment 8 has also decreased in size compared to prior study which could be related to a no focal hepatic toxicity related to oxaliplatin.PET/CT 11/21/2024:Interval resolution of the previously seen four hypermetabolic liver lesions and hepatic segments 2, 7, and 8. Of note, small hepatic lesions are difficult to characterize with PET/CT accurately and would be better evaluated with MRI if there is clinical concern. Interval resolution of the hypermetabolic soft tissue nodules in the rectovesicular pouch.Persistent activity in the right hilar region, which is indeterminate.CT Body Consult 10/15/2024:The lesions seen on hepatobiliary phase of the prior MRI are much smaller on this exam. It is not certain whether this represents response to therapy or differences in technique, particularly given that the lesions could not be seen on portal venous phase of the prior MRI as well. Adequate comparison would require a repeat MRI examination with hepatobiliary phase. Stable indeterminate 8 mm solid nodule in the right lower lobe. This was not hypermetabolic on the prior CT examination, but a right hilar lymph node which measures at the upper limits of normal for size was hypermetabolic and could represent a metastasis. Small stable 7 mm groundglass nodule left lower lobe.MRI Abdomen Pelvis 8/28/2024:Vague hepatobiliary phase hypointense lesions in segment 2, 4A and 7, corresponding to FDG avid lesions on PET/CT 07/25/2024. The vague appearance of these lesions likely indicates treatment response. Previously described lesion in the liver dome in segment 8 on PET/CT is not seen on the current examination. Treated rectovesicular pouch lesions without evidence of residualmetastatic disease in the pelvis. Conventional hepatic arterial anatomy. Peripheral wedge-shaped area of hepatobiliary phase hypointensity in segment 8 without a correlate on other sequences is nonspecific, but is unlikely to represent metastatic disease.PET OSH 7/25/2024 CONSULTAt least four hypermetabolic liver lesions involving segment II, VII and VIII compatible with metastatic disease. Two intensely hypermetabolic soft tissue nodule deposits in the rectovesical pouch are compatible with metastatic diseaseSURGERY 7/1/2024Colonoscopy 5/29/2024Bone scan 5/22/2024CT AP OSH 5/7/2024CT AP 12/28/2023Assessment/Plan Alexander R Towell is a 50 y.o. Non-Hispanic male with metastatic small bowel adenocarcinoma with liver and pelvis metastases who presents for follow up. Metastatic Terminal Ileum Adenocarcinoma, MSS, RAS WT, with liver and pelvic ? Metastases- we reviewed his MRI images noting the 2 new liver lesions. - we reviewed his PET/FDG images with him and his wife which showed minimal uptake in segment 4A lesion and no other areas of FDG avidity.- We reviewed labs today which were notable for normal CEA, platelets 131- We discussed possibility of liver recurrence vs benign process. Dr. Chapman willing to see the pt next week to discuss possible exploration and resection/biopsy of these 2 liver lesions. Pt agreeable to plans- will hold systemic therapy for now- RTC in 3-4 weeksBenjamin R. Tan, MDElectronically signed by Benjamin Tan, MD at 11/20/2025 12:00 PM CSTdocumented in this encounter

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

Jeannette K - 12/01/2025 4:07 PM CSTFormatting of this note might be different from the original.Pt scheduled for surgery on 12/18/25 at 11:30 AM. Him and his partner, Kim are aware of date, time, arrival time, instructions, and location. MyChart message also sent. Electronically signed by Jeannette K at 12/01/2025 4:07 PM CSTdocumented in this encounter

Jeannette K - 12/16/2025 7:43 AM CSTFormatting of this note might be different from the original.Confirmed pts upcoming surgery for 12/18/25 at 11:30 AM. Arrival time 9:30 AM. Location discussed. Pt and his spouse voiced understanding.Electronically signed by Jeannette K at 12/16/2025 8:11 AM CSTdocumented in this encounter

Reshma Mulla, MD - 12/19/2025 6:25 AM CSTFormatting of this note is different from the original.Images from the original note were not included.Hepatobiliary Surgery Daily Progress HPI:Mr. Alexander R Towell is a 50 y.o. year old admitted for Metastatic colon cancer to liverLength of Hospitalization: 1Post Procedure Day: 12/18/2025 Procedure(s):XI LIVER RESECTION - LAPAROSCOPIC ROBOTIC ASSISTED SEGMENT 5 8 and 4B, INTRAOPERATIVE ULTRASOUND and TAP BLOCK SUBJECTIVE/ INTERVAL HISTORY-Patient denies uncontrolled pain, nausea, fever, shortness of breath. -No AEON-Voided urine around 500 ml-denies any nausea or vomiting-pain well controlled Objective Physical Exam Constitutional: Appears comfortable. Lying in bed. No distress. HENT: No nasal cannula nor NGT Eyes: Conjunctivae are normal. Pulmonary/Chest: Effort normal No respiratory distress. No grossly audible wheezes nor ralesAbdominal: Soft. No distension. Appropriately tender. Incision closed with dermabond no warmth, erythema, fluctuance, drainage. No drain . There is no rebound and no guarding. Musculoskeletal: Normal range of motion. No edema or deformity. Neurological: Alert and oriented to person, place, and time. Skin: Skin is warm and dry. No rash noted. Not diaphoretic. No erythema. Psychiatric: Normal mood and affect. Current Facility-Administered Medications: acetaminophen (TYLENOL) tablet 1,000 mg, 1,000 mg, oral, Q6H SCH, 1,000 mg at 12/19/25 0538 Carrier Fluids for Secondary Infusion - 0.9% Sodium Chloride, 30 mL, intravenous, PRN enoxaparin (LOVENOX) syringe 40 mg, 40 mg, subcutaneous, Daily-2100, 40 mg at 12/18/25 2042 gabapentin (NEURONTIN) capsule 100 mg, 100 mg, oral, BID, 100 mg at 12/18/25 2042 levothyroxine (SYNTHROID) tablet 125 mcg, 125 mcg, oral, Daily - 0600, 125 mcg at 12/19/25 0538 lidocaine (LIDODERM) 5 % patch 1 patch, 1 patch, transdermal, Q24H methocarbamoL (ROBAXIN) tablet 1,000 mg, 1,000 mg, oral, TID, 1,000 mg at 12/18/25 2042 ondansetron (ZOFRAN) injection 4 mg, 4 mg, intravenous, Q6H PRN oxyCODONE (ROXICODONE) tablet 5 mg, 5 mg, oral, Q4H PRN, 5 mg at 12/18/25 1831 propranoloL (INDERAL) tablet 20 mg, 20 mg, oral, Daily - 0600, 20 mg at 12/19/25 0538 senna-docusate (PERICOLACE) 8.6-50 mg per tablet 1 tablet, 1 tablet, oral, BID, 1 tablet at 12/18/25 2042 sodium chloride 0.9% flush 0.5-20 mL, 0.5-20 mL, intra-catheter, Q8H SCH (ALT), 10 mL at 12/18/25 2042 sodium chloride 0.9% flush 0.5-20 mL, 0.5-20 mL, intra-catheter, PRNLab/Radiology/Diagnostic Review:Laboratory studies from the past 24 hours were reviewed and significant forHematology Lab History Latest Ref Rng & Units 11/6/2025 09:13 11/20/2025 07:58 11/26/2025 10:50 12/19/2025 04:12 Labs - Hematology WBC 3.80 - 9.90 K/cumm 5.69 4.35 5.39 9.25 Total Hb, POC 13.0 - 17.5 g/dL 15.5 15.3 15.3 14.3 Hct 38.9 - 50.3 % 44.5 43.9 45.8 41.4 Plt 150 - 400 K/cumm 160 131 204 164 Neutrophil abs 1.50 - 6.50 K/cumm 3.35 2.66 Lymphocytes, abs 0.80 - 3.30 K/cumm 1.56 0.95 Chem/LFT Lab History Latest Ref Rng & Units 10/23/2025 12:31 11/6/2025 09:13 11/20/2025 07:58 12/19/2025 04:12 Labs-Chem/LFT Sodium 135 - 145 mmol/L 141 137 140 137 Creatinine 0.80 - 1.30 mg/dL 1.05 1.07 1.11 1.12 Bilirubin, total 0.1 - 1.2 mg/dL 0.6 0.7 0.9 1.1 AST 10 - 50 Units/L 24 23 28 105 ALT 7 - 55 Units/L 36 29 46 101 Alk phos 40 - 130 Units/L 68 71 80 71 CrCl- Actual Body Weight (Cockcroft-Gault) 123.1 121.7 117 113.9 No results found for: “AMYLASEFL"Recent Radiology studies were reviewed and significant for: PET/CT imaging(11/19/2025)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.MRI Abdomen and Pelvis(11/11/2025)-Interval development of two hepatic segment 4A/8 lesions, suspiciousfor metastatic disease.Vitals:24hr Min/Max:Temp Min: 36.3 °C (97.4 °F) Max: 36.9 °C (98.4 °F)Pulse Min: 50 Max: 78BP Min: 102/68 Max: 166/100Resp Min: 12 Max: 25SpO2 Min: 92 % Max: 98 %Most Recent:Vitals: 12/19/25 0538 BP: 110/64 Pulse: 67 Resp: Temp: SpO2: I/O last 2 completed shifts:In: 1313.7 [I.V.:1313.7]Out: 820 [Urine:800; Blood:20]I/O this shift:In: 273.2 [P.O.:50; I.V.:223.2]Out: 350 [Urine:350]Recent Interventions: Assessment/Plan 1. Metastatic colon cancer to liver2.Advance diet as tolerated3.OOBC4. DischargeReshma Mulla, MD12/19/20256:26 AM Cosigned by William Chapman, MD at 12/19/2025 9:10 PM CSTElectronically signed by Reshma Mulla, MD at 12/19/2025 12:22 PM CSTElectronically signed by William Chapman, MD at 12/19/2025 9:10 PM CSTRiadh Cheddadi, MD - 12/18/2025 7:20 PM CSTFormatting of this note is different from the original.Surgery Post Op Check NoteAlexander R Towell8/4/1975104670153Pt returns from the OR 12/18/2025 s/p XI LIVER RESECTION - LAPAROSCOPIC ROBOTIC ASSISTED SEGMENT 5 8 and 4B, INTRAOPERATIVE ULTRASOUND and TAP BLOCK by Chapman, William Cavanaugh, MD for Pre-op Diagnosis * Metastatic colon cancer to liver [C18.9, C78.7]Patient transferred from PACU to floor in stable condition. Patient is resting comfortably in bed. Pain controlled with scheduled and PRN medication. Denies nausea, emesis, chest pain, or SOB. Vital signs have been reviewed and are stable.Diet: Dietary Orders (From admission, onward) Start Ordered 12/18/25 1808 Adult Diet Clear Liquid Diet effective now Question: (BJH) Diet type Answer: Clear Liquid 12/18/25 1807 Physical Exam:Vitals: 12/18/25 1905 BP: 141/88 Pulse: 57 Resp: 18 Temp: 36.3 °C (97.4 °F) SpO2: 98% Constitutional: Alert and oriented x4 and no acute distressCV: Regular rate.Pulm: Unlabored respirations. Equal and symmetric chest rise.Abdomen: Soft, appropriately tender, nondistended. Incisions c/d/i with no active drainage or bleeding. No hematoma noted. No rebound tenderness or involuntary guarding. Neuro: Grossly nonfocal.Extremities: Warm and well perfused.Assessment and PlanThe patient is doing well in the immediate postop period following- CLD- mIVF- Multimodal pain control regimen- Follow up PM labs- DVT ppx- Encourage OOB and IS use Riadh Cheddadi, MDGeneral Surgery ResidentElectronically signed by Riadh Cheddadi, MD at 12/18/2025 7:20 PM CSTdocumented in this encounter

Sarah Matson, PA - 12/29/2025 9:30 AM CSTFormatting of this note is different from the original.PATIENT NAME: Alexander R TowellDOB: 8/4/197512/29/25CHIEF COMPLAINT: Postoperative evaluation after robotic resection of 2 metastatic colorectal cancer sites to the liverHISTORY OF PRESENT ILLNESS: Mr. Towell is a 50 y.o. male s/p robotic resection of 2 metastatic colorectal cancer sites to the liver approximately 11 days ago, who presents for postoperative visit today. He denies complaintsCURRENT MEDICATIONS: Current Outpatient Medications: acetaminophen 500 mg capsule, Take 2 capsules (1,000 mg total) by mouth every 6 (six) hours, Disp: , Rfl: cetirizine (ZyrTEC) 10 mg tablet, Take 1 tablet (10 mg total) by mouth daily as needed for allergies or rhinitis, 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: gabapentin (NEURONTIN) 100 mg capsule, Take 1 capsule (100 mg total) by mouth 2 (two) times a day, Disp: 60 capsule, Rfl: 11 levothyroxine (SYNTHROID) 125 mcg tablet, Take 1 tablet (125 mcg total) by mouth early morning before breakfast, Disp: , Rfl: lidocaine (LIDODERM) 5 %, Place 1 patch on the skin daily for 12 hours Remove & discard patch(es) within 12 hours or as directed by MD, Disp: , Rfl: [Paused] 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 early morning before breakfast, Disp: , Rfl: oxyCODONE (ROXICODONE) 5 mg immediate release tablet, Take 1 tablet (5 mg total) by mouth every 6 (six) hours as needed for pain, Disp: 10 tablet, Rfl: 0 [Paused] 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 early morning before breakfast, Disp: , Rfl: senna-docusate (PERICOLACE) 8.6-50 mg, Take 1 tablet by mouth daily as needed for constipation, Disp: , Rfl: [Paused] 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 AllergiesREVIEW OF SYSTEMS: Denies fever/chills, weight loss, abdominal pain. PHYSICAL EXAM: VitalsBP 133/77 Pulse 51 Temp 36.4 °C (97.5 °F) Ht 185.4 cm (6’ 1") Wt 107.7 kg (237 lb 6.4 oz) BMI 31.32 kg/m² General Appearance: awake, alert, oriented x3, in no acute distress Skin: there are no suspicious lesions or rashes or jaundiceHead: NCAT, Eyes: EOMI and Sclera nonictericNeck: neck- suppleLungs: Chest wall: symmetricAbdomen: Soft, non-tender, no hernia, mass, or fluid collection appreciated. Incisions healing wellExtremities: no lower extremity edema bilaterallyASSESSMENT:50 y.o. male s/p robotic resection of 2 metastatic colorectal cancer sites to the liver LABS: Lab Results Component Value Date WBC 9.25 12/19/2025 HGB 14.3 12/19/2025 HCT 41.4 12/19/2025 Lab Results Component Value Date SODIUM 137 12/19/2025 POTASSIUM 4.2 12/19/2025 GLUCOSE 110 12/19/2025 BUNSER 13 12/19/2025 CREATININE 1.12 12/19/2025 SURGICAL PATHOLOGY:

Diagnosis: A. Liver, segment 5/8, resection: - Metastatic moderately-differentiated adenocarcinoma with necrosis, morphologically compatible with colorectal primary, in hepatic parenchyma. - Margin of resection, negative for carcinoma. B. Liver, segment 4B, resection: - Metastatic moderately-differentiated adenocarcinoma with necrosis, morphologically compatible with colorectal primary, in hepatic parenchyma. - Margin of resection, negative for carcinoma. PLAN: His surgical pathology was reviewed todayHe is scheduled for follow up with Dr. Tan in 2 weeksHe will call with questions or concerns. I, Sarah Matson, PA-C, MMS, have personally taken a history, examined the patient, and documented the assessment and plan as noted. The patient was seen in the Center for Advanced Medicine. Sarah Christine Matson, PA-C, MMSElectronically signed by Sarah Matson, PA at 01/09/2026 3:04 PM CSTdocumented in this encounter

Ellen S - 01/15/2026 9:42 AM CSTFormatting of this note might be different from the original.Dr.Tan changed his mind from Tempus to Guardant.Electronically signed by Ellen S at 01/15/2026 12:26 PM CSTdocumented in this encounter

Benjamin Tan, MD - 01/15/2026 11:30 AM CSTFormatting of this note is different from the original.Images from the original note were not included.Oncology Return/Follow Up VisitAlexander R TowellDOB:8/4/1975 DATE OF VISIT:1/15/2026 Oncology History Overview Note DIAGNOSIS:Sigmoid Adenocarcinoma Stage IIIMetastaticTerminal Ileum Adenocarcinoma, MSS, RAS WT, with liver metastasesGENOMIC DATA:- DYPD normal1. TEMPUS XT for small bowel adenocarcinoma2. TEMPUS XT on Liver specimen 5/14/20253. TEMPUS XF- 07/08/2025ONCOLOGIC HISTORY:presented with anemia with tiredness, constipation, abdominal pain and fatigue back in 2021. He required blood transfusions- 11/22/2021 Colonoscopy showed malignant appearing mas in descending colon with ulceration and partial obstruction- 11/23/2021 labs notes wbc 3.8, Hb 9.4, platelets 310K, creatinine 1.8, bilirubin 0.3, CEA 1.4- 12/09/2021 CT scan showed exophytic sigmoid colon mass (2.6 cm) with Lymph nodes suspicious for metastatic disease and sclerotic focus in the left iliac bone.- 12/10/2021 Consultation with Dr. Syed (Oncology)- 12/29/2021 laparsocopic sigmoid colectomy pathology showed moderately differentiated colon adenocarcinoma 1 of 23 LN +, MSS, RAS WT- stage IIIB pT4N1M0- 02/16/2022 to 08/29/2022 adjuvant FOLFOX x 12 cycles with dose reduction. Toxicities include neuropathy and diarrhea, fatigue- 01/01/2023 CT scans showed no recurrence- 01/09/2023 Colonoscopy showed normal findings- 12/29/2023 CT showed no metastases- 05/29/2024 Colonoscopy showed large ulcerated mass in the terminal ileum, biopsy confirmed moderately differentiated adenocarcinoma- 07/01/2024 right hemicolectomy - showed 4 of 14 LN +, PNI+, no LVI, RAS WT, MSS- 07/11/2024 Tempus XF - 07/25/2024 PET scan done showed liver lesions. Started chemotherapy with Cycle 1 FOLFIRI- 08/12/2024 Cycle 2 FOLFIRI/bevacizumab: has diarrhea treated with immodium- 08/15/2024 Consultation with medical oncology (tan) to discuss HAI pump therapyTREATMENT HISTORY: laparoscopic sigmoid colectomy 12/29/2021Adjuvant FOLFOX x 12 cycles 2/16/2022- 8/2022Right hemicolectomy 7/1/2024FRONTLINE FOLFIRI/Bevacizumab- 07/25/2024 Cycle 1 FOLFIRI- 08/12/2024 Cycle 2 FOLFIRI/Bevacizumab- 02/12/2025 Maintenance 5FU/bevacizumab- 04/16/2025 Maintenance 5FU/Bev (last dose prior to surgery)5. Robotic Segment 2 resection (Chapman) 5/14/20255. Resumption of 5FU +/- bev- 07/31/2025 Cycle 1 5FU 2400 CIVI- 08/13/2025 MRI/PET no evidence of recurrence- 08/14/2025 Cycle 2 5FU 2400 CIVI- 08/28/2025 Cycle 3 5FU 2400 CIVI- 09/11/2025 Cycle 4 5FU 2400 CIVI- 09/25/2025 Cycle 5 5FU 2400 CIVI- 10/09/2025 Cycle 6 5FU 2400 CIVI- 10/23/2025 Cycle 7 5FU 2400 CIVI- 11/06/2025 Cycle 8 5FU 2400 CIVI (CEA 2.9)- 11/06/2025 CT Chest stable lung lesions- 11/09/2025 MRI abdomen with 2 new liver lesions- 11/19/2025 PET/FDG suggestion of subtle uptake in segment 4A- 01/15/2026 CT/MRI stable pulmonary nodules, Malignant neoplasm metastatic to liver (HCC) 8/16/2024 Initial Diagnosis Malignant neoplasm metastatic to liver (HCC)Active Treatment & Therapy Plans for Towell, Alexander R “Alex” Oncology Chemotherapy Treatment: FOLFIRI+Bev: (Fluorouracil / Leucovorin / Irinotecan / Bevacizumab) 14 Day Cycles - Colon/Rectum (On Hold) Current day: Day 1, Cycle 9 (Planned for 11/20/2025) Following planned day: Day 1, Cycle 10 (Planned for 12/4/2025) Line Care : IV Maintenance Therapy Plan Current treatment: Treatment 1 (Planned for 8/14/2025) Subjective Mr. Alexander R Towell is a 50 y.o. Non-Hispanic male who comes to the Gastrointestinal Oncology Clinic at Washington University for a follow up oncology visit.He was last seen 11/6/2025 and continued on 5FU. He last received cycle 8 5FU on 11/6/2025. He underwent resection of the 2 liver lesions on 12/18/2025. Operative findings noted normal looking liver and 2 surface based tumors in segment 4 and 5/8. A non-anatomic excisional resection was performed by Dr. Chapman. His case was reviewed at Tumor board this morning and consensus is to refer back to dr. Chapman to discussed possible wedge resections for these two peripheral liver lesions and confirm if indeed recurrent vs benign. He was discharged 12/19/2025. He had repeat scans today which showed post operative changes with no suspicious lesionsHe comes today with his SO and notes:- feeling well- no abdominal pain- no jaundice- no nausea, vomiting- his surgical scars are well healed with no bleeding or suppuration, there is an area of healing wound with granulation in the abdomen- no fever, chillsPast 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 Prior to Admission medications Medication Sig Start Date End Date Taking? Authorizing Provider levothyroxine (SYNTHROID) 88 mcg tablet Take 1 tablet (88 mcg total) by mouth daily 3/23/23 Provider, Historical, MD No Known AllergiesSocial History Tobacco Use Smoking status: Never Smokeless tobacco: Never Substance and Sexual Activity Drug use: Never Sexual activity: Defer Alcohol Use: Not At Risk (12/18/2025) AUDIT-C Frequency of Alcohol Consumption: Never Average Number of Drinks: Patient does not drink Frequency of Binge Drinking: Never Family History Problem Relation Age of Onset Prostate cancer Father 69 Anesthesia problems Neg Hx Review of SystemsReview of Systems Constitutional: Negative. Negative for chills and fever. HENT: Negative. Eyes: Negative. Respiratory: Negative. Negative for cough and shortness of breath. Cardiovascular: Negative. Negative for chest pain. Gastrointestinal: Negative. Negative for abdominal pain, blood in stool, nausea and vomiting. Endocrine: Negative. Genitourinary: Negative. Musculoskeletal: Negative. Skin: Negative. Neurological: Negative. Hematological: Negative. Pain: negative.Negative for: new onset pain.Objective Vitals:Height: 185.4 cm (6’ 1")Weight: 104.3 kg (230 lb)ECOG: 0PHYSICAL EXAMINATIONPhysical ExamVitals reviewed. Constitutional: Appearance: Normal appearance. HENT: Head: Normocephalic and atraumatic. Nose: Nose normal. Eyes: General: No scleral icterus. Conjunctiva/sclera: Conjunctivae normal. Cardiovascular: Rate and Rhythm: Normal rate and regular rhythm. Heart sounds: Normal heart sounds. Pulmonary: Effort: Pulmonary effort is normal. No respiratory distress. Breath sounds: Normal breath sounds. Abdominal: General: Bowel sounds are normal. There is no distension. Palpations: Abdomen is soft. Tenderness: There is no abdominal tenderness. Musculoskeletal: General: Normal range of motion. Cervical back: Normal range of motion. Right lower leg: No edema. Left lower leg: No edema. Skin: General: Skin is warm and dry. Coloration: Skin is not jaundiced. Neurological: General: No focal deficit present. Mental Status: He is alert and oriented to person, place, and time. Mental status is at baseline. Psychiatric: Mood and Affect: Mood normal. Behavior: Behavior normal. Thought Content: Thought content normal. Lab/Radiology/Diagnostic Review:No results found for this or any previous visit (from the past 24 hours).Hematology Lab History Latest Ref Rng & Units 11/6/2025 09:13 11/20/2025 07:58 11/26/2025 10:50 12/19/2025 04:12 Labs - Hematology WBC 3.80 - 9.90 K/cumm 5.69 4.35 5.39 9.25 Total Hb, POC 13.0 - 17.5 g/dL 15.5 15.3 15.3 14.3 Hct 38.9 - 50.3 % 44.5 43.9 45.8 41.4 Plt 150 - 400 K/cumm 160 131 204 164 Neutrophil abs 1.50 - 6.50 K/cumm 3.35 2.66 Lymphocytes, abs 0.80 - 3.30 K/cumm 1.56 0.95 Chem/LFT Lab History Latest Ref Rng & Units 10/23/2025 12:31 11/6/2025 09:13 11/20/2025 07:58 12/19/2025 04:12 Labs-Chem/LFT Sodium 135 - 145 mmol/L 141 137 140 137 Creatinine 0.80 - 1.30 mg/dL 1.05 1.07 1.11 1.12 Bilirubin, total 0.1 - 1.2 mg/dL 0.6 0.7 0.9 1.1 AST 10 - 50 Units/L 24 23 28 105 ALT 7 - 55 Units/L 36 29 46 101 Alk phos 40 - 130 Units/L 68 71 80 71 CrCl- Actual Body Weight (Cockcroft-Gault) 123.1 121.7 117 113.9 Tumor Marker History Latest Ref Rng & Units 10/9/2025 07:55 10/23/2025 12:31 11/6/2025 09:13 11/20/2025 07:58 Tumor Markers CEA <=5.0 ng/mL 3.3 4.1 2.9 2.6 PATHOLOGY REVIEW:12/18/2025A. Liver, segment 5/8, resection: - Metastatic moderately-differentiated adenocarcinoma with necrosis, morphologically compatible with colorectal primary, in hepatic parenchyma. - Margin of resection, negative for carcinoma. B. Liver, segment 4B, resection: - Metastatic moderately-differentiated adenocarcinoma with necrosis, morphologically compatible with colorectal primary, in hepatic parenchyma. - Margin of resection, negative for carcinoma. 5/14/2025 A. Liver, segment 2, resection - Metastatic adenocarcinoma morphologically compatible with the patient’s colorectal primary. - Adenocarcinoma present at cauterized resection margin. - Perineural invasion identified. 7/1/20245/29/202411/22/20219/20/2022THYROID, RIGHT LOBE, RIGHT LOBECTOMY:- NODULAR HYPERPLASIA (NODULAR GOITER)-ADDITIONAL PATHOLOGIC FINDINGS - ONE (1) LYMPH NODE NEGATIVE FOR METASTASIS (0/1).- LYMPHOCYTIC THYROIDITIS:- PARATHYROID GLAND(S): ONE PRESENT IN THE LOWER POLE, WITHOUT HISTOLOGIC ABNORMALITIES.7/29/2022THYROID LOBE, RIGHT, ULTRASOUND GUIDED NEEDLE BIOPSY:- ADEQUATE FOR INTERPRETATION. - SUSPICIOUS FOR FOLLICULAR NEOPLASM. BETHESDA CLASS IV. 5/11/2022A. THYROID LOBE, RIGHT, (1ST NODULE), ULTRASOUND-GUIDED NEEDLE BIOPSY; - ADEQUATE FOR INTERPRETATION.- BENIGN, CONSISTENT WITH BENIGN FOLLICULAR NODULE (INCLUDES ADENOMATOID NODULE, COLLOID NODULE, ETC.). BETHESDA CLASS II.B. THYROID LOBE, RIGHT (2ND NODULE), ULTRASOUND-GUIDED NEEDLE BIOPSY: - ADEQUATE FOR INTERPRETATION.- ATYPIA OF ON DETERMINE SIGNIFICANCE. FOLLICULAR CELLS WITH MILD FOCAL ARCHITECTURAL ATYPIA. BETHESDA CLASS IIIctDNA7/11/2024RADIOLOGY REVIEW:MRI/CT 1/15/2026Interval postsurgical changes of nonanatomic resection of hepatic segment 4A/5/8 lesions with postoperative collections in the righthemiliver. No new enhancing hepatic lesion.1. Stable pulmonary nodules.2. No evidence of new or increasing metastatic disease in the chest.PET/FDG 11/19/2025Suggestion 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.MRI Abdomen Pelvis 11/09/2025Interval development of two hepatic segment 4A/8 lesions, suspiciousfor metastatic disease. - 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.Chest CT 11/6/20251. Stable right lower lobe indeterminate pulmonary nodule. 2. Stable groundglass nodule in the left lower lobe. 3. No disease progression in the chest.MRI Abdomen/PET/CT 8/13/2025Posttreatment changes to hepatic segment 2. No evidence of recurrentor metastatic disease in the abdomen or pelvis. 1. No PET/CT evidence of residual/recurrent locoregional or distantmetastatic disease.2. The right suprahilar lymph node is favored to be reactive, giventhe stable size and FDG avidity.3. The bilateral lung lower lobe nodules, are favored to be benign,given the lack of FDG uptake and stable size, dating back to CT inDecember 2024.4. Diffuse persistent left hemithyroid activity. Recommendevaluation with thyroid function tests. MRI Abdomen 4/30/2025:Unchanged hepatic segment 2 lesion consistent with continued treatment response. No evidence of progressive or new metastatic disease in the abdomen. Near complete resolution of the wedge shaped lesion in hepaticsegment 8, which was previously thought to represent focal hepatictoxicity related to oxaliplatin. Focal liver lesions: Unchanged hepatic segment 2 lesion measuring up to 7 mm, likely representing treated metastatic disease (series 26 image 22), previously 2.3 cm on 08/20/2024. The reported cortical irregularity within hepatic segment 7 seen on prior study is not seen on today’s exam. Interval near complete resolution of the ill-defined wedge-shaped hypoenhancement hepatic segment 8.MRI Abdomen Liver 11/29/2024:Posttreatment changes related to previously seen hepatic lesions with decrease in size compared to the prior study consistent with treatment response. No new lesions identified. Ill-defined wedge shaped decreased uptake in hepatic segment 8 has also decreased in size compared to prior study which could be related to a no focal hepatic toxicity related to oxaliplatin.PET/CT 11/21/2024:Interval resolution of the previously seen four hypermetabolic liver lesions and hepatic segments 2, 7, and 8. Of note, small hepatic lesions are difficult to characterize with PET/CT accurately and would be better evaluated with MRI if there is clinical concern. Interval resolution of the hypermetabolic soft tissue nodules in the rectovesicular pouch.Persistent activity in the right hilar region, which is indeterminate.CT Body Consult 10/15/2024:The lesions seen on hepatobiliary phase of the prior MRI are much smaller on this exam. It is not certain whether this represents response to therapy or differences in technique, particularly given that the lesions could not be seen on portal venous phase of the prior MRI as well. Adequate comparison would require a repeat MRI examination with hepatobiliary phase. Stable indeterminate 8 mm solid nodule in the right lower lobe. This was not hypermetabolic on the prior CT examination, but a right hilar lymph node which measures at the upper limits of normal for size was hypermetabolic and could represent a metastasis. Small stable 7 mm groundglass nodule left lower lobe.MRI Abdomen Pelvis 8/28/2024:Vague hepatobiliary phase hypointense lesions in segment 2, 4A and 7, corresponding to FDG avid lesions on PET/CT 07/25/2024. The vague appearance of these lesions likely indicates treatment response. Previously described lesion in the liver dome in segment 8 on PET/CT is not seen on the current examination. Treated rectovesicular pouch lesions without evidence of residualmetastatic disease in the pelvis. Conventional hepatic arterial anatomy. Peripheral wedge-shaped area of hepatobiliary phase hypointensity in segment 8 without a correlate on other sequences is nonspecific, but is unlikely to represent metastatic disease.PET OSH 7/25/2024 CONSULTAt least four hypermetabolic liver lesions involving segment II, VII and VIII compatible with metastatic disease. Two intensely hypermetabolic soft tissue nodule deposits in the rectovesical pouch are compatible with metastatic diseaseSURGERY 7/1/2024Colonoscopy 5/29/2024Bone scan 5/22/2024CT AP OSH 5/7/2024CT AP 12/28/2023Assessment/Plan Alexander R Towell is a 50 y.o. Non-Hispanic male with metastatic small bowel adenocarcinoma with liver and pelvis metastases who presents for follow up. Metastatic Terminal Ileum Adenocarcinoma, MSS, RAS WT, with liver and possible lung metastases- we reviewed his operative note noting 2 superficial liver lesion which were resected- we reviewed his pathology confirming adenocarcinoma. We discussed obtaining Guardant Tissue and Guardant 360 to determine MRD status- we reviewed his scan images and report done today noting stable lung nodule and post operative changes in the liver- we reviewed his labs noting normal CMP and cbc, CEA normal- Discussed possibility that the lung nodule may represent metastatic disease vs benign process. His Pet scan 11/2025 showed no uptake in the lung but this lesion is subcm.- Discussed options for:- 1. Observation with frequent CEA and scans- 2. “Adjuvant” therapy with FOLFOX, note he had prior FOLFOX and had neuropathy- 3. FOLFOX/panitumumab, given wildtype status and possible lung metastasis.-after discussion, he would like to await guardant results and he will decide.- RTC in 2-3 weeksBenjamin R. Tan, MDElectronically signed by Benjamin Tan, MD at 01/15/2026 2:02 PM CSTdocumented in this encounter

Sleep Medicine Referral for Sleep apnea

Referring Physician: Nathini Suthan, Internal Medicine, (618) 258-0485

Encounter Date: 07/25/2023

Gastroenterologist Referral for Occult blood detected in feces

iron deficiency

Please contact patient to schedule appointment. Thank you

Referring Physician: Nathini Suthan, Internal Medicine, (618) 258-0485

Encounter Date: 10/12/2021

Sleep Medicine Referral for Sleep apnea

Please contact patient to schedule appointment. Thank you

Referring Physician: Nathini Suthan, Internal Medicine, (618) 258-0485

Encounter Date: 09/27/2021

Reason for Referral Date Referral was Provided

Provider Office Contact Location

November 22, 2021 Edmundo A. Rodriguez-Frias 618-391-5070 6812 STATE ROUTE 162 SUITE 204 MARYVILLE,IL 62062