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Jiangmen Central Hospital
Discharge Record
Name: XXXX, XXXX   Gender: Female   Age: 50Department: Hepatobiliary and Gastrointestinal Surgery
Bed Number: 1561 Medical Record Number: 296643

Admission Date: 09 May, 2008   Discharge Date: 10 May, 2008     A total of 1day
 Admitting Diagnosis:  Peritoneal chemotherapy after colon cancer surgery

Case History: Chemotherapy should be taken as scheduled after one month of colorectal surgery. Inpatient examination: No superficial lymph nodes swelling, tummy flat, no stomach or intestinal-type. Whole abdominal soft, no tenderness or rebound tenderness, no masses. Liver and spleen were impalpable. Murphy’s sign (-) was positive. No percussion pain of liver, no shifting dullness, bowel sounded normal. Related examinations had been taken with no obvious contraindications. 5-Fu, HCPT (hydroxycamptothecine) and DDP were taken for peritoneal chemotherapy successfully on May 9, 2008. The patient was discharged with no discomfort today.

Discharge Status:It was stable without chief complaints about discomfort. Physical examinations: consciousness, normal mental state. No superficial lymph nodes swelling. Lung (-), heart (-), abdomen (-), pathological characteristics (-).

Discharge Diagnosis: Peritoneal chemotherapy after colon cancer surgery

Discharge Instructions:
1. Rest
2. Regular follow-up; return visit should be taken in 2 weeks.

Resident: BBBB
(Associate) Chief Physician: GONG, AAAAA

Jiangmen Central Hospital
Admission Record
Name: XXXX, XXXXDepartment: Hepatobiliary and Gastrointestinal SurgeryBed Number: 1561      
Medical Record Number: 296643

Name: XXXX, XXXX     Gender: Female     Age: 50     Ethnic Group: Han       Marital State: Married
Occupation: worker        Place of Birth: XinHui
Address: An Xi, Xinhui City AAAAA
Admission date: 10:38   09 May, 2008      Record date: 11:19   09 May, 2008
Complainer: patient       Relatives’ name: XXXX, XXXX

Chief Complaints: Peritoneal chemotherapy after colon cancer surgery for a month

Present Illness: Left hemicolectomy was taken with intravertebral anesthesia on the morning of 17 April, 2008. Postoperative pathological: colorectal tubular adenocarcinoma, infiltrated wholly, no residual cancer cut on both sides; villous polypoid, tubular polypoid adenoma; palpated 7 pieces of lymph nodes, 3/7 of which metabolized. No omentum metastasis. Treatments were taken after surgery. No fever and chill, no nausea and vomiting, no dizziness and headache, no dyspnea and tachypnea, no abdominal distention and pain, etc. Chemotherapy should be taken as scheduled after colorectal surgery. Appetite and sleep were normal. Defecation was also normal. No obvious change on weight.

Past History: She denied hepatitis, tuberculosis, hypertension, heart disease, or diabetes. She either denied the history of surgery and trauma. She had no history of allergy to food or drugs.
Individual History: She wasborn in local city. No history of epidemic water and area contact. Activity regularity. No history of excursion, smoking and drinking, no history of drug abuse and raw fish materials taking.
Family History: No family history of similar illness and heredity.
Marital History: Menopause and married. Spouse and offspring were healthy.

Physician examinations
T: 36.5°C    R: 20 per minute   P: 80 per minute    BP: 120/80mmHg
Well-developed, balanced nutrition, active position, consciousness, normal mental state, alert and cooperative. Skin mucosa was not pale, jaundiced or cyanotic. No Subcutaneous hemorrhage. No superficial lymph nodes swelling. Regular features. Sclera was not jaundiced. Pupils were equal and active to the light, D=3mm. No congestion, no reddened and enlarged tonsils. Neck was supple with centralized trachea. No jugular venous distention. No enlarged thyroid. No chest deformity, no tenderness. Both lungs acted normally. Tactile sensation and tremor were normal.Resonant to percussion and clear to auscultation without dry rale. No pleuritic rub. No prominent chest. Apical impulse was normal without tremor.Border of cardiac dullness was within normal limits, 80 per minute. No arrhythmia. Normal heart sounds. No systolic murmur. Abdomen: found in special situation. Anus and genitalia were not checked. Spinal and extremities were not deformity. No clubbing finger. Joints were not redness or swelling, no edema status. It took physiological response rather than pathological reflex
Special Situation: tummy flat, one old surgery scar could be observed. No redness, swelling, exudation, tenderness and rebound tenderness. No masses. Liver and spleen were impalpable. Murphy’s sign (-) was positive. No tenderness, bowel sounded normal, 3 per minute.

Auxiliary examinations
Outpatient: BCA, EBC10, LB12 and no abnormal.
Admitting Diagnosis:  Peritoneal chemotherapy after colon cancer surgery
Resident: BBBB