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Jiangmen Central Hospital Discharge Record
Name: XXXX, XXXX Gender: Female Age: 50 Department: Hepatobiliary and Gastrointestinal Surgery Bed Number: 1538 Medical Record Number: 296643
Admission Date: 09 Apr, 2008 Discharge Date: 28 Apr, 2008 A total of 19 days
Admitting Diagnosis: Descending colon multiple primary cancers
Case History: XXXX, XXXX, female, 50 year-old with mucous bloody stool for more than a year was admitted to hospital on 09 April, 2008. Related examinations had been taken with no obvious contraindications. Left hemicolectomy was taken with intravertebral anesthesia on the morning of 17 April, 2008. Treatments were taken after surgery. The patient was discharged with no discomfort today. 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.
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: Descending colon cancer
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: 1508 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: 08:53 09 Apr, 2008 Record Date: 10:52 09 Apr, 2008 Complainer: patient Relatives’ Name: XXXX, XXXX Chief Domplaints: mucous bloody stool for more than a year Present Illness: It beganmucous bloody stool with purulent blood one year ago. There was an increase in frequency, 3-4 per day. No fever, discomfort, endless and tenesmu when defecating. No nausea and vomiting. No abdominal pain. Paroxysmal dull pain on the left upper abdomen occurred a month ago. Some treatments were taken in local hospital (unknown). Colonoscopy taken in our hospital showed it was descending colon multiple primary cancers. She was admitted for further therapy. No cough andexpectoration, no dizziness and palpitation. Appetite, sleep and mental status were normal. Urine 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 was born 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.
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