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1、病人介绍Dongfashun male patient 70 years old 主诉His chief complaint was “constipated with the caliber of the stools narrowing for 9 months diagnosed as rectal cancer 5 months ago preoperative chemotherapy for 3 times.” 现病史The patient felt burning pain and tenesmus in his anus accompanied by constipation
2、and caliber of stools narrowing since 某年某月。No fever no pale no abdominal pain or distension no bowel obstruction no terry stool or mucous bloody stool. The symptoms lasted for 4 months without alleviation or aggravation. 5 months ago the patient went to local hospital and received rectal endoscopy t
3、hey found a cauliflower like mass in rectal lumen 5 cm away from the anus and then they took biopsy the pathology showed a moderate-poor differentiated adenocarcinoma. The patient came to our hospital for further diagnosis and treatment in 某年某月 . Our pathology consultation confirmed that it was a re
4、ctal adenocarcinoma invading the submucous layer with some signet ring cells. Consequently the patient received preoperative chemoradiotherapy according to the Xelox regimen. There was no manifested complication and discomfort during the chemotherapy. Now the patient was admitted for surgery. During
5、 his illness he had a good appetite spirit and physical force. He slept well at night. His emiction was normal. He passed loose stools about 3 times a day without terry stool or mucous pus stool. No obvious decrease in his weight. 既往史Past Medical History: Hypertension for 5 years. Well controlled by
6、 depressor drugs. No cardiac and pulmonary disease no diabetes. No infectious disease No surgical history. He is allergic to PG . He had aspirin for 1 year stopped taking the pills for 2 weeks. 个人史Personal History: He was born in xxx and always lives there until now. He has never been to epidemic ar
7、ea. No drug or alcohol abuse. No chemical material contact. 婚育史Marriage: He is married. Both his wife and child are healthy. 家族史Family History: He denied the hereditary infectious disease and tumor associated disease. 体格检查Physical exam: Physical vital signs are normal T 37.5 P 130/min R 23/min BP 10
8、0/60mmHg. He is well nourished conscious and cooperated. No pale no jaundice of his skin and sclera. Superficial lymph nodes were not found enlarged. The pupils were round regular equal in size and the reflection was normal. Lips are red. No pharynx congestion. No tonsils swelling. No resistance of
9、his neck no jugular vein distension. Trachea was in the middle. Thyroids are not found enlarged. No thoracic deformation. Tactile fremitus and percussion are equal and normal. Rale and pleural friction rub are not heard. The cardiac border and impulse are normal. The heart rate is 90 times per minut
10、e with regular rhythm. No extra cardiac sound or murmur. The shape and movements of his spine and extremities are normal. No abnormal sign found in nervous system. 专科查体Specific exam His abdomen is flat and soft bulge or depression. There is no varix in abdominal wall neither is the gastrointestinal
11、type or peristalses. Tenderness was obvious around the navel and in lower abdomen. No rebound tenderness or muscle tension. No masses are found. Liver and spleen are untouched. The Murphys sign is negative. Shifting dullness is negative too. Gurgling sound is normal. No vascular murmurs. Anus finger
12、 exam in knee-chest position: There is a hard mass in the rectal lumen 5 cm away from the anal margin about 3 cm in diameter nine oclock in direction and difficult to move. Finger blood can be seen after the exam. 辅助检查Laboratory test: Blood test shows his hemoglobin is 69g/l triglyceride and cholest
13、erol exceed the upper limits other variables are normal. CT shows there is a mass in the pelvic floor which is enhanced obviously in the arterial phase. The boundaries between the mass and other organs in the neighborhood are clear. No metastasis or enlarged lymph node is found. Transrectal ultrasou
14、nd shows the mass invades into the muscular layer. 诊断 Rectal adenocarcinoma Preoperative chemoradiotherapy 3 times Hypertension grade 2 鉴别诊断 The diagnosis of rectal cancer is confirmative but we still need to be careful to exclude the possibility of the other primary tumor such as gastric cancer or multiple colon tumors. 治疗方案 Comprehensive treatment based on surgery 1. The patients TNM classification is T3N0M0 so he need to receive preoperative chemoradiotherapy for 2-4 times. 2. Complete the preoperative examination and evaluation. 3. Laparoscopic Dixon or Appear preparing miles.
