乙状结肠癌（英文病历）.docVIP

病人介绍：Patient’s name is Huhuanfen, female, 47 years old 主诉：Her was admitted to our hospital with the chief complaint of “Intermittent diarrhea for half year, accompanied by dull pain in lower quadrant.” 现病史：The patient began to suffer diarrhea without obvious incentives 6 months ago, water like stools, about 3-4 times a day, accompanied by dull pain in lower quadrant. No fever, no pale, no abdominal pain or distension, no bowel obstruction or diarrhea, no terry stool or mucous bloody stool. She didn’t pay attention to it. Last week, she went to hospital for regular examination, the fecal occult blood test was positive, then she took the colonoscopy, they found that there was a pedunculated polyps in the sigmoid colon, 15 cm away from anal margin, long diameter is about 2 cm, the surface of the mass was full of erosion. Pathology showed the mass was a tubulovillous adenoma (tubular adenoma/villous adenoma). Now the patient was admitted for surgery. During her illness, she had a good appetite, spirit and physical force. She slept well at night. Her emiction was normal. No obvious decrease in her weight. 既往史：Past Medical History: No hypertension, no cardiac and pulmonary disease, no diabetes. No infectious disease, No blood transfusion history. The patient was diagnosed as endometrial carcinoma in 2006, and then she received the curative surgery and postoperative chemotherapy. No recurrence was found. Allergic history is negative. 个人史：Personal History: She was born in xxx and always lives there until now. She has never been to epidemic area. No drug or alcohol abuse. No chemical material contact. 婚育史：Marriage: She is married. Both her husband and child are healthy.家族史：Family History: She 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 100/60mmHg. He is well nourished, conscious, and cooperated. No pale, no jaundice of his skin and sclera. Superficial lymph node