直肠癌（英文病历）原创.docVIP

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 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, they 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 rectal 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 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 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 area. 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 heredit