Sino-Japanese Friendship Hospital, Ministry of Health

Discharge Records

Name XXX

(Page 1)

Medical Record No. 1346384

Name: SUN YAN MI                 Gender: female                Age: 48 years old              Date of Admission: October 22, 2012

G

Admission Department: Anorectal surgery         Discharge Department: Anorectal surgery          Date of Discharge: November 5, 2012

Admission Information: SUN YAN MING, the patient, female, 48 years old,

Mainly due to the 4-year upper abdominal discomfort, the patient was admitted to the hospital for "1. Gastric cancer; 2. Post-total hysterectomy". Four years ago, under non-obvious incentive, the patient had upper abdominal discomfort associated with heartburn and sour regurgitation, without abdominal pain or without being associated with nausea or vomiting, and without hematochezia, diarrhea or fever, which was remitted after eating. Since rabeprazole was taken, the symptom has been remitted. Since then, the patient has never seen a doctor. The results for the October 17, 2012 dated gastroscopic examination in the Affiliated Zhongshan Hospital of Dalian University showed HP+ giant gastric ulcer, suspected gastric cancer. And the pathological examination results showed signet-ring cell carcinoma in the gastric angulus and the gastric antrum, But the patient was left untreated. Over four years, the patient’s upper abdominal discomfort associated with heartburn and sour regurgitation is becoming heavier, so her oral rabeprazole dose is increasing. Now for the sake of treatment, the patient has come to our hospital. The outpatient department admitted the patient for "gastric cancer". Physical examination: T 36.7 ℃, P 72 times / min, R 20 beats / min, Bp 130/80mmHg. Impalpable enlargement of superficial lymph nodes all over the body. Impalpable enlargement of left supraclavicular lymph nodes, flat abdomen, visible 15cm surgical scar. No abdominal wall varicosis, no gastrointestinal type and peristaltic waves, the presence of abdominal breathing. Soft omen, no tenderness, no muscle tension or rebound. No palpable clear tumor in the whole abdomen, not involving liver, spleen and ribs, and negative Murphy sign. "Drum-like" percussion sound, without percussion pain in the liver and kidney areas, negative shifting dullness. Normal bowel sounds.  Auxiliary examination: October 17, 2012; Gastroscopy; giant gastric ulcer, suspected gastric cancer; outside the hospital; October 17, 2012; Pathology; signet-ring cell carcinoma in the gastric angulus and the gastric antrum. Outside the hospital

Admission Diagnosis: 1. Gastric cancer; 2. Post-total hysterectomy

Diagnosis and Treatment: The preoperative examination was improved after admission, without surgical contraindications. On October 26, 2012, under general anesthesia, " radical gastrectomy for gastric cancer (distal subtotal gastrectomy + Billroth I) was performed, with one peritoneal drainage pipe. The surgical procedure was successful. During the surgery, a little blood has flowed out, and the anesthesia was stable. The patient safely returned to the ward after anesthesia recovery. The post-operational pathological examination showed: poorly differentiated adenocarcinoma (ulcerated, with the volume of 3.5*0.6*1.1cm), partial signet-ring cell carcinoma, invasion through the muscle layer into the subserosal adipose tissue. Omentum uninvolved. Clean surgically treated bilateral stumps Visible metastases in perigastric lymph nodes (0/7 of lymph node at the side of greater curvature, 3/8 of lymph node at the side of gastric lesser curvature). Immunohistochemical results showed: CK20 (+), CK7 (-), HER-2 (4B5) (-), CK (+); duodenal stump CEA (-), CK (-). After the surgery, anti-inflammation, rehydration, nutrition support and other therapy were given. With stable condition, the patient was discharged.

Discharge Information: The patient’s vital signs were stable, which was generally available.

Discharge Diagnosis: 1. Gastric cancer; 2. Post-total hysterectomy

Special seal for Copying of Medical Record of Sino-Japanese Friendship Hospital