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RECTAL

ADENOCARCINOMA
A CASE PRESENTATION BY KURT S. ZEPEDA, JUNIOR INTERN
BRTTH DEPARTMENT OF SURGERY
JULY 07, 2018
• General data:
A case of E.G., 65 y/o male, married Roman Catholic from
Gogon, Legazpi City
• Chief complaint:
Difficulty defecating
• History of present illness:
9 months PTA, patient complained of difficulty defecating. He was passing
small stools, described as similar to that of a goat. No fresh blood noted
and no associated pain on defecation. He sought consult at this institution,
where PE revealed presence of mass in the rectal area.
8 months PTA, pt. underwent CT scan, which corroborated the PE findings
of rectal mass. Pt. also underwent proctosigmoidoscopy, whose pathology
report revealed well-differentiated rectal adenocarcinoma.
• History of present illness:
Patient was referred to undergo radiotherapy and completed
one-month radiation treatment at Rizal Medical Center 4
months PTA.
Patient was scheduled for resection of the rectal mass at this
institution, hence his admission.
• Past medical history:
Previous operations: excision of mass on posterior leg (1993)
excision of 4 cysts at right back (1997-1998)
(+) HPN – since May 2017 (-) TB
(-) CKD (-) CVD
(-) BA (-) DM
• Personal and social history:
Presently non-smoker, non-alcoholic drinker (history of smoking
– 49 pack years)
Usual diet is fish and vegetables
Has no exercise regimen
• Family history:
(+) HPN – father and older brother
(+) Stomach Ca – father
(+) Liver Ca – mother (-) DM
(+) BA – younger brother
(+) kidney dse – older sister
• Review of systems:
General: afebrile; (-) weakness; (-) wt. loss/gain; (-) anorexia
Skin: (-) pruritus; (-) rashes; (-) dryness
EENT: (-) dysphagia; (+) myopia; (-) hearing loss
Musculoskeletal: (-) muscle pain; (-) joint pain; (-) stiffness
• Review of systems:
Respiratory: (-) DOB; (-) orthopnea; (-) cough
Cardiovascular: (-) chest pain; (-) palpitations
Genitourinary: (-) dysuria; (-) polyuria; (-) frequency; (-) incontinence
Nervous: (-) tingling; (-) numbness
• Physical Exam:
General survey: conscious, coherent, ambulatory, NICRD
Vital signs:
Skin: (-) jaundice; (-) lesions
HEENT: anicteric sclerae, pink palpebral conjunctivae; (-) cervical
lymphadenopathy; (-) neck vein engorgement
Chest/lungs: symmetric lung expansion; (-) retractions; clear breath sounds
• Physical Exam:
Heart: adynamic precordium; (-) murmurs; (-) bruits; (-) thrills
Abdomen: flat, soft, nontender abdomen; normoactive bowel
sounds
Extremities: (-) cyanosis; (-) edema; (-) gross deformities; full pulse
Neuro exam: GCS 15; oriented to place, person and time
• Course in the Ward:
Day 1
Admitting diagnosis: Rectal adenocarcinoma
Diagnostics: CBC c BT, CEA, Na, K, BUN, Crea, ECG
Plan: for ‘El’ abdominoperineal resection
Meds: Metronidazole 500mg TIV prior to OR then 500mg TIV q8; Cefazolin 2g TIV prior to
OR
IM referral: moderate risk of developing cardiopulmonary complications intraoperatively
• Course in the Ward:
Day 2
OR deferred
Day 3 – Day 4
Present management continued
Day 5
Preop orders given
• Course in the Ward:
Day 6
Operation done around 8:30 pm: Ex-lap low anterior resection colo-anal anastomosis;
double barrel ileostomy
Day 7
On HBR, may chew candy, daily wound care, colostomy bag applied
Day 8
General liquid diet; DAT c SAP at 6pm
• Diagnostics results:
CEA (6/27/18): 3.72 ng/mL
Hematology (6/26/18): WBC 4.70; RBC 3.73 (L); Hgb 114 (L); Hct 0.34 (L); Pt 160;
Neutrophil 73 (H); Lymphocytes 18 (L); Monocytes 5; Lymphocytes 3; Basophils 1
Blood chemistry (6/26/18): Na 127 mmol/L; K 4.1 mmol/L; Cl 116 mmol/L
ECG: sinus bradycardia
Liver ultrasound: normal size liver with parenchymal changes; no focal mass lesion
seen; normal sonogram of the biliary tree
Thank you!

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