PREPARATION FOR MAJOR OPERATION-CASE HISTORY

1. PREPARATION FOR MAJOR OPERATION-CASE HISTORY

2. HISTORY • James Brown, a 70-year-old retired farmer, with a proven carcinoma at the rectosigmoid junction admitted electively for an anterior resection of the rectum

3. Present complaint • Seen urgently in outpatient clinic 3 weeks ago with a 5-week history of loose stools three to five times a day, without blood or mucus. GP reported three stool specimens were positive for occult blood. Lost about 4 kg in weight over the last 3 months, but has been trying to lose weight anyway.

4. Results of outpatient investigations • Flexible sigmoidoscopic examination-obvious fungatingtumour of upper rectum. Scope could not be passed beyond it. Biopsies confirmed adenocarcinoma • Contrast enhanced CT scan of abdomen and pelvis-no other synchronous colonic cancers seen; liver free of metastases • Chest X-ray-normal, no metastases • Transrectal ultrasound for local staging-no spread outside the bowel wall • Blood tests: full blood count-haemoglobin 11.6 g/L, otherwise normal. Urea and electrolytes, liver function tests-normal

5. Systems enquiry • Generally well, but recent onset of shortness of breath after walking 200 metres on flat ground and occasional fast palpitations. No other cardiorespiratory symptoms. Poor stream on micturition. Nil else on systemic enquiry

6. Past medical history • Appendicectomy aged 14; no anaesthetic complications. Serious farming injury to left elbow aged 20. Jaundiced during the Second World War in Asia, nil since. Hypertensive for 10 years and on drug treatment for 5 years. Diabetes discovered 3 years ago on routine urine testing, controlled by diet alone

7. Family history • Mother was obese; died age 55 from complications of diabetes (gangrene). Older brother had major stroke at 64 but partially recovered. No family history of bowel cancer.

8. Social history • Widowed for 2 years, wife died of breast cancer. Has one son and one daughter, both married with young children but living far away. Lives in own house with an upstairs lavatory, on a smallholding with a few stock animals. Lives independently, and uses car for shopping. Smoked 20 cigarettes a day since age 15; alcohol intake averages 4 units a day

9. Drug history • Takes atenolol 50 mg (a beta-blocker) and bendroflumethiazide 2.5 mg (a diuretic) once a day in the morning for hypertension. Takes aspirin 75 mg daily 'for his heart'. Told in the past not to have penicillin, but cannot recall why; does not remember when he last had penicillin. Not allergic to iodine.

10. EXAMINATION • General- Fit-looking man of 70, not obviously anxious. Tanned; not evidently anaemic; no cyanosis, jaundice, lymphadenopathy or clubbing; no thyroid enlargement. Fingers tobacco stained. Not febrile

11. Cardiovascular and respiratory system • Pulse 68 beats per minute and regular. BP 150/110 mmHg. Soft systolic murmur at the left sternal edge. No ankle swelling and JVP not elevated. Extensive bilateral varicose veins. Chest examination unremarkable apart from a few crepitations which do not clear with coughing

12. Abdomen • Moderately obese. Appendicectomy scar. Soft to palpation. No organomegaly. Possible mass in left iliac fossa-not indentable (i.e. not faeces). No groin hernias. External genitalia normal. Rectal examination-moderately enlarged smooth prostate and normal-coloured stool

13. Central nervous system and locomotor system • Fixed flexion deformity of left elbow at 90°, otherwise normal