胸腔外科0925 case presentation
TRANSCRIPT
Case Presentation
Clerk 鄭雯欣 (D12)Clerk 李偉慈 (D13)Clerk 陳彥佑 (D16)
Basic Data
• Name: 賴○○• Age: 50y/o• Sex: male• Occupation: businessman• Marital status: married• Ethnic origin: 閩南• Admitted via OPD.
Chief Complaint
• Cough off and on for 5 months
Present Illness
Past Medical History
• Pneumonia after EBUS-TBNA• RUL lung adenoCa T1aN2M0 stage IIIA• Anxiety
Social and Personal History
• No cigarette smoking• No alcohol drinking• No drug abuse• No betel nut chewing
Allergic History
• No known allergy
Family History
• His mother was died of lung cancer
Review of SystemsRespiratory Sputum / Cough
Physical ExaminationHeight / Weight 168cm / 78kg
Mental state Alert and well oriented
Vital signs Temp: 36.5℃Pulse: 78 per min
Respiration: 18 per minPerfusion: warm
Oxygenation: no cyanosis
Lab Data
Image Study
Diagnosis
• RUL lung cancer with mediastinal T1aN3M0 stage IIIB post CCRT
Plans
• Arrange VATS with RUL lobectomy tomorrow• Complete pre-OP survey• Explained surgical risks, methods, potential
complications and alternative to the patient
Hospital Course