胸腔外科0925 case presentation

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