1. Case Presentation
Clerk 鄭雯欣(D12)
Clerk 李偉慈(D13)
Clerk 陳彥佑(D16)

2. Basic Data
• Name: 賴○○
• Age: 50y/o
• Sex: male
• Occupation: businessman
• Marital status: married
• Ethnic origin: 閩南
• Admitted via OPD.

3. Chief Complaint
• Cough off and on for 5 months

4. Present Illness

5. Past Medical History
• Pneumonia after EBUS-TBNA
• RUL lung adenoCa T1aN2M0 stage IIIA
• Anxiety

6. Social and Personal History
• No cigarette smoking
• No alcohol drinking
• No drug abuse
• No betel nut chewing

7. Allergic History
• No known allergy

8. Family History
• His mother was died of lung cancer

9. Review of Systems
Respiratory Sputum / Cough

10. Physical Examination
Height / Weight 168cm / 78kg
Mental state Alert and well oriented
Vital signs Temp: 36.5℃
Pulse: 78 per min
Respiration: 18 per min
Perfusion: warm
Oxygenation: no cyanosis

11. Lab Data

13. Image Study

14. Diagnosis
• RUL lung cancer with mediastinal T1aN3M0
stage IIIB post CCRT

15. Plans
• Arrange VATS with RUL lobectomy tomorrow
• Complete pre-OP survey
• Explained surgical risks, methods, potential
complications and alternative to the patient

16. Hospital Course