CS Case Presentation

안암 PK M 조
2018180064 우은채
 CASE
PRESENTATION
PATIENT IDENTIFICATION
Identification

Chief Complaint
• Name : 이 * 자
Present Illness

History
• Sex / Age : F / 67
Review of System

Physical Examination

Initial Lab Findings

• Admission date : 2022.10.23
Diagnosis & Plan

CHIEF COMPLAINT
Operation

• 수술받으러 왔어요
 CASE
PRESENTATION
PRESENT ILLNESS
Identification

Chief Complaint
• 기저질환 HTN, Dyslipidemia, Cerebral atherosclerosis 로 NU f/u 하던 분
Present Illness

History • 2022 년 7 월 치과 진료 도중 발견한 CT 에서 LUL 3cm nodule 발견됨

Review of System
• 본원 PU 내원하여 PCNB 및 EBUS 시행한 결과 LUL adenocarcinoma 와
Physical Examination

Initial Lab Findings 이와 별개의 2R LN neuroblastic tumor 확인되었음

Diagnosis & Plan
• 10/23 일 폐암 수술 위해 흉부외과 입원
Operation
 CASE
HISTORY
PRESENTATION

Identification
• DM/HTN/TB/Hepatitis/Dyslipidemia (-/+/-/-/+)
Chief Complaint

Present Illness • Parathyroid adenoma

History
• Central giant cell granuloma
Review of System

Physical Examination
• Cerebral atherosclerosis
Initial Lab Findings • Admission/Operation : Rt. parathyroidectomy &Lt. adrenalectomy ['22-09-15]
Diagnosis & Plan
• Medication (+)
Operation
✔ NU medi. : losartan, clopidogrel
✔ Trauma (-/-)
• Alcohol, Smoking (-/-, never smoker)
• Family Hx (+, 어머니 뇌경색 )
 CASE
PRESENTATION
REVIEW OF SYSTEM
Identification

Chief Complaint
General Fever/Chilling (-/-), General weakness/Fatigue (-/-) Weight loss/gain (-/-)

Present Illness
headache/dizziness(-/-), sore throat(-), C/S/R(-/-/-), dry mouth(-),
History
HEENT polydipsia(-), Ptosis(-), diplopia(-), dysarthria(-), dysphagia(-), anosmia(-),
Review of System

Physical Examination
orthostatic dizziness(-), visual hallucination(-)
Initial Lab Findings
Chest pain (-), Dyspnea (-), Orthopnea (-), Palpitation (-), Hemoptysis
Diagnosis & Plan Chest
(-)
Operation

GI A/N/V/C/D (-/-/-/-/-), Abdominal pain (-), Melena/Hematochezia (-/-)

F/U/N/D(-/-/-/-), hematuria(-), urinary incontinence(-) foamy urine(-),

GU
oliguria/polyuria(-/-)

Neuromuscular weakness(-), arthralgia(-), myalgia(-), joint stiffness(-)

 PHYSICAL EXAMINATION
CASE
PRESENTATION

Identification Vital Sign BT 37.2 HR 78 RR 20 BP 126/84

Chief Complaint

Present Illness General 158.1cm, 53.7kg

History Appearance mental: alert, cooperative
Review of System

Physical Examination
HEENT Anemic conjunctiva(-), Icteric sclera(-), Tongue dehydration(-)
Initial Lab Findings

Diagnosis & Plan Chest Symmetric chest expansion, Normal breath sound
Operation

Abdomen Distension(-), Normoactive bowel sound

Extremity Rash(-), Pitting edema(-)

 CASE
XR Chest PA [22.07.12]
PRESENTATION

Identification

Chief Complaint

Present Illness

History

Review of System

Physical Examination

Initial Lab Findings

Diagnosis & Plan

Operation
 CASE
Chest CT [22.07.20]
PRESENTATION

Identification

Chief Complaint

Present Illness

History

Review of System

Physical Examination

Initial Lab Findings

Diagnosis & Plan

Operation
 CASE
Chest CT [22.07.20]
PRESENTATION

Identification

Chief Complaint

Present Illness

History

Review of System

Physical Examination

Initial Lab Findings

Diagnosis & Plan

Operation
 CASE
Chest CT [22.07.20]
PRESENTATION

Identification

Chief Complaint

Present Illness

History

Review of System

Physical Examination

Initial Lab Findings

Diagnosis & Plan

Operation
 PET-CT [2022.07.20]
CASE
PRESENTATION

Identification

Chief Complaint

Present Illness

History

Review of System

Physical Examination

Initial Lab Findings

Diagnosis & Plan

Operation
 PET-CT [2022.07.20]
CASE
PRESENTATION

Identification

Chief Complaint

Present Illness

History

Review of System

Physical Examination

Initial Lab Findings

Diagnosis & Plan

Operation
 Bone scan [2022.07.25]
CASE
PRESENTATION

Identification

Chief Complaint

Present Illness

History

Review of System

Physical Examination

Initial Lab Findings

Diagnosis & Plan

Operation
 Brain MRI [2022.08.03]
CASE
PRESENTATION

Identification

Chief Complaint

Present Illness

History

Review of System

Physical Examination

Initial Lab Findings

Diagnosis & Plan

Operation
 PCNB
CASE
PRESENTATION

Identification

Chief Complaint

Present Illness

History

Review of System

Physical Examination

Initial Lab Findings

Diagnosis & Plan

Operation
 EBUS-TBNA
CASE
PRESENTATION

Identification

Chief Complaint

Present Illness

History

Review of System

Physical Examination

Initial Lab Findings

Diagnosis & Plan

Operation
 Diagnosis & Plan
CASE
PRESENTATION
▪ Diagnosis
Identification

Chief Complaint ✔ Chest CT

Present Illness

History
• LUL 2.9cm nodule
Review of System
✔ PET-CT
Physical Examination

Initial Lab Findings • a moderately hypermetabolic nodule in LUL with fissural retraction (3.99)
Diagnosis & Plan

Operation
• an isometabolic nodule or LN in the Rt highest mediastinum

✔ CT guided percutaneous needle biopsy

• adenocarcinoma

-> r/o Adenocarcinoma, Left upper lobe

 Diagnosis & Plan
CASE
PRESENTATION

Identification ▪ TNM staging : cT1cN0M0 -> Stage IA3

Chief Complaint

Present Illness

History

Review of System

Physical Examination EBUS-TBNA : (-)

Initial Lab Findings

Diagnosis & Plan

Operation
 Diagnosis & Plan
CASE
PRESENTATION

Identification ▪ Plan
Chief Complaint

Present Illness ✔ TNM staging : T1N0M0 -> Stage IA3

History

Review of System

Physical Examination

Initial Lab Findings

Diagnosis & Plan

Operation
 Pre-op check up
CASE
PRESENTATION

Identification ▪ Nutritional status : good

Chief Complaint

Present Illness ▪ Performance Status

History

Review of System
✔ ECOG 0
Physical Examination

Initial Lab Findings

Diagnosis & Plan

Operation
 Pre-op check up
CASE
PRESENTATION

Identification ▪ Cardiac function

Chief Complaint

Present Illness
✔ HTN / 병동 BP 126/84~77 HR 78 : stable
History
✔ EKG [10/11] : normal sinus rhythm
Review of System

Physical Examination
✔ 2D ECHO 미시행
Initial Lab Findings

Diagnosis & Plan ✔ Tx: ARB, clopidogrel(10/16~ cut 7DA)

Operation
 Pre-op check up
CASE
PRESENTATION ▪ Respiratory function
Identification
✔ Respiratory symptom (-)
Chief Complaint

Present Illness ✔ Chest X-ray [10/5] : improved pleural effusion since 9/18/22
History

Review of System
✔ Chest CT [9/19] :
Physical Examination
• Subsegmental atelectasis in left lingular segment and BLL.
Initial Lab Findings

Diagnosis & Plan • LN enlargement in right retrotracheal area; D/D Metastatic, decreased enhancement.
Operation
• Small pleural effuion in both, increased. RUL ant segment 에 이전 CT [2020/12/30] 에
비해 크기 증가

✔
PFT FEV1 2.31L (97%), FVC 2.85 (92%) FEV1/FVC 81% DLCO 19.6 (111%)

pH 7.39 – PCO2 33 mmHg - PO2 186 mmHg – HCO3- 20.0 mmol/L –

ABGA
 CASE
PRESENTATION
Operation [22.10.24]
Identification  Surgery Report
Chief Complaint

Present Illness ■ 수술 전 진단명 ■ 수술소견 & 검체소견

History
Lung cancer, Left Upper Lobe - Preop. WH0/ECOG: 1, Karnofsky score: 85
- Preop. TNM: T2aN0M0
Review of System
■ 수술 후 진단명 - Mild pleural adhesion
Physical Examination
Lung cancer, Left Upper Lobe - No pleural effusion
Initial Lab Findings - Complete fissure
Diagnosis & Plan ■ 수술명 - Tumor was located just next to LLL
Operation Lobectomy of lung, RLL, robotic surgery -> wedge resection of LLL to get enough
Robotic LULobectomy with MLND resection margin
(2 ports, 3 arms)
■ 마취종류
* 마취종류 : General
 CASE
PRESENTATION
Operation
Identification  Surgery Report
Chief Complaint
■ 수술방법 ■ 수술추가정보
Present Illness
- One-lung ventilation
History - Left lateral position · 수술 중 혈액 손실 : 300cc 미만
- 4cm working port at 8th ICS, 12mm port at 7th ICS
Review of System · 수술 중 특이 합병증 : No
- 8mm scope and 8mm trocar insertion at working port
Physical Examination
- Cardiere forcep insertion at 8mm port and Marryland forcep
· 외상으로 인한 수술 : No
Initial Lab Findings and Endowrist stapler at 12mm port · Tissue to path: Yes
Diagnosis & Plan - wedge resection of LLL to get enough resection margin with · Drain: Yes
Endodowrist stapler 1ea
Operation
- Superior pulmonary vein division with Endowrist stapler 1ea
- LUL pulmonary artery division with Endowrist stapler 3ea
- LUL bronchus division with Endowrist stapler 1ea
- Complete mediastinal LN dissection
- Bleeding control with Surgiguard
- Air leak control with Beriplast
- ON-Q pain catheter and chest tube insertion
- Wound closure
Disease Review
lung cancer staging work-up
TNM Staging
TNM Staging
Treatment
Treatment
Reference
▪ Harrison’s Principles of Internal Medicine, 21th edition

▪ NCCN Guidelines Version 4. 2022, Non - small cell lung cancer