คำศัพท์ทางการแพทย์ Final diagnosis/Problems
1 MALIGNANT NEOPLASM OF lEFT BREAST (Main Condition)
2 ALLERGIC RHINITIS ( Comorbidity)
Other Clinical Diagnosis:
Hospital course. treatment and complication(s)
Known case @ IDC of Lt.breast
-Mammogram (17/4/57):
Suspected cancer at left breast. BI-RADS 5: Highly suspicious of
malignancy. appropriate action should be taken.
>>S/P Trucut 24/4/57: left needle biopsy: Fibrosis,
negative for malignancy.
>>S/P USG guide biopsy 1/5/57 :IDC, Gr 3, No LVI
-ER, PR Her-2: Neg
>>USG 25/5/57: fatty liver without evidence of hepatic lesion.
>>Ech 3/6/57 : Normal EF
PE:V/S: BT 36.3*C PR 78 bpm RR 20/min BP 107/83 mmHg
Lt.breast: palpable mass 4*3 cm at upper inner quadrant 11 o clock, not tender ,hard,consistency,movable,