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분야
doc2. Past History
3. Family History
4. Present Illness
5. Review of System
6. Physical Examination
7. Intial Impression
8. Initial Plan
9. Image Study
10. Lab Data
11. Other study
12. Current diagnosis
13. Progression
CBC
WBC COUNT 3.74 4.0~10.8 10^3/μL L
RBC COUNT 3.94 4.0~5.4 10^6/μL L
Hemoglobin 9.5 12.0~16.0 g/dL L
Hct 29.8 37.0~47.0 % L
MCV 75.6 80.0~98.0 fL L
MCH 24 27.0~33.0 pg L
MCHC 31.8 33.0~37.0 g/dL L
RDW 18 11.5~14.5 % H
PDW(fL) - 9.0~17.0 fL
PDW(%) 46.8 25~65 %
MPV 8.5 7.4~10.4 fL
PLT Count PLT Count 131 150.0~400.0 10^3/μL L
WBC Differential Count
Neutrophil(%) 56.7 40~74 %
Lymphocyte(%) 32 19~48 %
Monocyte(%) 4.6 3.3~9 %
Eosinophil(%) 4.1 0~7 %
Basophil(%) 0.2 0~1.5 %
LUC(%) 2.5 0~4 %
nRBC(%) - 0.0~2.3 %
Neutrophil(#) 2.12 2~7 #
Lymphocyte(#) 1.2 1.5~4 # L
Monocyte(#) 0.17 0.2~0.8 # L
Eosinophil(#) 0.15 0~0.5 #
Basophil(#) 0.01 0~0.2 #
LUC(#) 0.09 0.0~0.4 #
Reticulocyte Count Reti(%) 0.91 0.5~2.31 %
Reticulocyte Count Reti(count) 33.6 20.8~109.6 10^3/μL
Peripheral Blood Smear
Atyp. Lymph ▦ 0 0~0 %
Blast ▦ 0 0~0 %
Imm. Cell ▦ 0 0~0 %
Promyelocyte ▦ 0 0~0 %
Myelocyte ▦ 0 0~0 %
Metamyelo ▦ 0 0~0 %
Band Neutrophil ▦ 0 1~10 % L
Seg. Neutrophil ▦ 62 40~74 %
Lymphocyte ▦ 32 19~48 %
Monocyte ▦ 6 3.3~9 %
Eosinophil ▦ 0 0~7 %
Basophil ▦ 0 0~1.5 %
nRBC ▦ 0 0~2.3 / 100 WBC
Corrected WBC count ▦ - 4.0~10.8 10^3/μL
Plasma
Prothrombin Time(PT) PT(Sec) 13.2 9.8~13.4 sec
PT(Percentage) 84 77~100 %
PT(INR) 1.11 0.91~1.16 INR
aPTT aPTT 37.4 27.9~41.6 sec
Routine U/A with Microscopy
Blood,RBC 1+
Urobilinogen +/-(0.1)
WBC 3+
Turbidity Hazy
CRP Quantitation < 1.00 0.0~0.8 mg/dL -
11. Other study
Cardiac catheterization HOD#3
s/p TOF total correction
PDA ligation
PFO direct closure
residual PS (dP=55mmHg)
mainly supravalvular (d=11mmHg, dP=45mmHg)
LPAJS (d=11mm, dP=10mmHg)
PI(moderate), TR(G1~2/4), MR(trivial), AR(G1/4), mild LVE
12. Current diagnosis
TOF, PDA, PFO, LPAJS
s/p TOF total correction
s/p PDA ligation
