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분야
doc2. Present Illness
3. Past history
4. Family History
5. Review of System (2009.06.25)
6. Physical Examination (2009.06.25)
7. Impression
8. Plan
9. Image study
10. Lab data
11. current diagnosis
12. Progress
DORV c VSD, PS, s/p Glenn shunt, ASD creation, s/p coil embolization of AP collateral, Fontan op예정
DORV c VSD and PS. s/p Rt bidirectional Glenn shunt.
RSVC 12mm, hilar RPA 6.9x6.9mm, LPA 8x6.8mm.
s/p coil embolization of AP collaterals.
No airway anomaly or compression.
Echocardiography (2009.05.21)
{S ,D, D}DORV /c VSD(Remote), PS, Hypoplastic MPA & both PA
s/p Bid.Glenn shunt(Rt)
ASD creation(d=22mm)
TAP
T/D prev.B-T shunt(Rt.)
s/p stent insertion on RPA shunt anastomisis site
RSVC(d=10mm) flow pv=0.3m/sec
RPA & LPA:d=8mm / CPA:d=9mm
TR(G1/4, dp=81mmHg) MR(trivial) AR(trivial)
BVH(esp.RVH)
TV chordae attached IVS
minor AP collaterals
No pericardial effusion
both ventricle EF=58~60%
10. Lab data
일반혈액 (2009.6.24)
CBC
WBC COUNT 13.31 4.0~10.8 10^3/μL H
RBC COUNT 5.10 4.5~6.1 10^6/μL
Hemoglobin 14.3 14.0~18.0 g/dL
Hct 42.7 40.0~50.0 %
PLT Count PLT Count 286 150.0~400.0 10^3/μL
WBC Differential Count
Neutrophil(%) 62.7 40~74 %
Lymphocyte(%) 25.9 19~48 %
Monocyte(%) 4.2 3.3~9 %
Eosinophil(%) 4.9 0~7 %
Basophil(%) 0.4 0~1.5 %
Neutrophil(#) 8.35 2~7 # H
Lymphocyte(#) 3.45 1.5~4 #
Monocyte(#) 0.56 0.2~0.8 #
Eosinophil(#) 0.65 0~0.5 # H
Basophil(#) 0.05 0~0.2 #
ESR(Infrared Ray,Spin) 19 0.0~15.0 mm/hr H
일반화학(2009.6.24)
Serum
Routine Chemistry
Calcium 9.5 8.8~10.8 mg/dL
Inorganic P 5.3 2.5~4.5 mg/dL H
Glucose 106 70~110 mg/dL
BUN 12.3 5.0~25.0 mg/dL
Creatinine 0.45 0.50~1.20 mg/dL L
Uric Acid 4.0 2.5~7.5 mg/dL
Cholesterol 160 100~220 mg/dL
Total Protein 6.8 6.0~8.0 g/dL
Albumin 3.9 3.8~5.4 g/dL
Alk. Phos 141 60.0~300.0 IU/L
AST(GOT) 32 13.0~34.0 IU/L
ALT(GPT) 18 5.0~46.0 IU/L
T. Bilirubin 0.2 0.2~1.2 mg/dL
Na 138 135.0~145.0 mmol/L
K 4.0 3.5~5.5 mmol/L
Cl 102 98~110 mmol/L
tCO2 24 20~30 mmol/L
CRP 1.200mg/dl (2009.6.8)
Pleural fluid (2009.6.9)
Pleural fluid
Routine Body Fluid Ex.
Color Straw
Turbidity Hazy
RBC 100
WBC 12500
Polymorphonuclear cells 93
Mononuclear cells 7
Eosinophils 0
Basophils 0
Other 0
SG 1.021
pH 7.2
Cholesterol 62 mg/dL
Total Protein 3200.0 mg/dL
Albumin 1900.0 mg/dL
Amylase 15 U/L
Triglyceride 31 0.0~50.0 mg/dL
LD(LDH) 421 IU/L
Glucose 104 mg/dL
Hct
