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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. Laboratory data (09.04.26)
9. 사지 BP
10.Image finding
11. Progress
12. Plan
- Complete TGA{S, D, D} /c VSD(large), PDA, PFO
- 4년 전 수술 후 F/U cath.
8. Laboratory data (09.04.26)
CBC 6930/12.0/36/302K (69/22/3)
OT/PT 26/13 BUN/Cr 13.5/0.49
PT/PTT 95% 37s CK/CK-MB 139/4.65
T.pro/Alb 7.0/4.9 LDH 239
9. 사지 BP
09.04.26 Right Left
Upper 111/59 101/55
Lower 129/64 130/51
10.Image finding
(1) EKG (09.03.16)
Normal sinus rhythm
Possible left ventricular hypertrophy
Borderline prolonged QT, may be secondary to QRS abnormality
(2)Echocardiogram (09.3.16)
Complete TGA{S, D, D} /c VSD(large), PDA, PFO
s/p Arterial switch op,VSD patch repair
PDA division, PFO direct closure
No residual VSD & PDA shunt flow
No AS(flow PV=1.0m/sec)
No PS(MPA flow PV=1.1m/sec)
mild RPAJS(d=9mm dp=9mmHg) /distal(d=12mm)
LPA:d=12mm
MR(trivial>G1/4, dp=85mmHg) d/t mild MVP(AML)
TR(trivial, dp=19mmHg)
PI(trivial), AR(trivial)
mild LAE & LVE(LVEDD:d=37mm, 112% of NL)
No pericardial effusion
*poor echo window
(3) Chest PA (09.04.26)
No active Lung disease
-
11. Progress
- HOD#2 (09.04.27)
S: “병원에 와서 긴장되나 봐요.”
