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[의학과][소아심장] 생후 10일된 여아환자 입원 사례(on service note)에 대한 자료입니다.
목차
1. Chief Complaint
2. 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. current diagnosis
12. Progress
본문내용
8. Plan
Operation
O2 saturation 유지 안되면 atrial septostomy & eglandin 투여
9. Image study
Chest PA (2009.05.25)
Echocardiography (2009.05.25) – final diagnosis
Complete TGA{S, D, D} c IVS
PDA(large, d= 5mm)
ASD secundum(d= 5mm, PFO type)
AO: PA= 10.9 : 11.7 mm
commissure가 맞지 않음.
TR(trivial)
MR(trivial)
PI(trivial)
No CoA. NL PVR
coronary arteries-usual pattern
EKG (2009.05.25)
10. Lab data
일반 혈액 (2009.05.25)
검사명 검사명 결과 참고치 단위 판정
CBC WBC COUNT 27.18 4.0~10.8 10^3/μL H
RBC COUNT 4.48 4.5~6.1 10^6/μL
Hemoglobin 16.4 14.0~18.0 g/dL
Hct 49.6 40.0~50.0 %
PLT Count PLT Count 266 150.0~400.0 10^3/μL
WBC Differential Count Neutrophil(%) 87.5 40~74 % H
Lymphocyte(%) 5.1 19~48 % L
Monocyte(%) 6.5 3.3~9 %
Eosinophil(%) 0.3 0~7 %
Basophil(%) 0.2 0~1.5 %
LUC(%) 0.3 0~4 %
nRBC(%) - 0.0~2.3 %
Neutrophil(#) 23.77 2~7 # H
Lymphocyte(#) 1.39 1.5~4 # L