DISCHARGE SUMMARY
ID No : O803051132 | NAME : BABY KAVYASHREE | AGE : 3 YEAR/ FEMALE |
DOA : 16.03.2005 | DOP : 17.03.2005 | DOD : 18.03.2005 |
DIAGNOSIS : Congenital heart disease
Multiple artrial septal defect
Non compaction of ventricles
Bi-Ventricular dysfunction
Moderate pulmonary artery hypertension
PROCEDURE DONE : Cardiac catheterization done on 17.03.2005
BRIEF HISTORY :
3 year old Kavyashree is the only child born to non consanguineous parents. Full term
normal delivery. No history of birth asphyxia. History of recurrent respiratory tract infection.
No history of cyanosis / spells / convulsions. Family history of congenital heart disease. (Father
underwent atrial septal defect closure).
CLINICAL EXAMINATION :
Weight – 13 kgs Satuation – 98%
HR – 110/min, regular All peripheral pulses are well felt.
BP – 100/64mmHg CVS –S1 normal, S2 wide and fixed split,ESM at LUSB, PSM at apex
RS – clear
INVESTIGATIONS:
Hb – 11.8 gms / dl; PCV –36%; Platelets – 2.7 lacs / mm ; Total leucocyte count – 13,800 cells /
Cmm; Neutrophils – 39%; Lymphocytes –56%; Eosinophils – 03%; ESR 1/2 hr – 06 & 1 hr – 15
Mm; Random blood sugar –117 mgs / dl; Blood urea – 22 mgs / dl; S. Creatine – 0.6 mgs / dl;
Total bilirubin – 2.3 mgs / dl; Direct bilirubin – 0.8 mgs / dl; Indirect bilirubin – 1.5mgs / dl;
SGOT – 35 Iu/L; SGPT – 16 Iu / L; Akl. Phosphate –386 Iu / L; Total proteins – 6.5 gms / dl
S.Albumin – 3.5 gms / dl; S.Globulin – 3 gms / dl; Sodium – 137 mEq / L; Potassium – 3.12
MEq / L; Serology – Non reactive
COAGULATION PROFILE:
P.T. Test 18.6 sec control 13.5 sec
INR 1.49
A.P.T.T Test 33.0 sec. Control 32.0 sec
CXR : CTR – 75%, increased pulmonary biventricular function, pulmanory venus
congestion
ECG : Sinus rhythm, BAE,
ECHO : Multiple ASD with L® R shunt. Ventricular non compaction involving both
RV and
Regurgitation.
COURSE IN THE HOSPITAL :
She was advised Cardiac Catheterization with Balloon occlusion to decide about feasibility of
ASD closure in view of the ventricles. Cardiac cath done on 17.03.2005 revealed multiple ASDs
Non compaction of ventricles with biventricular dysfunction, moderate pulmonary hypertension.
Elevated Lv and RVDEP. There was no changes in haemodynamics following Balloon occlusion
Of the large ASD for 5 minutes. She tolerated the procedure well and was shifted to the ward with
Stable haemodynamics. No haematoma or oozing from the punctured site.
CONDITION ON DISCHARGE : Patient stable
PLAN: Case was discussed in the cath conference. She is advised ASD closure at high risk in
View of biventricular dysfunction. The parents have been explained about risks involved.
DR. VIMALA. J. MD, DM
CONSULTANT PAED.CARDIOLOGIST