FORMER MATHS TEACHER AT DAV-BHEL SCHOOL, RANIPET(1999-2022)

Sunday, March 22, 2009

03 Discharge after cath Test

 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,  LV  dominance,  rSR in V1

 

ECHO             :     Multiple ASD with L® R shunt. Ventricular non compaction involving both

                                RV and LV with compromised biventricular function. Mild mitral

                                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