Alhamdulillah. Terima Kasih atas doa semua.

Naqiuddin kini dah kembali ke rumah di Pandan indah setelah 1 bulan 10 hari di IJN.

Siapa yang faham bacala discharge summary kat bawah 🙂

DISCHARGE SUMMARY

Name : Ahmad Naqib Naqiuddin Bin Ahmad Kamil
MRN : 16XXXX
IC : 0409XXXXXXXX
Date of Birth : 22/09/2004
Admission Date : 28/11/2004
Discharge Date: 07/01/2005
Consultant : Dr. Haifa Abdul Latif / Mr. Hamdan Leman
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Principal Diagnosis : Simple transposition of great arteries with involuted right ventricle. Status post balloon atrial septostomy (23/9/2004).
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Secondary Diagnosis: Pre-existing conditions or complications that arose which required treatment during this hospitalisation:
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Principal Operation(s) and or Procedure(s) :

1). Right Blalock-Taussig Shunt and pulmonary artery banding for left ventricular retraining were done on 3rd December 2004 by Mr. Hamdan’s team. Findings: Left ventricle involuted.

  • Left ventricle pressure 20/16. Left ventricle / aorta < 0.7.
  • Right ventricle 80/40..
  • D-transposition of great arteries..
  • Aorta anterior to the right of pulmonary artery.
  • Pulmonary artery : aorta =2:1.
  • Single coronary artery.
  • Post pulmonary artery banding and right Blalock-Taussig Shunt:
  • Oxygen saturation 67% on Fi02 100%.
  • Left ventricle 60/20. Aorta 80/38.

2). Arterial switch operation and pulmonary artery debanding were done on 17th December 2004 by Mr. Hamdan’s team.
Findings:

  • D-transposition of great arteries. Aorta anterior to pulmonary artery (30% anterior to the right).
  • Pericardial adhesion.
  • Right Blalock-Taussig Shunt functioning. Pulmonary artery banding in-situ. Patent ductus arteriosus small and patent.
  • Coronaries 1 – LR 2Cx.

3). Delayed sternal closure was done on 18th December 2004 by Mr. Hamdan’s team.
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Brief Hospital Course:

A). Post pulmonary artery banding and Blalock-Taussig Shunt.
1). Blocked shunt.
– About 2 hours postop, he was noted to desaturated to 40%.
– Urgent echocardiography revealed :

  • No pericardial effusion.
  • Tachycardic heart.
  • Poor left ventricular function LVEF = 32%.
  • Pulmonary artery band pressure gradient 39mm Hg.
  • Right Blalock-Taussig Shunt not seen.

– So heparin infusion lOunits/kg/hour was commenced immediately.
– Following that oxygen saturation gradually improved.
– About 7 hours later shunt murmur could be heard and his oxygen saturation maintain > 75%.
– Repeat echocardiography reveal Blalock-Taussig Shunt flow seen but minimal.

2). Pneumonia.
– Serial CXR done since post operative day 4 showed pneumonic changes.
– Initially he was treated with IV Rocephine and IV Amikacin.
– However as he still having low grade fever after 6 days of these antibiotics, he was started on IV Imipenam.
– All cultures were negative.

3). Ventilator dependent.
– On post operative day 5, he persistently had lowish oxygen saturation despite on high ventilator settings.
– So nitric oxide ventilation was commenced immediately.
– Following that his oxygen saturation improved.
– So his nitric oxide ventilation was gradually wean down and managed to off after 6 days.
– However he required quite high ventilator settings and had difficulty in weaning down his setting.
– Discussion was done in the cardiothoracic – paediatric cardiology meeting and decided
to proceed with arterial switch and pulmonary artery debanding.

B). Post arterial switch operation:

1). Pulmonary hypertension.
– Immediately postop, he was noted to have high pulmonary artery pressure that is about 1/2 systemic.
– So nitric oxide ventilation and primacor infusion were commenced immediately.
– Following that his pulmonary artery pressure gradually decreased to 1/3 systemic.
– So his nitric oxide ventilation and primacor infusion were gradually wean down and was off by post operative day 3 and post operative day 6 respectively.

2). Renal impairment.
– Few hours postop, he was noted to have decreased urine output and his body became oedematous.
– So peritoneal dialysis was inserted and lasix infusion were commenced immediately.
– Following that he had good urine output.
– His peritoneal dialysis and lasix infusion were discontinued by post operative day 3.

3). Wound infection.
– On post operative day 6, his wound was noted to be infected.
– Wound swab C&S : no growth.
– Treated with IV Vancomycin and IV Amikacin for 10 days.

4). Presumed sepsis.
– On post operative day 12 he was noted to have thrombocytosis and leucocytosis.
– Treated with IV Imipenam for 1 week.
– Blood C&S : no growth.

5). Chronic lung disease.
– His serial CXR since post operative day 6 shows chronic lung changes.
– Had failed trial of extubation twice.
– Finally managed to extubate him by post operative day 10.
– He was given IV Dexamethasone according to BPD regime and was put on Budesonide MDI and combivent MDI.

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Condition of Patient upon Discharge :

Pink with oxygen saturation > 95% on air.
Mildly tachypnoeic.
Afebrile.
Lungs : clear.
Cardiovascular system: Ejection systolic murmur at left sternal edge 3/6.
Echo:
– No pericardial effusion / pleural effusion.
– Both diaphragm moving well.
– Normal chambers size.
– Good left ventricular function ejection fraction 70%.
– No mitral regurgitation / tricuspid regurgitation.
– Mild pulmonary regurgitation pressure gradient 11mm Hg ( normal pulmonary artery pressure ).
– Proximal right pulmonary artery / left pulmonary artery well seen and no obstruction.
– Small patent foramen ovale with left to right shunt.
* Pleural and pericardia! effusion are common complications following cardiac surgery. They should be suspected if the patient presents with cardio-respiratory symptoms.

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Medications :
Syr. Lasix – 5mg tds
Syr. Captopril – 3mg bd
Syr. Aldactone – 6.25mg bd
Syr. Viagra – 2mg 6 hourly
Budesonide MDI – 400mcg bd
Combivent MDI – 200mcg 6 hourly

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Follow up care (Clinic Visit) :
To come again 6 weeks for review ( 22/2/2005 @ 11.00am) – Cardiothoracic doctor .
To come again 3 months for review (13/4/2005 @ 10.00am) – Paediatric cardiology doctor.

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Referring Doctor :
Prof. Madya Dr. Bilkis Abd. Aziz
Pakar Perunding Kardiologi Kanak-Kanak Address :
Hospital Universiti Kebangsaan Malaysia
Jalan Yaacob Latif
Bandar Tun Razak
56000 Cheras
Kuala Lumpur.

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Senior Registrar / Medical Officer : Dr. Rozaina Hj Md Said, Senior Medical Officer
MBBS (UM)
Department of Pedriatic Cardiology,
Institut Jantung Negara Sdn Bhd,
Kuala Luimpur.
Date : 7th January 2005

One Comment

  1. Alahamdulillah syukur kepadaNya semuanya selamat dan bolehlah ponaanku membesar dean bermain dengan sepupunya dan cepat boleh berjalan dan tolong mak bapaknya dengan pakai baju sendiri

    wassaam

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