Pediatric Cardiology Unit Referral Report
To:
Madinah Cardiac Center-MCC
King Faisal Specialist Hospita-Jeddah
King Faisal Specialist Hospita-Riyadh
Prince Sultan Cardiac Center-Riyadh
All Centers
Medical Report
Referral Type:
Routine
Urgent
Appointment
On Family's Request
Patient Information
Date:
Name:
Nationality:
Saudi
Non-Saudi
Age:
Years:
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Months:
0
1
2
3
4
5
6
7
8
9
10
11
Days:
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
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16
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20
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22
23
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25
26
27
28
29
Sex:
Male
Female
Ambiguous
Weight (Kg):
MRN:
Location:
Home
Ward
PICU
NICU
ER
Mobile 1:
Mobile 2:
Diagnosis
Atrial Septal Defect
Ventricular Septal Defect
Partial Atrioventricular Septal Defect
Complete Atrioventricular Septal Defect - Balanced
Complete Atrioventricular Septal Defect - Unbalanced
Tetralogy of Fallot
Tetralogy of Fallot/Pulmonary Atresia
Valvar Pulmonary Atresia
Pulmonary Stenosis
Pulmonary Insufficiency
Aortic Stenosis
Bicuspid Aortic Valve
Hypoplastic Left Heart Syndrome
Hypoplastic Left Heart Syndrome Variation
Interrupted Aortic Arch
Coarctation of the Aorta
Right Aortic Arch
Ebstein's Anomaly
Non-Ebstein Tricuspid Dysplasia
D-Transposition of the Great Arteries
L-Transposition of the Great Arteries/CCTGA
Partial Anomalous Pulmonary Venous Return
Total Anomalous Pulmonary Venous Return
Scimitar Syndrome
MAPCAS
Double Outlet of the Right Ventricle
Double Outlet of the Left Ventricle
Double Inlet of the Left Ventricle
Double Inlet of the Right Ventricle
Dilated Cardiomyopathy
Hypertrophic Cardiomyopathy
Rheumatic Heart Disease
Dilated Coronaries/Kawasaki Disease
ALCAPA
ARCAPA
Acute Myocarditis
Pericardial Effusion
To select more than one diagnosis from the list, hold down the CTRL key.
History
Examination
Non-dysmorphic
Dysmorphic
Normal Breathing Pattern
Respiratory Distress
Well perfused
Normal Pulses
Asymmetrical Pulses
Weak Pulses
Distended Abdomen
Hepatomegaly
No Murmur
Soft Murmur
Harsh Murmur
Vital Signs
Heart Rate:
bpm
Respiratory Rate:
rpm
O2 Sat:
%
Blood Pressure:
mmHg
ECG
Sinus rhythm, normal PR and QTc intervals
Grade I AV block
Grade II Mobitz I AV block
Grade II Mobitz II AV block
Complete AV block
Left Axis Deviation
Right Axis Deviation
Partial Right Bundle Block
Complete Right Bundle Block
Partial Left Bundle Block
Complete Left Bundle Block
Brugada Pattern
Occasional PVCs
Frequent PVCs
Right Atrial Overload
Left Atrial Overload
Right Ventricle Overload
Left Ventricle Overload
Left Anterior Superior Bundle Block
Long QTc
Sinus Tachycardia
Sinus Bradycardia
Sinus Arrhythmia
To select more than one ECG finding, hold down the CTRL key.
Chest X-ray
Investigations
Echocardiogram
Situs Solitus, normal AV/VA connection, normal systemic and pulmonary venous return, no ASD, no VSD, normal chambers and biventricular function, unremarkable valves, no RVOTO, No LVOTO, normal coronaries, left arch with no CoA, no PE, no intracardia masses, no signs of PHTN.
Management / Hospital Course
Recommendation
-- Select Recommendation --
Referral to Higher Center for further Assessment and Management
Referral to MCC for Holter
Referral do MCC for Cath: device closure
Referral to MCC for Cath: PDA stenting
Referral to MCC for Cath: investigative study
Referral to MCC for total surgical repair
Referral to MCC for pacemaker implant
Referral to higher center for second opinion
Report written on family's request
Treating Consultant
-- Select Consultant --
Dr. Adnan Aselan
Dr. Ibrahim Almozini
Dr. Saeed AlGhamdi
Dr. Rodrigo Oliveira
Head of Pediatric Cardiology Unit
-- Select Head --
Dr. Adnan Aselan
Dr. Ibrahim Almozini
Dr. Saeed AlGhamdi
Dr. Rodrigo Oliveira
Generate Report
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