Vous êtes sur la page 1sur 2

Sample Type / Medical Specialty: Cardiovascular / Pulmonary

Sample Name: Cardiac Catheterization - 11


Description: Patient with significant angina with moderate anteroapical ischemia
on nuclear perfusion stress imaging only. He has been referred for cardiac cath
eterization.
(Medical Transcription Sample Report)
A 60-year-old gentleman with markedly abnormal stress test in my office today wh
o is admitted with significant angina with moderate anteroapical ischemia on nuc
lear perfusion stress imaging only. He has been referred for cardiac catheteriza
tion. I discussed the procedure in detail with the patient and his wife as well
as perform a risk/benefit/alternative analysis with benefits being more definiti
ve exclusion of significant obstructive coronary artery disease and evaluation o
f such to help guide further treatment, alternatives being alternative stress im
aging or empiric medical therapy which I was not recommending nor was the patien
t interested in and risks including but not limited to and the patient and his w
ife were aware that this was not an all inclusive list of over-sedation from con
scious sedation, risk of aspiration pneumonia from regurgitation of stomach cont
ents, risk of excessive fluoroscopic exposure causing skin necrosis, risk of dye
reaction as well as due to the inherent invasive nature of cardiac catheterizat
ion at least 1 in 1,000 risk of stroke, heart attack, heart failure, death, kidn
ey failure, peripheral vascular disease, femoral arteriotomy access site complic
ations including bleeding, need for surgical intervention of the femoral arterio
tomy access site, aneurysmal formation, pseudoaneurysmal formation, and/or need
for blood transfusions. The patient expressed understanding of this risk/benefit
/alternative analysis and stated in a clear competent and coherent fashion that
he wished to go forward with the cardiac catheterization which I felt was approp
riate.
The patient and his wife had the opportunity to ask questions, all of which were
answered for them and the patient stated in a clear, competent and coherent fas
hion that he wished to go forward with cardiac catheterization which I felt was
appropriate.
PROCEDURE NOTE: The patient was brought to the Cardiac Catheterization Lab in a
fasting state. All appropriate labs had been reviewed. Bilateral groins were pre
pped and draped in the usual fashion for sterile conditions. The appropriate tim
e-out procedure was performed with appropriate identification of the patient, pr
ocedure, physician, position and documentation all done under my direct supervis
ion and there were no safety issues raised by the staff. He received a total of
2 mg of Versed and 50 mcg of Fentanyl utilizing titrated concentration with good
effect. Bilateral groins had been prepped and draped in the usual fashion. Righ
t femoral inguinal fossa was anesthetized with 1% topical lidocaine and a 6-Fren
ch vascular sheath was put into place percutaneously via guide-wire exchanger wi
th a finder needle. All catheters were passed using a J-tipped guide-wire. Left
heart catheterization and left ventriculography performed using a 6-French pigta
il catheter. Left system coronary angiography performed using a 6-French JL4 cat
heter. Right system coronary angiography performed using a 6-French CDRC cathete
r. Following the procedure, all catheters were removed. Manual pressure was held
with the Neptune pad and the patient was discharged back to his room. I inspect
ed the femoral arteriotomy site after the procedure was complete and it was beni
gn without evidence of hematoma nor bruit with intact distal pulses. There were
no apparent complications. A total of 77 cc of Isovue dye and 1.4 minutes of flu
oroscopy time were utilized during the case.
FINDINGS:
HEMODYNAMICS: LV pressure is 120, EDP is 20, aortic pressure 120/62, mean of 82.

LV function is normal, EF 60%, no wall motion abnormalities.


CORONARY ANATOMY:
1. Left main demonstrates 30-40% distal left main lesion which is tapering, not
felt significantly obstructive.
2. The LAD demonstrates proximal moderate 50% lesion and a severe mid-LAD lesion
immediately after the take-off of this large diagonal of 99% which is quite sev
ere with TIMI-3 flow throughout the LAD and the left main.
3. The left circumflex demonstrates mid-90% severe lesion with TIMI-3 flow.
4. The right coronary artery was the dominant artery giving rise to right poster
ior descending artery demonstrates mild luminal irregularity. There is a moderat
e distal PDA lesion of 60% seen.
IMPRESSION:
1. Mild to moderate left main stenosis.
2. Very severe mid-LAD stenosis with severe mid-left circumflex stenosis and mod
erate prox-LAD CAD.
We are going to continue the patient's aspirin, beta blocker as heart rate toler
ates as he tends to run on the bradycardic side and add statin. We will check a
fasting lipid profile and ALT and titrate statin therapy to keep LDL of 70 mg/de
ciliter or less but in the past the patient's LDL had been higher or high.
Keywords: cardiovascular / pulmonary, wall motion abnormalities, cardiac cathete
rization, mid lad, timi flow, femoral arteriotomy, catheterization, ischemia, an
gina, distal, stenosis, stress, artery, coronary, lad, cardiac,

Vous aimerez peut-être aussi