Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Surgery
Sample Name: Heart Catheterization - 1

Description: Chest pain and non-Q-wave MI with elevation of troponin I only. Left heart catheterization, left ventriculography, and left and right coronary arteriography.
(Medical Transcription Sample Report)

PROCEDURES: Left heart catheterization, left ventriculography, and left and right coronary arteriography.

INDICATIONS: Chest pain and non-Q-wave MI with elevation of troponin I only.

TECHNIQUE: The patient was brought to the procedure room in satisfactory condition. The right groin was prepped and draped in routine fashion. An arterial sheath was inserted into the right femoral artery.

Left and right coronary arteries were studied with a 6FL4 and 6FR4 Judkins catheters respectively. Cine coronary angiograms were done in multiple views.

Left heart catheterization was done using the 6-French pigtail catheter. Appropriate pressures were obtained before and after the left ventriculogram, which was done in the RAO view.

At the end of the procedure, the femoral catheter was removed and Angio-Seal was applied without any complications.

FINDINGS:
1. LV is normal in size and shape with good contractility, EF of 60%.
2. LMCA normal.
3. LAD has 20% to 30% stenosis at the origin.
4. LCX is normal.
5. RCA is dominant and normal.

RECOMMENDATIONS: Medical management, diet, and exercise. Aspirin 81 mg p.o. daily, p.r.n. nitroglycerin for chest pain. Follow up in the clinic.

Keywords: surgery, arteriography, coronary arteriography, heart catheterization, ventriculography, angiograms,
NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. All names and dates have been changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or place or anything else to real world is purely incidental.
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Transcribed Medical Transcription Sample Reports and Examples