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 & Angiography

Description: Left and right heart catheterization and selective coronary angiography. Coronary artery disease, severe aortic stenosis by echo.
(Medical Transcription Sample Report)

INDICATION: Coronary artery disease, severe aortic stenosis by echo.

PROCEDURE PERFORMED:
1. Left heart catheterization.
2. Right heart catheterization.
3. Selective coronary angiography.

PROCEDURE: The patient was explained about all the risks, benefits and alternatives to the procedure. The patient agreed to proceed and informed consent was signed.

Both groins were prepped and draped in usual sterile fashion. After local anesthesia with 2% lidocaine, 6-French sheath was inserted in the right femoral artery and 7-French sheath was inserted in the right femoral vein. Then right heart cath was performed using 7-French Swan-Ganz catheter. Catheter was placed in the pulmonary capillary wedge position. Pulmonary capillary wedge pressure, PA pressure was obtained, cardiac output was obtained, then RV, RA pressures were obtained. The right heart catheter _______ pulled out. Then selective coronary angiography was performed using 6-French JL4 and 6-French 3DRC catheter. Then attempt was made to cross the aortic valve with 6-French pigtail catheter, but it was unsuccessful. After the procedure, catheters were pulled out, sheath was pulled out and hemostasis was obtained by manual pressure. The patient tolerated the procedure well. There were no complications.

HEMODYNAMICS:
1. Cardiac output was 4.9 per liter per minute. Pulmonary capillary wedge pressure, mean was 7, PA pressure was 20/14, RV 26/5, RA mean pressure was 5.
2. Coronary angiography, left main is calcified _______ dense complex.
3. LAD proximal 70% calcified stenosis present and patent stent to the mid LAD and diagonal 1 is a moderate-size vessel, has 70% stenosis. Left circumflex has diffuse luminal irregularities. OM1 has 70% stenosis, is a moderate-size vessel. Right coronary is dominant and has minimal luminal irregularities.

SUMMARY: Three-vessel coronary artery disease with aortic stenosis by echo with normal pulmonary artery systolic pressure.

RECOMMENDATION: Aortic valve replacement with coronary artery bypass surgery.

Keywords: surgery, lad proximal, femoral artery, sheath, catheter, selective coronary angiography, coronary artery disease, pulmonary capillary wedge, capillary wedge, coronary angiography, coronary artery, heart catheterization, catheterization, heart, artery, stenosis, angiography, pressure, coronary,
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