Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Heart Catheterization & Angiography - 1

Description: Left heart cath, selective coronary angiography, LV gram, right femoral arteriogram, and Mynx closure device. Normal stress test.
(Medical Transcription Sample Report)

CLINICAL INDICATION: Normal stress test.

PROCEDURES PERFORMED:
1. Left heart cath.
2. Selective coronary angiography.
3. LV gram.
4. Right femoral arteriogram.
5. Mynx closure device.

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

Both groins were prepped and draped in the usual sterile fashion. After local anesthesia with 2% lidocaine, a 6-French sheath was inserted in the right femoral artery. Left and right coronary angiography was performed using 6-French JL4 and 6-French 3DRC catheters. Then, LV gram was performed using 6-French pigtail catheter. Post LV gram, LV-to-aortic gradient was obtained. Then, the right femoral arteriogram was performed. Then, the Mynx closure device was used for hemostasis. There were no complications.

HEMODYNAMICS: LVEDP was 9. There was no LV-to-aortic gradient.

CORONARY ANGIOGRAPHY:
1. Left main is normal. It bifurcates into LAD and left circumflex.
2. Proximal LAD at the origin of big diagonal, there is 50% to 60% calcified lesion present. Rest of the LAD free of disease.
3. Left circumflex is a large vessel and with minor plaque.
4. Right coronary is dominant and also has proximal 40% stenosis.

SUMMARY:
1. Nonobstructive coronary artery disease, LAD proximal at the origin of big diagonal has 50% to 60% stenosis, which is calcified.
2. RCA has 40% proximal stenosis.
3. Normal LV systolic function with LV ejection fraction of 60%.

PLAN: We will treat with medical therapy. If the patient becomes symptomatic, we will repeat stress test. If there is ischemic event, the patient will need surgery for the LAD lesion. For the time being, we will continue with the medical therapy.


Keywords: cardiovascular / pulmonary, selective coronary angiography, lv gram, femoral, mynx, heart cath, mynx closure device, heart catheterization, femoral arteriogram, stress test, coronary angiography, heart, arteriogram, catheterization, lad, coronary, angiography,
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