Cardiovascular / Pulmonary
Sample Name: Pacemaker (Single Chamber) - 1
Description: Implantation of a single-chamber pacemaker. Fluoroscopic guidance for implantation of single-chamber pacemaker.
(Medical Transcription Sample Report)
1. Tachybrady syndrome.
2. Chronic atrial fibrillation.
PROCEDURES PLANNED AND PERFORMED
1. Implantation of a single-chamber pacemaker.
2. Fluoroscopic guidance for implantation of single-chamber pacemaker.
FLUOROSCOPY TIME: 1.2 minutes.
1. Ancef 1 g.
2. Benadryl 50 mg.
3. Versed 3 mg.
4. Fentanyl 150 mcg.
CLINICAL HISTORY: The patient is a pleasant 73-year-old female with chronic atrial fibrillation. She has been found to have tachybrady syndrome, has been referred for pacemaker implantation.
RISKS AND BENEFITS: Risks, benefits, and alternatives of implantation of a single-chamber pacemaker were discussed with the patient. The patient agreed both verbally and via written consent. Risks that were discussed included but were not limited to bleeding, infection, vascular injury, cardiac perforation, stroke, myocardial infarction, need for urgent cardiovascular surgery, and death were discussed with the patient. The patient agreed both verbally and via written consent.
1. Pulse generator, manufacturer St. Jude model 12345, serial #123456.
2. Right ventricular lead, manufacturer St. Jude model 12345, serial #ABCD123456.
MEASURED INTRAOPERATIVE DATA: Right ventricular lead impedance 630 ohms. R wave measures 17.5 mV. Pacing threshold of 0.8 V at 0.5 msec.
DEVICE SETTINGS: VVI 70 to 120.
1. Successful implantation of the single-chamber pacemaker with adequate pacing and sensing function.
2. No acute complications.
1. The patient will be admitted for overnight observation and dismissed at the discretion of primary service.
2. Chest x-ray to rule out pneumothorax and verify lead position.
3. Completion of course of antibiotics.
4. Device interrogation in the morning.
5. Home dismissal instructions provided in a written format.
7. Enrollment in Device Clinic.
Keywords: cardiovascular / pulmonary, tachybrady, atrial fibrillation, single-chamber pacemaker, fluoroscopic guidance, st jude model, axillary vein, ventricular lead, single chamber, pulse, generator, pocket, pacing, device, atrial, chamber, implantation, pacemaker,