Sample Name: Coronary CT Angiography (CCTA) - 2
Description: CCTA with Cardiac Function/Calcium Scoring
(Medical Transcription Sample Report)
Your patient, (ABC), a 59-year-old female with no known coronary artery disease was referred to us for a CT coronary angiogram. The patient's cardiac risk factors include chest discomfort, family history of coronary artery disease, and hypercholesterolemia. She is on no cardiac medications at the time of testing. The patient's resting ECG demonstrated no ischemic changes.
CARDIAC CT INCLUDING CORONARY CT ANGIOGRAPHY
PROCEDURE: Breath hold cardiac CT was performed using a 64-channel CT scanner with a 0.5-second rotation time. Contrast injection was timed using a 10 mL bolus of Ultravist 370 IV. Then the patient received 75 mL of Ultravist 370 at a rate of 5 mL/sec.
Retrospective ECG gating was performed. The patient received 0.4 milligrams of sublingual nitroglycerin prior to the to the scan. The average heart rate was 62 beats/min.
The patient had no adverse reaction to the contrast. Multiphase retrospective reconstructions were performed. Small field of view cardiac and coronary images were analyzed on a 3D work station. Multiplanar reformatted images and 3D volume rendering was performed by the attending physician for the purpose of defining coronary anatomy and determining the extent of coronary artery disease.
1. The technical quality of the scan is adequate.
2. The coronary ostia are in their normal position. The coronary anatomy is right dominant.
3. LEFT MAIN: The left main coronary artery is patent without angiographic stenosis.
4. LEFT ANTERIOR DESCENDING ARTERY: The proximal aspect of the left anterior descending artery demonstrates a mixed plaque consisting of both calcified and noncalcified lesion which is less than 30% in stenosis severity. Diagonal 1 and diagonal 2 branches of the left anterior descending artery demonstrate mild irregularities.
5. The ramus intermedius is a small vessel with minor irregularities.
6. LEFT CIRCUMFLEX: The left circumflex and obtuse marginal 1 and obtuse marginal 2 branches of the vessel are patent without significant stenosis.
7. RIGHT CORONARY ARTERY: The right coronary artery is a large and dominant vessel. It demonstrates within its mid-segment calcified atherosclerosis, less than 50% stenosis severity. Left ventricular ejection fraction is calculated to be 69%. There are no wall motion abnormalities.
8. Coronary calcium score was calculated to be 79, indicating at least mild atherosclerosis within the coronary vessels.
1. Mild coronary artery disease with a preserved left ventricular ejection fraction of 69%.
2. Recommendation is aggressive medical management consisting of aggressive lifestyle modifications and statin therapy.
Thank you for referring this patient to us.
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