SARELGAURMD
Interventional Radiologist
Cardiac Rotation Dictation Templates
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Cardiac Coronary CT Angiogram:
Impression
1. [Excellent] quality study.
2. Coronary artery calcium score by Agatston's criteria is [ ], representing [ ] percentile by age, gender and ethnicity based on the MESA criteria.
3. On the coronary CTA portion of the study, there is [no evidence for obstructive CAD].
4. Aortic size is [normal] in the visualized portions; in the visualized portions, there is [no] evidence of thoracic aortic dissection.
Recommendation
[No specific recommendation.]
Clinical Information
[Chest pain]
Technique
Cardiac CTA was performed on a [320]-slice cardiac CT scanner with prospective ECG [gating technique].
Procedure: EKG gated CT without contrast material and CT angiography with contrast material of the heart and coronary arteries, including 3D image post processing was performed.
Contrast Agent: [Ultravist 370]
Contrast Dose: [ ] cc
Contrast Reaction: [ ]
Study Quality: [ ]
Non-Diagnostic Study: [No]
DLP: [ ]
Effective dose: [Multiply DLP by 0.014] mSv
Results:
Coronary Artery Calcium Score:
Whole-Heart Agatston Score: [0]
MESA Percentile Rank: [0]
LM Agatston Score: [0]
LAD Agatston Score: [0]
Left circumflex Agatston Score: [0]
RCA Agatston Score: [0]
Ramus intermedius Agatston Score: [0]
Whole-heart volume Score: [0]
INTERPRETATION OF TOTAL AGATSTON CALCIUM SCORE
CALCIUM SCORE 0: Negative exam.
CALCIUM SCORE 1-10: Minimal plaque. Coronary artery disease unlikely.
CALCIUM SCORE 11-100: Mild plaque. Minimal stenosis is likely.
CALCIUM SCORE 101-400: Moderate plaque. Non-obstructive coronary artery disease is likely.
CALCIUM SCORE OVER 400: Extensive plaque. At least one significant stenosis (>50% diameter) is likely.
Results:
Coronary Artery CT Angiogram:
Coronary Dominance:
Right dominant [x]
Left dominant []
Co-dominant []
Anomalous coronary artery:
No [x]
Yes []
Coronary fistula:
No [x]
Yes []
Coronary arteries:
LM: [Normal]
LAD: [Normal]
LCX: [Normal]
RCA: [Normal]
Results:
Non-Coronary Findings:
Ascending thoracic aorta: [ ] cm.
Descending thoracic aorta: [ ] cm.
Coarctation:
Yes []
No [x]
Patent ductus arteriosus
Yes []
No [x]
Aortic Dissection
Not present [x]
Myocardial structure:
Ventricular Structure / Enlargement: Normal
Septal Abnormality: Not present
Pericardium:
Normal [x]
Pericardial effusion: None
Myocardial Infarction (myocardial thinning and low-attenuation):
No [x]
Incidental findings:
No evidence of pulmonary embolus in the scanned field of views]
Visualized Lung Parenchyma: Clear
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Medical Transcription Editor
Impression
1. [Good] quality study.
2. No anomalous pulmonary venous drainage.
3. Negative for left atrial appendage thrombus.
4. Pulmonary vein measurements as detailed below.
5. [Accurate assessment for coronary artery stenosis is not possible.]
6. Negative for pulmonary embolism, thoracic aortic dissection or aneurysm in the SFOV.
RECOMMENDATION:
[No specific recommendation based on CT findings.]
HISTORY: [Prior to atrial fibrillation ablation].
PROCEDURE: EKG Gated computed tomographic angiography, heart, coronary arteries with contrast material, including 3D image post processing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous structures, if performed). Delayed images were performed to evaluate for left atrial appendage thrombus.
CONTRAST MEDIA: [70] ml of intravenous Omnipaque 350
DLP (DOSE-LENGTH PRODUCT): [] mGy x cm
CORONARY CT ANGIOGRAM (not optimized): []
PULMONARY VEINS
Anatomic variants: [None.]
Left atrial appendage morphology: []
Right upper pulmonary vein:
Average diameter: [] mm
Maximum diameter: [] mm
Minimum diameter: [] mm
Area: [] cm squared
Distance to first branch-point: [] mm
Right lower pulmonary vein:
Average diameter: [] mm
Maximum diameter: [] mm
Minimum diameter: [] mm
Area: [] cm squared
Distance to first branch-point: [] mm
Left upper pulmonary vein:
Average diameter: [] mm
Maximum diameter: [] mm
Minimum diameter: [] mm
Area: [] cm squared
Distance to first branch-point: [] mm
Left lower pulmonary vein:
Average diameter: [] mm
Maximum diameter: [] mm
Minimum diameter: [] mm
Area: [] cm squared
Distance to first branch-point: [] mm
THORACIC AORTA: No aortic dissection in the SFOV.
Sinuses of Valsalva: [] cm
Sinotubular Junction: [] cm
Ascending aorta: [] cm
Descending aorta: [] cm
LV: [Normal].
LA: [Dilated. No evidence of left atrial appendage thrombus].
RV: [Normal].
RA: [Normal].
ATRIAL AND VENTRICULAR SEPTA: [Unremarkable].
PERICARDIAL EFFUSION: [None].
NONCARDIOVASCULAR: []
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EF CARDIAC:
Medical Transcription Editor
Impression
1. [Excellent] quality study.
2. Agatston's calcium score: [0], MESA percentile: [N/A]
3. [Normal coronary arteries.]
4. No thoracic aortic aneurysm or dissection [in the SFOV].
5. Negative for pulmonary embolus [in the SFOV].
6. [Clear lungs.]
Recommendation
[Aggressive coronary artery disease risk factor modification and medical management as clinically indicated.]
Clinical Information
[ ] year-old [female] with chest pain.
Technique
EKG-gated cardiac CT angiography with 3-D Image post processing was performed both before and after the administration of [ ] ml of 350 mg/ml Omnipaque IV contrast with bolus tracking timing technique to specifically evaluate for coronary artery disease. Maximum displayed field of view (DFOV) multiplanar reformations were generated for evaluation of non-cardiovascular anatomy. A MESA percentile was performed, which compares this patient to an age, gender and ethnicity-matched cohort free of clinical cardiovascular disease and treated diabetes at baseline. (www.mesa-nhlbi.org/CACReference.aspx).
DOSE-LENGTH-PRODUCT (DLP): [ ] mGy x cm
Results: Coronary Artery Calcium Score
LM: [0]
RAMUS: [N/A]
LAD: [0]
LCX: [0]
RCA: [0]
Whole Heart Total: [0]
MESA percentile: [N/A]
Results: Cardiac CT Angiogram
LM: [Normal].
pLAD: [Normal].
mLAD: [Normal].
dLAD: [Normal].
D1: [Normal].
D2: [Normal].
pLCX: [Normal].
m/dLCX: [Normal].
OM1: [Normal].
OM2: [Normal].
pRCA: [Normal].
mRCA: [Normal].
dRCA: [Normal].
PDA: [Normal]. [Right dominant].
PLB: [Normal]. [Right dominant].
AORTA: [No aortic dissection within the SFOV].
Ascending Aorta: [ ] mm
Descending Aorta: [ ] mm
AORTIC VALVE: [Trileaflet with complete coaptation in diastole]. [No prominent fibrocalcific degeneration is present].
MITRAL VALVE: [Grossly normal morphology in diastole].
LV: [Normal].
LA: [Normal].
PULMONARY ARTERY: No pulmonary embolus [in SFOV]. [Normal] diameter at [ ] mm.
RV: [Normal].
RA: [Normal].
ATRIAL SEPTUM: [Normal].
VENTRICULAR SEPTUM: [Normal].
PERICARDIUM: [Normal].
Results: Non-Coronary Findings
Mediastinum: [No enlarged lymph nodes].
Airway, Lungs and Pleura: [Clear lungs].
Upper Abdomen: [Normal in appearance].
Musculoskeletal: [No fracture or aggressive destructive lesion].
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Triple R/O
Impression
1. [Excellent] quality study.
2. Agatston's calcium score: [0], MESA percentile: [N/A]
3. [Normal coronary arteries.]
4. [No thoracic aortic aneurysm or dissection].
5. [Negative for pulmonary embolus].
6. [Clear lungs.]
Recommendation
[Aggressive coronary artery disease risk factor modification and medical management as clinically indicated.]
Clinical Information
[ ] year-old [female] with chest pain.
Technique
EKG-gated cardiac CT angiography with 3-D Image post processing was performed both before and after the administration of [ ] ml of 350 mg/ml Omnipaque IV contrast with bolus tracking timing technique to specifically evaluate for coronary artery disease, thoracic aortic dissection and pulmonary embolism. Maximum displayed field of view (DFOV) multiplanar reformations were generated for evaluation of non-cardiovascular anatomy. A MESA percentile was performed, which compares this patient to an age, gender and ethnicity-matched cohort free of clinical cardiovascular disease and treated diabetes at baseline. (www.mesa-nhlbi.org/CACReference.aspx).
DOSE-LENGTH-PRODUCT (DLP): [ ] mGy x cm
Results: Coronary Artery Calcium Score
LM: [0]
RAMUS: [N/A]
LAD: [0]
LCX: [0]
RCA: [0]
Whole Heart Total: [0]
MESA percentile: [N/A]
Results: Cardiac CT Angiogram
LM: [Normal].
pLAD: [Normal].
mLAD: [Normal].
dLAD: [Normal].
D1: [Normal].
D2: [Normal].
pLCX: [Normal].
m/dLCX: [Normal].
OM1: [Normal].
OM2: [Normal].
pRCA: [Normal].
mRCA: [Normal].
dRCA: [Normal].
PDA: [Normal]. [Right dominant].
PLB: [Normal]. [Right dominant].
AORTA: [No thoracic aortic dissection].
Ascending Aorta: [ ] mm
Descending Aorta: [ ] mm
AORTIC VALVE: [Trileaflet with complete coaptation in diastole]. [No prominent fibrocalcific degeneration is present].
MITRAL VALVE: [Grossly normal morphology in diastole].
LV: [Normal].
LA: [Normal].
PULMONARY ARTERY: [No pulmonary embolus].[Normal] diameter at [ ] mm.
RV: [Normal].
RA: [Normal].
ATRIAL SEPTUM: [Normal].
VENTRICULAR SEPTUM: [Normal].
PERICARDIUM: [Normal].
Results: Non-Coronary Findings
Mediastinum: [No enlarged lymph nodes].
Airway, Lungs and Pleura: [Clear lungs].
Upper Abdomen: [Normal in appearance].
Musculoskeletal: [No fracture or aggressive destructive lesion].
Cardiac MRI KY Template
Examination Date:
Comparison:
Indication:
Clinically suspected cardiomyopathy.
This study is performed to assess myocardial ischemia, viability, and damage, and to quantitate left ventricular and valvulatlar function.
Technique:
1.5 T MRI Scanner
Turbo spin echo and gradient echo imaging for anatomic definition.
Dynamic cine imaging (SSFP, GRE, and EPI) for cardiac chamber and wall motion analysis, and valvular analysis.
Dynamic perfusion sequences at stress and rest during gadolinium-chelate administration
Flow quantification sequences for hemodynamics
Delayed gadolinium enhancement analysis after injection of gadolinium chelate (total of __ cc )
Adenosine (0.014 mg / kg) was administered over 4 minutes with continuous monitoring of blood pressure, heart rate, and EKG.
Baseline vital signs were :
Peak adenosine stress vitals signs were:
5 minute recoveryvital signs were:
There were no significant EKG changes from baseline
Result:
Chest wall, Mediastinum, and Pericardium: Normal
Adenopathy: negative
Lungs: no gross abnormalities
Thoracic aorta: normal course and caliber. No acute pathology.
Pulmonary arteries: Normal
Cardiac chambers: Normal atrioventricular and ventriculoarterial concordance, and system and pulmonary venous return. The cardiac chamber sizes are normal.
The left ventricle is normal and has normal function.
Quantitative left ventricular functional values are as follows:
EDV= Field 12 cc; EDVi= [ ] cc/m^2
ESV = [ ] cc; ESVi = [ ] cc / m^2
Stroke volume = [ ] cc; SVi = [ ] cc/ m^2
LVEF = [ ] %
Absolute Cardiac Ouput = [ ] L / min; COi = [ ] L / min /M^2
LV mass = [ ] gm, LVMi = [ ] gm / m^2
Aortic, mitral, and tricuspid valve function are normal.
Flow quantification through the ascending aorta:
Forward volume = [] cc/ beat
Reverse volume = [ ] cc/ beat
Net Forward volume = [ ] cc/ beat
Aortic regurgitant fraction = [ ] %
The right ventricle appears normal in size, shape, and function.
Flow quantification sequences through the SVC and the right upper lobe pulmonary vein reveal normal flow patterns consistent with normal right and normal left atrial pressures.
Limited imaging through the upper abdomen reveals no abnormalities.
Impression:
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The left ventricle is normal in size, shape, and function. There are no segmental wall motion abnormalities. Quantitative values are as noted above.
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There are no finding to suggest pharmacologic stress induced ischemia. There are no findings to suggest prior ischemic damage or an infiltrative process.
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Normal aortic, mitral, and tricuspid valve function.