Cardiovascular / Pulmonary
Sample Name: Stenting
Description: Successful stenting of the left anterior descending. Angina pectoris, tight lesion in left anterior descending.
(Medical Transcription Sample Report)
NAME OF PROCEDURE: Successful stenting of the left anterior descending.
DESCRIPTION OF PROCEDURE: Angina pectoris, tight lesion in left anterior descending.
TECHNIQUE OF PROCEDURE: Standard Judkins, right groin.
CATHETERS USED: 6 French Judkins, right; wire, 14 BMW; balloon for predilatation, 25 x 15 CrossSail; stent 2.5 x 18 Cypher drug-eluting stent.
ANTICOAGULATION: The patient was on aspirin and Plavix, received 3000 of heparin and was begun on Integrilin.
INFORMED CONSENT: I reviewed with the patient the pros, cons, alternatives and risks of catheter and sedation exactly as I had done before during his diagnostic catheterization, plus I reviewed the risks of intervention including lack of success, need for emergency surgery, need for later restenosis and further procedures.
HEMODYNAMIC DATA: The aortic pressure was in the physiologic range.
ANGIOGRAPHIC DATA: Left coronary artery: The left main coronary artery showed insignificant disease. The left anterior descending showed fairly extensive calcification. There was 90% stenosis in the proximal to midportion of the vessel. Insignificant disease in the circumflex.
SUCCESSFUL STENTING: A wire crossed the lesion. We first predilated with a balloon, then advanced, deployed and post dilated the stent. Final angiography showed 0% stenosis, no tears or thrombi, excellent intimal appearance.
VITAL SIGNS: Blood pressure 160/88, temperature 98.6, pulse 83, respirations 30. He is saturating at 96% on 4 L nonrebreather.
GENERAL: The patient is a 74 year-old white male who is cooperative with the examination and alert and oriented x3. The patient cannot speak and communicates through writing.
HEENT: Very small moles on face. However, pupils equal, round and regular and reactive to light and accommodation. Extraocular movements are intact. Oropharynx is moist.
NECK: Supple. Tracheostomy site is clean without blood or discharge.
HEART: Regular rate and rhythm. No gallop, murmur or rub.
CHEST: Respirations congested. Mild crackles in the left lower quadrant and left lower base.
ABDOMEN: Soft, nontender and nondistended. Positive bowel sounds.
EXTREMITIES: No clubbing, cyanosis or edema.
NEUROLOGIC: Cranial nerves II-XII grossly intact. No focal deficit.
1. Successful stenting of the left anterior descending. Initially, there was 90% stenosis. After stenting with a drug-eluting stent, there was 0% residual.
2. Insignificant disease in the other coronaries.
PLAN: The patient will be treated with aspirin, Plavix, Integrilin, beta blockers and statins. I have discussed this with him, and I have answered his questions.
Keywords: cardiovascular / pulmonary, tight lesion, standard judkins, balloon for predilatation, angina pectoris, coronary artery, stenting, anterior, respirations, descending,