This echocardiography report documents an examination of a 71-year-old female patient with a history of diabetes, hypertension, and prior CABG surgery. The echocardiogram found mildly reduced left ventricular systolic function with an ejection fraction of 6.5%, diastolic dysfunction type 2, and no significant valvular abnormalities. Overall conclusions were mild septal hypertrophy, slight enlargement of the left atrium, and reduced systolic function with diastolic dysfunction.

1. Subject: 016704 (41521)
ADMISSION NOTE
ADMISSION DATE: 29/Nov/2011 8:30 p.m. HOSPITAL’S ADMISSION DATE: 28/Nov/2011
NAME:
AGE: 71 SEX: FEMALE TELEPHONE:
ADDRESS:
CLINICAL HISTORY: IDDM (+) INSULIN NPH 20-20UI
HTN (+) ENALAPRIL, ATENOLOL
CABG 3 YEARS AGO
CARDIAC CATHETERIZATION 2011??
MEDICATION: INSULIN NPH 20-20
ENALAPRIL 20mg/12h
ATENOLOL
ALLERGIES: NONE
DESCRIPTION:
Patient indicates that she has been suffering from chest oppression and chest pains for
the last 2 years when making moderate efforts. She now states that this occurs when
she makes light efforts, this being why she is seeking emergency services. She notes that
the pain has been the oppressive type, with an irradiation towards the back. She took
ISB, but saw no apparent improvement; thus, she arrived to Emergency.
BP: 113 / 46 FC: 61 FR: 18 TEM:
PHYSICAL EXAMINATION
TESTS:, PATIENTS’S REGULAR GENERAL APPEARANCE, GOOD HYDRATION AND GOOD NUTRITION
CONDITIONS, <2SEC CAPILLARY REFILL, STC IN MODERATE AMOUNT
THORAX- LUNGS: NORMAL BREATH SOUNDS IN BOTH LUNG FIELDS, NO RSA, NO GALLOP, JVP (-)HJR (-)
CV: RCRR NO MURMURS JVP (-) HJR (-)
ABDOMEN: B/D NO PAIN IN THE DEEP OR SUPERFICIAL PALPATION
NEUROLOGICAL: WELL ORIENTED IN TIME AND SPACE, NO SIGNS OF MENINGEAL OR FOCAL
NEUROLOGIC SIGNS
EKG: RS: FC60X AXIS: 60O, NO SIGNS OF ACUTE ISCHEMIA
CPK-MB: 1.68 TROPONIN: 0.003 TOTAL CPK: 0 HB:11.5
GLUCOSE: 366 CREATININE: 1.23 HEMOGRAM: NORMAL
OTHER EXAMINATIONS:
DIAGNOSTIC IMPRESSION
1. UNSTABLE ANGINA

2. 2. ECOC REVASCULARIZED
3. UNCONTROLLED DM
4. HTN
WORK PLAN
UCICOR PROFILE, INVASIVE STRATIFICATION. REVIEW OLD HISTORY.

3. 016170 (41521)
RELEASE REPORT
The Head of Cardiology Services at the Edgardo Rebagliati Martins Hospital reports that a 71-year old
female patient by the name of … … … was admitted for cardiology services on 29/Nov/2011.
During her hospitalization:
Patient indicates that she has been suffering from chest oppression and chest pains for the last 2 years
when making moderate efforts. She now states that this occurs when she makes light efforts, this being
why she is seeking emergency services. She notes that the pain has been the oppressive type, with an
irradiation towards the back. She took ISB, but saw no apparent improvement; thus, she arrived to
Emergency.
Cardiac catheterism was conducted on Nov/6/11. Internal mammary artery bypasses graft to Anterior
Descending Artery. Saphenous vein bypass graft to marginal branches and saphenous vein bypass graft
to Posterior Descending Artery: all permeable. Poor Anterior Descending Artery distal bed: poor distal
bed. Marginal branches: thin vessel. Conclusion: Continue with medical treatment.
Pharmacological and Supplementary Treatment Aspirin Clopidogrel
Irbesartan Elantana Bisoprolol Hydrochlorothiazide
Atorvastatin Cephalexin Insulin NPH
Main Diagnosis of Release Unstable angina 120.0
Secondary Diagnosis NIDDM E11
HTN I10
Condition at Release: IMPROVED
Appointment: Outpatient.
The staff and management of this Service thank you for allowing us to take care of you, and for any
suggestions and opinions you may wish to pass on in the requested survey.
Edgardo Rebagliati National Hospital
ESSALUD
_________________________________

4. CATHETERIZATION REPORT 1031
Name: Insurance No.
Age: 71 Gender: Female Catheterization Date: 5/Dec/2011
Type: Left Surgeons: MR3 Paredes
Technique: SELDINGER’S APPROACH THROUGH RIGHT FEMORAL ARTERY INTRODUCER 6Fr
Dominance: Right Cylinder: AI
Right Coronary Artery: Blood vessel of good size mildly diffused atheromatosis.
Posterior descending artery: Beginning of OT, opacified with venous bypass. Poor distal bed.
Left Main Coronary Artery: Long, trifurcated. 70% ostium lesion.
Posterior descending artery: Segmentation lesion in middle third, up to 95%. Flow involved in distal
third. Poor distal bed.
Diagonal: 1° DG thin vessel, with ostium lesion of up to 95%.
Circumflex: Vessel with a moderate caliber. SLAS, thin distal bed.
Marginal: 1° opacified through venous bypass, thin vessel.
2° - 3° Mg: thin, SLAS
Collateral and bypasses:VENOUS BYPASS: Ao-DP: PERMEABLE
VENOUS BYPASS: Ao-Mg, PERMEABLE
BYPASS: AMI – AD: PERMEABLE
Ventriculography: Not performed.
Issues: None.
Ao Pre Pressure: 145 / 72
LV Pre Pressure : 0/0
Ao Post Pressure : 0/0
LV Post Pressure : 0/0
Average blood pressure : 0
Ejection fraction : 0%

5. CONCLUSIONS: Atheromatous coronary artery disease, LMCAD (Left Main Coronary Artery
Disease), and LAD (Anterior Descending Artery) . Permeable coronary bypasses.
Suggestions: Medical Treatment

6. Patient 016704 (4152)
“EDGARDO REBAGLIATI MARTINS” National Hospital
CARDIOLOGY SERVICE
ADULT ECHOCARDIOGRAPHIC REPORT
Name: Date: 30/Nov/2011
Age: 71 SI:
Ultrasonic Access: Acceptable
Medication Aortic root : 30 mm
IV Septum : 13 mm Aortic valves : 18 mm
LV Diastole : 41 mm LV outflow tract : mm
LV Systole : 26 mm Aortic ring : mm
LV Posterior wall : 10 mm Right Ventricular: 29 mm
Left atrium : 38 mm (23) m2 Right atrium : mm (14) cm2
Systolic Function Diastolic Function
Ejection fraction: 6.5 % Flow velocity E : 70 cm/sec
Diastolic Vol. : ml Flow velocity A : 80 cm/sec
Systolic Vol. : ml Slowdown time E : 280 m/sec
Ejection Vol. : ml Tissue velocity E: 5 9 cm/sec
dp /dt : mm/Hg/sec Tissue velocity A: 6 10 cm/sec
DOPPLER VALVULAR ASSESSMENT
MITRAL DIASTOLIC: Max. Vel.:__ Max.Slope:___ Average Slope:____ HPT:_____ Mitral Area: Normal
MITRAL SYSTOLIC: Failure: Negative
AORTIC SYSTOLIC: Max. Slope: 1.3 Medium Slope: 6.76 TSV: _____ Valve Area: Normal
AORTIC DIASTOLIC: HPT:___ deceleration slope:____ Failure Grade: No
SYSTOLIC TRICUSPID: VD-AD Slope: 29 mmHg Systolic pressure PA: 29 mmHg
SYSTOLIC PULMONARY: Max. Vel. ________________ cm/sec RV-LAD Slope:_________mmHg
SHUNTS: No
DESCRIPTION
Heart valves: Damaged
left ventricular contractile pattern Right ventricular contractile pattern (NO)
BASAL MEDIAL APICAL
Anterior Septal 0 : not tested
Posterior Septal 1 : normal
Anterior 1 1 1 2 : hypokinesia
Inferior 3 : akinesia
Lateral 4 : dyskinesia
Posterior 5 : aneurysm
Ascending Aorta: ____

7. Pericardium: Normal
Pulmonary Artery: _____
Masses: No
Conclusions:
1. Mild septal hypertrophy of the LV (left ventricle)
2. Slight Growth of LA (Left Atrium)
3. Systolic function of the LV = Normal
4. Diastolic dysfunction of LV type 2
5. Valve function with no significant (illegible) alterations
(signature)
(illegible)
HNERM-ESSALUD