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The documentation:
Why aren't the risk factors of "hypertension, oral hypoglycemic-treated diabetes, alcohol abuse, and a history of current cigarette use (within the last month)" reported?
CARDIOLOGY
SEX: FEMALE
AGE: 52
Transthoracic Echocardiography Report
Limited 2D Study with M-Mode, Limited Spectral Doppler, and Color Doppler
01/01/20XX
Account: Status: Inpatient
Location: Tape: Ht 68 in (172.7 cm)
Wt 202.8 lb (92.2 kg)
BSA 2.06 m squared
Diagnoses: - CEREBROVASC DISEASE NOS
Echo Attending: Echo Technologist: Attending Ordering: Summary
Procedure information: This was a technically difficult study.
Left ventricle: Systolic function was normal. Ejection fraction was estimated in the range of 55% to 65%. There were no regional wall motion abnormalities. Doppler parameters were consistent with abnormal left ventricular relaxation (grade 1 diastolic dysfunction).
COMPARISONS: No previous study is available for comparison. HISTORY: PRIOR HISTORY: Peripheral vascular disease. Risk factors: hypertension, oral hypoglycemic-treated diabetes, alcohol abuse, and a history of current cigarette use (within the last month). PROCEDURE: The procedure was performed at the bedside. This was a routine study. The transthoracic approach was used. Limited or follow-up 2D echocardiography study was performed with M-mode, limited spectral Doppler, and color Doppler. The heart rate was 105 b.p.m. at start. Systolic blood pressure was 148 mmHg at start. Diastolic blood pressure was 96 mmHg at start. Echocardiographic views were limited by poor patient compliance. This was a technically difficult study. LEFT VENTRICLE: Size was normal. Systolic function was normal. Ejection fraction was estimated in the range of 55% to 65%. There were no regional wall motion abnormalities. Wall thickness was normal. DOPPLER: There was an increased relative contribution of atrial contraction to ventricular filling. Doppler parameters were consistent with abnormal left ventricular relaxation (grade 1 diastolic dysfunction).
AORTIC VALVE: The valve was not well visualized.
AORTA: The root exhibited normal size. MITRAL VALVE: Valve structure was normal. There was normal leaflet separation. DOPPLER: The transmitral velocity was within the normal range. There was no evidence for stenosis. There was no mitral regurgitation. LEFT ATRIUM: Size was normal. RIGHT VENTRICLE: The size was normal. Systolic function was normal. Wall thickness was normal. DOPPLER: Systolic pressure was not estimated.
TRICUSPID VALVE: The valve structure was normal. There was normal leaflet separation. DOPPLER: The transtricuspid velocity was within the normal range. There was no evidence for stenosis. There was no tricuspid regurgitation. SYSTEMIC VEINS: IVC: The inferior vena cava was not well visualized. PERICARDIUM: There was no pericardial effusion. The pericardium was normal in appearance. Robert Jones, MD
Electronically signed by ROBERT JONES, MD 1/1/20XX
SEX: FEMALE
AGE: 52
Transthoracic Echocardiography Report
Limited 2D Study with M-Mode, Limited Spectral Doppler, and Color Doppler
01/01/20XX
Account: Status: Inpatient
Location: Tape: Ht 68 in (172.7 cm)
Wt 202.8 lb (92.2 kg)
BSA 2.06 m squared
Diagnoses: - CEREBROVASC DISEASE NOS
Echo Attending: Echo Technologist: Attending Ordering: Summary
Procedure information: This was a technically difficult study.
Left ventricle: Systolic function was normal. Ejection fraction was estimated in the range of 55% to 65%. There were no regional wall motion abnormalities. Doppler parameters were consistent with abnormal left ventricular relaxation (grade 1 diastolic dysfunction).
COMPARISONS: No previous study is available for comparison. HISTORY: PRIOR HISTORY: Peripheral vascular disease. Risk factors: hypertension, oral hypoglycemic-treated diabetes, alcohol abuse, and a history of current cigarette use (within the last month). PROCEDURE: The procedure was performed at the bedside. This was a routine study. The transthoracic approach was used. Limited or follow-up 2D echocardiography study was performed with M-mode, limited spectral Doppler, and color Doppler. The heart rate was 105 b.p.m. at start. Systolic blood pressure was 148 mmHg at start. Diastolic blood pressure was 96 mmHg at start. Echocardiographic views were limited by poor patient compliance. This was a technically difficult study. LEFT VENTRICLE: Size was normal. Systolic function was normal. Ejection fraction was estimated in the range of 55% to 65%. There were no regional wall motion abnormalities. Wall thickness was normal. DOPPLER: There was an increased relative contribution of atrial contraction to ventricular filling. Doppler parameters were consistent with abnormal left ventricular relaxation (grade 1 diastolic dysfunction).
AORTIC VALVE: The valve was not well visualized.
AORTA: The root exhibited normal size. MITRAL VALVE: Valve structure was normal. There was normal leaflet separation. DOPPLER: The transmitral velocity was within the normal range. There was no evidence for stenosis. There was no mitral regurgitation. LEFT ATRIUM: Size was normal. RIGHT VENTRICLE: The size was normal. Systolic function was normal. Wall thickness was normal. DOPPLER: Systolic pressure was not estimated.
TRICUSPID VALVE: The valve structure was normal. There was normal leaflet separation. DOPPLER: The transtricuspid velocity was within the normal range. There was no evidence for stenosis. There was no tricuspid regurgitation. SYSTEMIC VEINS: IVC: The inferior vena cava was not well visualized. PERICARDIUM: There was no pericardial effusion. The pericardium was normal in appearance. Robert Jones, MD
Electronically signed by ROBERT JONES, MD 1/1/20XX
Why aren't the risk factors of "hypertension, oral hypoglycemic-treated diabetes, alcohol abuse, and a history of current cigarette use (within the last month)" reported?