DIPYRIDAMOLE (PERSANTINE) / ADENOSINE STRESS

Resident Name

Staff Name

Patient Name

Date of scan

Type of procedure

Clinical indication

Referring M.D.

REPORT:

History: (Please dictate brief pertinent history here).

SUMMARY OF THE PRELIMINARY DATA FROM THE EXERCISE LAB:

[You need to PRINT OUT the cardiology report from CCC to get the indication for the study (the indication will NOT appear on the computer monitor).]  (Note: Do NOT discuss "maximum predicted heart rate" parameters when dictating this report.  Because the stress is pharmacologic, the changes in coronary perfusion are secondary to the drug, not the exercise level; therefore, the maximum heart rate is not considered in the same light as it is with exercise stress).

(For persantine:) Dipyridamole was infused intravenously for 4 minutes at a dose of 0.142 mg/kg/min.  Two minutes after the cessation of infusion, (Tc99m sestamibi, Tl-201) was administered IV.  Imaging protocol: ___. (usually Gated SPECT, but also could be Planar, Gated Planar, or SPECT). 

(For adenosine :) Adenosine was infused at a rate of 0.070 to 0.140 mg/kg/min for 3 to 6 minutes.  Just prior to cessation of infusion, (Tc99m sestamibi, Tl-201) was administered IV.  Imaging protocol: _____. (Usually Gated SPECT, but also could be Planar, Gated Planar, or SPECT)

Resting perfusion images were obtained with _____ (Tl-201, Tc99m sestamibi).  Tracer was injected 15 minutes prior to obtaining the resting images.

FINDINGS:

The image quality is (good/adequate/poor) … due to the presence of (large body habitus/ breast attenuation/left arm attenuation/patient motion/etc). This study was interpreted using the 17-segment myocardial perfusion model.

Left ventricular cavity size is normal/enlarged (with stress and/or rest).

Rest and stress perfusion images reveal uniform tracer uptake throughout the

myocardium.

-OR-

Stress perfusion images show (mild/moderate/severe) reduction in tracer distribution involving the (basal/mid/distal) (location) wall(s). Rest perfusion images show that this defect is (reversible/partially reversible/predominantly fixed/fixed).

(The location for each defect can be described as allowed by the 17-segment model. The segment numbers do not need to be given.)

(Repeat for each defect)

Gated images reveal (normal wall motion/hypokinesis or akinesis of the (location) walls). The calculated left ventricular ejection fraction is __%.

Compared with the study of (date)…

IMPRESSION:

(for normal studies)

1. Normal myocardial perfusion (at the level of stress achieved).

2. Normal left ventricular cavity size and function.

(for abnormal studies)

1. (Probable) (reversible/partially reversible/predominantly fixed/fixed) defect involving the expected (LAD/PDA/OM) territory.

(Repeat for each territory under a new number)

2. (Increased) left ventricular cavity size. (Mildly/moderately/severely) depressed left ventricular function with (location) (akinesis/hypokinesis).