General Practitioner-Vorlage
Coronary Angiogram ± coronary angiogram -PCI Procedure Letter Templates
Eine professionelle General Practitioner-Vorlage für medizinisches Fachpersonal.
Über diese Vorlage
Need a clear and concise record of a coronary angiogram or PCI procedure? This template is designed for cardiologists and interventionalists to document the details of these complex procedures. It covers patient details, indications, access, coronary anatomy, interventions, and post-procedure care. This template, when used with Heidi, ensures all critical information is captured accurately and efficiently, saving valuable time and improving the quality of your documentation. With Heidi, you can quickly generate comprehensive procedure letters, improving communication with referring physicians and ensuring continuity of care.
Vorlagenvorschau
**Full Procedural Letter Version**
Patient Details:
This is a 68-year-old male weighing 85 kg and height 178 cm (BMI 26.8), referred for a coronary angiogram ± PCI.
Indication & Procedure Context:
The procedure was performed as an elective case for the indication of stable angina. Informed consent was obtained following discussion of potential risks including stroke, myocardial infarction, bleeding, vascular injury, contrast nephropathy, arrhythmia, and radiation exposure.
Sedation & Access:
The procedure was undertaken under conscious sedation via radial arterial access. Vascular access was obtained using a 6F sheath.
Coronary Canulation Catheters / Guides:
6 Fr catheters used
Coronary Anatomy:
Coronary angiography demonstrated the following:
- Left Main: No significant stenosis.
- LAD: 70% stenosis in the mid segment.
- LCx: No significant stenosis.
- RCA: No significant stenosis.
Intervention:
Coronary intervention was undertaken with the following details:
Guidewires used included BMW guidewire. Predilatation was performed with a 2.5mm balloon at 12 atm. Stents were deployed (sizes/types/pressures: 3.0 x 28mm drug-eluting stent at 14 atm).
The patient received 5000 units of unfractionated heparin intra-procedurally. Current antiplatelet therapy consisted of aspirin 75mg daily and clopidogrel 75mg daily, and anticoagulation status was not on any anticoagulation.
Procedure Metrics:
Total procedure duration was 60 minutes. Contrast volume administered was 120 ml. Radiation dose was 2.5 Gy.
Outcome:
The procedure was successful. Final angiographic result demonstrated TIMI 3 flow.
Post-procedure Care Plan:
Haemostasis was achieved with a radial artery closure device at the access site. The patient will be transferred to the cardiology ward.
Post-procedure pharmacotherapy will include dual antiplatelet therapy with aspirin and clopidogrel and continuation of anticoagulation as appropriate.
Follow-up will be arranged in the cardiology clinic.
Date: 01/11/2024
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