Echocardiography Report
Indication:
Evaluation of new-onset dyspnoea and suspected mitral regurgitation in a 68-year-old male with a history of hypertension.
Imaging Summary:
Transthoracic 2D imaging, M-mode, colour Doppler, and spectral Doppler (pulsed and continuous wave) were performed. Images were of good quality, and the patient was cooperative throughout the examination, allowing for a technically adequate study for full interpretation.
Findings:
- Chamber size and wall thickness: Left atrium moderately dilated (LA dimension 4.5 cm). Left ventricle dimensions normal (LVEDD 5.2 cm, LVESD 3.4 cm). Right ventricle mildly dilated (RV basal diameter 4.5 cm). Left ventricular wall thickness normal.
- Global and segmental systolic function: Left ventricular ejection fraction estimated at 55% (visually assessed), representing preserved global systolic function. No regional wall motion abnormalities noted.
- Septal integrity: Intact atrial and ventricular septa.
- Valve morphology and function:
- Mitral Valve: Mildly thickened leaflets with restricted anterior leaflet motion. Severe mitral regurgitation (MR) noted by colour Doppler, with a regurgitant jet extending deep into the left atrium. EROA estimated at 0.45 cm², regurgitant volume 60 mL, and regurgitant fraction 50%. Mean transmitral gradient 4 mmHg.
- Aortic Valve: Mild aortic sclerosis, trace aortic regurgitation.
- Tricuspid Valve: Mild tricuspid regurgitation, with estimated pulmonary artery systolic pressure (PASP) of 38 mmHg.
- Pulmonary Valve: Morphologically normal, no significant regurgitation or stenosis.
- Outflow tracts and gradients: LVOT and RVOT appear clear with no significant gradients.
- Great vessels: Aorta appears normal in size and course. Pulmonary artery mildly dilated.
- Pericardial space: No pericardial effusion or signs of constriction.
- Any other relevant findings: No intracardiac masses or thrombi identified.
Interpretation:
This echocardiogram reveals severe mitral regurgitation in a patient presenting with dyspnoea, consistent with the clinical indication for the scan. Left atrial and right ventricular dilation are noted, along with elevated pulmonary artery systolic pressure, likely secondary to the chronic volume overload from severe MR. Left ventricular systolic function is currently preserved. This represents a significant progression of mitral regurgitation compared to the previous echocardiogram from two years prior, which reported only mild MR.
Recommendations:
Referral to cardiology for further evaluation of severe mitral regurgitation and consideration for interventional or surgical management. Recommend repeat echocardiogram in 6-12 months following specialist consultation, or sooner if clinical symptoms worsen.
Echocardiography Report
Indication:
[Document the clinical reason for the echocardiogram, such as murmur evaluation, post-operative follow-up, assessment of known congenital or acquired cardiac lesion, heart failure assessment, rheumatic disease surveillance, or investigation of symptoms such as dyspnoea or chest pain.] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Imaging Summary:
[Specify imaging modality and techniques used, such as transthoracic 2D imaging, M-mode, colour Doppler, spectral Doppler (pulsed and continuous wave), and any focused views (e.g. subcostal, suprasternal). Include comments on image quality, cooperation (especially in children), and whether the study was technically adequate for full interpretation.] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Findings:
[Summarise relevant structural and functional findings, including:]
- [Chamber size and wall thickness (e.g. LA, LV, RV dimensions)]
- [Global and segmental systolic function (e.g. ejection fraction, visual assessment)]
- [Septal integrity (e.g. atrial septal defect, ventricular septal defect)]
- [Valve morphology and function (stenosis, regurgitation, prolapse, vegetations)]
- [Outflow tracts and gradients (e.g. LVOT, RVOT)]
- [Great vessels (aorta, pulmonary artery)]
- [Pericardial space (e.g. effusion, constriction)]
- [Any other relevant findings (e.g. masses, thrombus, prosthetic valves)]
(Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Interpretation:
[State the clinical relevance of the findings above. Include any change since previous imaging if applicable (e.g. stable left ventricular function, progression of mitral regurgitation), and whether features are consistent with the indication for the scan.] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Recommendations:
[Outline follow-up plan such as: need for further imaging (e.g. transoesophageal echo, cardiac MRI), medical referral, interventional planning, surgical discussion, or frequency of routine surveillance.] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care – use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state that the information has not been explicitly mentioned in your output. Just leave the relevant placeholder or section blank if not explicitly mentioned. Use as many lines, paragraphs or bullet points as needed to capture all relevant information from the transcript.)