EFTA00282958.pdf

09-09-'16 10:20 FROM- Mount Sinai Heart T-234 P0001 F-333 Mount Stu' al Heart Cardiovascular Imaging Center 1428 Madison Avenue • New York, NY • 10024 Phone: • Fax: CT Report Name: MRN: DOB: Age/Gender: Epstein, Jeffrey 7206913 01/20/1953 63/M Scan Date: Acc Number: ReferringMD: AttendingMD: 09/06/2016 1497253 Rony Shimony, MD Adam Jacobi , MD Summary CT without contrast was performed for coronary calcium, chest, abdomen and pelvis evaluation. Reconstructions were transferred to a workstation for further analysis. 1. Coronary atherosclerosis without significant stenosis. 2. The calcium score is 63 (53rd percentile adjusted for age, gender and ethnicity). 3. Normal left ventricular size and systolic function. No regional wall motion abnormalities. 4. No abdominal aortic or iliac arterial aneurysm. Scan Info General Contrast Agent Type: None Dose: 85 ml Vitals Medication Administered During.scan Type: Metoprolol IV, NTG SL 0Amg Metoprolol IV, Dose: 10 mg Height: 72 in Height: 182.9 cm Body Weight: 190 Ms Body Weight: 86.2 kg BSA: 2.1 m^2 Heart Rate: 71 BPM Heart Rhythm: Sinus Rhythm Setup Type: Clinical Location: Outpatient ECG Gating Technique: Prospective Study Quality: Good Referring Provider: Rony Shimony, MD Attending Radiologist: Adam Jacobi , MD Attending Cardiologist: Gina LaRocca, MD Billing CPI Code(s) 71275, 74174 CTA Chest, ABD/Pelvis w/wo Contrast 75574, 71275 CIA Coronary & Chest w/wo Contrast ICD-10 Code(s). Miscellaneous Z13.6 Encounter for screening for cardiovascular disorders Finalized and signed by Adam Jacobi on 09/06/2016 13:57:56 (uid:180) Page 1 of 5 EFTA00282958 09-09-'16 10:20 FROM- Mount Sinai Heart 12123763190 T-234 P0002 F-333 EFTA00282959 09-09-'16 10:20 FROM- Mount Sinai Heart T-234 P0003 F-333 Mount Shad Heart Cardiac Carcliovascqlar Imaging Center 1428 M is enue • New York Phone: • Fax: CT Report Coronaries Coronpry Arteries Coronary Arterial Dominance) Right ARTERIES . .DIAMETER'STENOSIS . ' ..• PLAQUE STENT . ' Proximal RCA 0 Mid RCA 0 Distal RCA 0 PDA 0 LM 0 Proximal LAD 25% PC Mid LAO 2549% PC Distal LAD 25% PC D1 <25% NC D2 Proximal LCX 0 OM I 0 Mid LCX 0 OM 2 Distal LCX 0 Postorolateral Other 0 DIAMETER STENOSIS:0; <25%; 25%; 25-49%; <50%; 50%; 50-6996; 7049%; 75%; 100%; UE a UNEVALUABLE PLAQUE: NC = NONCALC.; PNC = PREDOMIN. NC; PC = PRECOMIN. C; C = CALCIFIED ST ENT: NORMAL: <60%;X50%. 0 = OCCLUDED; ? = CANNOT EXCLUDE . . . . Coronary Calcium Scoring' Score Percentile Agatston 63 53 Volume Additional Findings. 'Other' refers to a small ramus Intermedius artery. Chambers Finalized and signed by Adam Jacobi on 091061201613:57:56 (uid:180) Page 2 of 5 EFTA00282960 09-09-'16 10:20 FROM- Mount Sinai Heart T-234 P0004 F-333 Mount • Sitmi Heart Cardiovascular Imaging Center 1428 M Now Y Phone: • Fax: CT Report V.c!gcpctt!lcE+9Of.§. Volumetric Analysis [NRV] LV RV ROV (ml) [L: 81-220, R: 81.289] 180 ESV (m1) [L: 24.106, R: 25.140] 59 Cardiac Output (Urnin) it a Mass (g) (L: 48.166] Stroke Volume (ml) 121 EF (96) [1: 44.71, R: 42.74] 67 Vascular Upper Vascular EVALUATION OF THE THORACIC AORTA COMMENTS Proximal great arch vessels are widely patent. eialOaircin Sinus of Valsalva Max Diameter A: 3.5 cm Sinus of Valsalva Max Diameter 6: 3.4 cm ASCENDING AORTA • Dimension A: 3.6 cm Dimension Et: 9.6 cm ARCH OF THE AORTA Dimension A 2.8 Cm Dimension B: 214 an MID-DESCENDING AORTA Dimension k 2.5 cm Dimension B: 2.5 CM DISTAL DESCENDING AORTA Dimension A:2 A cm Dimension B: 2.3 cm See comments. Lower Vascular Finalized and signed by Adam Jacobi on 09/06/201613:57:56 (ukt:180) Page 3 of 5 EFTA00282961 09-09-'16 10:21 FROM- Mount Sinai Heart T-234 P0005 F-333 S Mount Sinai Heart Cardiovascular Imaging Center. 1428 Madiso anus • New York NY • 10024 Phone: • Fax: CT Report EVALUATION OF THE ABDOMINAL AORTA AND PELVIS CID O COMMENTS CErElo Hepatic artery arises separately from the suprarenal abdominal aorta. The celiac artery, SMA, IMA, and bilateral renal arteries are widely patent. Evaluation Details ABDOMINAL AORTA Dimension A: 1.6 cm Dimension 8: 2 cm 1. The infra renal Abdominal Aorta has focal calcium present. 2. .The Right Internal Iliac has mild calcium present. 3. 'The Left Internal iliac has focal calcium present. Other Findings Lung Nodules Lung Nodules?: Yes Pulmonary Lobe Location: Right Lower Calcified?: Yes Size (mm): 2 Other Findings Summary . . CARDIOVASCULAR: The heart is normal in size. There is no pericardial effusion. The aorta and pulmonary arteries are normal in caliber. LUNGS AND PLEURA: benign calcified granulomas in the right lower lobe. No focal consolidation or diffuse interstitial lung disease. The trachea and central airways are patent. No pleural effusion. LNER: Normal liver size. Wedge shaped region of hyperenhancement in the right hepatic lobe is likely related to perfusion phenomenon, but incompletely evaluated on this single phase arterial study. Normal gallbladder. No biliary duct dilatation. Finalized and signed by Adam Jacobi on 09/06/2016 13:57:56 (uid:180) Page 4 of 5 EFTA00282962 09-09-'16 10:21 FROM- Mount Sinai Heart T-234 P0006 F-333 Cardkvascular Imaging_Canter__ _ Mount Sinai Heart 1428 Madison Avenue • New York NY • 10024 Phone: • Fax: SPLEEN: No focal lesion. Normal size. PANCR EAS: No focal lesion. No calcification. No ductal dilation. CT Report GI TRACT: Stool is noted in the colon. s/p partial right colonic surgery with suture material noted. No evidence of significant diverticulosis. Limited bowel evaluation without oral contrast. LYMPH NODES: No lymphadenopathy by size criteria. GU: The kidneys are normal in size bilaterally with no focal lesion and no hydronephrosis. Mildly enlarged prostate (4.5 cm tranverse diameter) with central calcifications. MUSCULOSKELETAL: No aggressive osseous lesion. Mild degenerative changes of the spine. Finalized and signed byAdam Jacobi on 09/06/2016 13:57:56 (uid:180) Page 5 of 5 EFTA00282963