EFTA00298077.pdf

Niount Sinai Heart Cardiovascular Imaging Center 1428 Madison Avenue • New York, NY • 10024 Phone: 212-241-3000 • Fax: 646-537-9693 Name: Epstein, Jeffrey Scan Date: 09/06/2016 MRN: Acc Number: DOB: 01/20/1953 Ref erringMD: Rony Shimony, MD Age/Gender: 63/M Att endingMD: 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 Medication Administered During Scan Type: None Type: Metoprolol IV, NTG SL 0.4mg Dose: 85 ml Metoprolol IV, Dose: 10 mg Vital Height: 72 in Height: 182.9 cm Body Weight: 190 lbs Body Weight: 86.2 kg BSA: 2.1 rn^2 Heart Rate: 71 8PM 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 CPT Code(S) 71275, 74174 CTA Chest, ABD/Pelvis w/wo Contrast 75574. 71275 CTA Coronary & Chest w/wo Contrast ICD-10 Code (5) 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 EFTA00298077 Monti, Sinai Hear/ Cardiac Coronaries Coronary Arteries Coronary Arterial Dominance: Right Cardiovascular Imaging Center 1428 Madison Avenue • New York, NY • 10024 Phone: 212-241-3000 • Fax: 646-537-9693 ARTERIES DIAMETER STENOSIS PLAQUE STENT — Proximal RCA 0 Mid RCA 0 Distal RCA 0 PDA 0 LM 0 Proximal LAD 25% PC Mid LAD 25.49% PC Distal LAD 25% PC DI <25% NC D2 Proximal LCX OM I 0 Alla I " OM 2 Distal LCX Posterolateral Other 0 DIAMETER STENOSIS: 0: <25%; 25%: 2549%; <50%; 50%; 50.69%: 70.99%:75%: 100%; UE r UNEVALUABLE PLAQUE: NC = NONCALC.; PNC u PREDOMIN. NC; PC = PREDOMIN. C: C il CALCIFIED ST ENT; NORMAL <50%.:>5694:-Q7= OQCLUQED; 7 r CANNOT EXCLUDE Coronary Calcium Scoring Score Percentile Agatston 63 53 Volume Additional Findings 'Other' refers to a small ramus interrnedius artery. Chambers Finaized and signed by Adam Jacobi on 09/06/201613:57:56 (uid:180) Page 2 of 5 EFTA00298078 Mount Sinai I fear/ Volumetric Analysis Volumetric Analysis (NRV] LV RV EDV(ml) (L: 81.220. R: 81.260] tato ESV(ml) (L: 24.106, R: 28.140] ss Cardiac Output (L/min) 8.6 Mass (g) (L: 48-166] Stroke Volume (ml) 121 EF (96) (L: 44.71, R: 42.74] 67 Vascular Cardiovascular Imaging Center 1428 Madison Avenue • New York, NY • 10024 Phone: 212-241-3000 • Fax: 646-537-9693 Upper Vascular EVALUATION OF THE THORACIC AORTA COMMENTS Proximal great arch vessels are widely patent. Lower Vascular Evaluation Details AORTIC ROOT Sinus of Valsalva Max Diameter A: 3.5 cm Sinus of Valsalva Max Diameter B: 3.4 cm ASCENDING AORTA Dimension k 3.6 cm Dimension 8: 3.6 cm ARCH OF THE AORTA Dimension A: 2.8 cm Dimension 8: 2.8 cm MID•DESCENDING AORTA Dimension A: 2.5 cm Dimension B: 2.5 cm DISTAL DESCENDING AORTA Dimension A: 2.0 cm Dimension 6: 2.3 cm See comments. Finaized and signed by Adam Jacobi on 09106/201613:57:56 (uid:180) Page 3 of 5 EFTA00298079 Mount Sinai Heart Cardiovascular Imaging Center 1428 Madison Avenue • New York, NY • 10024 Phone: 212-241-3000 • Fax: 646-537-9693 EVALUATION OF THE ABDOMINAL AORTA AND PELVIS Inn COMMENTS 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 Aisne has local calcium present 2. The Right Internal Iliac has mild calcium present. 3. The Lett Internal Iliac has local 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. LIVER: 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 09/06/201613:57:56 (uid:180) Page 4 of 5 EFTA00298080 /, Mount Sinai I fear! SPLEEN: No focal lesion. Normal size. Cardiovascular Imaging Center 1428 Madison Avenue • New York, NY • 10024 Phone: 212-241-3000 • Fax: 646-537-9693 PANCREAS: No focal lesion. No calcification. No ductal dilation. 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 by Adam Jacobi on 09/06/201613:57:56 (uid:180) Page 5 of 5 EFTA00298081