Community Heart Function Diagnostic service referral

Surname: / First name:
Address (incl.
post code): / Telephone: / DOB:
NHS #
Surgery address: / Elms Medical CentreParkbury House SurgeryMaltings SurgeryColney Medical CentreLodge SurgeryMidway SurgeryHarvey HouseGrange Street SurgeryLattimore SurgeryHatifeld Rd SurgeryDavenport HouseRedbourn SurgeryVillage Surgery, London ColneyBricket Wood surgeryVillage Surgery, Harpenden / GP’s name:
Referral date:

REASONS FOR REFERRAL

SOB SOBOE SOBAR Oedema/SOA To confirm clinical diagnosis
Other:

RELEVANT PAST MEDICAL HISTORY

IHD Hypertension CVA/TIA DM AF
Other:

Current medication

Drug / Dose / Drug / Dose
Diuretic / FurosemideAmilorideCo-amilofruseBendroflumethiazideBumetanideMetolazoneBurinexBurinex K / mg / Spironolactone / mg
ACEI / RamiprilLisinoprilEnalaprilPerindoprilCaptoprilQuinalaprilFosinopril / mg / Digoxin / mcg
A-II blocker / LosartanCandesartanIrbesartanValsartanEprosartanOlmesartanTelmisartan / mg / Aspirin / 75 mg150 mg300 mg
B-blocker / AtenololBisoprololMetoprololCarvedilolSotalolPropranololNebivolol / mg / Warfarin / Yes No
NSAID/COX2? / mg / Other:

Allergies/Drug contraindications

Investigations (please indicate test results. BNP and ECG are essential)

BNP

/

ECG

Na

K / Spirometry/PEFR
Cr / CXR
Hb

Heart Failure diagnostic service feedback(/09)

Examination findings (full ECHO report enclosed if performed):

ECHO result / Other results / Value
Normal LV systolic functionLV systolic dysfunction: mildLV systolic dysfunction: moderateLV systolic dysfunction: severe / BP / mmHg
Other findings:
Left ventricular hypertrophyLV diastolic dysfunctionAortic sclerosisPulmonary HypertensionAortic stenosisCoarctation of aortaMitral valve prolapseMitral StenosisPossible HOCMBicuspid aortic valveVentricular septal defectAtrial septal defect
Left ventricular hypertrophyLV diastolic dysfunctionAortic sclerosisAortic stenosisCoarctation of aortaPulmonary HypertensionMitral valve prolapseMitral StenosisPossible HOCMBicuspid aortic valveVentricular septal defectAtrial septal defect / Weight / kg
Pulse rate / bpm
Heart rhythm / sinusirregularafpaced
Actions taken/suggested
Left ventricular systolic dysfunction excluded, heart failure therefore unlikely / Follow up to be arranged by own GP
Referred to cardiologist for further management / Follow up arranged today with specialist Heart Failure nurses
Start/increase diuretic / Relevant guidance enclosed regarding management
Start/increase ACE inhibitor
Start/increase A II blocker / Not assessed: referred for cardiology assessment as per NICE guidance
Start/increase beta blocker
Start/increase digoxin / Information required before assessment:
BNP ECG Tel # NHS #
Start/increase spironolactone

OTHER COMMENTS:

Dr Richard Pile, GpwSI in Echocardiography

Echo Report:

DOBNHS number:

Indication:

Date: /09Operator: RJP Disk/Video #: rjp24

Rhythm: Quality:

M-mode/2D MEASUREMENTS

2D / M-mode / Range
IVS (diastole) / 0.7 - 1.1 cm
LVID (diastole) / 3.5 - 5.6 cm
LVID (systole) / 2.5 - 4.1 cm
LVPW (diastole) / 0.7 - 1.1 cm
Aortic root diameter / 2.0 - 3.7 cm
LVOT diameter / n/a
LA internal dimensions / 1.9 - 3.9 cm

DOPPLER MEASUREMENTS & CALCULATIONS

Valve / Measurement / Value /

Range

Mitral

/ E/A ratio
DT / ms
Aortic / Velocity / m/s
Peak grad / mmHg
Mean grad / mmHg
AR P1/2T / ms
Pulmonary / Velocity / m/s
Tricuspid / Velocity / m/s
RVSP / + rap / mmHg

QUALITATIVE REPORT

Chambers: /

LV

/ Dimensions:Normal internal dimensions.Upper limit of normal.Dilated.Not clearly visualised
RWMA present?No regional wall motion abnormality.RWMA:
Systolic function:Good LV systolic functionLV systolic function appears preservedMild LV systolic dysfunctionModerate LV systolic dysfunctionSevere LV systolic dysfunction
LA / Dimensions:Normal internal dimensions.Upper limit of normal.Dilated.Not clearly visualised
RV / Dimensions:Normal internal dimensions.Upper limit of normal.Dilated.Not clearly visualisedGood RV contractility
RA / Dimensions:Normal internal dimensions.Upper limit of normal.Dilated.Not clearly visualised
Valves: / Aortic / Appearance:Structurally normal and competentStructurally normalSclerotic. Tri-leaflet. Opens wellBicuspidNot clearly visualised
AR?No ARTrivial ARMild ARModerate ARSevere AR AS?No ASMild ASModerate ASSevere ASMild to moderate ASModerate to Severe ASLVOT V1 = LVOT VTI = LVOT diam = AVA (peak velocity) = AVA (VTI) =
Mitral / Appearance:Structurally normal and competentStructurally normalProlapsing AMLProlapsing PMLNot clearly visualisedRegurgitation?Trivial mitral regurgitationMild mitral regurgitationModerate mitral regurgitationSevere mitral regurgitation
Tricuspid / Appearance:Structurally normal and competentStructurally normalNot clearly visualisedRegurgitation?Trivial tricuspid regurgitationMild tricuspid regurgitationModerate tricuspid regurgitationSevere tricuspid regurgitation

CONCLUSIONS

Dr Richard Pile

GPwSI in Echocardiography