Echocardiogram .gov



Date of Echocardiography:Left atrial antero-posterior dimension: cm:z-score:Left atrial enlargement?: FORMCHECKBOX Present FORMCHECKBOX AbsentLeft atrium view: FORMCHECKBOX M-Mode FORMCHECKBOX Parasternal long axisLeft atrial dimension: cm2Left atrial volume: mlLeft atrial area (measured from apical 4-chamber view): cm2Left Ventricle Trabeculations? FORMCHECKBOX Present FORMCHECKBOX AbsentIf present,Are any of these more than 2:1? FORMCHECKBOX Yes FORMCHECKBOX NoWhere were they positioned? FORMCHECKBOX Lateral FORMCHECKBOX Apical FORMCHECKBOX Septal FORMCHECKBOX Free wall FORMCHECKBOX Not specifiedTable SEQ Table \* ARABIC 1 Structure and Function valves (more than mild)ValveStenosisRegurgitationCommentsTricuspid valve disease FORMCHECKBOX None FORMCHECKBOX Mild FORMCHECKBOX Moderate FORMCHECKBOX Severe FORMCHECKBOX None FORMCHECKBOX Mild FORMCHECKBOX Moderate FORMCHECKBOX SevereData to be entered by siteMitral valve disease FORMCHECKBOX None FORMCHECKBOX Mild FORMCHECKBOX Moderate FORMCHECKBOX Severe FORMCHECKBOX None FORMCHECKBOX Mild FORMCHECKBOX Moderate FORMCHECKBOX SevereData to be entered by siteAortic valve disease FORMCHECKBOX None FORMCHECKBOX Mild FORMCHECKBOX Moderate FORMCHECKBOX Severe FORMCHECKBOX None FORMCHECKBOX Mild FORMCHECKBOX Moderate FORMCHECKBOX SevereData to be entered by sitePulmonic valve disease FORMCHECKBOX None FORMCHECKBOX Mild FORMCHECKBOX Moderate FORMCHECKBOX Severe FORMCHECKBOX None FORMCHECKBOX Mild FORMCHECKBOX Moderate FORMCHECKBOX SevereData to be entered by siteMitral valve prolapse? FORMCHECKBOX Yes FORMCHECKBOX NoDoppler:Mitral E velocity: m/sMitral A velocity: m/sMitral annular E’ velocity: cm/sLeft ventricular hypertrophy: FORMCHECKBOX Present FORMCHECKBOX AbsentLeft ventricular concentric remodeling (size normal): FORMCHECKBOX Present FORMCHECKBOX AbsentRight atrial enlargement?: FORMCHECKBOX Present FORMCHECKBOX AbsentRight ventricular enlargement: FORMCHECKBOX Present FORMCHECKBOX AbsentRight ventricular systolic dysfunction: FORMCHECKBOX Present FORMCHECKBOX AbsentTable SEQ Table \* ARABIC 2 Ventricle FindingsFindingsLeft VentricleRight VentricleEjection Fraction (%)Data to be entered by siteData to be entered by siteFractional Shortening (%)Data to be entered by siteData to be entered by siteFunction FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Normal FORMCHECKBOX AbnormalWall motion abnormalities? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoEnd Diastolic Internal DimensionData to be entered by siteData to be entered by siteEnd Systolic Internal DimensionData to be entered by siteData to be entered by siteEnd Diastolic Volume (mL)Data to be entered by siteData to be entered by siteEnd Diastolic Volume Index (mL/m2)Data to be entered by siteData to be entered by siteEnd Systolic Volume (mL)Data to be entered by siteData to be entered by siteEnd Systolic Volume Index (mL/m2)Data to be entered by siteData to be entered by siteEnd Diastolic Septal Thickness IVSTdData to be entered by siteData to be entered by siteEnd diastolic Posterior Wall Thickness PWTdData to be entered by siteData to be entered by siteLV MassData to be entered by siteData to be entered by siteLV Mass IndexData to be entered by siteData to be entered by siteNon-compaction? FORMCHECKBOX Present FORMCHECKBOX Absent FORMCHECKBOX Present FORMCHECKBOX AbsentIf Yes, attach lab printout with wall motion abnormalities and trabeculation.Intracardiac findings (check all that are present): FORMCHECKBOX Device lead FORMCHECKBOX Thrombosis FORMCHECKBOX MassRight ventricular systolic pressure (estimate): mmHg (plus right atrial pressure):Pressure estimated by: FORMCHECKBOX TR FORMCHECKBOX Other, specifyPericardial effusion/abnormality: FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, describe:Quality of Study: FORMCHECKBOX Technically Difficult FORMCHECKBOX Suboptimal FORMCHECKBOX Fair FORMCHECKBOX Good FORMCHECKBOX ExcellentEchocardiogram Results (check only one): FORMCHECKBOX Normal FORMCHECKBOX πAbnormal, Not Clinically Significant FORMCHECKBOX πAbnormal, Clinically Significant FORMCHECKBOX πBorderline FORMCHECKBOX πUnable to evaluateπ For any Echocardiogram result that is not Normal, provide comments:General InstructionsThis form contains data elements that are collected to measure heart function.Specific InstructionsPlease see the Data Dictionary for definitions for each of the data elements included in this CRF Module.Date of Echocardiography - Record the date in the format yyyy-mm-dd. If any part of the date is Unknown, record as 9999.Left atrial area – This value is measured from the apical 4-chamber viewRight ventricular systolic pressure – This value is an estimated value of the right ventricular systolic pressure.Echocardiogram Results – For any result that is not Normal, provide comments ................
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