Originally Posted by Initial Examination

HISTORY
The patient is a 33-year old man under the care of Dr. XXX. The patient has heart murmur which was evaluated via

echocardiogram performed 10/15/04 at XXX and read by Dr. XXX as suggestive of possible atrial septal defect. The patient is

now being admitted for outpatient transesophageal echocardiogram to further evaluate the finding.

He reports that he has been told by Dr. XXX that blood pressure is elevated. Patient feels that this represents "white coat

hypertension". Patient's blood pressure taken at home has been normal.

The patient has been in good health. He takes no medications. He does not smoke cigarettes. There have been no

hospitalizations and no surgeries. He has had mildly elevated blood pressure. He does 40 minutes of aerobic exercise daily

without symptoms.

EXAM
Heart rate 72. Blood pressure 156/90.
Peripheral pulses are of good quality and bilaterally equal.
No caratoid bruit is heard. Venous pressure is not elevated.
Neck is supple. There is no thyromegaly or adenopathy.
There is good air exchange bilaterally. Lungs are clear to percussion and auscultation.
Precordium is quiet without lift, heave, thrill or bulge. There is a Grade II systolic ejection murmur at the upper left

sternal border with some radiation to the apex. The murmur varies with respiration, but not with position.
Abdomen is soft and nontender. Bowel sounds are normal. There is no hepatosplenomegaly. No masses are palpable.
There is no edema.

IMPRESSION
1. Possible atrial septal defect.

DISPOSITION
Patient to have transesophageal echocardiogram, to be performed by Dr. XXX. The patient has been advised of the reasons for

performing the study and of alternative management. He appears to understand the discussion.

Originally Posted by TEE

ANESTHESIA
Local anesthesia with Hurricane spray and intravenous sedation with Demerol and Versed.

DETAILS OF PROCEDURE
Patient had signed the informed consent. He came to the GI Laboratory after a light breakfast in the morning. He had an IV

started in his right arm. He was placed on oxygen at two liters by nasal cannula, continuous pulse oximetry, periodic blood

pressure check, and continuous EKG monitoring throughout the procedure.

The posterior pharynx was anesthesized with Hurricane spray. The patient was made to lie down in the left lateral position.

He received 1 mg of IV Versed and 12.5 mg of Demerol IV.

The Acuson multiplane transesophageal transducer was next advanced into the posterior pharynx and into the upper, mid, and

lower esophagus.

Echocardiographic pictures were obtained by gently rotating the transducer in clockwise and anti-clockwise manner as well as

flexing and antiflexing the tip to get optimum pictures. Color doppler study was also recorded.

Agitated saline was injected to review the contrast echocardiogram. The superior vena cava and pulmonary artery as well as

descending thoracic aorta were visualized. At the end of the procedure, the transducer was withdrawn.

The patient tolerated the procedure well. His vital signs remained stable. He was discharged to the Recovery Room without

incident.

FINDINGS
Technically excellent study. All the chambers of the heart were recorded. A small amount of patent foramen ovale was

determined with a minimal amount of left to right shunting across the foramen ovale. This was classically laminar flow. Some

negative contrast was also noted along the interatrial septum. This appeared to be coming from the superior vena cava. The

tricuspid valve was competent. The left heart structures were completely normal. There was no evidence of mitral

insufficiency. The left atrial cavity was free of any thrombi. The left atrial appendage was normal. Left ventricular

contractility was normal. Right heart structures were unremarkable as well. The pulmonic valve was recorded and was normal.

There was no evidence of intraventricular shunting. With Valsalva, there was no evidence of paradoxical shunting
across the interatrial septum. There was no pericardial effusion noted.

CONCLUSION
MILDLY ABNORMAL TRANSESOPHAGEAL ECHOCARDIOGRAM SHOWING PATENT FORAMEN OVALE WITH MINIMUL LEFT TO RIGHT SHUNT. NO DEFINITE

ATRIOSEPTAL DEFECT COULD BE IDENTIFIED. MITRAL, TRICUSPID, PULMONIC, AND AORTIC VALVES WERE NORMAL. LEFT VENTRICULAR

CONTRACTILITY WAS NORMAL. NO EVIDENCE OF INTRACAVITARY THROMBI OR VEGETATIONS.