Ministry of Health & Medical Education
Shiraz university of medical sciences:
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Medical Center:
Unit No:
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ECHOCARDIOGRAPHY REPORT
Attending Physician:
Date of Admission:
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Ward
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Room:
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Name:
Date of Birth:
Family Name:
$ - 1 2' 1 Father Name:
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Bed:
BMI:
$ # ! 567 Weight:
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Height:
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4 Size:
$
$ 8- 9+ 1
Diagnosis:
Normal values
Left – ventricle
End diastole …………………………………:
mm
35-54 mm
End –systole …………………………………:
mm
23-34 mm
F.S. …………………………………………:..
mm
30-45%
Left atrium ……………………………………:
mm
19-39 mm
Aortic root ……………………………………:
mm
20-37 mm
Separation……………………………………:
mm
15-26 mm
EPSS
mm
0-5 mm
AV opening……………………………………:
mm
Right ventricle:
mm
End – diastole: ………………………………:
mm
0.9-2.6 mm
LV. septum diast: ……………………………:
mm
0.6-1.1 mm
LV. post wall diast: …………………………:
mm
0.6-1.1 mm
THICKNESS:
MOTION:
LV. septal wall: ………………………………
LV. post wall: …………………………………
Other:
VALVES:
Mitral V.
MV ring diameter:
Aortic V.
No of cusps:
Pulmonic V.
Tricuspid V.
Normal
AV ring diameter:
Normal
Normal
Stenosis
Normal
Stenosis
Stenosis
Thickened
Stenosis
Others
Others
Prolapse
Thickened
.
.
Flail
Prolapse
.
.
Vegetation
Vegetation
.
.
Others
Others
.
.
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PERICARDIUM$
Normal
Thickened:
Effusion
Location$
Ant:
Post
Ant. / Post
Degree:
Mild
Moderate
Massive
'
Tamponade:
DOPPLER STUDIES (PW & CW COLOR DOPPLER):
Aoric Flow (Normal value: 1.0 – 1.7 m/s)
Mitral Flow (Normal value: 0.6 – 1.3 m/s)
Normal
Normal
Mitral stenosis (
)
)
Aortic stenosis (
Peak Velocity:
m/s
Peak Velocity:
m/s
Peak gradient:
mm Hg
Peak gradient:
mm Hg
MV area:
cm2
Mitral regurgitation (
)
)
Aortic regurgitation (
Tricuspid Flow (Normal value: 0.3 – 0.7m/s)
Pulmonic Flow (Normal value: 0.6 – 0.9 m/s)
Normal
Normal
Pul. stenosis (
)
Peak Velocity:
m/s
Peak gradient:
mm Hg
Tricuspid stenosis (
)
Peak Velocity:
m/s
Peak gradient:
mm Hg
Tricuspid regurgitation (
Pul. Regurgitation (
)
)
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LV Function$
Normal
A: Akinetic
D: Dyskinetic
TH: Thrombosis
LV Dysfunction
H: Hypokinetic
PX: paradoxical
Tu : Tumor
$?6
Conclusion:
$ 8- 9+ 1
Clinical diagnosis:
Name & signature of Physician:
#
$,- . /
@ A

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Dr. med. Diana Aicher Herz-Thorax