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1 Patient Name: DOE, JOHN D. Gender: M Date of Study: 4/2/2013 Date of birth: 6/28/1962 Age: 50 Medical Record #: Ordering Physician: JANE INTERNIST, MD History: Atypical Angina, Abn ECG, High Cholesterol, Hypertension, Positive Treadmill Test Indications: Assessment of chest pain, Positive ETT 5.8 mci of Tc-99m sestamibi was administered via IV injection at rest. Approximately 45 minutes afterwards, cardiac SPECT imaging was performed. A stress test was then performed and at peak exercise, 17.9 mci of Tc-99m sestamibi was injected IV; approximately 45 minutes post injection, cardiac gated SPECT and prone cardiac gated SPECT imaging was performed. Attenuation correction was not used. STRESS PROTOCOL: Exercise Stress Test The patient exercised on a treadmill utilizing the Bruce protocol; they completed 11 minutes & 10 seconds, achieving approximately 12.9 METS. Baseline heart rate was measured at 62 bpm, and increased to 185 bpm at peak exercise; which is 108% of the maximum predicted heart rate. The heart rate response was normal. Baseline blood pressure was 142/78 mmhg and increased to 168/92 mmhg at peak exercise, which is a normal response to exercise. Resting ECG demonstrated normal sinus rhythm with diffuse non-specific ST-T wave abnormalities. During exercise, the ECG showed non-sustained V-tach. At peak stress, the ECG revealed downsloping ST-T depression of mm. During exercise, the patient developed dyspnea, chest pain level 4 of 10, fatigue. The reason for exercise termination was chest pain, fatigue, dyspnea, patient's request. Symptomatology resolved during standard recovery period. EXERCISE TEST SUMMARY: min on Bruce protocol Chest pain level 4 of 10 Dyspnea Exercise ST-T changes noted Stopped for chest pain, fatigue, dyspnea, patient's request. EXERCISE TEST IMPRESSION: Positive Study quality: suboptimal due to artifact Left Ventricle: Normal Artifacts: sub-diaphragmatic activity SPECT imaging demonstrated transient ischemic dilation of the left ventricle on the post-stress images, along with a medium size, mostly reversible perfusion abnormality of moderate severity located in the apical anterior, apical septal, mid anterior segment(s) of the left ventricle. The stress perfusion defect extent was 20%, the rest perfusion defect extent was 6%, and the stress ischemia extent was 14%. Gated SPECT imaging revealed normal left ventricular wall motion, thickening, and overall LV systolic function. The estimated post-stress ejection fraction was 52%. Abnormal myocardial perfusion: There was transient ischemic dilation of the left ventricle on the post-stress images. This is associated with severe CAD. Also, there was a medium size mostly reversible perfusion abnormality of moderate severity located in the apical anterior, apical septal, mid anterior segment(s) of the left ventricle. Stress defect extent = 20%; Rest defect extent = 6%; Stress ischemia extent = 14%. Normal left ventricular systolic function: All segments of left ventricle demonstrated normal wall motion and thickening. Ejection fraction = 52%. Results indicate that myocardial ischemia is possibly the cause of patient chest pain. Recommend cardiac catheterization, PCI if indicated. Joe Cardiologist, MD FACC Date of Final Report: 4/2/2013 cc: SALLY SPECIALIST,MD 123 Main St NY, New York ph: (202) fax: (202)

2 Patient Name: DOE, JOHN A. Gender: M Date of Study: 4/2/2013 Date of birth: 8/24/1955 Age: 57 Medical Record #: History: Fatigue, DOE, Dyslipidemia, A-Fib Indications: Assessment of anginal equivalents (Fatigue) (DOE) 5.7 mci of Tc-99m tetrofosmin was administered via IV injection at rest. Approximately 30 minutes afterwards, cardiac SPECT imaging was performed. A stress test was then performed and at peak stress, 20.3 mci of Tc-99m tetrofosmin was injected IV; approximately 30 minutes post injection, cardiac gated SPECT imaging was performed. Prone images were also acquired to mitigate attenuation artifact(s). STRESS PROTOCOL: Regadenoson Stress Test Reason for Pharmacologic Stress: V-paced, reactive airway disease The patient was intravenously infused with 5ml of regadenoson over 10 seconds for a total dose of.4 mg, followed by a 5ml saline flush over 10 seconds, followed by stress radiotracer administration seconds later. Adjunctive exercise was not used during pharmacologic stress infusion. Heart rate was 64 bpm at baseline, and changed to 89 bpm at peak stress. The heart rate response was normal. Baseline blood pressure was 120/80 mmhg and changed to 80/52 mmhg at peak stress, which is a hypotensive response to regadenoson. Resting ECG demonstrated normal sinus rhythm w/ PVCs, PACs with IVCD, LAHB. During stress the ECG revealed no additional arrythmia. At peak stress, the ECG revealed no diagnostic ST-T changes. During exercise, the patient developed a "funny" feeling, abdominal discomfort, dyspnea. The reason for infusion termination was end of protocol. 100 mgs of aminophylline was infused IV during recovery to reverse vasodilator stress agent. Symptomatology resolved approximately 3 minutes after standard recovery period. REGADENOSON STRESS IMPRESSION: Equivocal Study quality: adequate Left Ventricle: Normal Artifacts: diaphragmatic attenuation, frequent PVCs; gated study suboptimal SPECT imaging demonstrated homogeneous perfusion on the rest and stress images, with transient ischemic dilation of the left ventricle on the post-stress images. Gated SPECT imaging of the left ventricle was abnormal, demonstrating mild global hypokinesis of the left ventricle. Overall left ventricular systolic function was mildly impaired. The estimated resting ejection fraction was 55%, and the calculated post-stress ejection fraction was 43%. Abnormal myocardial perfusion: there was transient ischemic dilation of the left ventricle on the post-stress images. This is associated with severe CAD. Abnormal left ventricular systolic function: Mild global hypokinesis of the left ventricle. Ejection fraction = 43%. John Hancock, MD FACC Date of Final Report: 4/2/2013

3 Patient Name: DOE, JOHN Gender: M Date of Study: 4/2/2013 Date of birth: 3/15/1945 Age: 68 Medical Record #: History: Chest Pain, DOE, Sleep Apnea, Diabetic, Palpitations, Fam Hx of CAD Indications: Assessment of chest pain, Ischemic Equivalent (DOE) 5.6 mci of Tc-99m sestamibi was administered via IV injection at rest. Approximately 45 minutes afterwards, cardiac SPECT imaging was performed. A stress test was then performed and at mid-point of vasodilator infusion, 18.5 mci of Tc-99m sestamibi was injected IV; approximately 45 minutes post injection, cardiac gated SPECT imaging was performed. STRESS PROTOCOL: Adenosine Stress Test Reason for Pharmacologic Stress: Rate-related LBBB A dose of 140ug/kg/min of adenosine infused IV over 4 minutes for a total dose of 58.7 mg. Adjunctive exercise was used during pharmacologic stress infusion. The radiopharmaceutical was injected at 2 minutes into the infusion. Heart rate was 68 bpm at baseline, and changed to 89 bpm at midpoint of vasodilator infusion. The heart rate response was normal. Baseline blood pressure was 126/76 mmhg and changed to 112/72 mmhg at midpoint of vasodilator infusion, which is a physiologic response to adenosine. Resting ECG demonstrated normal sinus rhythm w/ PACs with rightward axis, early r-wave progression. During infusion the ECG revealed no additional arrythmia. At peak infusion, the ECG revealed no diagnostic ST-T changes. During infusion, the patient developed a "wierd" feeling, shortness of breath, flushing. The reason for infusion termination was end of protocol. 100 mgs of aminophylline was infused IV during recovery to reverse vasodilator stress agent. Symptomatology resolved during standard recovery period. ADENOSINE STRESS IMPRESSION: Nondiagnostic Study quality: suboptimal due to artifact Left Ventricle: Normal Artifacts: diaphragmatic attenuation SPECT imaging demonstrated uniform (normal) tracer distribution throughout the myocardium at rest and at peak stress. Gated SPECT images revealed normal thickening, wall motion, and overall left ventricular systolic function. The calculated post-stress ejection fraction was 57%. IMPRESSION: Normal Normal myocardial perfusion. Normal left ventricular systolic function: All segments of left ventricle demonstrated normal wall motion and thickening. Ejection fraction = 57%. John Hancock, MD FACC Date of Final Report: 4/3/2013

4 Patient Name: DOE, JANE B. Gender: F Date of Study: 4/3/2013 Date of birth: 2/9/1937 Age: 76 Medical Record #: Ordering Physician: JANE INTERNIST, MD History: Atypical Chest Pain, Depression, PVD, Positive Treadmill Test Indications: Assessment of chest pain, + ETT 5.3 mci of Tc-99m tetrofosmin was administered via IV injection at rest. Approximately 45 minutes afterwards, cardiac SPECT imaging was performed. A stress test was then performed and at ~ 3 minutes after infusion, 18.4 mci of Tc-99m tetrofosmin was injected IV; approximately 30 minutes post injection, anterior cardiac planar & cardiac gated SPECT imaging was performed. CT based attenuation correction was used. STRESS PROTOCOL: Dipyridamole Stress Test Reason for Pharmacologic Stress: V-paced The patient was intravenously infused with dipyridamole at 142ug/kg/min over 4 minutes for a total dose of 51.3 mg. Adjunctive exercise was used after the pharmocologic stress infusion; the stress dose of radiotracer injected then. The radiopharmaceutical was injected 3 minutes after the infusion. Heart rate was 69 bpm at baseline, and increased to 110 bpm at time of radiopharmaceutical injection. The heart rate response was normal. Baseline blood pressure was 138/84 mmhg and increased to 142/86 mmhg at time of radiopharmaceutical injection, which is a physiologic response to dipyridamole. Resting ECG demonstrated normal sinus rhythm w/ PVCs, PACs with lateral Q-waves. During dipyridamole infusion the ECG revealed PACs, PVCs. At peak infusion, the ECG revealed horizontal ST-T depression of mm. During infusion, the patient developed diaphoresis, nausea. The reason for infusion termination was end of protocol. Symptomatology resolved during standard recovery period. DIPYRIDAMOLE STRESS IMPRESSION: Positive by ECG criteria Study quality: adequate Left Ventricle: Normal Artifacts: none SPECT imaging demonstrated a medium size, fixed perfusion abnormality of moderate severity located in the mid inferolateral, basal inferolateral, mid anterolateral segment(s) of the left ventricle. Gated SPECT imaging of the left ventricle was abnormal, demonstrating moderate hypokinesis of the lateral segment(s) of the left ventricle (this abnormality matches a fixed perfusion defect, suggesting myocardial scarring from previous myocardial infarction). Overall left ventricular systolic function was mildly impaired. The estimated post-stress ejection fraction was 44%. Abnormal myocardial perfusion: Medium to large size fixed perfusion abnormality of moderate severity located in the mid inferolateral, basal inferolateral, mid anterolateral segment(s) of the left ventricle. Abnormal left ventricular systolic function: Moderate hypokinesis of the lateral segment(s) of the left ventricle. Ejection fraction = 44%. Compared to previous study on 1/18/2009, perfusion shows new infarction. There is new LV function abnormality. John Hancock, MD FACC Date of Final Report: 4/1/2013 cc: SALLY SPECIALIST,MD

5 Patient Name: DOE, JANE R Gender: F Date of Study: 4/2/2013 Date of birth: 9/24/1951 Age: 61 Medical Record #: History: Abn ECG, Syncope, Diabetic, Obesity(Morbid), High triglycerides Indications: Assessment of ischemic equivalent (Syncope), Abn ECG NUCLEAR IMAGING PROTOCOL: Dual Isotope 3.1 mci of Tl-201 thallium chloride was administered via IV injection at rest. Approximately 10 minutes afterwards, anterior cardiac planar & cardiac SPECT imaging was performed. Transmission source attenuation correction was used. A stress test was then performed and at peak stress, 21.1 mci of Tc-99m Cardiolite was injected IV; approximately 45 minutes post injection, cardiac gated SPECT and prone cardiac SPECT imaging was performed. Transmission source attenuation correction was used. STRESS PROTOCOL: Dobutamine Stress Test Reason for Pharmacologic Stress: Unable to exercise, COPD Dobutamine was infused incrementally, starting at a dose of 5 mcg/kg/min, which was increased at 3-minute intervals to 20, then 30 mcg/kg/min over 10 minutes & 19 seconds for a total dose of 24.1 mg. Adjuntive atropine was infused IV for a total dose of.5 mg. Baseline heart rate was 63 bpm and increased to 147 bpm at peak stress which represents 92% of the MPHR. The heart rate response was normal. Baseline blood pressure was 124/76 mmhg and increased to 164/88 mmhg at peak stress, which is a physiologic response to dobutamine. Resting ECG demonstrated normal sinus rhythm with LAD, IVCD. During stress the ECG revealed occaisonal PVCs. At peak stress, the ECG revealed flat to upsloping ST-T depression of mm. There was T-wave inversion during stress. During stress, the patient developed shortness of breath, chest pain (level 4 of 10). The reason for infusion termination was achievement of target heart rate. Symptomatology resolved during standard recovery period. DOBUTAMINE STRESS IMPRESSION: Positive by ECG criteria Study quality: suboptimal secondary to body habitus, artifact Left Ventricle: Normal Artifacts: diaphragmatic attenuation SPECT imaging demonstrated a small to medium size, mostly reversible perfusion abnormality of severe intensity located in the anterior lateral segment(s) of the left ventricle. The 17-segment summed stress score was 8, the summed rest score was 2, and the summed difference score was 6. Gated SPECT imaging revealed normal left ventricular wall motion, thickening, and overall LV systolic function. The calculated resting ejection fraction was 52%, and the calculated post-stress ejection fraction was 55%. Abnormal myocardial perfusion: Small to medium size mostly reversible perfusion abnormality of severe intensity located in the anterior lateral segment(s) of the left ventricle. SSS= 8; SRS= 2; SDS= 6 Normal left ventricular systolic function: All segments of left ventricle demonstrated normal wall motion and thickening. Ejection fraction = 55%. John Hancock, MD FACC Date of Final Report: 4/2/2013

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