Children S Hospital & Regional Medical Center
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Children’s Hospital & Regional Medical Center Name: ______Electrophysiology Study Preliminary Report MRN: ______Study date: ______Page __ of __
Indication: ______Antiarrhythmia drugs: ______
Baseline intervals: SCL _____ PR _____ QRS _____ Mapping AH _____ HV _____ QT _____ QTc _____ Site Interval
Atrial Overdrive Pacing: Max SNRT ______CSNRT ______Site _____ AV Block Cycle Length _____ Atrial Extrastimulus Testing: Site BCL FPERP AVNERP APERP Decremental? Y N AMERP Pre-excited? Y N Ventricular Overdrive Pacing: Induced Arrhythmias: Site _____ VA Block Cycle Length _____ Site Ventricular Extrastimulus Testing: Sequence Site Morphology BCL TCL VAERP Termination VMERP Mechanism Decremental? Y N
Intervention: Drug/Procedure ______Atrial Extrastimulus Testing: Dose: ______Site BCL Baseline intervals: SCL _____ PR _____ QRS _____ FPERP AH _____ HV _____ QT _____ QTc _____ AVNERP APERP Atrial Overdrive Pacing: AMERP Max SNRT ______CSNRT ______Decremental? Y N Site _____ AV Block Cycle Length _____ Pre-excited? Y N
Ventricular Overdrive Pacing: Induced Arrhythmias: Site _____ VA Block Cycle Length _____ Site Ventricular Extrastimulus Testing: Sequence Site Morphology BCL TCL VAERP Termination VMERP Mechanism Decremental? Y N
Conclusions:
Electrophysiologist ______