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echocardiography:tee:screening_form

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Screening Form

Transesophageal echocardiography is generally considered a safe and low risk procedure. As with all procedures there are some risks.

Oropharyngeal Lip bruising/laceration, loose/chipped tooth, displaced dentures, pharyngeal laceration, perforation of the hypopharynx, accidental tracheal intubation
Esophageal Pain with swallowing, trouble swallowing, laceration/perforation, tear in esophagus
Gastric Tear of stomach, bleeding
Miscellaneous Splenic laceration, compression of mediastinal structures, airway compromise, thermal injury burn, tongue necrosis
☐ Yes ☐ No Problems swallowing
☐ Yes ☐ No History of surgery involving your esophagus (swallowing tube)
☐ Yes ☐ No History of cirrhosis or esophageal varices

J Am Soc Echocardiogr 2010;23:1115-27

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