Lenox Hill Hospital Fax (212) 434-2024 (212) 434-2522 Department of Radiology - 3Rd Floor 100 East 77Th Street, New York, NY 10021
Total Page：16
File Type：pdf, Size：1020Kb
Neal Epstein, MD Tel. (212) 434-2900 Chairman Lenox Hill Hospital Fax (212) 434-2024 (212) 434-2522 Department of Radiology - 3rd Floor 100 East 77th Street, New York, NY 10021 www.lenoxhillhospital.org PATIENT’S NAME: m MRI m CT SCAN/64 SLICE m CT SCREENING STUDIES m ULTRASOUND - Cont’d If there is a history of IV (not covered by insurance) m Endovaginal MRI is contraindicated in Pulmonary CT patients with Pacemakers, contrast allergy, please call our m m Obstetrical Cochlear Implants & Cerebral office prior to the exam and m Cardiac Calcium Scoring m Sonohysterogram Aneurysm Clips. indicate in clinical history. m Custom Body Scan m Extremity Venous Doppler Virtual Colonoscopy Any IV Contrast study on m m Right m Left Coronary CTA for Screening m With m Without Gadolinium patients 70 years old or over, will m m Scrotal m Brain require BUN and Creatinine NUCLEAR MEDICINE Sono Guided Biopsy IAC m m m levels. m Other m Orbits m Bone - Whole Body m Sinuses m Oral m IV m No IV Contrast m Bone 3 Phase m BREAST IMAGING & BIOPSY m Sella BUN Creat Bone Limited m m Mammography m TMJ m RT m LT m BILAT m Brain Bone W/SPECT/CT Sinuses Instatrak m m Screening m Neck Soft Tissue m m White Blood Cell Study Brachial Plexus RT LT Temporal Bones m m Baseline m m m m Gallium Scan Cervical Spine m Orbits m m Breast Ultrasound m Cardiac Gated W/EF m Thoracic Spine m Facial Bone m m Stereotactic Biopsy m Lumbar Spine m Neck Soft Tissues m Prostascint m Ultrasound Guided Core Biopsy m Chest m Chest m Lymphoscintigraphy m Preop Wire Localization m Abdomen m Abdomen m Plasma Volume Red Cell Mass m Pelvis m Pelvis m Renal Scan m BONE DENSITOMETRY Renal Stone (no oral or IV) m MRCP m m Diuretic Renography m Breast m RT m LT m BILAT m Parathyroid Localization Biliary Scan FLUOROSCOPY Pulmonary Embolus m m m MR Guided Breast Biopsy m with GBEF RT LT Brachial Plexus m Esophagram m m m Lung Scan m Shoulder RT LT m Cervical Spine m m UGI Series m m m Gastric Emptying m Arthrogramm RT m LT m Thoracic Spin m m Small Bowel Series Thyroid Uptake & Scan m Elbow m RT m LT m Lumbar Spine m m Barium Enema m Wrist m RT m LT m Screening Body CT m Parathyroid m Hysterosalpingogram m Hip m RT m LT m Extremity m 1131 Wholebody m Knee m RT m LT m RT m LT m with Thyrogen m GENERAL RADIOGRAPHY m Ankle m RT m LT m CT Guided Biopsy Monoclonal Antibody Imaging m Chest m Foot m RT m LT m Other Specify: m m Ribs RT LT m Other CT ANGIOGRAPHY m m m m m Brain SPECT KUB Therapy Specify: m m Abdominal m IVP Other: m m Carotids m m Obstructive Series Other Organs m m PET m Skeletal Survey m MRI ANGIOGRAPHY m Coronary Artery Skull Series Whole Body PET m m Intracranial All coronary studies m m Sinuses Brain PET m Extracranial require BUN & Creatinine m m Nasal Bones m Aorta m Thoracic m Abdominal Facial Bones Renal Artery BUN Creat m ULTRASOUND m m m Cervical Spine Celiac/SMA Indications (check one): Thyroid m m m Thoracic Spine m Peripheral Vessels m Chest Pain Parathyroid Shortness of Breath m m Lumbar Spine MRV m m Salivary Gland Pelvis m m Abnormal ECG m Brain Equivocal/Abnormal m Carotid Duplex m Hip m RT m LT m m Abdomen m Abdomen Perfusion Study m m Extremities m Pelvis m Post CABG Follow Up m Renal m RT m LT m Chest m Post Stent Follow Up m Aorta/Retroperitoneum m Other m Coronary Atherosclerosis m Pelvic - Transabdominal Clinical History: Appointment Date Please arrive at the Radiology Reception Area on the 3rd Floor on: , at Reason for Exam: DAY DATE TIME Payment is expected at the time of service. If you have any questions regarding insurance information or if you are unable to Prior exam at Lenox Hill Hospital? r Yes r No keep your appointment, please call (212) 434-2900. Referring Physician Visa MC AMEX Phone Fax Please see reverse side for procedure instructions and directions Pre-Authorization to Lenox Hill Hospital. Physician’s Signature Date Patient Information: Consult your physician about medications you are taking. Following these instructions carefully will help to ensure the quality of your examination. Please plan to arrive 30 minutes before your scheduled appoint- ment time. Upon arrival, you will meet briefly with registration, to facilitate processing of insurance information. • All MRI Scans Pelvis: If you are claustrophobic, please contact our office for instructions. Music Requires full bladder. Please drink 4 to 6 glasses of water starting 1 to 1-1/2 is available during the examination. If you prefer, bring your own tape or CD hours prior to test. Do not urinate after drinking the water. for the exam. Obstetrics: • MRI without Contrast Follow Pelvic Preparation. No preparation required. Hair pins/clips must be removed prior to your Sono Guided Biopsy: examination. Please advise us if you are pregnant or have a cardiac pace- Light Breakfast. No aspirin or aspirin-containing medications or maker, cardiac valves, implanted cardiac defibrillator, aneurysm clips, Vitamin E for 1 week prior to procedure. Prior ultrasound reports cochlear ear implants, heart stents and/or retinal implants. must be forwarded to the Ultrasound Department for the radiologist • MRI with Contrast/MRA/MRV to review prior to the biopsy. Do not eat or drink anything for two hours prior to examination. Please fax: (212) 434-4567 • MRI Abdomen All Other Ultrasound Exams: Do not eat or drink anything for three hours prior to examination. No Preparations • Breast MRI • Nuclear Medicine Please schedule examination 8-13 days after the first day of your last men- Nuclear Thyroid Uptake and Scan: strual cycle. Hormone Replacement Therapy (HRT) should be discontin- Do not eat kelp, seaweed, vitamins with minerals, or seafood for at least ued 3 months prior to the exam. 3 days prior to the test. • All CT Scans Hepatobiliary (HIDA) Scan: If you have diabetes please have your recent (6 months or less) BUN No solids or liquids by mouth for 4 hours prior to the test. and Creatinine levels from your last blood test available. • PET Scan Please notify our office for special instructions at least 3 days in advance if Nothing to eat or drink, except water for 6 hours prior to the proce- you are allergic to iodinated contrast (“iodine dye”) or have a history of mul- dure. No nicotine, caffeine, alcohol for 12 hours prior to the exam. If tiple allergic reactions. you are diabetic, please notify our office for special instructions. Please notify our office for special instructions at least 3 days in advance if Please bring any outside studies at the time of the exam. you are currently taking Metformin (ex: Glulcophage, Glucovance, • IVP Avandammet, Metaglip). If you require iodinated contrast for the CT scan, Purchase Dulcolax tablets from a pharmacy. Take 2 Dulcolax tablets at glucophage should not be taken for 48 hours following the contrast injec- 9:00pm the night prior to test. Nothing to eat or drink after midnight. tion. Your doctor must recheck your blood levels of BUN and Creatinine • Venogram before you restart your medication. Nothing to eat 3 hours prior to test. Nothing to drink one hour prior to • Coronary CTA test. Please advise if patient is allergic to contrast. No coffee, tea, Viagra, Levitra, or Cialis for 12 hours before study. • Mammography Please drink 2-3 glasses of water prior to arrival. No talcum, underarm deodorant, body lotion or Vitamin E day of • CT with Injected/IV Contrast test. (Please bring all previous mammograms and breast sono- Do not eat anything for four hours prior to examination. grams.) • CT without Injected/IV Contrast Premedication Regimen for Iodinated Contrast (“Iodine Dye”): No preparation required. Reactions: Please notify the office of you have had prior contrast reac- • CT Guided Biopsy tions. If intravenous contrast is still deemed necessary please follow the No Breakfast. No aspirin or aspirin-containing medication or Vitamin following instructions: E for 1 week prior to procedure. Prior to the biopsy, CT films must Prednisone: 50mg by mouth 13 hours prior to scan; 50mg by mouth 7 be forwarded to the CT Department for the radiologist to review prior hours prior to scan; 50mg by mouth 1 hour prior to scan; Benadryl: to the biopsy. No breakfast. 50mg by mouth 1 hour prior to scan. NOTE: You will not be able to drive • Cardiac Calcium Scoring or return to work for 12 hours. No nicotine, caffeine, alcohol or other stimulants 6 hours prior to the Needle localization or Stereotatic Biopsy: exam. Nothing to eat or drink after midnight prior to test (Please bring all • GI Series and/or Small Bowel previous mammograms and breast sonograms.) Nothing to eat or drink after midnight prior to test. • Barium Enema Directions: Department of Radiology Purchase a Fleet Prep Kit #3 from a pharmacy. Follow instructions for 24 hour 100 East 77th Street, 3rd Floor (Between Park & Lexingon) prep. Nothing to eat or drink after midnight prior to test. (212) 434-2900 • Fax (212) 434-2024 Ultrasound Studies • Please fax all prescriptions and reports. Please bring any previous Hysterosalpingogram or Sonohysterogram: films to your appointment that are relevant to the exam being per- Please call our office on the first day of your next period to schedule formed for comparison.