PAREDES INSTITUTE FOR WOMEN'S IMAGING, P.C.

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1 Breast Biopsy Pre Assessment NAME: CHART #: PROCEDURE SCHEDULED: U/S BIOPSY STEREO BIOPSY MRI BIOPSY LOCATION: COX ROAD GASKINS ROAD Date: TIME: ****** PLEASE ARRIVE 15 MINUTES EARLIER TO THIS TIME ****** DO YOU HAVE A HISTORY OF THE FOLLOWING? DIABETES YES NO LIVER DISEASE YES NO BLEEDING PROBLEMS YES NO RHEUMATIC FEVER YES NO ARTIFICIAL HEART VALVES YES NO ARTIFICIAL JOINTS YES NO DO YOU TAKE ANTICOAGULANTS (BLOOD THINNERS)? YES NO (EXP: HEPARIN, PLAVIX, COUMADIN) DO YOU TAKE ASPIRIN OR NONSTEROIDAL DAILY? YES NO PT NEEDS TO BE OFF THESE MEDS FOR AT LEAST 5 DAYS DO YOU TAKE PROPHYLACTIC ANTIBIOTICS BEFORE SURGERIES ORDENTAL PROCEDURES? YES NO DO YOU HAVE ANY ALLERGIES? YES NO IF SO, WHAT? DO YOU TAKE ANY ANTI-ANXIETY/SEDATIVES MEDICATIONS? YES NO (EXP: XANAX, VALIUM, ATIVAN, ETC.) ANTICOAGULANTS, ARTHRITIS, NONSTEROIDAL, ANTI-ANXIETY MEDS CANNOT BE TAKEN PRIOR TO BX WITHOUT PERMISSION ***By signing this I acknowledge I have been given a copy of the breast biopsy instruction sheet. I also understand that if I fail to follow the instructions my biopsy may need to be rescheduled. It is also understood that if I am more than 30 minutes late I may have to be rescheduled. PATIENTS SIGNATURE: DATE / / SCHEDULERS SIGNATURE: DATE / / PT PRE ASSESMENT 04/14/2013

2 Instructions After to Breast Biopsy Dear Patient: You have just completed a breast biopsy. The local anesthesia should keep you comfortable for 1-2 hours. After Biopsy Breast Care: 1. Wear a supportive bra the day of your biopsy, a sports bra is best if you have one. You may be more comfortable sleeping in your bra. The biopsy site has been dressed with surgical tape and covered with gauze. It is not necessary to change these dressings. 2. Apply ice to your biopsy site every 2 to 3 hours on the day of the biopsy (twenty minutes each time). This helps considerably with pain management and bruising. 3. The outer gauze bandage can be removed the morning after the biopsy. Leave the surgical tape in place. 4. The steri-strips (tapes over the biopsy site) can be removed 3days after the biopsy. 5. Do NOT shower or swim or get your biopsy site wet for 48 hours after the procedure. Medications: 1. Do NOT take Aspirin, Advil, Motrin, Aleve, Ibuprofen or any medications that contain these drugs for the next 24 hours. 2. You may use Tylenol for discomfort if needed. Follow dosage instructions on the bottle. 3. You may continue all your usual medications today unless directed otherwise by us. Activities: 1. You may resume most daily activities after the biopsy, including going to work. 2. Avoid vigorous activities such as swimming, tennis, an aerobic workout, vacuuming, running, lawn care and lifting over 10 pounds for the next hours. If bleeding occurs, apply FIRM pressure until it stops. If it continues call us. When to call us: Call back to the office if you notice any signs of bleeding or infection such as excessive swelling, intense pain, soaked gauze dressing, redness, or heat around the biopsy area. It is normal to experience mild discomfort, bruising, and lumpiness near your biopsy site. It is normal to see a small amount of blood under the tapes and on the gauze. During regular office hours call After 5:00 pm and on weekends please call Biopsy Results: 1. Dr. Paredes or a designated staff member will inform you and your physician of the results of your breast biopsy. The results are usually ready within 1-2 business days. You may be scheduled for a follow up visit for a wound check and results. 2. If you have not been notified of your results within one week please call the office at Thank you for allowing us to server you. PT AFTER INSTRUCTIONS 04/14/2013

3 Instructions Prior to Breast Biopsy NAME: CHART #: PROCEDURE SCHEDULED: U/S BIOPSY STEREO BIOPSY MRI BIOPSY LOCATION: COX ROAD GASKINS ROAD Date: TIME: ****** PLEASE ARRIVE 15 MINUTES EARLIER TO THIS TIME ****** Medications: 1. Do not take Aspirin, Ibuprofen, Advil, Motrin, Aleve or any medications containing these drugs for 5 days prior to your biopsy. You may take Tylenol if needed. 2. Inform us if you take any blood thinner medications such as Coumadin, Heparin or Plavix. We will give you special instructions on when to stop these medications. 3. Inform us if you take arthritis medications or nonsteroidals. These medications may need to be stopped prior to your biopsy. 4. Do not take any relaxant/anti-anxiety medications prior to the biopsy without consulting us. Breast biopsies are well tolerated with local anesthesia. 5. Do take your usual medications unless directed by us otherwise. 6. If you normally take antibiotics prior to dental or surgical procedures you should take them one hour prior to your biopsy. Please inform us if you need a prescription. Food/Nutrition: 1. Do eat and drink fluids the day of your biopsy. 2. Do bring a snack with you if are diabetic or hypoglycemic. On the day of the biopsy: 1. Take a shower with an antibacterial soap the morning of your biopsy. 2. You may wear deodorant but avoid powders or lotions on breasts 3. Do bring your photo ID and insurance card with you on the day of 4. Do plan to be at the Paredes Institute a minimum of2 hours the day of your biopsy. 5. Do wear a two piece clothing outfit and wear a supportive bra. 6. It is not necessary to have someone drive you home the day of the biopsy unless otherwise instructed by us. 7. If the person having the biopsy is a minor (under 18 y!), she must be accompanied by a parent or legal guardian. 8. Please reschedule your biopsy if you are not feeling well or have a fever. Special Instructions: If you have additional questions/concerns please call ( ) our office and ask to speak with a technologist or nurse. PT PRE INSTRUCTIONS 04/14/2013

4 Ellen Shaw de Paredes, MD, FACR Founder and Director Victor Paredes, MD, FACOG Gynecologist Terry Wright MD Radiologist Dear Patient: PATIENT INFORMED CONSENT FOR BREAST NEEDLE BIOPSY Thank you for trusting us with your healthcare. This consent form has the purpose of informing you about your breast biopsy procedure. Please read this form carefully and ask any questions before you decide whether or not to give your consent for this procedure. PURPOSE OF A BREAST BIOPSY: The purpose is to obtain a small quantity of tissue in the precise location where the abnormality is located. Imaging is used to localize the abnormality. After numbing the skin with a local anesthetic, the biopsy needle is placed into the abnormality through a small skin nick. In order to obtain an accurate diagnosis several samples will be obtained from the abnormal area. A tiny surgical clip will be left at the site of the biopsy for future mammographic reference. Tsz Ng, MD Radiologist Alice Shaw Administrator Diane Loudermilk RTRM Director of Images Chrystal Sullivan, RTRM Chief Technologist Louise Logan Secretary Erin Robinson Billing Latorsha Miller Scheduling The biopsy will be performed on my (right/left/both) breast. BENEFITS: The biopsy will allow us to diagnose the problem with a smaller amount of tissue than surgical biopsy, avoiding surgical scar and reducing the recovery time. This procedure allows the avoidance of surgical excision if the biopsy is negative (not cancer) or appropriate surgical planning if the biopsy is positive for cancer. RISKS: Although all procedures carry some risks, most patients experience only mild discomfort. Occasionally a moment of pain will be felt if a small nerve is touched. These moments of pain are infrequent and unpredictable. Because a needle is entering your breast, the possibilities of infection, bleeding or vessel injury at the biopsy site exist but are uncommon. In extremely rare circumstances (less than 1%) the bleeding could be severe enough to require further care. If you have a history of excessive bleeding or if you are taking medications that increase this risk (Aspirin, NSAIDS, Coumadin or Heparin), you must inform the physician before the procedure. Because local anesthesia is used there may be a risk of allergy. If you are aware of any allergies please notify the physician. Very infrequently the tissue obtained may be insufficient for diagnosis. In this instance you may be advised to repeat the biopsy or to have a surgical biopsy. If you have breast implants there is a small risk of implant rupture Cox Road, Suite l 00 Glen Allen, VA (804) Fax (804) Gaskins Road, Suites B & C Richmond, VA 23238

5 EXPECTED OUTCOME: Definitive diagnosis is expected in greater than 98% of patients. Following the biopsy you may have tenderness, bruising, slight oozing or bleeding at the site of the biopsy. This is not unusual. You may feel firmness at the biopsy site for several days or weeks following the procedure. ALTERNATIVES TO PROCEDURE: A surgical biopsy in which the abnormal area is localized with mammographic or ultrasound guidance by placement of a needle and wire into the breast before its excision with surgery. This is typically performed in an outpatient surgical operating room. BIOPSY RESULTS: Typically, results will be available in 1-2 working days. If you have not heard from us in 2 days you should call the office and inform us that you had a biopsy and are awaiting results. You always have the right to refuse any procedure at any time. It is your obligation to inform us if you do not want the procedure or wish to stop after it has started. It is also your responsibility to inform us of any adverse outcome or reaction to a similar study or anesthetic. Your signature on this form indicates that you have read and understand the information provided regarding the nature and character of this proposed procedure as well as the benefits and risks involved. Second, that you have had a chance to ask questions and that you have received all information you desire concerning the procedure, and that you authorize and consent to the performed procedure. Finally, that you recognize that during the course of this procedure, unforeseen circumstances may necessitate additional or different procedures than those set forth. Therefore, you authorize the below-named physician, and his or her assistants, to perform such procedures as in his or her professional judgment are necessary and desirable. Patient/Other Legally Responsible Person Signature Date Time Witness Radiologist Signature