CARDIAC CT ANGIOGRAM APPOINTMENT FORM AND INSTRUCTIONS

Transcription

1 CARDIAC CT ANGIOGRAM APPOINTMENT FORM AND INSTRUCTIONS Your Cardiac CT Angiogram appointment is:, : am pm (date) (time) (circle one) Please expect to be at your appointment for 1 HOUR. Please call in advance if you need to cancel or reschedule your appointment or if you have any questions about this test. ** The test will take place in the Radiology Department on the main floor of The Chester County Hospital. ** About Your Test: Your doctor has ordered a CT scan of your heart. This test is performed in a CT scanner using x-rays, and an IV contrast material which contains iodine. Before Your Test: 1. Creatinine blood test must be drawn and completed within last 60 days (fax or bring results to appointment) 2. Please drink 32 ounces of water the day before your exam. 3. Fast for four hours before appointment continue to drink water to maintain hydration. 4. Take the provided Metoprolol mg tablet at bedtime, and 1 50 mg tablet two hours before scan unless instructed otherwise by your doctor. Note: You may not be able to take this medication if you have asthma, emphysema, congestive heart failure, or other conditions. Please discuss with your physician. 5. No caffeine, cold remedies (including Claritin D and Allegra D), smoking or exercise for at least 12 hours before your appointment 6. Metal-free clothing and no jewelry from the waist up 7. Bring the Cardiac CT Angiogram Order Form to the appointment 8. Bring your insurance card to the appointment 9. You may bring a guest with you if you would like. You will be fine to drive yourself to and from your exam if you prefer. For Patients taking Metformin (Glucophage, Avadament, Glucovance): please discontinue the day of exam and speak with the Radiology Nurse regarding post-procedure instructions. All other medications should be taken as normal. For Patients with Contrast Dye Allergy: pre-medication (Prednisone/Benedryl) advice must be followed. Please speak to your physician if you have any questions. During Your Appointment: When you arrive for your appointment a nurse will check your heart rate and blood pressure. If your heart rate is over 60 beats per minute, you may be given an additional beta-blocker (Metoprolol) to lower your heart rate. The nurse will place an IV in your arm and you will be connected to an EKG monitor to assess your heart rate. Once your heart rate is at or below 60 you will be taken into the scanner room. You will lie on your back with your arms above your head. You will be asked to take a deep breath and hold it. The longest you will have to hold your breath is approximately 20 seconds. You may want to practice this at home before your exam. The scan takes less than 10 minutes. 3-4 pictures will be taken with the scanner, each lasting about 10 seconds. For the last scan a contrast dye will be administered through your IV to help to visualize the inside of your arteries. You may notice a warm sensation or possibly feel a metallic taste in your mouth. These are normal responses to the contrast and should subside very quickly. Calcium measurement will be obtained prior to the CTA being completed. If your score is greater than 500, the study will not be completed because the doctor cannot read the vessels at that time. When the scans are completed and the IV is removed, your heart rate and blood pressure will be monitored for 15 minutes following the exam. The physician that ordered your scan will contact you to discuss the results.

2 DISCHARGE INSTRUCTIONS: 1. Please drink plenty of liquids after your exam. Water is preferable. At a minimum, you should drink 64 ounces of water over the 24 hour period following your exam. 2. Do not drink any caffeinated beverages the rest of the day (coffee, tea, caffeinated sodas). 3. Do not drink any alcoholic beverages for the next 24 hours. Note: We ask you to drink these fluids to dilute the x-ray dye that was used for your test. Caffeine and alcohol will not allow this flushing to occur effectively. Patient Signature Date

3 PATIENT INFORMATION FORM Name: Street Address: City: State: Zip: Home Phone: Work Phone: Cell Phone: Gender: Male Female Date of Birth: / / Age: May we contact you via regarding your test results, follow up and related issues? Yes No Please initial: Insurance Company: Policy #: Group #: Referring Physician: Name of Referring Physician: Address: City: State: Zip: Phone: Would you like us to send a copy of the report to another physician? Yes No Please initial: If yes, please provide the following information: Name of Physician: Address: City: State: Zip: Phone:

4 PATIENT PRE-SCAN HISTORY Have you experienced any of the following symptoms in the past six (6) months? Chest pain Chest tightness or pressure Shortness of breath Palpitations Angina Leg pain with walking Slurring of speech Fainting Have you ever had: Heart Attack Yes No Date: Bypass Surgery Yes No Date: Angioplasty Yes No Date: Coronary Stent Yes No Date: Cardiac Cath Yes No Date: Normal Abnormal Cardiac Stress Test Yes No Date: Normal Abnormal Congestive Heart Failure Yes No Stroke or TIA Yes No Diabetes Yes No Asthma Yes No Kidney Disease Yes No Polycystic Kidney Disease Yes No High Blood Pressure Yes No Sickle Cell Disease Yes No Cancer Yes No Date: Type Multiple Myeloma Yes No Date: Tumors of the Adrenal Cells Yes No Date: Asbestos Exposure Yes No Currently Pregnant Yes No Date of last menses: Have you ever received Intravenous Contrast (dye) before? Yes No If yes, please list any adverse reactions you had: Please list all allergies to medication, food, or Iodine: Cardiac Risk Factors Date of Birth: Age: Cholesterol Have you ever been told you have high or abnormal cholesterol? Yes No Please indicate levels (if known): Total Cholesterol: HDL: LDL: Triglycerides: Are you currently taking cholesterol-lowering medication? Yes No If yes, please list name of the medication?

5 Do you know your Calcium Score? Yes No If yes, please list score: Do you take daily aspirin? (baby aspirin, 81 mg) Yes No (adult aspirin, 325 mg) Yes No Tobacco Use Do you currently smoke? Yes No If yes, please list the number of packs/day: Did you ever smoke in the past? Yes No If yes, please list the number of packs/day: Please list how long you smoked: Date you stopped smoking: High Blood Pressure Have you ever been told that you have high blood pressure? Yes No If yes, please list year: Current BP: Diabetes Do you have high blood sugar or diabetes? Yes No If yes, please list year: If yes, please list prescribed treatment: Insulin Oral drugs Diet Exercise Do you regularly exercise? Yes No If yes, please list the number of days per week: ; and minutes per session: Family History Has a parent or sibling had any of the following at an early age? Father before age 55: Heart Attack Bypass Surgery Angina Stroke None Mother before age 65: Heart Attack Bypass Surgery Angina Stroke None Brother before age 55: Heart Attack Bypass Surgery Angina Stroke None Sister before age 65: Heart Attack Bypass Surgery Angina Stroke None Current Medications Medication / Vitamin Dosage Frequency Other Medical History: Please sign and date to acknowledge accuracy of the information. Signature Date

6 PATIENT INFORMATION SHEET Beta Blocker (Metoprolol) Your doctor has scheduled you for an x-ray examination that requires you to take a Beta Blocker prior to the exam. The Beta Blocker is also called Metoprolol. Beta Blockers help to lower your heart rate which improves the accuracy of the CT scan. Before taking Metoprolol: Tell your doctor and CT nurse if you are allergic to Metoprolol or any other medications. Tell your doctor and CT nurse what prescription and nonprescription medication, vitamins, nutritional supplements, and herbal products you are taking. Be sure to mention any of the following: fluoxetine (Prozac, Sarafem); paroxetine (Paxil); propafenone (Rythmol); quinidine (Quinidex); and reserpine (Serpalan, Serpasil, Serpatab). Tell your CT nurse if you have or have ever had asthma or other lung disease; a slow heart rate; heart or liver disease; diabetes; or an overactive thyroid gland (hyperthyroidism). Tell your CT nurse if you are pregnant, plan to become pregnant, or are breast feeding. You should know that Metoprolol may make you drowsy. Do not drive a car or operate machinery until you know how this medication affects you. Remember that alcohol can add to the drowsiness caused by this medication. Please note that the premedication is not optional. If you are not currently taking a Beta Blocker and your resting heart rate is above 60 beats per minute, please take one tablet at bedtime and one tablet 2 hours before the appointment. If you have any questions or have an allergy to Metoprolol, please contact your physician or CT nurse for other options. I have read, or have had read to me, and understand, the above information. I have had the opportunity to ask questions, and I have had my questions answered to my satisfaction. Patient / Authorized Representative Signature: Witness: Radiologist Viewing Study: Date: Time: am pm

7 PATIENT INFORMATION SHEET Intravenous Injection of Contrast Material Your doctor has scheduled you for an x-ray examination that requires an injection of Contrast Agent into your bloodstream. The Contrast Agents are also called Contrast Medium, Contrast Material, or X-Ray Dye. Contrast Agents are visible with x-ray and CT equipment, and give the Radiologist information that will be used in diagnosing your case. Depending on the type of x-ray study your doctor ordered, the Contrast Medium might be given through a small needle. The needle is placed into a vein, usually on the inside of your elbow, the back of your hand, in your foot, or lower leg. Normally, Contrast media are considered quite safe; however, an injection carries a slight risk of harm, including injury to a nerve, artery or vein, infection, or reaction to the material being injected. Occasionally, a patient will have a mild reaction to the Contrast Agent and will experience nausea, vomiting, sneezing, or hives. These reactions usually pass within a few minutes. Uncommonly, a more serious reaction to the Contrast Agent occurs, and our physicians and staff are trained to treat these reactions. Very rarely, death has occurred related to Contrast Media administration. Our standard practice is to use a non-ionic Contrast Agent. Statistically, the non-ionic agent appears to have a lower incidence of reactions; however, no Contrast Agents are totally free of reaction, even serious ones. Certain patients are at higher risk for experiencing a reaction to the Contrast Agent. Patients who are a higher risk for adverse effects from Contrast Media are: 1. Patients with a history of a previous adverse reaction to Contrast Material; with the exception of a sensation of heat, flushing, or a single episode of nausea or vomiting. 2. Patients with a history of asthma or allergies. 3. Patients with a known heart problem. 4. Patients with generalized severe debilitation. I have read, or have had read to me, and understand, the above information. I have had the opportunity to ask questions, and I have had my questions answered to my satisfaction. Patient / Authorized Representative Signature: Witness: Radiologist Viewing Study: Date: Time: am pm

8 CARDIAC Computed Tomography Angiogram (CTA) Worksheet Patient Name: Appt Date/Time: CTA Order Form: Yes No Pregnancy: Yes No N/A LMP: Allergies (Food/Drug/Environment) & Reaction: Height: Weight: Date of Birth: / / Previous Contrast Allergy: Yes No Pre-medicated: Yes No Labs: Location: Drawn Within 30 Days: Yes No Cr Less Than 1.7? Yes No Diabetic? Yes No Oral Meds: Yes No Date of Last Dose: F/U Labs Ordered: Yes No Asthma? Yes No Vital Signs on Arrival: BP BMI HR IV Location: Gauge By Beta-Blocker Administered: Yes No Time Drug/Dose IV/PO Vital Signs Initials SCAN PARAMETERS Contrast Media Protocol: PO Contrast? Yes No Type Test Bolus: ml/sec Scan Delay Time: sec Tracking Bolus: ml/sec Scan Bolus: ml/sec Scan HR: Saline Chaser: ml/sec Contrast Reaction: Supervising MD: On Call On Site In Suite IV D/C d: F/U call for Diabetics re: labs Signed: CT Technician Registered Nurse