Gastroenterology Associates of Pittsburgh Pittsburgh, PA ...

[Pages:16]Gastroenterology Associates of Pittsburgh T. Jan Ravi, M.D.

Andrew W. Thomas, M.D. Frank J. Koziara, II M.D. 3285 Babcock Blvd

Pittsburgh, PA 15237-2829

Phone: (412) 318-0075 Fax: (412) 318-0081

PLEASE READ ALL OF THE INSTRUCTIONS BEFORE BEGINNING THE TEST PREPARATION

THESE DIRECTIONS ARE FOR: Flexible Sigmoidoscopy OR

Flexible Sigmoidoscopy/Endoscopy on the same day

You are scheduled at ALLEGHENY HEALTH NETWORK, WEXFORD SURGERY CENTER -- 12311 Perry Highway, Wexford, PA 15090. Enter this facility through the main entrance and take the main elevators to the 2nd floor. If you are unable to keep this appointment for any reason, please notify our office at 412/318-0075.

DAY BEFORE THE TEST: NO SOLID FOOD (unless otherwise noted by the physician)!!! DRINK ONLY CLEAR LIQUIDS!!! YOU MAY CONTINUE TO HAVE CLEAR LIQUIDS UNTIL 6 HOURS PRIOR TO YOUR ARRIVAL TIME.

CLEAR LIQUID DIET LIST BEVERAGES/SOUPS/DESSERTS Water, tea or coffee (no milk or non-dairy creamer) - Adding sweeteners is okay Low sodium chicken or beef bouillon/broth Hard candies - NO RED or PURPLE Soft drinks (7-up, cola, ginger ale, Sprite), Gatorade, Kool-aid, lemonade -- NO RED or PURPLE Jell-O (lemon, lime or clear) -- No fruit toppings/NO RED or PURPLE Strained fruit juices without pulp (i.e. apple, white cranberry, white grape) Popsicles - No sherbets or fruit bars/NO RED or PURPLE

ON THE DAY OF YOUR TEST: Take all of your medications except those listed below. Use as little water as possible and take your medications as early as possible.

FIVE DAYS PRIOR TO OUR TEST: DO NOT TAKE iron pills. ONLY AFTER OUR OFFICE HAS CONFIRMATION FROM YOUR PRIMARY CARE PHYSICIAN, PLEASE DISCONTINUE the following medications that can cause bleeding: Coumadin (Warfarin), Arixtra, Fragmin, Plavix, Clopidogrel, Aggrenox, Effient, Mobic, Pradaxa, Xarelto, Ticlid, or Aspirin 325mg. Please advise our office if you are taking one of these medications or another blood thinner which is not listed above.

TWO DAYS PRIOR TO YOUR TEST: Discontinue ALL fiber supplements, which would include Metamucil, Citrucel, Fiberall, Benefiber, etc. AVOID foods with small seeds such as tomatoes, sesame seeds, kiwi and cucumbers.

DIABETICS: Please contact your primary care physician for instructions on how to take your diabetes medication.

It is very important to drink liquids during the bowel preparation process. You will lose a significant amount of fluid, which is normal. It is very important that you replace this fluid to prevent dehydration.

No laxative preparation is fun. You must complete all of the preparation for the test. If you are unable, contact our office to reschedule your appointment. Your test will be cancelled if your preparation is inadequate. Please follow each instruction exactly as written.

NO DRIVING: You cannot drive, use a taxi, or a bus after the procedure. You must be accompanied by an adult who must remain with you at the hospital while your procedure is being done. According to the hospital regulations, someone must remain with you after the procedure for 24 hours. If you cannot make these arrangements, please notify the office and we will reschedule your appointment.

For women, if you are having a menstrual period, it is ok to wear a tampon.

Gastroenterology Associates of Pittsburgh

MAGNESIUM CITRATE FLEXIBLE SIGMOIDOSCOPY PREPARATION

This is an over-the-counter product and can be found in the laxative section at any store. Follow the steps listed below - NOT THE INSTRUCTIONS ON THE BOTTLE

ON THE DAY BEFORE YOUR TEST: Remain close to the bathroom. Drink only clear liquids for breakfast, lunch and dinner unless otherwise directed by our office.

Drink one 10 - ounce bottle at 9:00 PM Drink one 10 - ounce bottle at 11:00 PM

Many patients find that soft toilet tissue, such as Charmin Plus, minimizes anal irritation from repeated wiping. For additional comfort, rub a small amount of hydrocortisone cream around the anal area to lessen the irritation.

For the rest of the evening before your test, DRINK ONLY CLEAR LIQUIDS TO KEEP YOURSELF WELL HYDRATED. Plan to remain within easy reach of toilet facilities. Alcoholic beverages are prohibited during this preparation. If you develop vomiting during the prep, temporarily stop for one hour and resume. If vomiting persists, stop the prep and call our office for instructions.

***YOU MAY CONTINUE TO HAVE CLEAR LIQUIDS UNTIL 6 HOURS PRIOR TO ARRIVAL TIME.***

ON THE DAY OF YOUR PROCEDURE: 1. Do not eat or drink anything. You may brush your teeth. 2. If you take medication, you may take it on the morning of the procedure with a small amount of water. 3. On the day of your exam, wear comfortable easily removable clothing and leave jewelry and other valuables at home.

Please complete & bring with you the

next 12 pages

of attached information to your appointment

GASTROENTEROLOGY ASSOCIATES OF PITTSBURGH HEALTH HISTORY FORM - PRE/OP VISIT DR. T. JAN RAVI DR. ANDREW W. THOMAS DR. FRANK J. KOZIARA, II MANEESHA A. WALKER, PA-C KRISTEN M. ZON, PA-C

Today's Date:

/ /

Name: Chief Complaint:

DOB:

AGE: SS#:

How long have you had this problem?

FOR PATIENT USE: Please check off any problems or symptoms

FOR DOCTOR'S USE:

Weight:

Height:

General Appearance:

Temperature:

Marital status: B/P:

Mitral Valve Prolapse Rheumatic Fever Diabetes Hypertension Congestive Heart Failure Chest Pain/Angina Heart Attack Anxiety Fatigue Gallbladder

Gastric/Duodenal Ulcer Liver Disease Gastric Polyps

Colon Polyps Difficulty Swallowing

Weight loss/gain Rectal Bleeding Constipation Diarrhea/Loose Bowels

Rectal Pain Nausea Vomiting Indigestion/Heartburn Hemorrhoids

Anemia Change in bowel habits

PHYSICIAN REVIEW COMMENTS ON CC: PHYSICIAN REVIEW COMMENTS ON PMH: (HPI: LOCATION, QUALITY, SEVERITY, DURATION,TIMING, CONTEXT, MODIFYING FACTORS, ASSOC SIGNS/SYMPTOMS)

Have you had any previous testing for the above problems or symptoms?

NAME: FOR PATIENT USE: PAST SURGICAL HISTORY:

DATE: FOR DOCTOR'S USE: PHYSICIAN COMMENTS ON PSH:

PAST MEDICAL HISTORY:

PHYSICIAN COMMENTS ON PMH:

PLEASE LIST THE MEDICATIONS YOU ARE CURRENTLY TAKING:

PHYSICIAN REVIEW OF MEDICATIONS:

NAME: ALLERGIES TO MEDICATIONS

DATE: PHYSICIAN REVIEW OF PATIENT ALLERGIES:

SOCIAL HABITS: Smoke: Packs daily Caffeine: Drugs/Alcohol use" Sleep pattern

FAMILY HISTORY:

How long?

PHYSICIAN REVIEW OF SOCIAL HABITS: PHYSICIAN REVIEW OF FAMILY HISTORY

FOR DOCTOR'S USE: (staff or patient may document)

REVIEW OF SYSTEMS: + - OR NA

EYES

ABNORMAL

? Visual Disturbances

No _Yes

ENT ? Auditory disturbances ? Sinus Problems

_No No

ABNORMAL Yes Yes

CARDIO ? Hypertension ? Palpitations ? Chest pain ? Rheumatic fever ? Murmurs ? Mitral Valve Prolapse

RESP ? Shortness of Breath ? Asthma ? Sleep Apnea ? Cough

GU ? Frequency ? Dysuria ? Incontinence ? PSA

GI ? As per presenting problem

oc0000

4ZZ 4

1 111Z141

Yes Yes _Yes Yes Yes Yes

_No No No No

Yes _Yes

Yes Yes

No

Yes

No

Yes

No

Yes

No _Yes

ABNORMAL

ABNORMAL ABNORMAL ABNORMAL

MUSCULOSKELETAL

? Muscle Pain or Weakness

No

? Joint Pain

No

SKIN ? Rashes or itching

_No

Yes _Yes

ABNORMAL

ABNORMAL _Yes

NAME:

NEURO/PSYCH ? Headaches ? Seizures ? CVA's ? Depression ? Anxiety ? Sleep Disturbances

cooco o 4ZZZZZ

1 1 1 1 11

Yes _Yes _Yes

Yes Yes Yes

ABNORMAL

HEME ? History of transfusions ? Anemia ? Bleeding problems

No _No _No

_Yes _Yes _Yes

ABNORMAL

GENERAL ? Weight loss ? Decreased appetite ? Fever/night sweats/chills

_No

No No

___YYYeeesss

ABNORMAL

GYN ? Endometriosis ? LMP ? Mammogram/PAP

ABNORMAL

No _Yes

No

Yes

No _Yes

PHYSICAL EXAMINATION:

EYES

CLEAR CONJUNCTIVA, ANIECTERIC SCLERA, PEARLLA

EARS, NOSE, THROAT NECK GASTROINTESTINAL

CARDIOVASCULAR

TM'S INTACT, NO PHARYNGEAL CONGESTION

SUPPLE, NO MASSES, THYROID WITHIN NORMAL LIMITS, PALPABLE CAROTID ARTERIES, NO BRUITS

ABD SOFT -- NON-TENDER, NORMOACTIVE BOWEL SOUNDS, NO ORGANOMEGALY, ABNORMAL PULSATIONS OR MASSES, NO INGUINAL HERNIA OR LYMPHADENOPATHY, GOOD SPHINCTER TONE, NO MASSES/ HEMORRHOIDS, TENDERNESS OR ASCITES

REG RATE/RHYTHM, NO MURMURS, RUBS/GALLOPS, EXTERMITTES -- NO CLUBBING/ CYANOSIS OR EDEMA

RESPIRATORY PSYCH/NEURO

LUNGS CLEAR TO AUSCULTATION/PERCUSS, GOOD AIR EXCHANGE, SYMMETRICAL, EXCUSTON

AWAKE, ALERT, ORIENTED / PATIENT'S JUDGEMENT & INSIGHT, MOOD, CRAINIAL NERVES GROSSLY INTACT

SKIN

WITHOUT RASHES, LESIONS, ULCERS, NODULES, GOOD SKIN TURGOR

LYMPHATIC SYSTEM

EXAMINATION OF ORGANS AND NODES

ALL OTHERS NEGATIVE

DATE:

ABNORMAL: ABNORMAL: ABNORMAL: ABNORMAL:

ABNORMAL: ABNORMAL: ABNORMAL ABNORMAL ABNORMAL ABNORMAL

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