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Medical Imaging Renaissance Radiology 401 E. Highland Ave. (909) 883-8711 ext. 3633 (909) 881-7650 Patient Name: Date of Birth: Gender: M Exam History: SS #: Referring Physician: Physician Signature: X-RAY R L R L R L R L R L R L R R R R R R R L L L L L L L R R R R L L L L R L R L R L R R R R L L L L Abdomen Series - Acute Abdomen/KUB AC Joints Ankle Ankle - Ltd. Calcaneus Cervical Spine C-Spine - Ltd. Chest-1 view Chest-2 view Clavicle Elbow Elbow - Ltd. Facial Bones Femur Fingers Foot Foot Ltd Forearm Hand Hand - Ltd. Hips - Bilateral Hip Humerus Knee Ltd Knee Lumbar Spine L-Spine - Ltd. L-Spine Flex/Ext. Nasal Bones Paranasal Sinuses Pelvis AP Ribs-Unilat. w/ CXR Ribs-Bilat. w/ CXR Sacroiliac Joints Sacrum / Coccyx Scoliosis Study Shoulder Arthro-Shoulder Skull - Ltd. Skull Sternum Thoracic Spine Thoracolumbar Spine Tibia/Fibula Toes Wrist Wrist - Ltd. 74022 74000 73050 73610 73600 73650 72050 72040 71010 71020 73000 73080 73070 70150 73550 73140 73630 73620 73090 73130 73120 73520 73510 73060 73560 73562 72110 72100 72120 70160 70220 72170 71101 71111 72202 72220 72090 73030 73040 70250 70260 71120 72070 72080 73590 73660 73110 73100 MRI Barium Enema IVP Esophagram Cine Esophagram Upper GI UGI & Small Bowel UGI w/air contrast VCUG Bone Survey 74270 74400 74220 74230 74240 74245 74247 R L 74450 R L 77075 R L ULTRASOUND R L R L R L R L ICD -9 or narrative: F Abd Ltd-single organ Abdomen Art. Doppler - Extremity Art. Doppler – Extem Ltd Bladder Breast Carotid Duplex - bilateral Chest Echoencephalogram Extremity – non vascular Fetal Profile - biophysical Follicular Pelvis – non OB Preg OB < 14 wks Preg OB > 14 wks Preg OB-Ltd. Retroperitoneum/Renal Retroperitoneum - Ltd. Scrotum/Testicular Soft Tissue Head/Neck Transplant Kidney - Ltd. Transvaginal U/S Guided Biopsy Ven Doppler - Extremity Ven Doppler - Extem Ltd 76705 76700 93923 93926 76857 76645 93875 R L 76604 R L 76506 R L 76881 76818 76857 76856 76801 76805 76815 76770 76775 76870 76536 76775 76830 76942 93965 93971 MAMMOGRAPHY Mammo Screening Mammo Diagnostic R L Mammo Post Bx - unilat. Mammo Needle Plcmt. G0202 G0204 G0206 77032 STEREOTACTIC Stereo Biopsy Stereo Clip Vac Imaging 77031 19295 19103 DEXA SCAN DXA 1/1+ sites DXA Forearm IVC Vertebrae Assmt. 77080 77081 77082 Abdomen w/wo Abdomen w/o (MRCP) Brain w/wo Brain w/o C-spine w/wo C-spine w/o Lower Extrem. joint w/o Lower Extrem. w/o Lower Extrem. w/wo L-Spine w/wo L-Spine w/o Orb/Face/neck w/wo Pelvis w/wo Pelvis w/o T-spine w/wo T-spine w/o Upper Extrem. joint w/o Upper Extrem. w/o Upper Extrem. w/wo Abdomen angio w/o Brain angio w/o Low Extrem. angio - bilat. Neck angio w/o CT 74183 74181 70553 70551 72156 72141 73721 73718 73702 72158 R L 72148 R L 70543 72197 72195 72157 72146 73221 73218 73220 C8901 70544 C8912 70547 NUCLEAR MEDICINE Bone Image - Ltd. Bone Image - 3 phase Bone Image - whole body Cardiac Blood pool - multi Cisternogram Gastric emptying Hepatobiliary (HIDA) scan I -131 Thyroid Mets - WB I -131 Thyroid Therapy Indium - 111 Leukocytes Lymph sys - Sentinel node Octreoscan – whole body Parathyroid imaging Pulmonary Vent/Perf scan Renal flow/fu w/o Rx Renal flow/fu w/ Rx Renal flow/fu - multi Galium Loc Myocard Spect – single Myo Spect - multi no/gate Myocard Spect multi gated Myocard planar - multi Thyroid - scan only Thyroid uptake & scan Thyroid uptake - single 78300 78315 78306 78473 78630 78264 78226 78018 79005 78806 78800 78802 78070 78582 78707 78708 78709 78805 78451 78452 78452 78454 78010 78007 78006 Abdomen w/ Abdomen w/o Abdomen w/wo Abdomen / Pelvis w/o Abdomen / Pelvis w/ Abdomen / Pelvis w/wo C-Spine w/o C-Spine w/ CT Guided Biopsy Extrem. - Upper w/o Extrem. - Lower w/o Brain w/o Brain w/wo L-Spine w/ L-Spine w/o Maxillofacial w/o Maxillofacial w/ Pelvis w/ Pelvis w/o Pelvis w/wo Soft Tissue Neck w/ Soft Tissue Neck w/wo Temp Bones (IAC) Thorax w/ Thorax w/o Thorax w/wo T-Spine w/ T-Spine w/o Head angio w/wo Heart angio w/wo Abdomen angio w/wo Abd angio w/run-off Chest angio w/wo Neck angio w/wo Pelvis angio w/wo Call for appointments for all exams other than routine diagnostic x-rays. Please arrive 30 minutes before your appointment for check in. Exam appointment Date/Time: ___________, ______ AM/PM. Call back number for STAT examination: ______________________ Please Fax completed Imaging Requisitions to: (909) 881-4439 OTHER 74160 74150 74170 74176 74177 74178 72125 72126 77012 73200 73700 70450 70470 72132 72131 70486 70487 72193 72192 72194 70491 70492 70480 71260 71250 71270 72129 72128 70496 75572 74175 75635 71275 70498 72191 Instructions for Medical Imaging Examinations Barium Enema; Adult preparation: • • • • • The day before the examination, have a clear liquid lunch. Clear liquids include: Jell-O, bouillon, apple juice, etc. No dairy products. Beginning at 4:00 p.m., the day before the examination, follow the instructions found in the evacuation kit. Drink a minimum of 8 oz. of fluid, every hour until 10:00 p.m. Nothing by mouth after 10:00 p.m. until your appointment. Two hours before you leave for your scheduled appointment, follow the instructions found in the Fleets Enema Kit. If you regularly take medication in the a.m., they may be taken with a small amount of water. UGI Series: • Nothing by mouth 4 hours before the appointment time. Intravenous Pyelogram (IVP) kidneys: • • • • The day before the examination, have a clear liquid lunch. Clear liquids include: Jell-O, bouillon, tea, apple juice, etc. No dairy products. Beginning at 4:00 p.m. the day before the examination, follow the instructions found in the evacuation kit. Drink a minimum of 8 oz. of fluid, every hour until 10:00 p.m. Nothing by mouth after 10:00 p.m., or four hours before your appointment. If you regularly take medicine in the a.m., please contact the Medical Imaging department for instructions. CT Abdomen/Pelvis scans: • • • • (Liver, pancreas, kidney, spleen, aorta, adrenals and gallbladder): Have the patient pick-up the prep kit from Radiology (oral contrast) before the scheduled appointment. If the patient is unable to pick up the prep, call the department for instructions. NPO (nothing by mouth) 4 hours before the CT examination. Drink at least 2 or 3 eight ounce glasses of fluids the night before. Administer the prep kit two hours before the scheduled appointment time. CT Chest scans: • • • (Thorax, Mediastinum, Hilum, apex, etc.) Drink at least 2 or 3 eight ounce glasses of fluids the night before. NPO (nothing by mouth) 2 hours before the CT examination Bring in a most recent chest films or CD (if done elsewhere); indicate on the schedule where patient had the images taken. CT Head scans: (Brain, posterior fossa, facial bones, orbits, temporal bone, Sella, pituitary, etc.) • • Drink at least 2 or 3 eight ounce glasses of fluids the night before. NPO (nothing by mouth) 2 hours before the CT examination CT Spine scans: (cervical, thoracic, lumbar, etc.) • Have patient arrive 30 minutes before the appointment. Ultrasound OB or pelvic examinations: • • • • Empty your bladder two hours before your exam. Start and finish drinking 32 ounces of water within the first hour. Transvaginal patients should have empty bladders Do not void until after your exam is completed. Ultrasound Abdomen: • Nothing by mouth 6 hours before the appointment time. MRI Abdomen (MRCP): • Nothing by mouth 6 hours before the appointment time. Please call St. Bernardine Medical Center’s Medical Imaging Department at (909 883-8711, ext 3790) for questions relating to your examination.
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