Instructions For Completing The CT Request Form

Transcription

1 Instrutions For Completing The CT Request Form Setion I Referring Veterinarian Information Always inlude YOUR NAME, the HOSPITAL NAME, and a ontat TELEPHONE NUMBER. In the event we have questions about the ondition of the patient or need to disuss the san request, it is very important that we be able to ontat you, or an assoiate familiar with the ase, during the proedure. Setion II CT San Requested Please hoose a CT san from the list attahed, or ontat the UT Veterinary Imaging Servies diretly for assistane in determining whih san you need. Please inlude your presumptive diagnosis/ rule outs for the urrent problem. This will assist the CT tehnologist in providing a omprehensive san and will help the radiologist in interpreting the images. Setion III - CT Report A written report will be sent via or fax the next working day following the san. Please indiate your preferene for how you would like to reeive the report and provide the appropriate address or fax number. The images will be sent with the owner on a CD unless film is speifially requested. Setion IV - Patient Information Pet owner name and ontat information: Please provide the name and ontat information for the pet owner. This will enable us to reate a patient file prior to the time of the appointment. Although all patients reeive a physial examination when they arrive at the enter, it is important for us to know what to expet before they arrive. Please provide as muh information as you an about the patient in this setion. Please inlude the findings of additional testing, i.e. ECG, radiographs, ehoardiography, ontrast studies, bronhosopy, ultrasound, et. Please do not send radiographs with the lient. If the patient is an ARC 4-5, the animal will require a referral to UT-CVM Veterinary Medial Center, for speialized anesthesia are, reovery and aess to ICU. Please note that we are unable to aept referrals for animals not urrently vainated and aggressive animals. Anestheti risk assessment (ARC STATUS): Performing a CT san in animals requires general anesthesia or heavy sedation. Although rare, there are inherent risks and potential ompliations assoiated with anesthesia / sedation and the CT proedure. These inlude, but are not limited to, abnormal reation to anestheti or ontrast agents, organ failure (heart, liver, kidneys), airway obstrution, regurgitation, aspiration of vomitus, gastri dilatation-volvulus (GDV), nerve damage, hypothermia, equipment malfuntion, skin burns, and death. Please assign an Anestheti Risk Classifiation (ARC) to the patient using the instrutions below. This lassifiation will determine what pre-anestheti laboratory tests will be required prior to the san appointment and assist us in formulating an appropriate anesthesia protool for eah individual patient. If the patient is an ARC 4-5, a referral to UTCVM Veterinary Medial Center is required. Please note that blood-work should be no more than 2 weeks old. Veterinary Imaging Servies 2407 River Drive, Knoxville, Tennessee tel: fax: utvett@utk.edu utvett.om vis CT instrutions form

2 Anestheti Risk Classifiation (ARC) ** ARC Desription Examples 1 Exellent 2 Good 3 Fair 4 Poor* 5 Guarded* Apparently healthy No obvious signs of disease Mild systemi ompensated disease Neonatal or geriatri animals (<8 weeks or > 10 years) Moderate systemi disease Severe systemi disease that is a onstant threat to life Moribund patient Not expeted to survive 24 hours Hip dysplasia OCD lesions Vestibular disease Epistaxis Controlled seizures without other neurologi signs Unompliated intervertebral dis disease Low to moderate fever Mild to moderate anemia Chroni heart disease Diaphragmati hernia Moderate dehydration and hypovolemia Controlled seizures with other neurologial signs Anorexia Cahexia Pneumothorax Shok Uremia Severe anemia Unontrolled diabetes mellitus DIC High fever Sepsis Emaiation Severe pulmonary disease Severe dehydration and hypovolemia Deompensated ardia or renal disease Multisystem failure Severe head injury Profound shok Major trauma *ARC 4-5 will require referal to UT CVM Veterinary Medial Center Minimum Required Diagnosti Sreening Aording to Ar and Age ARC < 4 months old 4 months 5 years old > 5 years old 1, 2 PCV, TP, gluose PCV, TP, BUN PCV, TP, BUN, reatinine, USG 3 CBC, anesthesia profile CBC, UA, anesthesia profile CBC, UA, omplete profile 4, 5 CBC, UA, omplete profile CBC, UA, omplete profile CBC, UA, omplete profile PCV = paked ell volume; TP = total protein; BUN = blood urea nitrogen; CBC = omplete blood ell ount (to inlude a white blood ell ount and differential; a red blood ell ount and indies; a platelet ount; and hematorit, hemoglobin and plasma protein measurements); UA = urinalysis (to inlude olor, transpareny, speifi gravity, protein, gluose, ketones, bilirubin, oult blood, urobilinogen, ph, nitrate, and sediment analysis); anesthesia profile (to inlude gluose, BUN, reatinine, AST, ALT and ALP); omplete profile (to inlude gluose, BUN, reatinine, AST, ALT, ALP, albumin, potassium, sodium, hloride, alium, phosphorus, total CO 2, anion gap, total bilirubin and CPK) **Adapted from the Amerian Soiety of Anesthesiologists Physial Status Classifiation Veterinary Imaging Servies 2407 River Drive, Knoxville, Tennessee tel: fax: utvett@utk.edu utvett.om vis CT ar form

3 2407 River Drive Knoxville,Tennessee tel: fax: utvett.om CT San Request Form (please send original form with patient) General information: General anesthesia or heavy sedation is required for all CT examinations. The UT anesthetist will determine whether sedation or anesthesia will be used, depending on the san requested and patient s temperament and linial status. All patients must be fasted over night. We are unable to aept referrals for animals not urrently vainated and for aggressive animals. The san request and the laboratory results should be reeived at least 24 hours prior to the appointment to failitate safe sedation/anesthesia planning. Setion I - Referring Veterinarian Information Please note: It is very important that you or one of your assoiates is available by phone the day of the san. Name Speialty Hospital Name Street Address City State Zip Code Telephone ( ) Fax ( ) address Setion II - CT San Requested Please refer to the list of san regions, or all us for assistane. San requested: Presumptive diagnosis / Rule-outs: Setion III - CT Report A written report will be sent via or fax the next working day following the san. Please indiate your preferene: Fax ( ) Setion IV - Patient Information Refer to the instrution sheet to determine pre-anesthesia required laboratory tests based on ARC status, or all us for assistane. Please note that laboratory values should generally be no more than 2 weeks old. Anestheti Risk Classifiation (ARC): Please irle: Client name Contat number ( ) *Required First name Last name Pet name Speies Breed Weight (kg) Age Sex Relevant linial problems: Current mediations: Previous anesthesia or surgery? Yes No Please omment: Is there any metal in this animal? Yes No Please omment: Is the patient ambulatory? Yes No Please omment: Additional Comments: I agree to allow the UT Veterinary Medial Center to plae the report in its patient reords for future use. ARC 4-5 will require referal to UT CVM Veterinary Medial Center Referring Veterinarian (Signature) Referring Veterinarian (Name, please print) Date vis CT Request A form

4 CT San Regions (please send original form with patient) When filling in the request form, please hoose a CT san from the list attahed, or ontat the UT Veterinary Imaging Servies diretly for assistane in determining whih san you need. Please note that onsultation with the UT Veterinary Imaging Servies is mandatory for all brain and spinal sans. Please inlude your presumptive diagnosis/ rule outs for the urrent problem. This will assist the imaging tehnologist in providing a omprehensive san and will help the radiologist in interpreting the images Presumptive Diagnosis/Differentials: 1. Head Region Brain* 3. Nek Region Cervial soft tissues 5. Abdomen and Pelvi Region Dual phase hepati CT Mandible (liver masses, portosystemi shunts) Other* (explain) Dual phase panreati CT Maxilla (insulinoma) Nose (inluding sinuses) 4. Thorax CT urography (etopi ureter) Skull Lungs metastasis hek Adrenal glands Orbits Lungs pulmonary mass Intra-abdominal mass (explain) Temporomandibular joints Chest wall Pelvis Tympani bullae Mediastinum Abdominal wall Other* (explain) Pulmonary CT angiography (PTE) Other* (explain) 2. Spine Spine down Dahshund* Spine other* (explain) Lumbosaral spine* Other* (explain) Other* (explain) 6. Orthopedis Sapula/Shoulder (left/right) Elbow (left/right) Carpus (left/right) Hip (left/right) Stifle (left/right) Tarsus (left/right) Referring Veterinarian (Signature) Date Long bone (speify) Other* (explain) * These sans require onsultation with the UT Veterinary Imaging Servies Veterinary Imaging Servies 2407 River Drive, Knoxville, Tennessee tel: fax: utvett@utk.edu utvett.om vis CT Request B form

5 How to Prepare Client Instrutions Diagnosti imaging requires that the patient remains extremely still for a period of time. For this reason, it is neessary that your pet undergoes heavy sedation or general anesthesia. To prepare for this, all food, inluding treats, should be withheld starting at 10:00 p.m. the night before the examination; moderate amounts of water are allowed overnight. Water should be removed by 6 a.m. Depending on your pet s medial ondition, heavy sedation / anesthesia and CT imaging may involve some risks. This will be disussed with you in detail during the admission proess. During the admission proess, we will be happy to answer any questions you might have regarding the CT proedure. We will also ask that you sign a onsent form for the proedure, inluding the administration of sedation or anesthesia. You are welome to wait in the reeption area during the san proess, or, for your onveniene, you an leave your pet with us and shedule a time to return after the examination. If you hoose to leave the enter, please make sure our staff knows how to ontat you in the event of a question or sheduling hange. Please make arrangements to pik your pet up at the sheduled time. The CT Examination Proess 1. Your pet will undergo a physial examination in preparation for heavy sedation or anesthesia. 2. An intravenous atheter will be plaed in a leg vein for the administration of anestheti agents and ontrast media. Note: Preparation for the atheter requires hair lipping at the site; a small area on your pet s hest may also be shaved to plae a path that monitors heart rate. 3. Your pet will then be moved to the imaging suite, positioned, and sanned while under heavy sedation or anesthesia. 4. After the CT san is ompleted, your pet will be brought to a reovery room, where it will be allowed to wake up from sedation or anesthesia. Shortly thereafter your pet will be ready to go home. 5. The CT examination will be interpreted by a board-ertified veterinary radiologist. The written report will be sent to your referring veterinarian the next business day. 6. The typial length of a CT san is minutes, depending on the area sanned. However, individual animals vary in their reovery time. You should plan on leaving your pet with us between 4 8 hours. After the Exam A pressure bandage will be plaed on your pet s leg when the intravenous atheter is removed to prevent bleeding at the site. Be sure to remove this bandage after one hour. It is normal for pets to be quiet following general anesthesia or heavy sedation. One home, you may offer your pet small amounts of water. If no stomah upset is noted, this may be followed by a light meal. Although unommon, some pets may experiene a mild ough for several days following their anesthesia. If you observe any unusual behavior, or have any onerns, ontat your veterinarian immediately. Animals having been under anesthesia may behave in an unpreditable manner for hours following reovery. Animals may bite if onfused or startled: use aution during this time and keep pets away from young hildren. You will need to shedule an appointment with your veterinarian to disuss the results of the CT examination. Veterinary Imaging Servies 2407 River Drive, Knoxville, Tennessee tel: fax: utvett@utk.edu utvett.om vis CT CLIENT INSTRUCTION form

6 Consent for Anesthesia and Computed Tomography (CT) Proedures (please send original form with patient) I am the owner/agent for _ (name of patient) and have authority to exeute onsent for the diagnosti proedure known as Computed Tomography (CT). I understand that anesthesia or heavy sedation is required to perform CT. The reasons for this proedure, advantages and possible ompliations have been disussed with me. With full understanding of the above, the undersigned owner/agent authorizes the veterinary anesthetist at the UT Veterinary Imaging Servies to administer any sedative or anestheti deemed advisable for the CT proedure. Should further lifesaving proedures be deemed neessary by the attending veterinarian due to any unexpeted life-threatening emergeny, I onsent to these proedures and their additional osts. I understand that my veterinarian has determined that a CT proedure would be of assistane in treating my animal and has hosen the proedure to be performed by the University of Tennessee Veterinary Imaging Servies. Advaned diretives: In the rare event of a ardia arrest, the following response is authorized by me: (initials) q Do not resuitate q External resuitation q Invasive resuitation I have read and understand this authorization and onsent. Patient Name Owner / Agent (Please print) Owner / Agent Signature Witness UTCVM VMC PTN (for offie use only) Contat phone number during appointment Date Date Veterinary Imaging Servies 2407 River Drive, Knoxville, Tennessee tel: fax: utvett@utk.edu utvett.om vis CT OWNER CONSEnt form

7 Owner information (please send originals with patient) Client Information Name Phone number where you an be reahed during proedure ( ) Referring s Veterinarian Information Dotor s Name Pratie Name Patient Information Pet s name Desribe patient s problem: Does your pet have a mirohip? Yes No Is there any known metal in your pet (e.g. due to previous surgery et.)? Yes No If yes, please explain: Has your animal eaten anything sine 10 p.m. last night? Yes No Patient s urrent mediations: Mediation # of pills or milligrams How often? (1x/d, 2x/d, et.) What time would you like to pik up your pet? Have you reeived the Client Instrutions? Yes No Note: Your pet may be shaved in three areas in preparation for the san: 1) the leg for an IV atheter, 2) the hest for heart monitoring and 3) foot for blood pressure monitoring Veterinary Imaging Servies 2407 River Drive, Knoxville, Tennessee tel: fax: utvett@utk.edu utvett.om vis CT owner information form