{"text":"m\\\\\\m\\m\\u\\\\w\\m\\m\\\\m\\m\\'\\ | \nRADIOLOGY e \nConsultant: MOUV\\\/ \nM\/F: CHLI: \n10338654X RIS: \nCLELLAND 09\/09\/195; Title: Ward\/Dept. \nAGNES, Hosp. no. : \n39 Rennie Road P Copy to: \nJ 1syth \u2019 \u2018 \n; E;A:\u00e9gw G65 97Q Date of birth: \n-0809555328 \n; CHI-08 Walking: Should this patient Y \n. : fl;ha\"if: \"be handled as N \n' : ila. | Troley: \u2018at risk'?* \nPostcode: ..or attach label | Daytime telephone or mobile: | vpie Details: \nAmbulance*; \nDrip: \nOxygen: ) \nTy ati i . . URGENCY*: Pregnancy rule*: \nInvestigation required: Same day: | Overrule: \u2018 \nC\/f ( \\\/' \\ 5 . Days: Observe: 10d \n> _ - { Weeks: 28d \nClinical summary (to include indication and purpose of examination\/intervention under IR(ME)R 2000*)\u2019 \nYy \nOffice use only: \nDate received: \nPreparation: \n- Fast: Full bladder: Laxative: \nOral contrast: No prep: \nUrgency: Initials: \nIf requesting barium, CT, VU, 'angiogr\u00e9phy\/intewention or MRI studies or your patient has | IRIMER Justification: Initials: \ndiabetes\/renal impairment, please complete details below. \" (Sections marked * see notes overleaf) [YES[ | NO l:l Designation: \nName: Designation: Telephone\/page: | Signature: Date: \nDIABETICS\/RENAL IMPAIRMENT: - SAFETY QUESTIONAIRE: MRI SAFETY QUESTIONAIRE: \nFor diabetics and those with renal \nimpairment, contrast medium may \nbe nephrotoxic. For IVU, CT and \nangiographic procedures, please record \nfatest creatinine result: \n\u2018. . \nte of result: 8JWN J.OOX \nw mol\/l \nPrevious contrast reaction: \nANTICOAGULANTS\/COAGULOPATHY*: \nFor invasive procedures it is important \nto ensure a normal coagulation. \nAnticoagulant drugs should be stopped \nbeforehand and defects corrected. A \n\" coagulation screen must be performed: if \nthere is a history of coagulopathy, \nanticoagulant use or if the:intervention \ninvolves the puncture of.solid organs \n(eg liver, kidney, etc.). \nPlease record the latest coagulation- \nscreen\/INR result: \nDate.of result: - \"y . \nPlease complete for all contrast \nexams by circling \n(except MRI): \n@ \nY \n& \n0 \nKnown alIergieS: ' \nSevere asthma: \nDiabetes: \n()n Metformin*: \nKnown renal disease: \nKnown vascular disease: Y \n- \n\u00ae \n@ \n\u00ae \nOn Warfarin: Y \nPlease complete by circling: \nPrevious surgery to the heart: \nDo\u00e9s patient have a pacemaker? Y \nPrevious surgery to the head: \nAny history of metal in the eyes: Y \nY N \nN \nY N \n\"N \nIf \u2018Yes\u2019 to any of the above, give details \nand telephone MRI 20(1)3623 for \nadvice: \nIf \u2018Yes\u2019 to\u201cany of thie above, glve \ndetails: \n\u00a5 \nUSEFUL TELEPHONE NUMBERS: \nReception (Plain film,US, Barium): 13625 \nReport & Film Requests \u00b0 13624 \nA&E Radiology: .. 13630 . \nCT enqiries:\u201d -\u2019 13638 \nMRI enquiries: 13623 \nReports are only available online, via the RIS. \nTo obtain a password, contact 14169. \nCT\/MRI PROTOCOL: \n1. \nOffice use \u00e9mly: \nI}BPO\u2019 INTMENTS: 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