Microsoft Word - pillcam forms packet word

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PATIENT INSTRUCTIONS

PillCam ™ Capsule Endoscopy Magnesium Citrate

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Dear Patient:

Procedure Date

Arrival Time

Return to Office at

Today’s date:

Ordering Doctor

Location: 2

Floor Office Endoscopy Center of Red Bank



Location: 1

Floor Office Red Bank Gastroenterology

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FIVE (5) DAYS BEFORE your (Pill Cam) procedure; Stop Oral Iron Medications, Please check your

multivitamin for IRON (Fe). Take your last oral iron supplement on . You may resume your iron after

your procedure. Purchase a bottle of an over the counter product Citrate of Magnesia. (CLEAR ONLY) This

usually comes in 8 0r 10 ounce bottles. You will need 4 ounces of it.

THE BUSINESS DAY BEFORE your (Pill Cam) procedure; Please call before you start your prep, to

confirm your appointment (and to confirm insurance prior authorization if required). Should you have any

questions or need to reschedule, please call nurses Bonnie 732.936.8305 or Melissa 732.936.8318 at anytime.

Please note: Only if your insurance requires a “referral”, please obtain one from your primary doctor, we’ll

need a copy of it.

THE DAY BEFORE your (Pill Cam) procedure;

1. DIET: LIGHT BREAKFAST consisting of a soft cooked or scrambled eggs, toast without seeds, butter,

strained soups, cream of wheat, French toast, pancakes with butter and plain syrup, mashed potatoes, pasta

with butter or parmesan cheese, smooth yogurts without fruit, Jello, puddings, sherbets, smooth applesauce,

smooth peanut butter, and liquid nutritional supplements. No substitutions please.

2. DIET: CLEAR LIQUID LUNCH & DINNER for the remainder of the day. No red or purple colors as they

may look like blood. No coffee, no cola, and no milk. (See attached) * If you are a Diabetic, check with the

doctor who manages your diabetes about fasting/diabetes meds. Please see * below.

3. Between 5 – 7 PM the evening before your procedure, DRINK FOUR (4) ounces of Citrate of

Magnesia. Follow this with 3 more glasses of any clear liquid. You may drink clear liquids until 10PM.

4. 10:00PM: NOTHING to eat or drink except for with a sip of water for necessary medications either two

(2 )hours before you swallow the pillcam or two ( 2) hours after you ingest it.

*DIABETICS: Please check with the doctor who manages your diabetes about fasting/diabetes meds. Two (2)

hours after ingesting M2A pillcam you will have clear liquids. Four (4) hours after ingesting the pillcam you

can have solid food (a “light” lunch).Type 1 Diabetics: Check with your Endocrinologist regarding your

insulin. You may be instructed to take ½ your insulin. Type 2 or insulin dependent Diabetics: Do NOT take

your oral diabetes medication while on your clear liquid diet/ fasting. Please monitor your blood sugar level.

5. Medications that you are on for heart, blood pressure, or breathing should be taken (including the

morning of your procedure) with small sips of water only.

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THE DAY OF your (Pill Cam) procedure; Dress in loose, 2 piece (a sweat suit or a button-down works

well but not necessary) comfortable clothing.

6. Male patients; it may be necessary for us to trim body hair in order for lead stickers to adhere, see attached

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7. PLEASE BRING THIS ENTIRE PACKET WITH YOU ON THE DAY OF YOUR PROCEDURE. Thank you.

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Sincerely, Bonnie Woodward RN 732-936-8305

Melissa Agosto LPN 732-936-8318

Rev 5/27/15

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RedBankGastroenterologyAssoc.,•365BroadStreet,Suite1E,RedBankNewJersey07701•732‐842‐4294•Fax732‐548‐7408

EndoscopyCenterofRedBank•365BroadStreet,Suite2E,RedBank,NewJersey07701•732‐842‐9129

Website - www.rbgastro.com

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365 Broad Street, Red Bank, NJ 07701

T: 732-842-4294 T: 732-842-9129 F: 732-548-7408

www.rbgastro.com

CLEAR (TRANSPARENT) LIQUID DIET

This diet provides fluids that leave little residue and are easily absorbed with minimal

digestive activity. This diet is inadequate in all essential nutrients and is recommended

only if clear liquids are temporarily needed.

No Red or Purple liquids (they may look like blood) and you may not have coffee,

milk or anything opaque. Alcoholic beverages are not permissible.

YOU MAY HAVE: YOU MAY NOT HAVE:

Beverages

1. Apple juice

2. Clear (white) cranberry/grape juice

3. Crystal Light®

4. Lemonade

5. Soda, Sprite, ginger ale, seltzer

6. Sports drinks

7. Tea, hot and iced

8. Transparent coconut water

9. Transparent protein drinks

10. Water

Clear Broth

1. Chicken, beef, vegetable

2. Bouillon

3. Broth

4. Consommé

Desserts

1. Lemon popsicles

2. Lemon ices

3. Favored gelatin “Jello®”

(No red or purple flavors, No fruit chunks)

Miscellaneous

1. Sugar, honey, syrup

2. Clear, hard candy

3. Salt

You may brush your teeth or use mouthwash.

Please do not swallow any liquids

Red, purple colors, coffee,

milk or anything opaque.

Alcoholic beverages of any

kind are not permitted.

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CAPSULE ENDOSCOPY

(PILL CAM) INS

RUCTIONS

DAY OF PROCEDURE

WHAT TO DO TODAY

1. Afteringestingthecapsule,donoteatordrinkfor2hours. After2hoursyoumayhave

After4hours,youmayhavelunch. Werecommendsoupand½sandwich. Ifyouareasmoker,you

maysmokeagainafter4hours.

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2. Contactusifyouareexperiencinganyabdominalpain,nausea,orvomitingduringcapsuleendoscopy.

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3. Afteringestingthepillcamcapsule,anduntilitisexcreted,youshouldnotbenearanysourceof

powerfulelectromagneticfields,suchasanMRIoramateur(ham)radio.

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4. CapsuleEndoscopylastsapproximately8hoursandisconsideredcompleteaccordingtoyour

physician’sinstructions. Donotdisconnecttheequipmentorremovethebeltatanytimeduringthis

period. SincetheDataRecorderisactuallyasmallcomputer,itshouldbetreatedwiththeutmost

careandprotection. AvoidsuddenmovementandbangingoftheDataRecorder,orgettingitwet.

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5. DuringCapsuleEndoscopy,youwillneedtoverifyevery15minutesthatthesmalllightontopofthe

DataRecorderisblinkingtwicepersecond. If,forsomereason,itstopsblinkingatthisrate,record

thetimeandcontactnurseBonnie732‐936‐8305ornurseMelissa732‐936‐8318.

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6. Avoidanystrenuousphysicalactivity,especiallyifitinvolvessweating,anddonotbendoverorstoop

duringCapsule Endoscopy.

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7. Returntotheofficeat .

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8. Thecapsuleisdisposableandpassesnaturally. Youshouldnotfeelanydiscomfortwhenthecapsule

passes.

 Pleasenotifyusif,afterthetest,youdevelopfeverorincreasingchestorabdominalpain.

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365 Broad Street, Red Bank, New Jersey 07701 • 732-842-4294 • F 732-548-7408 • www.rbgastro.com

clear liquids.

. .

IMAGING

Sensor

Location

Guide

For

Small

Bowel

Capsule

Endoscopy

Intersection

right

7th

intercostal

space

and

right

mid-clavicular

line

Xiphoid

process

Intersection

left

7th

intercostal

space

and

left

mid-clavicular

line

Right

lumbar

region

umbilical

level

Above

Umbilicus

(Navel)

Left

lumbar

region

umbilical

level

Right

mid-inguinal

region

Left

mid-inguinal

region

English

DOC-034O-o1

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CONSENT FORM

I CONSENT TO HAVING A CAPSULE ENDOSCOPY

Capsule endoscopy is a new method of examining the small intestine. It is not intended

to examine the esophagus, stomach, or colon. It does not replace upper endoscopy or

colonoscopy.

I understand that there are reports of the capsule getting caught in narrowed segments of

bowel, a BOWEL OBSTRUCTION. An obstruction may require immediate surgery.

I am aware that I should avoid MRI machines during the procedure and until the capsule

passes following the exam.

I state that I do not have a cardiac pacemaker or an implanted defibrillator.

I understand that due to variations in a patient’s intestinal motility, the capsule may only

image part of the small intestine. It is also possible that due to interference, some images

may be lost and this may result in the need to repeat the capsule procedure.

I understand that images and data obtained from my capsule endoscopy may be used,

under complete confidentiality, for educational purposes in future medical studies.

As part of the capsule endoscopy, I will be loaned by Red Bank Gastroenterology

Associates (the “Practice”) a belt, leads and a data recorder (the “Equipment”). I

understand that I must return the Equipment to the Practice by

and that failure to return the Equipment in the same or substantially the same condition in

which it was loaned to me may result in costs for repairs assessed against me from

$750.00 and up.

Dr.

has fully informed me of my diagnosis, prognosis, the

procedure, the risks, the expected results of the procedure and any ancillary services that

may be determined to be necessary by Dr.

, along with alternative

diagnoses and treatments. I have been allowed to ask questions concerning the planned

procedure and at this time, I have no further questions.

Consent is given for Dr.

and any other health care professionals and

assistants to provide the appropriate care and treatment for me as determined by Dr.

I am fully aware that the practice of medicine is not an exact science and that the capsule

endoscopy and related treatments may involve risks of injury, serious injury and death.

Patient’s Name (please print) Patient’s Signature Date

Provider’s Name Provider’s Signature Date

Anatomy

the

small

bowel

Does

the

Capsule

Get

Eliminated,

Willi

Feel

Come

Out?

:apsule

disposable and

passes

naturally

your bowel movement.

You

should not feel

)ain or discomfort.

illCam

Capsule

Endoscopy

Solution

for

Everyone?

capsule endoscopy

not for everyone.

include capsule retention, aspiration,

irritation.

The risks

the

Agile™

lCy

test include capsule retention and

:ltion. Endoscopic placement may present

ional

risks. Medical, endoscopic,

:al

intervention

may be necessary

any

these complications, should they

. Please consult your physician

refer

givenimaging.com for detailed information.

(actual

size)

Instructions

from

Physician

Nurse:

not

have

MRI

for

days.

cannot

have

MRI

until:

----::--

Date

Notes:

For

additional

information

call:

GI\lEN' I

Pillcam1

Platform

IMAGING

www.givenimaging.com

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GIVen

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RAPID

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HOLDING

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INTERNATIONAL

CONFERENCE

CAPSULE

ENDOSCOPY.

VUESPAN.

BRAVO

SYSTEM

BRAVO.

and

ENDONETICS

are

TrademarkS

andJor

Registered

Trademarks

GIven

Imaging

Ltd

lIS

subsidiaries.

ana/or

affiliates

the

Uniled

States

and/or

other

countries

All

other

company

prOduct

names

are

the

trademarks

registered

trademarks

lllelf

respecuve

holders

All

rights

nol

expressly

granted

are

reserved.

5-000-261

".r.

III:'.

nurse Bonnie 732 936 8305

nurse Melissa 732 936 8318

Please no oral iron supplements(infusions ok)

5 days prior, please call business

day prior to confirm appointment

& review prep. Thank you.

The examination is over approximately eight

hours

after the

capsule

ingested.

Your

doctor

may

determine

that

a capsule

endoscopy

the small bowel is necessary

for

further

evaluation

your condition. Capsule

endoscopy

with

the

PillCam@5B

video capsule

will

provide

your

doctor

with

pictures

your

small

intestine.

Read

this

brochure

learn

about

the

procedure

and

get

answers

commonly asked questions. Feel

free

ask

your

doctor

nurse any addi-

tional questions

you

may have.

What

PillCam

Capsule

Endoscopy

the

Small

Bowel?

Capsule endoscopy

with

the

PillCam

video

capsule

enables

your

doctor

examine your

entire small

intestine.

Your

doctor will

have

you

ingest a video capsule that

has

its own camera

and

light

source.

You

can

move

freely

during

the exam, which lasts

about eight hours. While the video capsule

travels through your body,

sends

images

to a data recorder

you

will wear

your waist. Afterwards, your doctor

will

view

the images

a video monitor.

How

Should

Prepare

for

the

Procedure?

You

will

receive preparation instructions before

the

examination.

empty

stomach allows

optimal

viewing conditions,

you should

start

liquid

diet

after

lunch

the

day

prior

the

examination

and

have

nothing

eat

drink, including water, for approximately

hours before a small bowel examination.

Your

doctor

will

tell

you when to start fast-

ing. Tell your doctor in advance about any

medications you take

you might need to

adjust your usual dose

for

the examination.

Inform your doctor

your medical his-

tory, including

you have a pacemaker

other

electromedical

devices, any previous

abdominal surgery, swallowing problem,

history

obstructions

the

gastrointestinal

tract.

What

Can

Expect

During

PillCam

Capsule

Endoscopy?

The

doctor or

nurse

will

prepare

you

for the

exami-

nation

placing

sensors

your

abdomen.

The

video

capsule

swallowed

with

water

and

passes

naturally

through

your

digestive tract

while transmitting

video

images

to a data

record-

er that

you

will wear

to your waist.

You

will

able

to eat four

hours

after the

capsule

inges-

tion,

unless

your

doctor instructs

you

otherwise.

What

Happens

After

PillCam

Capsule

Endoscopy?

At the end

the procedure, the data

reo

and

sensors

will

removed

and

the irr

acqUired

during

your

exam

will

the

downloaded to a workstation for your

review.

After

ingesting

the

capsule

until

excreted,

you

should not

Magnetic

Resonance

Imaging

(MRI)

examin-

in the vicinity

MRI

machine.

How

Willi

Know

the

Results

thE

Procedure?

After

you

return

the equipment, your

doctor

will

process

the information from

the

data

recorder

and

will

view

color video

the

pictures taken

the

capsule.

After

the

doctor

has

looked at this video,

you

should

contacted

with

the results.

IMPORTANT

REMINDER:

This

brochure

provides

general

informa

and

should

not

used

definitive

basis

for

diagnosis

treatment

an)

case,

very

important

that

you

consult

your

doctor

about

your

specific