KMH Nuclear Cardiology Form - Health Services for Mississauga

1. Please complete form
and fax to KMH and
give to patient to bring
to appointment.
2. See back for patient
instructions.
NUCLEAR CARDIOLOGY
MYOCARDIAL PERFUSION
VENTRICULAR FUNCTION (MUGA)
 EXERCISE
 REST
 DOBUTAMINE
 PERSANTINE
VIABILITY STUDY
 DOBUTAMINE
 REST
CARDIOLOGY
 GRADED EXERCISE
TEST (GXT)
 24 Hrs. HOLTER
 AMBULATORY BLOOD
PRESSURE MONITOR
 48 Hrs. HOLTER
($65)
MONITOR
MONITOR
 ECHOCARDIOGRAPHY
 WITH CONTRAST
 STRESS ECHO
 WITH CONTRAST
 RESTING ECG
 CAROTID ULTRASOUND
 LOOP/CARDIAC EVENT MONITOR (2 weeks)
NUCLEAR MEDICINE
CNS
 CEREBRAL PERFUSION
SCAN (SPECT)
BONE SCAN
 TOTAL BODY
 SPECIFIC SITES:
G.I.
RENAL SCAN
 LIVER/SPLEEN SCAN
 RENAL SCAN
 LABELLED RED BLOOD
LIVER SCAN
 RENAL SCAN WITH
LASIX
 GASTRIC EMPTYING
 RENAL CORTEX SCAN
STUDY
 ESOPHAGEAL TRANSIT
STUDY
 SALIVARY SCAN
 RENAL SCAN WITH
CAPTOPRIL
ENDOCRINE
 THYROID

UPTAKE ONLY

SCAN ONLY

SCAN & UPTAKE
 PARATHYROID SCAN
MISCELLANEOUS
 OTHER:
 BILIARY SCAN
WOODSTOCK
437 Norwich Ave.
Woodstock, Ontario
N4S 3W4
06/14
Maps Not to Scale
KMH
KITCHENER
HWY 7
404
407
E
407
404
MILLS
DON
JOHN ST.
MINTHORN
BLVD
.
LESLIE ST
BAYVIEW AVE.
40
7
WOODBIN
HWY 7
LESLIE ST.
404
STEELES AVE. E.
401
DVP
401
TOWN CENTER
SCARBOROUGH
TORONTO
NORWICH AVE.
JULIANA DR.
SPRINGBANK AVE. S
PARKINSON RD.
HWY 401
59
WOODSTOCK
NUCLEAR CARDIOLOGY PATIENT INSTRUCTIONS
1.
2.
3.
4.
5.
A light breakfast/lunch and then nothing to eat or drink (except sips of water for medications) for 3 hours prior to the study. No caffeine for 12 hours prior
to the study (no tea, coffee, decaffeinated products, chocolate, soda pop or medications containing caffeine).
or erectile dysfunction medications.
The patient will then wait 45-60 minutes before additional imaging, which takes about 30 minutes.
Please bring a snack to eat once the test is completed.
NUCLEAR MEDICINE PATIENT INSTRUCTIONS
1. Biliary Scan, Esophageal Transit Study, & Gastric Emptying Study: Nothing to eat or drink for at least 4 hours prior to study, preferably after midnight the night before.
The bone scan protocol consists of 2 parts. The first portion lasts approximately 30 minutes. The patient can then leave the clinic,
2. Bone Scan:
3.
Thyroid Scan:
4.
Thyroid Uptake:
5.
but must return 2-4 hours later for imaging, which lasts 1 - 1.5 hours.
Check with your physician regarding medication and supplements. Bring a list of current medications to your appointment.
The study will take approximately 30 minutes.
Nothing to eat or drink for at least 4 hours prior to study, preferably after midnight the night before. Thyroid medication or food
containing iodine will affect the results. Check with your physician regarding medication and supplements. Avoid xray using iodine-based
contrast for 3 weeks prior to the study. Bring a current list of medication.The study takes 2 days: on Day 1, a capsule is taken orally
and a measurement is taken in1 hour; on Day 2, the measurement is taken within 15 minutes.
Consists of 2 days. Nothing to eat 4 hours prior to study on both days. Drink 4 glasses of water 1 hour prior to study on both
days. Check with your physician regarding possible discontinuation of medication.