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Microsoft word - d-lyte-08.doc

Douglas R. Adler, M.D.
Ronald A. Bloom, M.D.

Kenneth D. Chi, M.D.
Ruven Levitan, M.D.
Nina H. Merel, M.D.
Alan B. Shapiro, M.D.
847-677-1170
Procedure Scheduler Ext. 17 --- Nurse Line Ext. 51
Please read ALL instructions before your colonoscopy examination and MARK CALENDAR of anychanges you need to make. Please call with any problems or questions.
 Obtain one of the following four (4) liter bottles of prescription preparation at any pharmacy: Golytely
Nulytely
 Also obtain over the counter BISACODYL (generic Dulcolax, in the laxative section) Two (2)  DO NOT TAKE Aspirin, blood thinners, Ibuprofen, Vitamin E, or any Supplemental Iron.
You may take Tylenol products if needed.
 Arrange to have someone with you at the end of the exam that can drive you home. A taxi driver alone is not sufficient. You will be discharged approximately 60-90 minutes after yourprocedure is started.
 Fill the four (4) liter preparation bottle with warm water to the fill line, shake or mix until
dissolved, then REFRIGERATE.
For breakfast, lunch and dinner, DRINK ONLY CLEAR LIQUIDS. Please, no solid foods, milk or
milk products.
Drink as much or as little of the following “clear liquids” as you desire until Midnight.
“CLEAR LIQUIDS” (NOT COLORED RED OR PURPLE THAT MIGHT RESEMBLE BLOOD)
INCLUDE ALL OF THE FOLLOWING:

Carbonated and Non-carbonated soft drinks (example: Coke, Pepsi, 7-Up, Sprite – Diet or Reg) Clear Broth or bouillon (chicken or beef) Kool-Aid (or other fruit flavored drinks) Plain Jello (without added fruits or toppings) ONE DAY BEFORE YOUR EXAMINATION, between 3:00 and 4:00 PM  Take the 2 bisacodyl tablets with water or clear liquids.
 After your first bowel movement, but not later than 4 hours after taking the pills, begin to drink  Start drinking the prescription preparation (Colyte, Golytely, Nulytely or Trilyte) that you refrigerated. Drink half (½ ) of this gallon (one-half (½) of the four (4) liters) over the next one to
one-half (1 – 1½ ) hours, at a rate of one 8-ounce glass every 15-20 minutes.
Or, you
can drink more than 8-ounces every 15-20 minutes if you wish. You may drink more than half
of the 4 liters if your stools have not fully cleared.
 You may continue to drink clear liquids UNTIL MIDNIGHT if you desire.
 **NOTE: If you develop bloating or distention, take a short break and resume drinking the preparation UNTIL THE PRESRCIBED AMOUNT IS FINISHED (the one-half (1/2 ) gallon
preparation).
 Stay at home near the bathroom after you start drinking the preparation, as you will have DIARRHEA.
Your Colonoscopy is scheduled for _______
________
AM / PM at:
The Glen Endoscopy Center
Lutheran General Hospital
847-656-2400
847-723-5300
Golf Surgical Center
Rush North Shore Medical Center
8901 Golf Rd
847-933-6565
847-299-2273
DOT NOT EAT OR DRINK ANYTHING IN THE MORNING OF THE DAY OF YOUR EXAM,
EXCEPT ANY MORNING MEDICATIONS YOU ARE REQUIRED TO TAKE WITH WATER.
ALL HEART and BLOOD PRESSURE medications should be continued including day of
procedure with small amounts of water. Check with RN about taking daily medications
you are uncertain about.

PLEASE NOTIFY THE NURSE IF YOU NEED ANTIBIOTICS for procedures secondary to
heart valve replacement, joint replacement within the last year, or if you are taking
Coumadin, Insulin, or any medications for diabetes.

Please register in the Outpatient Registration Area. Arrive at __________.
Note: At Lutheran General Hospital, register @ West Lobby Outpatient Registration near the west elevators on the 1st floor.
BIOPSY RESULTS AFTER PROCEDURES (if applicable) Our office will call you with your biopsy results likely not earlier than ten (10) days after your
procedure is performed, despite what the discharge instructions state.

Due to HIPAA regulations, if you wish for us to leave a message with these results on your
machine or with any other family member, the release form in our office needs to be on file.

If you do not hear from us within two weeks regarding your biopsies, please call our office at 847-677-1170.
Note: At the time of your procedure, you wil be asked to sign a consent form. Please be aware that no procedure is without risk. The most common risks
associated with this procedure involve bleeding, tears (perforation), missed abnormalities and sedation associated risks. Your physician is Board Certified in
the practice of Gastroenterology and wil take the utmost care to avoid these outcomes. If you have concerns, please address these with your doctor prior to

the procedure.

Source: http://nsgastro.com/yahoo_site_admin/assets/docs/D-Lyte-08.100145813.pdf

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First Name:__________________________ M.I. _____ Last Name:____________________________ Male / Female D.O.B:_________________ Employer: _____________________________ MARRIED / SINGLE / OTHER Home Phone: _______________________ Cell: _____________________ Work: ________________________ Address: ____________________________City/State/Zip Code: _____________________________________________ Prim

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