UCLA Nuclear Medicine Clinic



UCLA Nuclear Medicine Clinic

RAI therapy for Recurrent Thyroid Cancer

Worksheet for consult and assessment

Patient _____________________________

MRN _____________________________

Phone _____________________________

Referring physician _____________________

Surgery _____________________________

Pathology _____________________________

MACIS _____________________________ Link to the Calculator

Treatment date [pic]

[pic]

[pic]

Treatment dose will be determined by diagnostic scan

Serum TSH, Tg, TgAb _______________

Dose diagnostic scan 3 mCi on ____________

WB diagnostic iodine scan _______________

Stop T4 hormone (Synthroid / Levothyroxine)

Start T3 (Cytomel / Liothyronine) [pic] 4 wks before therapy

Stop T3 (Cytomel / Liothyronine) [pic] 2 wks before therapy

Restart hormones [pic] 4th day after therapy

Start diet [pic] 10 days before therapy

Stop diet [pic] 4th day after therapy

Whole body scan [pic] 10 days after therapy [pic]

Comments ____________________________________________________________________

Date _____________________________

Physician _____________________________

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download