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 _____________________________
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