UCLA Nuclear Medicine Clinic
UCLA Nuclear Medicine Clinic
RAI therapy for remnant Thyroid ablation
Worksheet initial consult and therapy dose assessment
Patient _____________________________
MRN _____________________________
Phone _____________________________
Referring physician _____________________
Surgery _____________________________
Pathology _____________________________
MACIS _____________________________ Link to Calculator
Treatment date [pic]
[pic]
[pic]
Treatment dose _____________________
Serum TSH, Tg, TgAb ___________________
[pic]
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 Rx
Start diet [pic] 2 weeks before Rx
Stop diet [pic] 4th day after therapy
Whole body scan [pic] ~ 1 wk after Rx
Comments _____________________________
Date _____________________________
Physician _____________________________
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