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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