UCLA Nuclear Medicine Clinic
UCLA Nuclear Medicine Clinic
RAI therapy for remnant thyroid ablation
After Thyrogen stimulation
Worksheet initial consult and therapy dose assessment
Patient _____________________________
MRN _____________________________
Phone _____________________________
Referring physician _____________________
Surgery _____________________________
Pathology _____________________________
MACIS _____________________________ Link to the Calculator
Thyrogen 0.9 mg i.m. on [pic] and [pic] in Endocrinology [pic]
Serum TSH, Tg, TgAb on [pic] just before treatment
Treatment date [pic]
[pic]
[pic]
Treatment dose _____________________
Start diet [pic] 10 days before therapy
Stop diet [pic] 4th day after therapy
Whole body scan [pic] ~ 5 days after therapy [pic]
Comments ____________________________________________________________________
Date _____________________________
Physician _____________________________
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