XXX Nuclear Facility

6021 University Blvd., Suite 500

Ellicott City, MD 21043

Phone (123)123-1234

Fax (123)123-1234

131I Thyrogen Whole Body Scan Report (SAMPLE) 1

NOTE: This is a SAMPLE only. Protocols submitted with the application MUST be customized to reflect current practices of the facility.

XXX Nuclear Facility

6021 University Blvd., Suite 500

Ellicott City, MD 21043

Phone (123)123-1234

Fax (123)123-1234

Patient Name: Doe, Jane

ID Number: 123456

Date of birth: 4-2-61

Sex: Female

Referring physician: Dr. Jones

Date of the exam: 4-1-17

Radiopharmaceutical: 4.2 mCi 131I Sodium Iodide PO

131I Thyrogen Whole Body Scan Report (SAMPLE) 1

NOTE: This is a SAMPLE only. Protocols submitted with the application MUST be customized to reflect current practices of the facility.

XXX Nuclear Facility

6021 University Blvd., Suite 500

Ellicott City, MD 21043

Phone (123)123-1234

Fax (123)123-1234

Height: 53 in.

Weight: 104 lb

131I Thyrogen Whole Body Scan

Indications/History: 46-year-old female, status-post total thyroidectomy and subsequent 131I thyroid ablation for papillary thyroid carcinoma in March of 2016, referred for follow-up.

Previous Studies: Whole body I-123 scan dated 9/1/2016, post 131I ablation scan dated 3/8/2016 and pre 131I ablation whole body scan dated 2/28/2016.

Findings: Following a 2-day Thyrogen protocol administered by Dr. Wilcox, 4.24 mCi of 131I were administered orally and anterior and posterior whole body imaging was performed at 48 hours. Additional conedown views of the neck and chest were obtained. There is no abnormal functioning 131I activity identified in the neck or elsewhere within the body to suggest local or distant metastatic disease. Physiologic activity is seen in the salivary glands, GI and GU tracts.

Impression: No evidence of local or distant metastatic disease.

Electronically signed by Maria Costello, M.D. on April 2, 2017 at 09:30 AM

131I Thyrogen Whole Body Scan Report (SAMPLE) 1

NOTE: This is a SAMPLE only. Protocols submitted with the application MUST be customized to reflect current practices of the facility.