XXX Nuclear Facility
6021 University Blvd., Suite 500
Ellicott City, MD 21043
Phone (123)123-1234
Fax (123)123-1234
131I Radionuclide Therapy for Hyperthyroidism 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, John
ID Number: 123456
Date of birth: 4-2-33
Sex: Male
Height: 73 in
Referring physician: Dr. Jones
Clinical indications: Hyperthyroid
Date of the treatment: 4-1-17
Radiopharmaceutical: 10.1 mCi 131I Sodium Iodide PO
131I Radionuclide Therapy for Hyperthyroidism 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
Weight: 201 lb
131I Radionuclide Therapy for Hyperthyroidism
Indications/History: Hyperthyroid with elevated 131I uptake. Hyperthyroidism due to Graves’ Disease, Radioactive uptake value of 70% on 3-7-12. Biochemistry: Suppressed TSH and elevated free T4 and T3.
Pregnancy Status: N/A Male patient
Breast Feeding Status: N/A Male patient
Procedure: Patient was provided a detailed explanation of the risks and benefits of the procedure and signed written informed consent. Patient was administered 10.1 mCi I-131 sodium iodide orally for treatment of hyperthyroidism.
There were no immediate complications. Detailed instructions for radiation protection were provided.
Impression:
1. Administration of 10.1 mCi 131I sodium iodide orally for treatment of hyperthyroidism.
2. The further treatment plan is to see the patient in the nuclear medicine clinic (visit with Dr. XX) at 8 weeks post-therapy.
3. Medication(s) prescribed: continue propranolol 80 mg tid for 4 weeks, then decrease to 40 mg tid for 4 weeks.
Electronically signed by Maria Costello on April 2, 2017 at 10:30 AM
131I Radionuclide Therapy for Hyperthyroidism Report (SAMPLE) 1
NOTE: This is a SAMPLE only. Protocols submitted with the application MUST be customized to reflect current practices of the facility.