BONE:

Bone Scan was acquired 3 hours after MBqs i. v. injection of Tc 99m MDP.

No definite evidence of abnormal focal increased uptake of the radiotracer throughout the
skeleton.

No definite scintigraphic evidence of secondary skeletal metastases at present.

No significant change identified since the previous scan of April 2009.

No definite evidence of abnormal focal increased uptake of the tracer throughout the
skeleton.
No definite evidence of secondary skeletal metastases at present.

Soft tissue uptake in the left breast is compatible with the primary tumor.

Result is compatible with skeletal metastases (Stable disease).

Bilateral symmetrical and uniform radiotracer distribution is demonstrated elsewhere in the

skeleton.

Tracer distribution elsewhere is fairly symmetrical and uniform.

Intense heterogeneous uptake of the tracer is noted throughout the axial and appendicular
skeleton. Kidneys are not visualized due to high skeleton-to-background uptake ratio.
Result is compatible with extensive skeletal metastases (Superscan of malignancy).

Multiple focal areas of increased uptake of the tracer are noted in the distal shaft of the right
humerus, right 6th rib posteriorly & 8th rib laterally, spine particularly at the level of D11&
L1/3/5 vertebrae, right sacroiliac joint, left acetabulum, left ischium and right lesser
trochanter.

Irregular uptake of the tracer is noted in the lumbar spine particularly in D2/3 vertebrae,
which appears to be degenerative in origin. Arthritic changes are noted in both knee joints.
Rest of the scan is unremarkable

Subtle heterogeneity in the thoracic spine is degenerative in origin.

Heterogeneous uptake with scoliosis in the thoraco-lumbar is degenerative in origin.

Uptake in the left sacroiliac joint appears to be arthritic in nature, however, metastases can
not be entirely excluded. Radiological correlation is suggested for further evaluation.

Whole body static images show no definite evidence of abnormal focal increased uptake of
the radiotracer throughout the skeleton.

Whole body static images show intense focal increased uptake in the region of right knee
joint, particularly in the proximal shaft of the right tibia which is compatible with the primary
tumor site. Increased uptake in bilateral iliac crests is because of surgical intervention there
(Bone Grafting). Rest of the scan is unremarkable.

Whole body static images show mild arthritic changes in bilateral knee joints. Heterogeneity
in the thoraco-lumbar spine is compatible with degenerative changes. No definite evidence of
abnormal focal increased uptake of the radiotracer elsewhere in the skeleton.
Whole body static images show degenerative/arthritic changes in the lumbar spine at L5
vertebra and left knee joint.

The scan results are compatible with skeletal metastases at above described locations.
Comparison made with the previous scan dated 06-Feb-2009. New lesions are identified
particularly in the right clavicle and left sided ribs, signifying disease progression.

Three phase Bone Scan was acquired including initial dynamic imaging of bilateral knee joint
region and delayed whole body images 3 hours after MBqs i. v. injection of Tc 99m MDP.

No hyperemia or blood pool activity is noted in the lumbosacral region on the initial dynamic
images.
Delayed images show no definite evidence of abnormal focal increased uptake of the
radiotracer in the lumbosacral spine or elsewhere throughout the skeleton.
No definite scintigraphic evidence of any active bone pathology at present.

I-131

No definite evidence of abnormal focal increased uptake of the radiotracer on the present
scan.
Tg levels (0.2 ng/mL) are also within normal limits.

No scintigraphic evidence of NaI-131 avid disease at present.

No definite evidence of abnormal focal increased uptake of the radiotracer on the present
scan. Normal physiological radiotracer uptake is noted in the nasopharynx, gastrointestinal
tract and urinary bladder.
Tg levels (0.5 ng/mL) are also within normal limits.

Focal uptake of I-131 is noted in the anterior neck. Normal physiological radiotracer uptake
is noted in the nasopharynx, gastrointestinal tract and urinary bladder. Rest of the scan is
unremarkable
Scintigraphic evidence of I-131 avid disease in the anterior neck.

There is scintigraphic evidence of I-131 avid remnant of thyroid in the neck.

Radioactive Iodine Ablation therapy is recommended.

Scan: Thyroid scan was acquired 48 hours after the oral administration of 15 mCi of I-131
NaI. Views were repeated after marking SSN.

The scan shows uptake of the tracer by the hyperactive thyroid gland.
Well delivered I-131 dose to the hyperactive thyroid gland.
Adequate I-131 dose delivery to the hyperactive thyroid gland.

Focal uptake of NaI-131 is seen in the remnant of the thyroid.

Normal physiological uptake of the tracer is seen in nasopharynx, salivary gland, gut and
bladder region.
Rest of the scan is unremarkable.
Well delivered dose to the remnant of the thyroid.

Thyroid
Thyroid gland appears to be enlarged. A photon deficient area is identified in the isthmus and
adjacent part of the right lobe, corresponding to the clinically palpable neck nodule.
Homogeneous radiotracer distribution is noted in rest of the gland.
Thyroid uptake percentage = 1.14% (Normal = 0.4-4.5%).

Cold nodule in the right lobe of thyroid.

NB: Correlation with ultrasound findings and aspiration cytology of the cold nodule is
recommended.

Cold nodule in the right lobe of thyroid where aspiration cytology is recommended.

Thyroid gland appears to be enlarged with generalized intense uptake of the tracer in both
lobes.
No discrete nodules are identified in both lobes.
No focal abnormality is seen.
Thyroid uptake percentage = 24.3% (Normal = 0.4-4.5%).

Diffuse goiter with hyperfucntioning thyroid (Graves' disease).

NB: Radioactive Iodine ablation therapy is recommended.

A faint vertical streak of functioning thyroid tissue extending vertically up from the
inner aspect of the right lobe is the pyramidal lobe.

A streak of functioning thyroid tissue extending upwards from the inner aspect of the
left lobe corresponds to the pyramidal lobe.

The result shows typical scintigraphic evidence of hyperthyroidism (Graves' disease).

Radioactive Iodine ablation therapy is recommended.

The scan shows mild thyroid enlargement with homogeneous increased radiotracer uptake in
both thyroid lobes.
No discrete foci of increased or decreased radiotracer uptake are identified in bilateral lobes.
Thyroid uptake percentage = 11.8% (Normal = 0.4-4.5%).
Mild diffuse goiter with hyperfucntioning thyroid (Graves' disease).
NB: Radioactive iodine ablation therapy is recommended.

Thyroid gland appears to be enlarged with generalized reduced radiotracer uptake.

A photon deficient area is identified in the lower part of the right thyroid lobe, corresponding
to the clinically palpable nodule.
Heterogeneous radiotracer distribution is noted in rest of the thyroid lobes, but discrete
nodules could not be demarcated due to low uptake.
Thyroid uptake percentage = 0.24% (Normal = 0.4-4.5%).
Multinodular goitre with a dominant cold nodule in the right thyroid lobe.
Note:
Correlation with ultrasound findings and aspiration cytology of the cold nodule is
recommended if indicated.

Suppressed thyroid uptake is possibly due to medication, iodine containing diet or diminished
thyroid function. Please correlate clinically and with thyroid function tests.

The scan shows heterogeneous radiotracer uptake in both lobes of grossly enlarged thyroid
gland. Multiple foci of isotense and hyper intense radiotracer uptake are noted bilaterally.
Thyroid uptake percentage = 1.1% (Normal = 0.4-4.5%).
Multinodular goiter with a dominant cold nodule and a small functioning (warm) nodule in
the left thyroid lobe (As described above).

Please correlate with thyroid ultrasound findings to ascertain solid or cystic nature of
these nodules.

PARATHYRIOD:

Initial images of neck and chest at 20 and 60mins show diffused tracer uptake by both thyriod
lobes.
No focal abnormality is identified.

Delayed planer and SPECT - CT images at 120mins show washout of most of the tracer from
the thyriod.
No risidual focal uptake is identified to suggest hyperfuntcional parathyriod tissue.

No scitigraphic evidence of hyperfuction parathyriod tissue in the neck or chest.

RENAL:

Flow study shows simultaneous perfusion to both kidneys.

Sequential images show good uptake by both kidneys. The left kidney contributes 56% of the
total uptake function and the right 44%.Clearance and excretion appears to be within normal
limits bilaterally.
Estimated GFR is about 99 mls/minute which is within normal limits.

Normal renal study.

Adequate renal function.

Mild impairment of renal function.

Flow study shows good perfusion to the left kidney. Perfusion to the right kidney is delayed.
Sequential images show good uptake by the left kidney. The right kidney appears to be
shrunken with poor uptake of the tracer. The left kidney contributes 83% of the total uptake
function and the right 17%.
Clearance and excretion appears to be within normal limits by the left kidney. The clearance
and excretion of the right kidney cannot be commented upon due to poor uptake function.
Estimated GFR is about 59 mls/minute, which is lower than normal.
Poor functioning right kidney.

Right kidney is not visualized (Post Nephrectomy).

Flow study shows perfusion only to the left kidney.
Sequential images show good uptake by the left kidney followed by normal clearance and
excretion.
Estimated GFR is about 60 mls/minute which is also adequate.

Adequate renal function for solitary functioning left kidney.

Flow study shows simultaneous perfusion to both kidneys.

Sequential images show good uptake by the left kidney. The right kidney appears to be
comparatively small in size with slightly reduced uptake.
The left kidney contributes 60% of the total uptake function and the right 40%.
Clearance and excretion appears to be within normal limits bilaterally.

Estimated GFR is about 66 mls/minute which is slightly lower than the nomal limits.
Slightly reduced renal function.
Left kidney has normal function. Comparatively small sized right kidney has slightly reduced
function.

Flow study shows simultaneous perfusion to both kidneys.

Sequential images show good uptake by both kidneys. The left kidney contributes 56% of
the total uptake function and the right 44%.
Clearance and excretion appears to be within normal limits by the left kidney. Clearance and
excretion is delayed on the right side with pelvic retention of the tracer, that shows good
response to I/V Lasix.
Estimated GFR is 113 mls/minute which is adequate.

Adequate renal function.

There is evidence of non-obstructed dilatation of the right renal pelvis.

Left Kidney:
Flow study shows good perfusion to the left kidney.
Sequential images show good uptake by the left kidney which contributes 64% of the total
uptake function.
Clearance and excretion is slightly delayed but shows adequate response to I/V Lasix.

Right Kidney:
Flow study shows good perfusion to the right kidney.
The right kidney shows delayed and patchy cortical uptake of the tracer. Right kidney
contributes 36% of the total uptake function. Corticopelvic transit of the tracer is delayed.
There is gradual accumulation of tracer in the dilated pelvicalyceal system that shows poor
response to I/V Lasix.

Estimated GFR is about 85 mls/minute.

Adequate renal function.

Left kidney has normal function and clearance.
Hydronephrotic right kidney has mild reduced function with scintigraphic evidence of
significant outflow resistance.

Left Kidney:
Flow study shows slightly delayed perfusion to the left kidney.
Sequential images show moderately impaired uptake by the left kidney which contributes
84% of the total uptake function. Clearance and excretion is also delayed but shows adequate
response to I/V Lasix.

Right Kidney:
The right kidney appears to be small sized with impaired perfusion and cortical tracer uptake.
Right kidney contributes 16% of the total uptake function. Clearance and excretion by the
right kidney cannot be commented upon due to poor uptake function.

Estimated GFR is 58 ml/minutes which is lower than the normal range.

Reduced GFR.
Small sized, poor functioning right kidney with moderately impaired functioning left kidney.

Poor DTPA
Flow study shows simultaneous but delayed perfusion to both kidneys.
Sequential images show poor uptake by both kidneys. The left kidney contributes 52% of the
total uptake function and the right 48%. Clearance and excretion also appears to be delayed
bilaterally.
Estimated GFR is about 19 mls/minute which is markedly lower than normal limits.

Both kidneys are faintly visualized with impaired perfusion and poor renal cortical
radiotracer uptake (more marked on the right side) with 63% contribution by the left and 37%
by right kidney. Clearance and excretion cannot be commented upon due to poor uptake
function.

Estimated GFR is 14 ml/minutes which is markedly lower than normal range.

High background activity noted throughout the study.
Markedly impaired renal function.

In the present clinical scenario this is compatible with renal parenchymal pathology.
Markedly impaired renal function, more likely due to renal parenchymal disease.

Ectopic kidney scan:

Anterior position processing:

Flow study shows simultaneous perfusion to the right ectopic and normally located left
kidney.
Sequential images show good uptake by both kidneys.

Split renal function: Right ectopic: 61% Left kidney: 39%

Clearance and excreation appears to be normal with normal response to lasix.

Posterior position processing:

Flow study shows similtaneous perfusion to both kidneys.
Sequential images show slight delay in clearnce but no evidence of obstruction.

Split renal function: Right ectopic: 27% Left Kidney: 73%

Mean split renal function: Right ectopic: 44% Left Kidney: 56%

Mean estimated GFR: 86mls/min

DMSA
The right kidney appears to be slightly enlarged with regular contour and good renal cortical
radiotracer uptake .
Left kidney is not visualized and demarcated by a photopenic area.
The split renal function determined by geometric mean method found to be 99.3% and 0.7%
by right and left kidneys respectively.
Normal functioning and morphology of right kidney with slight compensatory hypertrophy.

SENTINEL

A sentinel lymph node along with a second tier node is well visualized towards the axillary
region.
A sentinel lymph node along with the tract of tracer transit is well visualized towards the
axillary region.

A sentinel lymph node is well visualized towards axillary region.

The study is positive for the localization of sentinel lymph node.

Nuclear medicine
================
Sentinel lymph node scintigraphy done
A sentinel lymph node is faintly visualized towards right axillary region.

Lympho

The scan normal ascent of the radiotracer in faintly visualized lymphatic of both legs, up
through the knees and thighs into the inguinal regions. Bilateral inguinal and left popliteal
lymph nodes are visualized in the delayed images.

Normal lymphatic drainage in bilateral lower limbs.

MUGA

Left ventricle appears to be of normal size.

Normal wall motion.
Resting LVEF = % (Normal > 55%).
The study is within normal limits.
Adequate left ventricular function.

MIBG

Normal physiological uptake of the radiotracer is seen in salivary gland, heart, hepatic
parenchyma and urinary bladder. No definite evidence of abnormal focal increased uptake of
the radiotracer throughout the imaged compartments.
No definite scintigraphic evidence of I-131 MIBG avid disease.

HIDA
The scan shows good hepatocyte extraction of the radiotracer. Transit of radiotracer is seen
into the gut within 60 minutes. Gallbladder is not visualized till 4 hrs of the study.

The scan findings are highly suggestive of acute cholecystitis.

The scan shows adequate hepatocyte extraction of the radiotracer. Gall bladder and biliary
channels are not visualized. No flow of the radiotracer to the bowel is seen in early or delayed
images till 24 hours of the study.
The radiotracer is following the alternate route of excretion through the kidneys.

The result shows scintigraphic evidence of biliary outflow obstruction (Biliary atresia).

Initial dynamic images show good perfusion to the hepatocytes.

Right, left and common bile ducts were visualized at 14 minutes.
Tracer activity is seen in gastrointestinal tract at 20 minutes of study, indicating patent biliary
channels and common bile duct.

MECKEL’s SCAN

Initial dynamic images show physiological tracer uptake in the stomach [gastric mucosa] 5
minute onwards. Faint tracer uptake is also seen in right lumbar region that has moved down
on subsequent images1 hour later and represents physiological renal activity.
Study does not show any abnormal tracer uptake in the region of abdomen and pelvis upto 1
hour.

CONCLUSION:
Study is negative for bleeding Meckel's diverticulum or ectopic gastric mucosa.

Dynamic images show physiological tracer uptake in the stomach [gastric mucosa] 3 minute
onwards which gradually increases with time.
Abnormal focal tracer uptake is also seen in right lumbar region simultaneously.
Physiological excreation of tracer is seen from the urinary bladder.
Abnormal focus in the right lumbar region is highly suggestive of a Meckel's diverticulum
with ectopic gastric mucosa.

GASTRIC EMPTYING

Initial dynamic images show tracer uptake in the stomach. There is movement of activity
from the stomach into the intestines. However, there is delay in gastric emptying with more
than 60% solid food retained in the stomach at approximately 90 minutes. [normal T1/2 for
gastric emptying is 60 to 90 minutes].

Gallium
Scan findings are consistent with delay in gastric emptying.
Gallium avid tracer uptake is seen in bilateral lacrimal and parotid glands (Panda sign).
Increased uptake is also seen in the right paratracheal and bilateral hilar regions (Lambda
sign).
Rest of the scan is unremarkable.

The scan features of panda and lambda signs are typical of sarcoidosis.

RBC LIVER HEMANGIOMA SCAN

Initial dynamic images show distribution of the labeled RBC's into the vascular
compartments.
A huge photon deficient area is seen in the right lobe of liver which is not concentrating
labeled RBC's in the delayed static and SPECT images.

No definite scintigraphic evidence of cavernous hemangioma in the liver.

Space occupying lesion visualized in the right lobe of liver.

V/Q SCAN:
Ventilation scan is limited due to poor inspiratory effort.
There are several non-segmental peripheral areas of decreased perfusion predominantly in the
right lung. There is diffuse decrease perfusion in the right lung seen only in the posterior
views suggesting presence of an effusion. No large segmental perfusion defects in either lung
to suggest the presence of pulmonary embolism.
CONCLUSION:
No evidence of pulmonary embolism. Mottled perfusion with peripheral non segmental
defects should be correlated on CT scan to exclude more concerning cause.

MIBI
Stress and rest images show normal and homogeneous perfusion throughout the myocardium.
Estimated left ventricular ejection fraction is 85%.
No definite evidence of stress induced ischemia at present.

Heart Rate (bpm) Baseline = 75 Peak Stress = 93

Blood pressure(mmHg) Baseline = 121/72 Peak Stress = 130/73
No ischemic changes are seen on the baseline and stress ECG.

EDV = ml
ESV = ml

Heart Rate (bpm) Baseline = 100 Peak Stress = 110

Blood pressure(mmHg) Baseline = 135/78 Peak Stress = 140/70
Deep S waves on baseline as well as stress ECG.
No ischemic changes are seen on the baseline and stress ECG.

Stress Scan:
Stress images show a small area of heterogeneous uptake in the antero-septal region.
Perfusion to the rest of the myocardium is within normal limits.

Rest Scan:
Rest images show relatively better perfusion in the antero-septal region.

Gated images show normal wall motion.

Estimated left ventricular ejection fraction is 62%.

Stress LVEF = 68%, EDV = 100ml, ESV = 32ml

Rest LVEF = 76%, EDV = 83ml, ESV = 20ml

No scintigraphic evidence of stress induced myocardial ischemia.

Normal stress-only study.

Post stress SPECT images demonstrate normal and homogeneous radiotracer distribution
throughout the myocardium.

The scan demonstrates a large area of marked reduced perfusion to the apex, anterior and
inferior wall, sparing only the lateral wall.
Left ventricular cavity is dilated.
Wall motion could not be assessed as Gating images were not acquired.

Large perfusion defect involving apex, anterior and inferior wall. Perfusion is preserved in
the lateral wall.

Left ventricular cavity is noted to be normal.

Gated SPECT imaging reveals normal myocardial thickening and wall motion.
Estimated LVEF = 79%.
Normal myocardial perfusion scan (Stress-only study).
EDV = 58 ml
ESV = 12 ml

MIBI STRESS WITH EXERCISE:

TECHNIQUE: Scan: Myocardial perfusion study (MIBI) using physical Stress and SPECT
was acquired. Patient was made to exercise on treadmill with modified Bruce Protocol. She
achieved heart rate of 132/min. Tc99m Sestamibi was injected 847 MBqs IV at peak
exercise for 6 minutes. Images were acquired one hour later. Rest study was acquired another
day after 813MBq of Tc99m Sestamibi.

Heart Rate (bpm) Baseline 66 Peak Stress 132

Blood pressure(mmHg) Baseline 140/70 Peak Stress 180/100

ST segment depression is noted on stress ECG.

Patient remained asymptomatic during stress.
78% of the maximum predicted heart rate is achieved.

Stress Scan:
Stress images show a small area ofreduced perfusion to the anteior wall. Perfusion to the rest
of the myocardium is within normal limits.

Rest Scan:
Rest images show relatively better perfusion in the anterior wall.

Gated images show normal wall motion.

Estimated left ventricular ejection fraction = 63%.
EDV = 67ml
ESV = 25ml

MIBI

Heart Rate (bpm) Baseline 75 Peak Stress 109

Blood pressure(mmHg) Baseline 123/64 Peak Stress 148/58

T wave inversion in Leads V1-V3 on baseline ECG.

Stress ECG shows mild ST depression in leads V4-V6.

Stress Scan:
Stress images show heterogeneous perfusion in the anterior wall. Perfusion to the rest of the
myocardium is within normal limits.

Rest Scan:
Rest images show no significant perfusion defect throughout the myocardium. Slight
worsening of the perfusion to the anterior wall represents attenuation artifact.

Estimated left ventricular ejection fraction = 74%.

Left ventricular cavity appears to be of normal size.
Gated images show normal wall motion.

EDV = 78ml
ESV = 20ml

CONCLUSION:
Result does not confirm presence of significant ischemic heart disease.
LVEF is 74%.

TECHNIQUE (for suboptimal MIBI) : Myocardial perfusion scan (MIBI) giving

pharmacological stress and SPECT study was acquired. Patient was given IV injection of
ml adenosine over 3min with IV injection of MBq of 99mTc Sesta MIBI at 1.5 minutes.
Images were acquired one hour later. Rest images were acquired separately one day later
using MBq of Sesta MIBI IV.

MIBI (Dobutamine)

MIBI stress scan was performed by slow I/V injection of dobtamine. Incremental dose was
started at the rate of 10mcg/min for 3 min, 20 mcg for 3 min and the desired heart rate of
130/min was achieved at 6 minutes of the study. At this time 850MBqs of Sestamibi was
injected. Rest study was performed on a separate day with I/V injection of 797 MBqs of
sestamibi.

DIAGNOSIS DURING THIS ADMISSION:

Papillary ca thyroid. T3N0M0

BACKGROUND MEDICAL PROBLEM(s)(LIST ANY CHRONIC MEDICAL

CONDITIONS THAT THE PATIENT MAY HAVE, SUCH AS DIABETES MELLITUS,
ASTHMA, HYPERTENSION):

DATE OF ADMISSION: 13-01-2011 15:15:05

DATE OF DISCHARGE: 17-01-2011 09:29:56
BACKGROUND DIAGNOSIS NOT APPLICABLE:YES
PRIMARY ONCOLOGIST:
ADMITTING CONSULTANT: Dr. Mohammad Khalid Nawaz
REASON FOR ADMISSION: Papillary ca thyroid. (T3N0M0) S/P Total thyroidectomy 20-
06-2010 Pre therapy WBS 08-NOV-2010 I-131 avid disease in the neck only.
TSH = 75 Admitted for RAI Ablation Therapy (120 mCi)

SIGNIFICANT PHYSICAL FINDINGS ON ADMISSION:

Post surgical changes in the neck.
Clinically hypothyroid.

MANAGEMENT DURING ADMISSION:

1. RAI ablation therapy with 100 mCi.
2. Prophylactic medications;
-Tab paracetamol 100 BID
-Dimenhydrinate 50 mg TID,
-Omeprazole 20 mg BID
-Dybenal lozeges 1.2 mg Q4H
3. Daily radiation exposure was checked.
4. Patient remained vitally stable during her stay in hospital.

DIAGNOSTIC ' PROCEDURES PERFORMED:

Post therapy Whole Body Scan done
CONDITION AT DISCHARGE:
Stable

FOLLOWUP INSTRUCTIONS:
1-Start thyroxine in TSH suppressive doses
2- F/U in thyroid clinic after 6months.

SIGNIFICANT TEST / PROBLEMS TO ADDRESS ON FOLLOWUP:

TSH and adjust thyroxine accordingly.

MEDICATION:
Thyroxine Tablets 50 250 mcg OD 6 Months PO
DIMENhydrinate Tablets 50 50 mg BID 5 Days PO
Omeprazole Capsules 20 20 mg BID 2 Weeks PO
Paracetamol Tablets 500 1000 mg BID 3 days PO

INSTRUCTIONS:
1 EXT 2494 (Secretary Nuclear Medicine) between 9 am to 5 pm, Monday to Friday.
2 Hospital Operator after 5 pm and before 9 am, Monday to Friday and all holidays to be
put through to the on call Internal Medicine Resident.
3 EXT 2253,2382,2237,2239 to schedule routine appointments.
4 In case of an emergency, contact the EAR on EXT 2496,2303 at any time.
Discharge Summary Explained to the Patient (or caregiver):YES

NPO till 5:00 pm on 17-05-2016. Regular cooked food after 5:00pm, Provide with plenty of
liquids (water, fresh juices) and lemon slices.
Restricted movement to the patient's room . No input /output monitoring required.
Medications as prescribed.

Patient is doing fine.

No active complaint.
No nausea
No Vomitting
No bodyaches
No swelling in the neck.

O/E: Unremarkable.
Rad exposure = uSv/hr.
Plan:
1.Continue with current treatment.
2-Plenty of fluids to drink.
3-Plan to discharge when Rad exposure is within accepatble limits.
4-Whole body scan before discharge.

Year I WBS done-unremarkable

Tg=0.2(valid)

Plan:
1. Start thyroxine in suppressive dosage.
2. Followup after 6 months in thyroid clinic.

Above plan explained to the patient.

Plan:
1. Start thyroxine in suppressive dosage.
2. TSH after 8 wks and dose adjustment accordingly.
3. Followup after 6 months in thyroid clinic.

Above plan explained to the patient.

Plan:
1. Start thyroxine in suppressive dosage from tomorrow.
2. Patient will stop thyroxine on
3. TSH will be done on
4. Admission for RAI Therapy on

Above plan explained to the patient.

PLAN:
1. RAI therapy with mci of Na-I-131.
2. PPIs, NSAIDs and anti-emetics.
3. Daily radiation exposure.
4. Discharge when radiation exposure is within acceptable limits.

Plan explained to the patient via translator (Sajjad Ahmed) and she voiced
understanding.

1st day post RAI (150 mCi) Therapy.

Diagnosis:

Subjective: No active complaint. No nausea. No Vomiting. No body aches.

Objective: No swelling in the neck, no erythema.

O/E: Unremarkable.

Plan:
1. Continue with current treatment.
2- Plenty of fluids to drink.
3- Plan to discharge when Rad exposure is within acceptable limits (current radiation
exposure is mSv /hr).
4- Whole body scan at discharge.

Above plan explained to the patient via translator (Ahmed Fraz) and she voiced
understanding.

Discharge Note.

2nd day post RAI (mci) Therapy.

Diagnosis:
Subjective:
No active complaint. No nausea. No Vomiting. No body aches.,no pain in neck.

Objective: No swelling in the neck, no erythema.

Rad exposure = uSv/hr.(20-7-11)

Plan:
1. As the patient is clinically stable and radiation exposure is within acceptable limits(less
than 20mSv /hr), the patient will be discharged today.
2. WBS prior to the discharge.
3. Start thyroxine in suppressive dosage.
4. Followup with TSH after 8 wks and dose adjustment accordingly.

Above plan explained to the patient and she voiced understanding of the plan.

PLAN:
---------
1. RAI ablation therapy with 100 mCi.
2. Prophylactic medications;
-Ibuprofen 400mg tid.
-Dimenhydrinate 50 mg tid,
-Omeprazole 20 mg bid.
-Dybenal lozenges 1.2 mg Q4H
3. Daily radiation exposure.
4. Plan to discharge when radiation exposure is within accepatble limits.
5. Whole body scan before discharge.
Above plan explained to the patient .

Total thyroidectomy done on 21-04-2014

Pre therapy WBS is done today.
A multifocal I-131 avid remnant is seen in the anterior region of neck.

Plan:
1.Pt. is booked for RAI therapy on 23-06-14.
2.Dietary instructions are given.
Plan is explained to the pt. and he voiced understanding.
False-negative rate is the proportion of axillary node dissection, positive cases with a
negative sentinel node at biopsy.

SALIVARY GLAND STUDY:

The left parotid and left submandibular gland appears bulky as compared to the right side.
Right parotid gland shows comparatively reduced tracer uptake. Prompt radiotracer uptake is
noted in the left parotid and bilateral submandibular glands.

Post citrus stimulation images show slow and delayed washout from the right parotid gland.
Normal washout of the radiotracer from the left parotid and bilateral submandibular gland.

Mild reduced function of right parotid gland with delayed clearance.

Normal function and washout from left parotid and bilateral submandibular glands.

THECNIQUE:
Scan: Salivary scan was acquired over 15 mins starting just after IV injection of 210 MBq of
Tc 99m pertechnitate. Continuous Dynamic images were acquired. 1 min analogue images
were created at 5 min interval. Citrus drink stimulus was given half way into the study. ROIS
were delineated and TAC's were displayed.

TAC: time activity curve.

GASTRIC EMPTYING:
Initial static images showed radiotracer uptake in the stomach with movement of activity
from the stomach into the intestines within 10 minutes of the meal. There is adequate
clearance of activity from the stomach over time.

Half time of emptying (Raw data T1/2) = 122 minutes

Linear Fit T1/2 is 124 minutes.

Reference: Tougas et al. Am J Gastroenterol 2000; (6) 1456-1462

Standardized gastric emptying protocol
Delayed gastric emptying if
1 hour < 10 % emptying
2 hours < 40 %
4 hours < 90%

CONCLUSION:
Study shows 45 % emptying at 2 hours and 95% emptying by 4 hours.
These findings are within normal limits.
V/Q SCAN:
RESULT:
Comparison made with chest X-Ray done on 7th May 2015.

Perfusion scan shows large perfusion defects involving apical posterior and anterior segments
of left upper lobe and superior segment of left lower lobe.
In addition, small subsegmental perfusion defects are also noted in the right lung involving
apical segment of right upper lobe and medial segment of right middle lobe.
No matching opacity is seen on the recent chest Xray.

CONCLUSION:
Result is suggestive of pulmonary embolism (moderate to high probability)