Patient Name: Doe, Jane

XXX Nuclear Facility 6021 University Blvd., Suite 500 Ellicott City, MD 21043 Phone: (123) 123-1234 Fax: (123) 123-1234

Phone (123)123- 1234 Fax (123)123-1234

Patient Name: Doe, Jane Referring physician: Dr. Jones ID Number: 123456 Date of the exam: 4-1-17 Date of birth: 4-2-81 Radiopharmaceutical: 10.1 mCi 99mTc MAG3 IV Sex: Female Height: 68 in Weight: 142lb Lasix Renal Scan

INDICATIONS/HISTORY: Left renal atrophy

Lasix Renal Plan (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

Phone (123)123- 1234 Fax (123)123-1234

FINDINGS: Following the intravenous administration of 10.1 mCi of Tc99m MAG-3, flow study overlying the kidneys was performed. There is symmetric flow to both kidneys, although there is obvious global atrophy of the left kidney. There is simultaneous appearance of isotope within the collecting system of each kidney, without evidence of hydronephrosis. There is no evidence of ureteral dilatation or obstruction on either side.

The time to peak for right kidney is normal. There is relatively flat left renogram. The split renal function studies demonstrate that there is 82.9% of activity arising from the right kidney and 17.1% of activity arising from the left kidney.

IMPRESSION: There is global atrophy of the left kidney with reduced function with the left kidney supplying only 17.1% of activity. There is no evidence of hydronephrosis or obstructive uropathy.

Lasix Renal Plan (SAMPLE) 2 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

Phone (123)123- 1234 Fax (123)123-1234

Electronically signed by Maria Costello, MD on April 2, 2017 at 10:30 AM

Lasix Renal Plan (SAMPLE) 3 NOTE: This is a SAMPLE only. Protocols submitted with the application MUST be customized to reflect current practices of the facility.