Radionuclide Therapy Consult Note (Theranostics)

Date/Time: [Encounter date and time]

Patient: [Full name, identifiers]

Consulting Service: [Nuclear Medicine / Theranostics]

Attending Physician: [Attending physician name, credentials]

Referring Clinician: [Name and specialty]

Encounter Type: [outpatient / inpatient]

Reason for Consult

[Requested therapy or evaluation, primary decision needed, and clinical urgency] (If the referral question was unclear, document clarification obtained and restate the working question.)

Theranostics Summary

[Concise narrative framing the consult] (Single paragraph: patient identity, cancer type and current status, key prior treatment lines, theranostic target status based on molecular imaging, and the decision being made. Include approximate dates for major milestones to explain why this evaluation is occurring now.)

History

Oncologic History and Prior Therapies

Diagnosis and Course: [Primary site, histology, grade, stage at diagnosis; key disease course transitions with dates; current disease status and date of most recent progression] (Attribute sources: patient report vs outside records.)

Key Biomarkers: [Biomarkers relevant to theranostic selection with dates]

• Prior Systemic Therapies:
  • [Regimen name] — [Timeframe or cycle count]; [Best response]; [Reason stopped]
  • (Repeat per regimen; include chemotherapy, targeted therapy, immunotherapy, hormonal therapy.)
• Radiation Therapy: [Fields/regions treated and approximate dates] (Note marrow exposure concerns if relevant.)
• Prior Radiopharmaceutical Therapies: [Agent, dates, best response, and specific toxicities with resolution status]

Symptoms and Functional Status

Performance Status: [ECOG 0 / 1 / 2 / 3 / 4] or [Karnofsky %]

• [Current symptom burden: pain, fatigue, xerostomia, GI symptoms, hormone-secretion symptoms, urinary symptoms]
• [Red flags requiring urgent alternative management] (Include only if present: cord compression, impending fracture, severe cytopenias, obstructive uropathy.)

Relevant Medical History

• [Renal disease, hydronephrosis/obstruction, nephrotoxic exposures, dialysis status]
• [Bone marrow reserve concerns: baseline cytopenias, prior extensive chemotherapy or radiation, marrow involvement]
• [Liver disease or dysfunction]
• [Prior allergic reactions to relevant infusions, antiemetics, amino acids, or contrast]
• [Salivary gland disease or sicca history] (For PSMA therapies)
• [GI risk factors relevant to proposed therapy]
• [Endocrine crisis risk for functional NET]

Medications and Allergies

• Current Medications: [Medications affecting eligibility, interactions, scheduling, renal function, bleeding risk, marrow suppression, or nausea control] (Include somatostatin analog timing for SSTR-directed therapy.)
• Planned Concomitant Medications: [Premedications, antiemetics, amino acid infusion, hydration protocols]
• Allergies: [Drug and contrast allergies with reaction types]

Reproductive Status

[Pregnancy status with verification method and date / Breastfeeding status / Contraception counseling with recommended duration] (Include only when applicable. Do not infer; if unknown, document as unknown with action plan to verify.)

Radiation Safety Feasibility

• [Living situation: caregivers, small children, pregnant household members]
• [Home infrastructure: shared bathroom/bedroom constraints]
• [Ability to return for multiple cycles and follow-up]
• [Language or health literacy needs; comprehension assessment]
• [Occupational considerations: close-contact work, childcare]
• [Feasibility determination and mitigation plan if constraints exist]

Objective

Vitals and Examination

[Vital signs and targeted physical exam findings] (Include only if examination performed. Focus on hydration status, performance status corroboration, edema, mucositis, neurologic deficits, infection or bleeding signs, abdominal findings for NET, xerostomia for PSMA therapies. Omit this subsection entirely if no exam was performed.)

Laboratory Data

• CBC with differential: [WBC], [ANC], [Hemoglobin], [Platelets] — [Date]
• Renal function: [Creatinine], [eGFR or CrCl with method] — [Date]
• Hepatic function: [AST], [ALT], [ALP], [Total bilirubin], [Albumin] — [Date]
• Coagulation studies: [PT/INR], [aPTT] — [Date] (If relevant)
• Disease biomarkers: [Marker and values with trend] — [Dates]
• [Critical labs missing or outdated with plan and timing to obtain] (Include only if applicable.)

Target Expression Imaging

Modality/Tracer: [68Ga PSMA PET/CT / 18F PSMA PET/CT / 68Ga DOTATATE PET/CT] — Date: [Date] — Review status: [Personally reviewed / Report only]

• Target positivity: [Meets criterion / Does not meet / Indeterminate] — [Reference criterion used]
• Heterogeneity: [Homogeneous / Heterogeneous] — [Target-negative or discordant lesions if present]
• [Key interpretive findings relevant to eligibility]

(This section is required. If target imaging not performed or unavailable, explicitly state and document plan to obtain prior to therapy.)

Staging and Response Imaging

• [Recent anatomic/functional imaging with dates and key findings]
• [Measurable disease sites and dominant symptomatic sites]

Eligibility Assessment

(For each criterion, document status and provide actual values with dates. For critical data—target imaging, CBC, renal function, pregnancy status when applicable—mark as unknown if unavailable with action plan.)

• Disease indication: [met / not met / indeterminate] — [Diagnosis, stage, line of therapy]
• Target expression: [met / not met / indeterminate] — [Modality, date, positivity criterion, heterogeneity]
• Marrow function: [met / not met / indeterminate] — [ANC], [Hemoglobin], [Platelets] — [Date]
• Renal function: [met / not met / indeterminate] — [Creatinine], [eGFR/CrCl] — [Date]
• Hepatic function: [met / not met / indeterminate / not applicable] — [Values] — [Date]
• Radiation precaution compliance: [met / not met / indeterminate] — [Summary and mitigation plan]
• Contraindications: [None identified / List with mitigation plan]
• High-risk features: [List features impacting expected benefit] (Include only if present.)

Assessment

• Primary oncologic problem: [Diagnosis] — [active / progressive / stable]; [Target status]; [Treatment intent: disease control / symptom palliation]; [Key supporting data with dates]; [Risk modifiers]
• [Other active problems affecting therapy planning] (List in order of clinical severity.)

Plan

Treatment Plan

• Agent: [Radiopharmaceutical name and target] — Intent: [Disease control / Symptom palliation]
• Regimen: [Number of cycles], [Interval], [Route and setting]
• Pre-cycle requirements: [Labs, imaging, time windows, pregnancy testing if applicable]
• Supportive care: [Antiemetics], [Amino acid infusion], [Hydration protocol]
• Concomitant therapies: [Continue / Hold] [specific therapies] — [Timing rules]
• Toxicity monitoring: [Schedule for labs and assessments]
• Dose modification criteria: [Thresholds for hold, reduction, or discontinuation]
• Post-therapy imaging: [Restaging and/or dosimetry plan with timing]
• Care coordination: [Ownership of orders, lab monitoring, adverse effect management]

(Use conditional language when appropriate: proceed if [conditions met]; otherwise [alternative actions].)

Expected Benefits and Goals

[Patient-prioritized goals: disease control, symptom improvement, delaying next line of therapy, quality of life] (Define success/failure criteria. Use probabilistic language; acknowledge uncertainty with heterogeneous target expression.)

Risks Discussed

• General risks: [Myelosuppression, infection, bleeding, renal toxicity, secondary malignancy]
• Agent-specific risks: [Xerostomia/salivary toxicity for PSMA; hepatotoxicity and hormonal crisis for SSTR]
• Patient questions and comprehension: [Questions addressed; understanding assessed]

Radiation Safety Counseling

• [Distancing from children and pregnant persons with duration]
• [Hygiene precautions: toilet use, handwashing, laundering, bodily fluid handling]
• [Hydration and frequent voiding to reduce bladder dose]
• [Sexual activity precautions and duration]
• [Travel and public place considerations]
• [Breastfeeding interruption or discontinuation] (If applicable)
• [Instructions if hospitalization needed; emergency contact pathway]

(Document that written instructions will be provided per institutional protocol and regulatory requirements.)

Alternatives

• [Other systemic options with rationale]
• [Clinical trials]
• [External beam radiation or surgery]
• [Best supportive care]
• [Other radiopharmaceuticals]

Orders and Coordination

• [Labs ordered with timing]
• [Imaging ordered with timing]
• [Referrals: oncology, urology, nephrology, palliative care, social work]
• [Communication: tumor board, referring clinician notification]
• [Patient education materials provided]

Follow-up

• [Next contact: pre-cycle clearance, post-cycle toxicity assessment, end-of-treatment restaging]
• [Return precautions and where to present for urgent symptoms]

(Include only sections with meaningful content. For noncritical missing data, omit the field. For critical data—target imaging, CBC, renal function, pregnancy status when applicable—include the field and mark as unknown with action plan. Attribute information sources. Do not infer target positivity, pregnancy status, imaging findings not reviewed, or patient understanding.)