XXX Nuclear Facility 6021 University Blvd #500 Columbia, MD 21043 Phone (123)123-1234 Fax (123)123-1234 Patient Name: Doe, Jane ID Number: 123456 Date of birth: 4-2-79 Sex: Female Referring physician: Dr. Jones Date of the exam: 4-1-12 Clinical Indications: Hiatal hernia Radiopharmaceutical: 2.1 mCi 99m Tc Sulfur Colloid PO Gastric Emptying Study INDICATIONS/HISTORY: 29-year-old female with ulcer disease complaining of early satiety and weight loss. PREVIOUS STUDY: No previous gastric emptying studies are available for review. FINDINGS: Following oral administration of a solid meal (eggbeaters) labeled with 2.1 mCi of Tc99m sulfur colloid, anterior and posterior imaging of the abdomen was performed through 90 minutes. Regions of interest were then placed over the stomach and gastric retention was calculated for 0.5, 1 and 2 hours. Approximately 28% of the administered radiopharmaceutical was retained in the stomach at 60 minutes (normal 30% or less). IMPRESSION: Normal gastric emptying study. Mary Beth Farrell, MD (electronically signed) Date of interpretation: 4-2-12 Date of final report: 4-3-12 Gastric Emptying Study (SAMPLE) 1 NOTE: This is a SAMPLE only. Protocols submitted with the application MUST be customized to reflect current practices of the facility.