Thyroid Nodule Evaluation Note

Date/Time: [Date and time of encounter]   Patient: [Full name]   DOB: [MM/DD/YYYY]   MRN: [Medical record number]   Referring Clinician: [Name, credentials]   Encounter Type: [new consult / follow-up]

Reason for Consultation

[Reason for referral and clinical question being addressed]

Executive Summary

[3–6 sentence narrative summary including: discovery circumstances and timing; ultrasound risk category and size of index nodule(s); lymph node status if survey performed; thyroid functional status; recommended plan with brief rationale] (Do not infer ultrasound features or lymph node status that were not explicitly reported. Use a single primary risk stratification system consistently throughout the note.)

History of Present Illness

Nodule Discovery and Timeline

[Narrative of discovery and clinical course including: date and modality of initial discovery; prior thyroid imaging with dates and key changes; prior biopsies with dates, sites, and results; growth concerns]

Compressive and Local Symptoms

• Dysphagia: [present / absent / not assessed] [Details if present]
• Globus sensation: [present / absent / not assessed] [Details if present]
• Dyspnea or positional breathing difficulty: [present / absent / not assessed] [Details if present]
• Voice change or hoarseness: [present / absent / not assessed] [Duration and characteristics if present]
• Neck pressure or fullness: [present / absent / not assessed] [Details if present]
• Cosmetic concern: [present / absent / not assessed] [Details if present]

Thyroid Dysfunction Symptoms

[Relevant hyperthyroid or hypothyroid symptoms, or "No symptoms of thyroid dysfunction" if negative]

Thyroid Cancer Risk Factors

(Always include this section, even if all findings are negative.)

• Prior head/neck radiation (especially childhood): [yes / no] [Details if yes]
• Family history of thyroid cancer or MEN2/familial syndromes: [yes / no] [Details and relation if yes]
• Personal history of thyroid or head/neck malignancy: [yes / no] [Details if yes]
• Rapid nodule growth: [yes / no] [Details if yes]
• Persistent hoarseness: [yes / no]
• Palpable lymphadenopathy: [yes / no] [Location if present]

Procedural Considerations

(Include if FNA may be indicated.)

• Anticoagulant/antiplatelet use: [Medication(s) and indication / none]
• Bleeding disorders: [yes / no] [Details if yes]
• Prior procedural intolerance: [yes / no] [Details if yes]
• Pregnancy status: [pregnant / not pregnant / not applicable]

Objective

Physical Examination

Neck: [Thyroid size and character; palpable nodules with size/firmness if appreciable; tenderness; mobility with swallowing; tracheal position]

Voice: [normal / hoarse] [Details if abnormal]

Lymph Nodes: [Cervical lymph node exam findings] (Do not document "no lymphadenopathy" unless a targeted exam was performed.)

Laboratory Data

• TSH: [value] [units] (ref [range]) [date] (If pending or unavailable, state "TSH pending" or "Labs not yet available.")
• Free T4: [value] [units] (ref [range]) [date] (Include only if TSH abnormal.)
• Free/Total T3: [value] [units] (ref [range]) [date] (Include only if indicated.)

Imaging Review

Ultrasound Source: [Date], [Facility], [images personally reviewed / report only]. [Limitations if any, such as incomplete lymph node survey]

(Select a primary risk stratification system—ACR TI-RADS or ATA—and use it consistently throughout this note. Do not infer features not explicitly reported.)

Thyroid Nodule Summary: (Include all nodules meeting biopsy or follow-up criteria, symptomatic nodules, or clinically dominant nodules. Repeat the following block for each clinically relevant nodule.)

Nodule #[X] ([side, pole]):
Size: [A × B × C cm; max dimension] [Comparison to prior with dates and growth assessment]
Composition: [solid / predominantly solid / mixed cystic-solid / spongiform / cystic]
Echogenicity: [hyperechoic / isoechoic / hypoechoic / very hypoechoic]
Shape: [wider-than-tall / taller-than-wide]
Margins: [smooth / ill-defined / lobulated / irregular / extrathyroidal extension]
Echogenic foci: [none / macrocalcifications / rim calcifications / punctate echogenic foci]
Risk Category: [ACR TI-RADS: TR level (points) / ATA: pattern] (If insufficient data, state "Risk category cannot be determined from available report.")
FNA Criteria Met: [yes / no] [Cite size threshold from chosen system]

[Summary of additional small nodules not individually detailed, e.g., "Multiple additional subcentimeter spongiform nodules without suspicious features; none meet biopsy thresholds."]

Cervical Lymph Node Assessment: [Dedicated survey performed / not performed / incomplete]. [If performed: compartments evaluated; suspicious nodes with side, level, short-axis size, and suspicious features] (Do not state "no suspicious lymph nodes" unless a dedicated survey was performed or explicitly reported.)

Prior Cytology/Pathology

(Include if applicable; repeat for each prior biopsy.)

• Target nodule: [Nodule #, location]   Date: [MM/DD/YYYY]   Adequacy: [diagnostic / nondiagnostic]   Bethesda category: [I–VI]   Molecular testing: [result / not performed]   Complications: [none / description]

Assessment and Plan

Thyroid Nodule(s)

(For each index nodule requiring a management decision, use the following format.)

Nodule #[X] ([Location])

Assessment: [Synthesis of nodule size, risk category, key suspicious features, relevant clinical risk factors, and thyroid functional status]

Plan: [FNA indicated: yes / no] [Cite specific criteria from chosen risk system and size thresholds]. [If FNA planned: target nodule(s), timing, anticoagulant management if needed, consideration of molecular testing if cytology indeterminate]. [If surveillance planned: imaging interval, triggers for earlier evaluation, whether plan follows guidelines vs patient preference]. [If surgical referral indicated: rationale and destination service]

Cervical Lymph Nodes

Status: [no suspicious nodes / suspicious nodes present / incomplete evaluation] (Do not state "no suspicious nodes" unless a survey was performed.)
Plan: [Comprehensive neck ultrasound with lymph node mapping / FNA of suspicious nodes with thyroglobulin washout / no further evaluation needed]

Thyroid Function

(Include only if TSH is abnormal or pending.)

[For suppressed TSH: plan for radionuclide scan and how results will affect biopsy decision. For elevated TSH: further workup or treatment considerations. For pending TSH: interim plan and how results will guide management.]

Compressive Symptoms

(Include only if compressive symptoms present.)

[Symptom severity and impact; need for cross-sectional imaging; referral plan to endocrine surgery, ENT, or laryngology]

Counseling and Shared Decision-Making

[Estimated malignancy risk explained in patient-friendly terms based on chosen risk stratification system]. [Options discussed: surveillance with rationale and interval; FNA with purpose and possibility of nondiagnostic result; surgery when indicated]. [Patient preferences and final decision]. [If FNA planned: discussion of risks (bleeding, infection, inadequate sample) and alternatives documented]. [Return precautions: new or worsening voice change, rapid growth, worsening swallowing or breathing, new neck mass]

Orders and Follow-up

• Labs: [Tests ordered with indication]
• Imaging: [Studies ordered with indication]
• Procedures: [FNA with target nodule(s) and rationale]
• Referrals: [Service and indication]

Follow-up: [Timeframe and modality]. Results communication: [Method]. Contingency plan: [Benign cytology → surveillance interval; malignant cytology → surgical referral; nondiagnostic → repeat FNA consideration; indeterminate → molecular testing vs diagnostic surgery]

Procedure Note

(Include only if FNA or cyst aspiration was performed during this encounter. Omit if procedure scheduled for future date.)

Procedure: [US-guided thyroid FNA / cyst aspiration]   Indication: [Nodule # meeting criteria]   Consent: [Risks, benefits, alternatives discussed; questions answered]   Timeout: [Site verified]

Technique: [Skin prep; local anesthetic if used; needle gauge; number of passes; real-time US confirmation of target; specimen handling]

Outcome: [Immediate complications: none / description]   Post-procedure: [Instructions and return precautions provided]