Thyroid Nodule/Goiter Evaluation Note

Date: [Date]

Clinician: [Name, credentials]

Clinic/Location: [Clinic or facility name]

Referring Clinician: [Name and specialty] (Include only if applicable)

Referral Question: [Reason for referral] (Include only if applicable)

PCP: [Primary care clinician name]

History Source: [Patient / family member / caregiver / records] (If interpreter used, specify language and modality)

Records Reviewed: [Outside imaging, labs, pathology, prior notes with source and date] (If a study is referenced by patient but not available, document as "not available for review" with retrieval status)

Chief Complaint

[One-line reason for visit: thyroid nodule or goiter with discovery mode—incidental imaging / palpable on exam / symptom-driven]

History of Present Illness

[Discovery and time course: when and how nodule/goiter was discovered, modality of discovery, prior imaging comparisons with growth or stability, prior workup including ultrasound, labs, radionuclide scan, FNA, molecular testing with key dates]

[Compressive and local symptoms: dysphagia (solids vs liquids, progressive vs intermittent), dyspnea (exertional vs positional), orthopnea, choking sensation, stridor, voice change/hoarseness, cough, neck pressure or visible enlargement, pain/tenderness; for large goiter/nodules note whether symptoms worsen with arm elevation] (State presence or absence for each relevant symptom)

[Thyroid dysfunction symptoms: hyperthyroid symptoms (palpitations, tremor, heat intolerance, weight loss, anxiety, diarrhea); hypothyroid symptoms (fatigue, weight gain, cold intolerance, constipation, dry skin, hair loss); recent neck pain or tenderness suggestive of thyroiditis] (State presence or absence)

[Malignancy risk factors—document each as present or absent: childhood head/neck radiation or significant ionizing exposure; family history of thyroid cancer in first-degree relatives or hereditary syndromes (MEN2, familial nonmedullary thyroid cancer); rapid nodule growth; persistent hoarseness/voice change; prior head/neck cancer or thyroid cancer] (Do not leave any factor implied; explicitly state present or absent for each)

[Procedural and management considerations: pregnancy status, anticoagulant/antiplatelet use with agent and dose, bleeding disorders, prior neck/thyroid surgery, known laryngeal nerve issues, recent iodinated contrast exposure with date, biotin supplementation with dose and timing, patient goals/preferences regarding surveillance vs biopsy vs surgery] (Include only factors relevant to this patient)

Review of Systems

(Document only systems actually reviewed; state pertinent positives and negatives relevant to thyroid pathology)

• Constitutional: [Weight change, fatigue, fever, night sweats]
• HEENT/Neck: [Voice change, dysphagia, neck swelling/pressure, pain]
• Respiratory: [Dyspnea, orthopnea, stridor, cough]
• Cardiovascular: [Palpitations]
• Gastrointestinal: [Diarrhea, constipation]
• Neurologic: [Tremor]
• Endocrine: [Heat intolerance, cold intolerance]

Past Medical and Surgical History

• [Thyroid disease history: Hashimoto's, Graves', prior thyroiditis, prior thyroid nodules/goiter]
• [Prior malignancies, especially head/neck, with treatment history]
• [Cardiopulmonary comorbidities affecting surgical risk or symptom interpretation]
• [Prior neck/thyroid surgery with type and date]
• [Radiation therapy to neck with indication and dates]
• [Other relevant medical/surgical history]

Medications

• [Thyroid hormone replacement: name, dose, schedule]
• [Antithyroid drugs: name, dose, schedule]
• [Amiodarone or lithium: dose and duration]
• [Anticoagulants/antiplatelets: name, dose]
• [Other current medications and supplements, including biotin]

Allergies

[Allergies with reaction type] (Note relevance to procedural planning if applicable)

Family History

• Thyroid cancer in first-degree relatives: [present / absent] (If present, specify relation and age at diagnosis)
• Autoimmune thyroid disease: [present / absent]
• MEN syndromes or hereditary cancer syndromes: [present / absent]
• [Other relevant family history]

Social History

• Tobacco: [never / former / current; pack-years if applicable]
• Occupational/environmental radiation exposure: [present / absent]
• [Alcohol or substance use] (Include only if clinically relevant)
• [Travel or location constraints affecting follow-up] (Include only if applicable)

Physical Examination

• Vitals: Weight [weight], HR [heart rate], BP [blood pressure], RR [respiratory rate], SpO2 [oxygen saturation] (Include SpO2 if respiratory symptoms present)
• General: [Appearance, distress level, work of breathing]
• Voice/Airway: Voice quality [normal / hoarse / breathy], stridor [present / absent]
• Neck/Thyroid:
  • Inspection: [Visible enlargement, asymmetry, surgical scars]
  • Palpation: Thyroid size [normal / mild / moderate / marked thyromegaly], [diffuse / nodular]
  • Palpable nodules: [For each: approximate size, laterality, lobe location, mobility, firmness, tenderness]
  • Trachea: [Midline / deviated]
  • Cervical lymph nodes: [Central and lateral compartments—size, tenderness, mobility/fixation if abnormal]
  • (If thyroid not adequately assessable due to body habitus or anatomy, document this limitation)
• Cardiovascular: [Rate and rhythm] (Include if symptoms warrant)
• Respiratory: [Breath sounds and effort] (Include if dyspnea reported)

Diagnostics Reviewed

Laboratory Data

• TSH: [Value, units] ([Date]) [normal / abnormal]
• Free T4: [Value, units] ([Date]) (Include if obtained)
• Free T3: [Value, units] ([Date]) (Include if obtained)
• Thyroid antibodies: [TPOAb, TgAb, TRAb/TSI as applicable with values and dates] (Include if clinically relevant)
• [Other relevant labs with dates] (Include only if available)

Imaging

(For each study: document modality, date, facility, and whether images personally reviewed or report only)

• [Modality, date, facility, images reviewed / report only]: [Key findings—thyroid size, nodule characteristics, suspicious lymph nodes, substernal extension, tracheal/esophageal compression]
• (Add additional imaging studies as needed)

Thyroid Ultrasound Nodule Characterization

(Document up to four index nodules prioritized by biopsy threshold, suspicion level, growth, or symptom correlation; use consistent nomenclature that will match cytology reports)

• Nodule 1 – [Right / Left / Isthmus] [upper / mid / lower] pole:
  • Size: [a × b × c cm]
  • Composition: [solid / solid-cystic / spongiform / cystic]
  • Echogenicity: [hypoechoic / isoechoic / hyperechoic / very hypoechoic]
  • Shape: [taller-than-wide / wider-than-tall]
  • Margins: [smooth / ill-defined / lobulated / irregular / extrathyroidal extension]
  • Echogenic foci: [none / macrocalcifications / peripheral rim / punctate echogenic foci]
  • Risk stratification: [ACR TI-RADS TR1-5 with points / ATA suspicion pattern]
  • Comparison to [prior study date]: [Significant growth: yes / no / no prior]
• Nodule 2 – [Location]: [Size, composition, echogenicity, shape, margins, echogenic foci, risk stratification, comparison] (Include if applicable)
• Nodule 3 – [Location]: [Nodule characteristics as above] (Include if applicable)
• Nodule 4 – [Location]: [Nodule characteristics as above] (Include if applicable)

Radionuclide Scan

(Include only if performed)

• [Date], [Tracer used]: Nodule function [hyperfunctioning (hot) / nonfunctioning (cold) / indeterminate]; [Impact on biopsy decision]

Cytology and Pathology

(Link each result to specific nodule using identical identifier and location as ultrasound documentation)

• [Date] – [Nodule identifier and exact location] – Bethesda [I-VI]: [Category name] – Molecular testing: [Results and actionability, or not performed] – Complications: [None / describe]
• (Add additional cytology entries as applicable)

Assessment

(Problem-oriented list ordered by clinical priority; include only applicable problems; tie risk stratification and management decisions to explicit imaging features and size thresholds)

• [Problem 1—highest priority concern]: [Working diagnosis or pending status, differential if uncertain, key supporting evidence from symptoms/exam/imaging/labs]
• [Problem 2]: [Assessment summary with supporting evidence]
• [Additional problems as applicable]: [Assessment summary]
• Thyroid functional status: [Euthyroid / Hyperthyroid / Hypothyroid / Pending labs] (Reference TSH/FT4/FT3)

Plan

Thyroid Nodule Evaluation

(Select and complete the applicable management pathway with explicit rationale tied to size and risk category)

• Surveillance: [Nodules under surveillance with risk category and size rationale] – Ultrasound follow-up in [interval] – Reassess sooner if [criteria] – Patient agrees with surveillance plan
• Fine-Needle Aspiration: [Nodule(s) meeting biopsy criteria with size and TI-RADS/ATA rationale] – [US-guided FNA ordered / referral placed to] – Anticoagulation plan: [continue / hold / bridge] – Timeline: [expected] – Results communicated by: [clinician/method]
• Surgical/ENT Referral: [Indication: compressive symptoms / substernal goiter / voice change / patient preference / repeated indeterminate cytology] – Referred to [service] – Pre-operative evaluation: [tests arranged]

Goiter Management

(Include only if goiter present)

• Symptoms attributed to compression: [List symptoms]
• Additional imaging for substernal extent: [Yes, ordered / No, not indicated]
• Management options discussed: [Observation / medical therapy / procedural / surgical]
• Referral: [Service and indication, if placed]

Thyroid Function

• [If TSH abnormal]: [Confirmatory labs ordered]; [Impact on nodule workup sequence]
• [If euthyroid]: Thyroid function consistent with available labs
• [If no recent TSH]: TSH ordered; management decisions will be revisited after results

Cervical Lymphadenopathy

(Include only if abnormal nodes identified)

• [Location and concerning features] – Planned evaluation: [Targeted US / FNA / cross-sectional imaging]

Patient Counseling

• Risk framing: [Malignancy risk estimate based on imaging category and size thresholds]
• Options discussed: [Surveillance vs biopsy vs surgery; benefits/risks reviewed; patient values and preferences]
• Written materials: [Provided / not provided]

Safety Precautions

(Include when compressive symptoms or high-risk features present)

• Return precautions given: Seek urgent care for worsening dyspnea, stridor, inability to swallow, rapid neck swelling, or rapidly progressive hoarseness

Orders and Follow-Up

(Include only categories where orders were placed; omit empty categories)

• Labs: [TSH, FT4, FT3, antibodies, pregnancy test as applicable]
• Imaging: [Thyroid ultrasound / radionuclide scan / CT or MRI with contrast considerations]
• Procedures: [US-guided FNA with anticoagulation plan]
• Referrals: [ENT / Endocrine surgery / Anesthesia pre-op / Genetics]
• Records Requested: [Outside imaging, prior pathology, operative notes]
• Follow-Up: [Interval] for [purpose]; [telehealth / in-person]; Results reviewed and communicated by [clinician/method]