Thyroid Ultrasound Report (Risk Stratification)

Patient: [Patient name or identifier]

DOB/Sex: [DOB]; [Sex]

Exam Date: [Exam date]

Ordering Clinician: [Ordering clinician name and credentials]

Interpreting Radiologist: [Radiologist name and credentials]

Indication

[Primary reason for thyroid ultrasound; pertinent clinical risk factors; relevant prior thyroid procedures or biopsy history] (Limit to 1–3 sentences. If no indication is available, output: "Indication: Not provided.")

Comparison

[Prior relevant imaging modality and dates] (Single line. If none, state: "Comparison: None available.")

Technique

Ultrasound of the thyroid [with / without] color Doppler was performed. Cervical lymph node survey [was included / was not performed]. [Study limitations, if any] (Include limitations only if present, such as body habitus, patient motion, incomplete survey, or overlying dressings.)

Findings

Thyroid Gland: Right lobe [CC × TR × AP cm]; Left lobe [CC × TR × AP cm]; Isthmus thickness [cm]. Parenchyma: [homogeneous / heterogeneous]. [Diffuse abnormalities if present] (If measurement unobtainable, state "cannot determine" with brief reason. Include diffuse features such as hypervascularity or thyroiditis pattern only if present.)

Nodules: [No discrete thyroid nodules. / Total of [count] nodules ≥1 cm identified.] (If more than four nodules present, describe up to four clinically relevant nodules, prioritizing highest TI-RADS category and those meeting size criteria for FNA or follow-up.)

Nodule 1: [Right / Left / Isthmus], [upper / mid / lower pole]; [L × W × H cm]
Composition: [cystic / spongiform / mixed cystic-solid / solid / cannot determine]
Echogenicity: [anechoic / hyperechoic / isoechoic / hypoechoic / very hypoechoic / cannot determine]
Shape: [wider-than-tall / taller-than-wide / cannot determine]
Margins: [smooth / ill-defined / lobulated or irregular / extrathyroidal extension / cannot determine]
Echogenic foci: [none / comet-tail artifacts / macrocalcifications / peripheral calcifications / punctate echogenic foci / cannot determine]
Change from prior: [stable / increased / decreased / new / N/A]
TI-RADS: [total points] points, TR[1 / 2 / 3 / 4 / 5]

Nodule 2: [Laterality], [pole]; [L × W × H cm]
Composition: [cystic / spongiform / mixed cystic-solid / solid / cannot determine]
Echogenicity: [anechoic / hyperechoic / isoechoic / hypoechoic / very hypoechoic / cannot determine]
Shape: [wider-than-tall / taller-than-wide / cannot determine]
Margins: [smooth / ill-defined / lobulated or irregular / extrathyroidal extension / cannot determine]
Echogenic foci: [none / comet-tail artifacts / macrocalcifications / peripheral calcifications / punctate echogenic foci / cannot determine]
Change from prior: [stable / increased / decreased / new / N/A]
TI-RADS: [total points] points, TR[1 / 2 / 3 / 4 / 5]

Nodule 3: [Laterality], [pole]; [L × W × H cm]
Composition: [cystic / spongiform / mixed cystic-solid / solid / cannot determine]
Echogenicity: [anechoic / hyperechoic / isoechoic / hypoechoic / very hypoechoic / cannot determine]
Shape: [wider-than-tall / taller-than-wide / cannot determine]
Margins: [smooth / ill-defined / lobulated or irregular / extrathyroidal extension / cannot determine]
Echogenic foci: [none / comet-tail artifacts / macrocalcifications / peripheral calcifications / punctate echogenic foci / cannot determine]
Change from prior: [stable / increased / decreased / new / N/A]
TI-RADS: [total points] points, TR[1 / 2 / 3 / 4 / 5]

Nodule 4: [Laterality], [pole]; [L × W × H cm]
Composition: [cystic / spongiform / mixed cystic-solid / solid / cannot determine]
Echogenicity: [anechoic / hyperechoic / isoechoic / hypoechoic / very hypoechoic / cannot determine]
Shape: [wider-than-tall / taller-than-wide / cannot determine]
Margins: [smooth / ill-defined / lobulated or irregular / extrathyroidal extension / cannot determine]
Echogenic foci: [none / comet-tail artifacts / macrocalcifications / peripheral calcifications / punctate echogenic foci / cannot determine]
Change from prior: [stable / increased / decreased / new / N/A]
TI-RADS: [total points] points, TR[1 / 2 / 3 / 4 / 5]

(Include only as many nodule blocks as needed. Score features per ACR TI-RADS; do not infer any feature not clearly visualized. For any feature that cannot be assessed, state "cannot determine" with brief reason.)

Cervical Lymph Nodes: [No suspicious cervical lymphadenopathy. / Suspicious node at [level/side], short axis [cm], with [suspicious features]. / Cervical lymph node survey not performed.] (If suspicious nodes present, document location, short-axis measurement, and features such as loss of fatty hilum, round shape, cystic change, calcifications, peripheral vascularity, or hyperechogenicity.)

Other Findings: [Relevant additional findings] (Include only if present, such as parathyroid lesion, thyroglossal duct cyst, or substernal extension. Omit this line entirely if no other findings.)

Impression

1. [Actionable nodule: laterality, pole, size, TI-RADS category] — [Recommend US-guided FNA / Recommend follow-up ultrasound in [timeframe] / No follow-up recommended per TI-RADS].
2. [Additional actionable nodules as needed with recommendation].
3. [Lymph node assessment: No suspicious cervical lymphadenopathy / Suspicious lymphadenopathy at [location] — [Recommendation]].
4. [Global thyroid assessment if clinically relevant]

(Order items by clinical urgency. Include only nodules requiring action per ACR TI-RADS size thresholds, those specifically relevant to the indication, or those with prior history. Omit low-risk nodules that require no follow-up unless they are the indication for the exam.)