Normal Thyroid Ultrasound Report Template
Normal thyroid ultrasound report template with lobe measurements, isthmus, echotexture and cervical lymph node wording, plus TI-RADS notes for nodules.
EXAMINATION: Thyroid ultrasound. CLINICAL HISTORY: [indication] COMPARISON: None available. TECHNIQUE: Real-time grayscale and color Doppler imaging of the thyroid gland and the cervical soft tissues. FINDINGS: Right lobe: [x] x [x] x [x] cm. Homogeneous echotexture. No nodule. Left lobe: [x] x [x] x [x] cm. Homogeneous echotexture. No nodule. Isthmus: Normal thickness, measuring [x] mm. Vascularity: Normal. Cervical lymph nodes: No abnormal cervical lymph node. IMPRESSION: 1. Normal thyroid ultrasound.
Dictation notes
- Every nodule gets the five ACR TI-RADS features scored, a total, and the size-dependent recommendation.
- Describe a nodule's position by lobe and third so the FNA proceduralist can find it.
Related references
Frequently asked questions
What belongs in a normal thyroid ultrasound report?
A thyroid ultrasound report gives three-plane measurements of each lobe, the isthmus thickness, gland echotexture and vascularity, an explicit statement about nodules, and an assessment of the cervical lymph nodes. The normal impression is 'Normal thyroid ultrasound.' When nodules are present, each is scored with the five ACR TI-RADS features and given the size-dependent recommendation.
How should a thyroid nodule be described in a report?
Each nodule should have all five ACR TI-RADS features scored — composition, echogenicity, shape, margin and echogenic foci — with the point total, the TR level and the size-based recommendation for FNA or follow-up. Location should be given by lobe and third (for example, mid right lobe) so a proceduralist can find the nodule at FNA. Maximum diameter determines whether the TR level's thresholds are met.
Which cervical lymph node features are suspicious on ultrasound?
Suspicious cervical node features include microcalcifications, cystic change, peripheral or chaotic vascularity, rounded shape with loss of the fatty hilum, and echogenicity resembling thyroid tissue. Reporting abnormal nodes alongside a thyroid nodule matters because nodal metastasis changes the management conversation regardless of the nodule's TI-RADS level. A normal study should still state that no abnormal cervical lymph node is seen.
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