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Thyroid Ultrasound Worksheet Patient Risk Factors (Circle All That Applies)

This document is a thyroid ultrasound worksheet that collects information about a patient's thyroid ultrasound. It includes sections to note patient risk factors for thyroid malignancy, the indication for the ultrasound, findings from a prior ultrasound if applicable, measurements of the thyroid lobes and nodules found, and a table to characterize up to 5 nodules based on size, composition, echogenicity, margins, echogenic foci, and total TI-RADS points.

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priya
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21K views1 page

Thyroid Ultrasound Worksheet Patient Risk Factors (Circle All That Applies)

This document is a thyroid ultrasound worksheet that collects information about a patient's thyroid ultrasound. It includes sections to note patient risk factors for thyroid malignancy, the indication for the ultrasound, findings from a prior ultrasound if applicable, measurements of the thyroid lobes and nodules found, and a table to characterize up to 5 nodules based on size, composition, echogenicity, margins, echogenic foci, and total TI-RADS points.

Uploaded by

priya
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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THYROID ULTRASOUND WORKSHEET

Patient risk factors (circle all that applies)


Personal history of thyroid malignancy: Yes, No
Family history of thyroid malignancy: Yes, No
Personal history of radiation: Yes, No
Personal history of endocrine syndrome: Yes, No
_____________________________________________________________________________________________________________________________ _
Indication for US (circle all that applies)
Goiter Palpable abnormality Incidental on CT MRI US PET (circle modality)
Hypothyroid Hyperthyroid Prior ultrasound follow-up
Other: __________

Prior thyroid ultrasound: Yes (date/interval __________) No Prior biopsy: Yes (date/interval __________) No
_______________________________________________________________________________________________________________________________
ULTRASOUND FINDINGS Technologist: _______
Size right lobe: ____ cm craniocaudal X ____ cm transverse X ____ cm anterior-posterior
Size left lobe: ____ cm craniocaudal X ____cm transverse X ____cm anterior-posterior
Size isthmus: ____ cm anterior-posterior
Overall texture (circle): Homogenous, Heterogenous
Estimated total number of nodules ≥1cm: _____ or (circle) 6-10 >10

TALLER-
TOTAL TI-RADS
№ IMAGES SIZE (cm) COMPOSITION ECHOGENICITY THAN- MARGINS ECHOGENIC FOCI
POINTS LEVEL
WIDE

X X

X X

X X

X X

X X
C Cystic 0 A Anechoic 0 No 0 S Smooth 0 N None 0 0 Pts TR1 Benign
Sp Spongiform 0 ↑ Hyperechoic 1 Yes 3 ID Ill-defined 0 CT Comet-Tail 0 2 Pts TR2 Not
M Mixed cystic and nodule 1 = Isoechoic 1 L Lobulated 2 M Macrocaks 1 Suspicious
S Solid 2 ↓ Hypoechoic 2 I Irregular 2 PC Periph calc 2 3 Pts TR3 Mildly
TWO largest nodules & any with IMPORTANT
↓↓ Very hypoechoic 3 E Extra- 3 P Punctate 3 Suspicious
FEATURES
*If cystic or spongiform, do not add thyroidal ext 4-6 Pts TR4 Mod
further points for other categories Suspicious
7+ TR5 Highly
Suspicious

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