Endocrine Procedure Note

Endocrine Procedure Note: Procedure Name: Fine-needle aspiration of thyroid nodule Indication: Patient presents with a 2.5 cm solitary, firm, non-tender thyroid nodule identified on routine physical examination and confirmed via ultrasound. Ultrasound characteristics (hypoechoic, irregular margins, microcalcifications) suggest potential malignancy, necessitating further investigation for definitive diagnosis. Pre-procedure Evaluation: Physical examination revealed a palpable, firm nodule in the right lobe of the thyroid. Patient counselled extensively on the procedure, potential risks (bleeding, infection, pain), and benefits. Informed consent obtained verbally and in writing, adhering to South African public sector protocol for elective procedures. Relevant labs: TSH within normal limits (1.8 mIU/L), normal coagulation profile. Previous ultrasound report reviewed, confirming nodule characteristics. Procedure Description: Performed in an outpatient clinic setting. The patient was positioned supine with neck extended. Skin prepped with chlorhexidine solution. Local anaesthesia (1% Lidocaine) infiltrated subcutaneously. Under real-time ultrasound guidance, a 25-gauge needle was advanced into the thyroid nodule. Multiple passes were made to obtain adequate cellular material. Smears were immediately prepared on glass slides and fixed in alcohol for cytological examination. Materials used: 25-gauge needle, 10cc syringe, sterile drapes, chlorhexidine, Lidocaine. No sedation administered. Findings: Ultrasound guidance confirmed accurate needle placement within the nodule. No immediate complications observed during the procedure (e.g., haematoma, significant pain). Adequate cellularity observed on rapid on-site evaluation by the pathologist. Patient tolerated the procedure well. Post-procedure Plan: Patient instructed to apply light pressure to the site for 10 minutes and to avoid strenuous activity for 24 hours. Advised on signs of potential complications (swelling, redness, increasing pain) and when to seek medical attention. Pain management with over-the-counter paracetamol as needed. Cytology results anticipated in 7-10 working days. Follow-up appointment scheduled for 1 November 2024 to discuss results and further management, which may include surgical referral depending on findings. All instructions are feasible within the South African public healthcare context.