CHART NOTE
The patient is a 71-year-old female who was noted to have a slowly enlarging lesion in the right lobe of her thyroid. Scans revealed this to be a cold nodule. Thyroid function studies were within normal limits. Fine-needle aspiration of this was thought to be a Hurthle cell adenoma.
The patient’s physical examination revealed a 2 x 1 x 1 mass in the right upper pole of the thyroid. There were no lymph nodes palpable. Patient was moderately obese but otherwise was unremarkable.
The patient did have an exploration of her right neck, and this was found to reveal a smooth mass in the right lobe of the thyroid, and a total right thyroid lobectomy was performed. The left lobe was totally unremarkable and was not resected.
FINAL DIAGNOSIS
Follicular adenoma of the right lobe of the thyroid with Hurthle cell change.
FOOTNOTE
Line 13. The dictator does not give the unit of measure. The transcriptionist on the job would ask the physician for clarification.
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