Abstract: This case study affords an opportunity for the pathologist interested in acquiring ultrasound-guided fine-needle aspiration skills to understand the benefits he or she can bring to the care of his patients and what new responsibilities he or she will newly assume. First, optimal ultrasound guidance is not merely a random sampling of a nodule but rather the targeted use of ultrasound to sample specific areas, such as a potential infiltrating border of a nodule. Second, by applying a spectrum of sonographic criteria for cancer risk to a given patient’s thyroid nodules, the pathologist can prioritize those nodules based on sonographic cancer risk assessment and select 1 or at most 2 nodules in the patient for sampling. To accomplish this, the pathologist must first have a clear understanding of the benign versus malignant criteria by ultrasound. Second, one has to have an orderly sonographic criteria “checklist” for examining a nodule, and one is outlined in this study. Finally, report writing for an ultrasound-guided needle aspiration biopsy has several unique features. First, the pathologist will need to suggest an appropriate follow-up to account for the fact that there is a low but finite false-negative rate in needle biopsy. Second, because the pathologist has a 100% cytology follow-up for every ultrasound examination, the pathologist’s diagnostic skill set will improve rapidly over time. There will come a time when the pathologist will have to prepare a report formally disagreeing with a radiologist’s opinion. In this case study, ways of accomplishing this for the benefit of the patient and ways that respect the radiologist’s opinion are presented.