Hyperthyroidism resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mydah Sajid, M.B.B.S.


Hyperthyroidism is a disease that results from thyroid hormone-induced hypermetabolism. The excess thyroid hormone is released from the thyroid gland as a result of excess thyroid hormone production, or by processes that disrupt the follicular structure of the gland with subsequent release of stored hormone. Most patients with severe hyperthyroidism present with a dramatic symptom constellation. Hyperthyroidism's typical symptoms include palpitations, heat intolerance, increased bowel movement, frequent tremors, anxiety, weight loss despite normal or increased appetite and shortness of breath. Goiter is commonly found on physical examination. As a physician, it is important to identify the severity of clinical signs, thyroid storm and treat them promptly. This section provides a short and straight-to-the-point overview of hyperthyroidism.


Life-Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.[1][2][3]

Common Causes


Shown below is an algorithm summarizing the diagnosis of hyperthyroidism according to the American Thyroid Association guidelines.[4]

Clinical assessment of signs & symptoms for hyperthyroidism:
Measure serum Thyroid-stimulating hormone levels
Low TSH (usually <0.01mU/L)
High TSH
Mild hyperthyroidism: Serum T4 and T3 values in normal range or only T3 levels are elevated.
Overt hyperthyroidism: Both serum T3 and T4 levels elevated
Elevated serum T4 and T3 levels
Perform thorough physical examination of thyroid gland and look for signs for thyroid eye disease. Thyroid gland diffusely enlarged with symmetrical hypertrophy and new onset of ocular symptoms
Repeat TSH levels in serial dilution
Yes. Graves' disease
Measure serum assays of TRAb and radioactive iodine uptake thyroid scan
High TSH levels due to hetrophilic antibodies
Look out for pituitary lesion
Measurement of serum levels of human anti-mouse antibodies
Diffuse increase in iodine uptake
Localized increase in iodine uptake
Subnormal or absent uptake of iodine
Graves' disease
Toxic nodular goiter
Subacute thyroiditis/ Postpartum thyroiditis
Factitious ingestion of thyroid hormones
Excess intake of iodine recently
High levels of thyroglobulin in serum
Low thyroglobulin levels
Measure spot urine iodine or 24 hour urine iodine level


Shown below is an algorithm summarizing the treatment of Graves' disease according to the American Thyroid Association guidelines.[5][6]

Overt Graves' disease
Antithyroid medications
Radioactive iodine ablation
  • Administered in patients with:
  • There is a risk of worsening of existing thyroid eye disease.
  • Total or near-total thyroidectomy is recommended for patients with:
  • The advantages are:




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    7. Carlé A, Knudsen N, Pedersen IB, Perrild H, Ovesen L, Rasmussen LB; et al. (2013). "Determinants of serum T4 and T3 at the time of diagnosis in nosological types of thyrotoxicosis: a population-based study". Eur J Endocrinol. 169 (5): 537–45. doi:10.1530/EJE-13-0533. PMID 23935127.
    8. Shigemasa C, Abe K, Taniguchi S, Mitani Y, Ueda Y, Adachi T; et al. (1987). "Lower serum free thyroxine (T4) levels in painless thyroiditis compared with Graves' disease despite similar serum total T4 levels". J Clin Endocrinol Metab. 65 (2): 359–63. doi:10.1210/jcem-65-2-359. PMID 3110204.
    9. McKee A, Peyerl F (2012). "TSI assay utilization: impact on costs of Graves' hyperthyroidism diagnosis". Am J Manag Care. 18 (1): e1–14. PMID 22435785.
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