Sandbox:ddx graves
| Suspected Graves' disease | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Measure serum TSH and free T4 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Normal TSH & free T4 | ↓ TSH & ↑ free T4 | ↓ TSH & Normal free T4 | Normal or ↑ TSH & ↑ free T4 | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| Hyperthyroidism ruled out | Hyperthyrodism | Measure free T3 | TSH secreting pituitary tumor, Thyroid hormone resistance or Assay interference | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| Measure TSH receptor antibodies | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
| ↑ free T3 | Normal free T3 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Present | Absent | T3 Toxicosis | Sub-clinical Hyperthyrodism | ||||||||||||||||||||||||||||||||||||||||||||||||||||
| Graves' Disease | Assess radioiodine uptake obtain radionuclide scan or both | Evolving Graves' disease Evolving toxic nodular goiter Excess thyroid hormone intake Non thyroidal illness | |||||||||||||||||||||||||||||||||||||||||||||||||||||
| Homogeneous increased uptake | Patchy uptake or single nodule | Low or no uptake | |||||||||||||||||||||||||||||||||||||||||||||||||||||
| Graves' disease | Toxic nodular goiter | Subacute thyroiditis Excess thyroid hormone intake HCG secreting tumor | |||||||||||||||||||||||||||||||||||||||||||||||||||||
| Cause of thyrotoxicosis | TSH receptor Antibodies | Thyroid US | Color flow Doppler | Radioactive iodine uptake/Scan | Other features |
|---|---|---|---|---|---|
| Graves' disease | Present | Hypoechoic pattern | ↑ | ↑ | Ophthalmopathy, dermopathy, acropachy |
| Toxic nodular goiter | Absent | Multiple nodules | - | Hot nodules at thyroid scan | - |
| Toxic adenoma | Absent | Single nodule | - | Hot nodule | - |
| Subacute thyroiditis | Absent | Heterogeneous hypoechoic areas | Reduced/absent flow | ↓ | Neck pain-fever and elevated inflammatory index |
| Painless thyroiditis | Absent | Hypoechoic pattern | Reduced/absent flow | ↓ | - |
| Amiodarone induced thyroiditis-Type 1 | Absent | Diffuse or nodular goiter | ↓/Normal/↑ | ↓ but higher than in Type 2 | High urinary iodine |
| Amiodarone induced thyroiditis-Type 2 | Absent | Normal | Absent | ↓/absent | High urinary iodine |
| Central hyperthyroidism | Absent | Diffuse or nodular goiter | Normal/↑ | ↑ | Inappropriately normal or high TSH |
| Trophoblastic disease | Absent | Diffuse or nodular goiter | Normal/↑ | ↑ | - |
| Factitious thyrotoxicosis | Absent | Variable | Reduced/absent flow | ↓ | ↓ serum thyroglobulin |
| Struma ovarii | Absent | Variable | Reduced/absent flow | ↓ | Abdominal RAIU |