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 |
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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 |