Evaluation of Thyrotoxicosis - Flowchart

Evaluation of Thyrotoxicosis - Flowchart

Evaluation of Thyrotoxicosis - Flowchart

«Flowchart»

Measure TSH, unbound T₄

Measure TSH, unbound T₄

Measure TSH, unbound T₄

₄

TSH low, unbound T₄ high

TSH low, unbound T₄ high

₄ TSH low, High

TSH low, unbound T₄ normal

TSH low, unbound T₄ normal

₄ TSH low, Normal

TSH normal or increased, high unbound T₄

TSH normal or increased, high unbound T₄

₄ Normal or increased

TSH and unbound T₄ normal

TSH and unbound T₄ normal

₄ Normal

TSH-secreting pituitary adenoma or thyroid hormone resistance syndrome

TSH-secreting pituitary adenoma or thyroid hormone resistance syndrome

TSH-secreting pituitary adenoma or thyroid hormone resistance syndrome

No further tests

No further tests

No further tests

Subclinical hyperthyroidism

Subclinical hyperthyroidism

Subclinical hyperthyroidism

Follow up in 6-12 weeks

Follow up in 6-12 weeks

Follow up in 6-12 weeks

Graves' disease

Graves' disease

Graves' disease

Toxic nodular hyperthyroidism

Toxic nodular hyperthyroidism

Toxic nodular hyperthyroidism

Destructive thyroiditis, iodine excess or excess thyroid hormone

Destructive thyroiditis, iodine excess or excess thyroid hormone

Destructive thyroiditis, iodine excess or excess thyroid hormone

Rule out other causes including stimulation by chorionic gonadotropin

Rule out other causes including stimulation by chorionic gonadotropin

Rule out other causes including stimulation by chorionic gonadotropin

^a Diffuse goiter, positive TPO antibodies, ophthalmopathy, dermopathy

^a Diffuse goiter, positive TPO antibodies, ophthalmopathy, dermopathy

^a Diffuse goiter, positive TPO antibodies, ophthalmopathy, dermopathy

^a a a

^b can be confirmed by radionuclide scan.

^b can be confirmed by radionuclide scan.

^b can be confirmed by radionuclide scan.

^b b b

End

End

End

Primary thyrotoxicosis

Primary thyrotoxicosis

Primary thyrotoxicosis

Features of Graves' disease^a?

Features of Graves' disease^a?

^a a a Features

T₃ toxicosis

T₃ toxicosis

₃ T(3) toxicosis

Measure unbound T₃

Measure unbound T₃

Measure unbound T₃

₃

High

High

High

Normal

Normal

Normal

Yes

Yes

Yes

No

No

No

Multinodular goiter or toxic adenoma^b?

Multinodular goiter or toxic adenoma^b?

Multinodular goiter or toxic adenoma^b?

^b b b b

Yes

Yes

Yes

No

No

No

Low radioiodine uptake?

Low radioiodine uptake?

Low radioiodine uptake?

Yes

Yes

Yes

No

No

No

T₃ toxicosis

T₃ toxicosis

T₃ toxicosis

₃