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Hyperthyroidism Evaluation
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TSH + free T3/T4 → RAIU pattern.
Decision
Outcome
Decision
Suspected hyperthyroidism. Initial labs?
✓
TSH + free T3 + free T4
Decision
Pattern?
✓
TSH low + T3/T4 high → primary
✓
TSH high + T3/T4 high → secondary (TSH-secreting adenoma)
Decision
Graves features (diffuse goiter + ophthalmopathy)?
✓
Yes → Graves disease
✓
No → RAIU + scan
Outcome
Graves: TSI/TRAb-positive; methimazole, RAI ablation, or thyroidectomy
PTU first trimester pregnancy and for thyroid storm; methimazole otherwise.
Decision
RAIU result?
✓
High, diffuse → Graves
✓
High, nodular → toxic adenoma or multinodular goiter
✓
Low uptake → check serum thyroglobulin
Outcome
Toxic adenoma or toxic MNG
Decision
Thyroglobulin?
✓
High → thyroiditis or iodine exposure
✓
Low → exogenous thyroid hormone
Outcome
Subacute or postpartum thyroiditis, or iodine exposure
Outcome
Factitious or excess levothyroxine
Outcome
MRI pituitary
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