Summary
Definition
History and exam
Key diagnostic factors
- goiter
Other diagnostic factors
- heat intolerance, hyperphagia, or weight loss
- depression
- nervousness or palpitations
- oligomenorrhea
- hyperdefecation
- stare or lid lag
- warm, moist skin
- tachycardia
- irregular pulse
- tremor
- muscle weakness
- shortness of breath or choking sensation
- Pemberton sign
Risk factors
- iodine deficiency
- age >40 years
- head and neck irradiation
- family history of thyroid nodules
- female sex
Diagnostic tests
1st tests to order
- thyroid-stimulating hormone (TSH)
Tests to consider
- free T4 (or total T4 with a measure of binding)
- total T3 with a measure of binding (or free T3)
- I-123 thyroid scan and uptake
- Tc-99 pertechnetate scan
- thyroid ultrasound
- metabolic panel
- CBC
- thyroid peroxidase antibodies
- TSH receptor antibodies
- ECG
- CT neck (noncontrast)
Treatment algorithm
nonpregnant nonlactating adults: without mass effect or suspicion of cancer
mass effect or suspicion of cancer
pregnant or lactating: without mass effect or suspicion of cancer
Contributors
Authors
Elizabeth N. Pearce, MD
Professor of Medicine
Boston University Medical Center
Boston
MA
Disclosures
ENP is a member of the Management Council of the Iodine Global Network. She was the 2018-2019 President of the American Thyroid Association (ATA) and served on its board and executive committee until 2020. She is a current member of the ATA's thyroid in pregnancy guidelines writing task force. She is currently a Deputy Editor at the Journal of Clinical Endocrinology and Metabolism and has previously served as an Associated Editor for the journals Thyroid, Endocrine Practice, and Clinical Thyroidology. She is an author of a number of references cited in this topic.
Acknowledgements
Dr Elizabeth N. Pearce would like to gratefully acknowledge Dr Sheila Feit, a previous contributor to this topic. SF was previously employed by BMJ.
Peer reviewers
Petros Perros, BSc, MBBS, MD, FRCP
Consultant Endocrinologist
Freeman Hospital
Newcastle-Upon-Tyne
UK
Disclosures
PP declares that he has no competing interests.
Ronald Merrell, MD, FACS
Professor of Surgery
Virginia Commonwealth University
Richmond
VA
Disclosures
RM declares that he has no competing interests.
Peer reviewer acknowledgements
BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.
Disclosures
Peer reviewer affiliations and disclosures pertain to the time of the review.
References
Key articles
Gharib H, Papini E, Garber JR, et al. American Association of Clinical Endocrinologists, American College of Endocrinology, and Associazione Medici Endocrinologi medical guidelines for clinical practice for the diagnosis and management of thyroid nodules - 2016 update. Endocr Pract. 2016 May;22(5):622-39.Full text Abstract
Zimmermann MB, Boelaert K. Iodine deficiency and thyroid disorders. Lancet Diabetes Endocrinol. 2015 Apr;3(4):286-95. Abstract
Ross DS, Burch HB, Cooper DS, et al. 2016 American Thyroid Association guidelines for diagnosis and management of hyperthyroidism and other causes of thyrotoxicosis. Thyroid. 2016;26:1343-1421.Full text Abstract
Haugen BR, Alexander EK, Bible KC, et al. 2015 American Thyroid Association Management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer: the American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid. 2016;26:1-133.Full text Abstract
Reference articles
A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
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