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fT4nl,TSH
fT4nl,TSH
fT4,TSH
fT4,TSH nl
nl
fT4,TSH
fT4,TSH
fT4,TSH
fT4,TSH
fT4,TSHnl
fT4,TSHnl or
or
Subclinical
Subclinical
hypothyroidism
hypothyroidism
Illness
Illness
Drugs(Iodine,
Drugs(Iodine,
Metaclopramide)
Metaclopramide)
T4treatment
T4treatment
Illness(rare)
Illness(rare)
Hyperemesis
Hyperemesis
Acutepsychosis
Acutepsychosis
Drugs
Drugs
FDH,RTH
FDH,RTH
Hypopituitary
Hypopituitary
(DoFSH,PRL,GH,etc)
(DoFSH,PRL,GH,etc)
RTH,TSHoma
RTH,TSHoma
Drugs,illness,hypopituitary
Drugs,illness,hypopituitary
TSHnl
TSHnl
T3nl
T3nl or
or
Goiter+
Goiter+
Ab
Ab ++
FDH
FDH
RTH
RTH
T4Rx
T4Rx
Probably
Probably
Hashimoto
Hashimoto
ss
T4replacement
T4replacement
Checkdose
Checkdose
Fam.Hist
Fam.Hist
IEF+
IEF+
Albppt
Albppt++
FDH
T4treatment
T4treatment
(normal)
(normal)
Psychosis
Psychosis
(usually
(usually
transient)
transient)
Pregnant(
Pregnant(
usually
usually
transient)
transient)
Fam.Hist
Fam.Hist
Ab
Ab
AbnormalT3suppression
AbnormalT3suppression
RTH
T3
T3
Propranorol
Propranorol
Steroids
Steroids
Amiodarone
Amiodarone
Adjust
Adjust
treatment
treatment
RT3or
RT3or
nl
nl
ASA
ASA
Dilantin
Dilantin
Othermed
Othermed
NTIS
NTIS
Observe
Observe
Therapy
Therapy
Poss
Posshypopituitary
hypopituitary
LH,FSH,PRL,
LH,FSH,PRL,
Testosteron
Testosteron
e,
e,
Estrogen,
Estrogen,
Cortisol,
Cortisol,
CT,MRI
CT,MRI
Consider
Consider
e.g.ITT,
e.g.ITT,
GnRH,TRH,
GnRH,TRH,
Treat
Treat
Hypopituitary
Hypopituitary
No.1
No.1
Managementofathyroidenlargement
SeeMNGalgorithm
SeeMNGalgorithm
fT4,TSH,Exam
fT4,TSH,Exam
Diffuse,measure
Diffuse,measure
Ab
Ab
fT4,TSH,Ab
fT4,TSH,Ab ++
Probably
Probably
Hashimotos
Hashimotos
fT4,TSH,Ab
fT4,TSH,Ab ++
Probably
Probably
Graves
Graves
Seepossible
Seepossible
hyperthyroidismor
hyperthyroidismor
treatmentalgorithms
treatmentalgorithms
multinodular
multinodular
Asymetric,nodular
Asymetric,nodular
Endemic
Endemic
US,TSH,Scan
US,TSH,Scan
TSH,
TSH,
singleor
singleor
multiple
multiple
TSHnl
Scan
Scan
FNA(S)
FNA(S)
Surgery,
Surgery,
131
131II
Symptomatic
Symptomatic
Asymptomatic
Asymptomatic
T4,Surgery,
T4,Surgery,
Observe,T4,
Observe,T4,
Iodine
Iodine
131
131I
See
See
nodule
nodule
algorithm
algorithm
No.2
No.2
PainfulorTenderThyroidGrandEvaluation
PainfulorTenderThyroidexamandUSifpossible
PainfulorTenderThyroidexamandUSifpossible
Diffusegoiter
Diffusegoiter
MNGorSingleTenderNodule
MNGorSingleTenderNodule
RAIU,fT4,TSH,Ab
RAIU,fT4,TSH,Ab ,WBC,CRP,Tg
,WBC,CRP,Tg
CRP,
CRP,
WBCornl
WBCornl
RAIU<3%
RAIU<3%
fT4,TSH,
fT4,TSH,
Tg
Tg
Swellingand
Swellingand
Lymphadenopathy
Lymphadenopathy
PossibleNecrosis,
PossibleNecrosis,
Observe
Observe
RAIU
RAIU nl
nl
fT4nl
or,
fT4nl or,
TSH
TSH nl
nl or
or
RAIU
RAIU
fT4,
fT4,
TSH
TSH
Resolves
Resolves
euthyroid
euthyroid
Toxic
Toxic
Follow
Follow
?AcuteThyroiditis,Lymphoma,Cancer
?AcuteThyroiditis,Lymphoma,Cancer
TSH,fT4,Ab,WBC,FNA,US,CT
TSH,fT4,Ab,WBC,FNA,US,CT
Doesnotresolve
Doesnotresolve
TSH,fT4,Ab,FNA,US,CT
TSH,fT4,Ab,FNA,US,CT
Acutethyroiditis
Acutethyroiditis
S.A.T.
S.A.T.
Hashimotos
Hashimotos
??
PainPersists,
PainPersists,
ConsiderFNA
ConsiderFNA
Hashimotos?
Hashimotos?
T4treatment
T4treatment
Observe
Observe
?Steroids
?Steroids
?Resect
?Resect forpain
forpain
Probably
Probably
Graves
Graves
Lymphoma
Lymphoma
Appropriate
Appropriate
Rx
Rx
Cancer
Cancer
benign
benign
Operate
Operate
Follow
Follow
?T4Rx
?T4Rx
Lymphoma
Lymphoma
Antibiotics
Antibiotics
Drainage
Drainage
Cyst
Cyst
Otheralgorithm
Otheralgorithm
Anaplastic
Anaplastic
Ca
Ca
Other
Other
Dx
Dx
?Ope
?Ope
Chemo
Chemo
Xray
Xray
Chemo
Chemo
Xray
Xray
No.4
No.4
PossibleHyperthyroidism:Diagnosis: fT4,TSH,(andT3)
fT4,TSH
Diffuse
Diffuse
goiter
goiter
Ab
Ab ++
Graves
Graves
disease
disease
Singleor
Singleor
Multiple
Multiple
nodules
nodules
Pregnant
Pregnant
Thyroid
Thyroid
function,nl
function,nl
or
or
US,scan
US,scan
hCG,Ab,
hCG,Ab,
vomiting
vomiting
Toxic
Toxic
nodule
nodule
?Postpartum
?Postpartum
?S.A.T.
?S.A.T.
?I2induced
?I2induced
?Transient
?Transient
thyrotoxicosis
thyrotoxicosis
RAIU<5%
RAIU<5%
fT4 TSHnl
Neonatal
Neonatal
CheckAb
CheckAb
TRAb+,
TRAb+,
FH,
FH,
Neonatal
Neonatal
Graves
Graves
Hyperemesis
Hyperemesis
syndrome
syndrome
Treatment
Treatment
Supportive
Supportive
T3elevated
T3elevated
Differentiate
Differentiate
Onhistory,
Onhistory,
exam,
exam,
Ab,course
Ab,course
TRAb,
TRAb,
Poss
PossFH,
FH,
?TSHR
?TSHR
mutation
mutation
Thyroidnl
Thyroidnl
Orsmall
Orsmall
Ab
Ab
?Factitious
?Factitious
?Struma
?Struma
ovary
ovary
Tg
Tg
Evaluate
Evaluate
Patient
Patient
RAIU
RAIU
Scan
Scan
pelvis
pelvis
fT4nl
fT4nl
TSH
TSH
0.050.3
0.050.3
fT4,T3
fT4,T3
TSHnl
TSHnl
or
or
Ab
Ab
fT3
fT3 nl
nl
SITSH
SITSH
fT3
fT3
T4Rx
T4Rx
FDH
FDH
Acute
Acute
Psychosis
Psychosis
Ab
Ab toT3,
toT3,
T4
T4
Propranorol
Propranorol
Steroids
Steroids
Amiodarone
Amiodarone
RarelyNTIS
RarelyNTIS
Subclinica
Subclinica
ll
Hyper
Hyper
thyroidism
thyroidism
Consider
Consider
sameDx.
sameDx.
?Treatmen
?Treatmen
tt
Seetext.
Seetext.
Familialhistory
Familialhistory
PituitaryMRI
PituitaryMRI
TSH
TSHgene
gene
TestT3suppression
TestT3suppression
GRTH
GRTH
TSHoma
TSHoma
PossibleATD
PossibleATD
Tx
Tx
No.5
No.5
PossibleHypothyroidism:Diagnosis: fT4,TSHandAb
fT4nl,TSH
fT4nl,TSH nl,
nl,
Ab
Ab +,
+,
Diffusegoiter+/
Diffusegoiter+/
Hashimotos
Hashimotos
NoRxrequired
NoRxrequired
fT4nl,TSH
fT4nl,TSH ,
,
Ab+/,
Ab+/,
Diffusegoiter+/
Diffusegoiter+/
fT4,TSH
fT4,TSH
,
,
Diffusegoiter+
Diffusegoiter+
Ab+
Ab+
SubClinical
SubClinical
Hypothyroidis
Hypothyroidis
m
m
See
See
Hypothyroidism
Hypothyroidism
Treatment
Treatment
Algorithm
Algorithm
Ab
Ab
fT4nl
fT4nl or,
or,
TSH
TSH
fT4,TSH
fT4,TSH nlor,
nlor,
Ab
Ab
Possible
Possible
Hypopituitary
Hypopituitary
Hashimotos
Hashimotos
Hypothyroidism
Hypothyroidism
SeePossible
SeePossible
Thryotoxicosis
Thryotoxicosis
Algorithm
Algorithm
OnDrugs
OnDrugs
ASA
ASA
Dilantin
Dilantin
Dopa
Dopa
Steroids
Steroids
NSAIDS
NSAIDS
T4treatment
T4treatment
Consider
Consider
Metabolicdefect
Metabolicdefect
Drugs
Drugs
SAT
SAT
Destruction
Destruction
Ab
Ab Hashimotos
Hashimotos
Seeother
Algorithm
LH,FSH,PRL,
LH,FSH,PRL,
Testosteron
Testosteron
e,
e,
Estrogen,
Estrogen,
Cortisol,
Cortisol,
CT,MRI
CT,MRI
Consider
Consider
e.g.ITT,
e.g.ITT,
GnRH,TRH,
GnRH,TRH,
TSHnl
TSHnl
No
No
Rx
Rx
Serious
Serious
Illness
Illness
T3
T3
RT3
RT3
ornl
ornl
NTIS
NTIS
Consider
Consider
Therapy
Therapy
Treat
Treat
Hypopituitary
Hypopituitary
No.6
No.6
SingleThyroidNoduleManagement
PossibleSingleNodule
<5mm
0.51cm,FNA
0.51cm,FNA
Ifdesired
Ifdesired
Notpalpable,>1cm,FNA
Notpalpable,>1cm,FNA
Nogrowth
Nogrowth
Follow
Follow
FNA
FNA
?Resect
?Resect
US,FNA,TSH,fT4
US,FNA,TSH,fT4
FollowbyUS
FollowbyUS
Growth
Growth
ClinicallyToxicNodule
ClinicallyToxicNodule
Canceror
Canceror
suspicious
suspicious
Suspiciousof
Suspiciousof
Follicularneoplasm
Follicularneoplasm
Considergenetic
Considergenetic
Cytology(BRAF)
Cytology(BRAF)
Non
Non
diagnostic
diagnostic
ReFNA
ReFNA
25yr*
25yr*
Riskincreased
Riskincreased
1.Xrayhistory
1.Xrayhistory
2.Familyhistory
2.Familyhistory
3.Nodes
3.Nodes
4.Growth
4.Growth
5.Male
5.Male
6.Age<20,>60
6.Age<20,>60
7.Pain
7.Pain
8.Hoarseness
8.Hoarseness
*ReFNAsoonerifFNAdoesnotfitthe
*ReFNAsoonerifFNAdoesnotfitthe
clinicaldiagnosisorthespecimenisscanty.
clinicaldiagnosisorthespecimenisscanty.
Repeatonce
Repeatonce
Cyst
Operate
Operate
RAIU,TSH,fT4
RAIU,TSH,fT4
Ablative
Ablative
Therapy
Therapy
Consider
Consider
resection
resection
Benign
Benign
FNA
Consider
Consider
T4Rx
T4Rx
ReFNA
ReFNA
2x
2x
Follow
Follow
serialUS
Recur
Recur
?Resect
?Resect
Suspicion
Suspicion
ofCancer
ofCancer
Resect
Resect
T4Rx
T4Rx
Cyst/SolidCheckcytology
Cyst/SolidCheckcytology
Growth
Growth
Operate
Operate
Same/Smaller
Same/Smaller
Follow
Follow
No.7
No.7
WhatistheCorrectThyroxineDosage
TSH,fT4
Replacement
Replacement
Pregnant
Pregnant
OnT4
OnT4
TSH0.42
TSH0.42
U/ml
U/ml
fT4nlor
fT4nlor
Dosage
Dosage
Increase
Increase
Expected
Expected
TSH
TSH
0.42.5or
0.42.5or
3U/ml
3U/ml
Trimesterspecific
Trimesterspecific
Revieweach
Revieweach
46weeks
46weeks
Nodule
Nodule
MultiNodular
MultiNodular
Suppression
Suppression
ResentCa.
CurrentCa.
Presumedcuredcancer
Presumedcuredcancer
TSH0.21U/ml
TSH0.21U/ml
fT4nlor
fT4nlor
Other
Other
Medical
Medical
Problem
Problem
TSH0.42
TSH0.42
U/ml
U/ml
fT4nlor
fT4nlor
+
Valueand
Valueand
Durationuncertain
Durationuncertain
SeeText
SeeText
TSH0.41
TSH0.41
U/ml
U/ml
fT4nlor
fT4nlor
TSH<0.1
TSH<0.1 U/ml
U/ml
fT4nlor
fT4nlor
No.8
No.8
PossibleThyroidEyeDisease
Exophthalmos
ClearlyGraves
DxUncertain
MRI,CT,TSH,fT4,TRAB
Treathyperthyroidism
Treathyperthyroidism
131I
ConsideroralorIVSteroids+
I
ConsideroralorIVSteroids+131
ConsiderThyroidectomy
ConsiderThyroidectomy
Minimal
Protection
Protection
Lubricants
Lubricants
Diuretics
Diuretics
Tarsorrhaphy
Tarsorrhaphy
CosmeticSurgery
CosmeticSurgery
Moderate
Consider
Consider
Xray
Xray
Therapy
Therapy
Graves
SeriousProgressive
Steroids,Xray
Steroids,Xray
Decompression
Decompression
Corrective
Corrective
Surgery
Surgery
Eyemuscle
Eyemuscle
SUrgery
SUrgery
Considerthyroid
Considerthyroid
ablation
ablation
131
131I+Steroids
I+Steroids
131I
orSurgery+
orSurgery+131
I
Otherdiagnosis
Otherdiagnosis
NoDisease
NoDisease
LocalorSpecific
LocalorSpecific
treatment
treatment
Follow
Follow
Consider
Consider
Rituximab
Rituximab
Immunosuppression
Immunosuppression
Plasmapheresis
Plasmapheresis
No.9
No.9
ThyroidCancerPatientTriage
FamilyHistory
OfCancer
Pressure
Pressure
Sx
Sx
Hoarseness
Hoarseness
Pain
Pain
History
ofXray
Thyroid Cervica
l
Mass
Nodes
SuspicionofThyroidCancer
Positivediagnosis
Positivediagnosis
Ofother
Ofother
ThyroidDisease
ThyroidDisease
Dxofother
Dxofother
NeckDisease
NeckDisease
Exam,US,andchestXray
Thyroid
Mass
Thyroid
Thyroid
Mass
Mass
+Nodes
+Nodes
Nodesor
Nodesor
Massonly
Massonly
Thyroidmass
Distant
metastases
Metastases
?Thyroid
Metastatic
Metastatic
Primary
Primary
SeeThyroidCancerOperationsorMetastaticDiseaseAlgorithms
SeeThyroidCancerOperationsorMetastaticDiseaseAlgorithms
No.10
No.10
DecidingonanOperationforThyroidCancer
ThyroidMass
ThyroidMass+Nodes
ThyroidMass+Nodes
NeckNodesorMass
Seenodulealgorithm
131Iscan
FNA,US,? 131
131
131Iscan,US,?FNA
ThyroidOpconsidered
FNAorBiopsy
FNAorBiopsy
Operation
Operation
not
not
indicated
indicated
T4Rx
OtherRx
Surgery
Surgery
Contra
Contra
indicated
indicated
Cellular
Cellular
adenoma
adenoma
FrozenSect.
FrozenSect.
And
And
Op=benign
Op=benign
FrozenSect.
FrozenSect.
And
And
Op=cancer>1c
Op=cancer>1c
m
m
FinalPath+
FinalPath+
LOB+STT
LOB+STT
Lobectomy
Lobectomy
See
See
Correct
Correct
Dosage
Dosage
Algorithm
Algorithm
TTorNTT
TTorNTT
CentralNode
CentralNode
BIopsy
BIopsy
FinalDx=Ca
FinalDx=Ca
Nodesneg.
Nodesneg.
PapillaryCa<1cm
PapillaryCa<1cm
Thyroid
Thyroid
Ca
Ca
InvasiveDIesase
InvasiveDIesase
Nodes
Nodes
Removetumorand
Removetumorand
metastasesaspossible
metastasesaspossible
NTTand
NTTand
Node
Node
Dissection
Dissection
FinalDx=Ca,Nodes+
FinalDx=Ca,Nodes+
T4Rx
Ablation
Ablation
optional
optional
Other
Other
Dx
Dx
OtherRx
OtherRx
30100mCiThyroidAblation
30100mCiThyroidAblation
TT=TotalThyroidectomy,NTT=NearTotalThyroidectomy
TT=TotalThyroidectomy,NTT=NearTotalThyroidectomy
RAITherapycycle
RAITherapycycle
Seealgorithm
Seealgorithm
Invasivedisease
Invasivedisease
Age>50
Age>50
131
131II Therapy
Therapy
Consider
Consider
Radiotherapy
Radiotherapy
No.11
No.11
RAIablationandTherapyCycle
TotalThyroidectomyorNearTotalThyroidectomy+
TotalThyroidectomyorNearTotalThyroidectomy+ removaloftumorandmets
removaloftumorandmets
FirstPostOptreatment
FirstPostOptreatment
TSH>30
TSH>30
T33weeks,off3weeks
T33weeks,off3weeks
doseprotocol
doseprotocol
rhTSH
rhTSH
PostRxScan+,tumorN1orM1
PostRxScan+,tumorN1orM1
T4Rx36mo.
T4Rx36mo.
withTSH,Tg<1ng/ml
withTSH,Tg<1ng/ml
T4Rx1224mo.
T4Rx1224mo.
RepeatScan12x
RepeatScan12x
OrfollowUS
OrfollowUS
TSH,Tg<1ng/ml
TSH,Tg<1ng/ml
T4Rx
T4Rx
Consider
Consider
Tg,US
Tg,US
only
only
T4Rx36mo.
T4Rx36mo.
TSH,Tg24ng/ml
TSH,Tg24ng/ml
Leveluncertain
Leveluncertain
WholeBodyScam,
WholeBodyScam,
US,CT,MRI
US,CT,MRI
?PET,boneScan
?PET,boneScan
Resectifpossible
Resectifpossible
?OtherRx
?OtherRx
Follow
Follow
131
Ablate30150mCi
Ablate30150mCi131II
Dependentontumorstage
Dependentontumorstage
Invasivedisease
Invasivedisease
RAIUintumor
RAIUintumor
DistantMets
DistantMets
Potentially
Potentially
treatablelesion
treatablelesion
131II
100200mCi
100200mCi131
Post
Post
Rx
Rx
Scan+
Scan+
131I
24mCi
24mCi131
IWholeBodyScan
WholeBodyScan
T33weeks,off3weeks
T33weeks,off3weeks
doseprotocol
doseprotocol
rhTSH
rhTSH
131IWholeBodyScan
24mCi
24mCi131
IWholeBodyScan
(?optional)
(?optional)
T4Rx36mo.
T4Rx36mo.
TSH,Tg>4ng/ml
TSH,Tg>4ng/ml
Notumorfound
Notumorfound
orresectable
orresectable
FollowupScan
Post
Post
Rx
Rx
Scan+
Scan+
Tg>4ng/ml
Tg>4ng/ml
ConsiderRepeat
ConsiderRepeat
T4Rx69mo.
T4Rx69mo.
Thyroidablation
Thyroidablation
131
3050mCi
3050mCi131II
RAIU
RAIU
Thyroidonly
Thyroidonly
75200mCI
75200mCI
131
131II ScanafterRx
ScanafterRx
T4Rx36mo.
T4Rx36mo.
Repeat
Repeat
imaging
imaging
US,Tg,
US,Tg,
131
131I,surgery,
I,surgery,
orXray
orXray
Forgrowth
Forgrowth
ConsiderotherRx
ConsiderotherRx
Chemotherapy
Chemotherapy
ThyrosineKinase
ThyrosineKinase
inhibitor
inhibitor
??Immunotherapy
??Immunotherapy
No.12
No.12
Evaluatingmetastaticcancer,possiblyfromThyroid
Thyroidmass+,metastases,FNA+
ThyroidOp
SolitaryMet
Metastaticdisease,?Thyroid
Metastaticdisease,?Thyroid
Tg+
MultipleMets
Excision
Immunostain
Immunostain
ScanorUS
ScanorUS
Immunostain+,
Immunostain+,
Tg
Tg
ScanorUS+
ScanorUS+
Tg
Tyroidectomy
Tyroidectomy
FordiagandRAIU
FordiagandRAIU
131
131IScan
IScan
131
131IThyroidAblation
IThyroidAblation
Therapy
Therapy
AndTherapy
AndTherapy
NoRAIU
NoRAIU
Otherdiag
Otherdiag
OtherRx
OtherRx
2mCiBodyScan
2mCiBodyScan
Scan+
Scan+
RAITherapy
RT,?Chemo
RT,?Chemo
Scan
Scan
OtherRx
No.13
No.13
PostpartumThyroiditisDiagnosisandManagement
SuspectPPT,testTSH,fT4andantiTPOAborantiTgAb
SuspectPPT,testTSH,fT4andantiTPOAborantiTgAb
TSH>4.0U/ml
TSH>4.0U/ml
fT4nl,Ab+/
fT4nl,Ab+/
TSH>4.0U/ml
TSH>4.0U/ml
fT4,Ab+/
fT4,Ab+/
Subclinical
Subclinical
HJypothyroid
HJypothyroid
PossibleAITD
PossibleAITD
HJypothyroid
HJypothyroid
TSH0.34.0
TSH0.34.0
U/ml
U/ml
fT4nl,Ab+
fT4nl,Ab+
TSH<1U/ml
TSH<1U/ml
Ab+
Ab+
fT4
fT4
RepeatTSH
RepeatTSH
In36months
In36months
fT4nl
fT4nl
DiagnoseHyperthyroid
DiagnoseHyperthyroid
LT4Rx
Reevaluate
Reevaluate
In36months
In36months
TSH>4.0
TSH>4.0
U/ml
U/ml
fT4
fT4
Consider
Consider
TaperingT4Rx
TaperingT4Rx
RepeatTSH
RepeatTSH
TSH>4.0
TSH>4.0
U/ml
U/ml
TSH0.34.0
TSH0.34.0
U/ml
U/ml
Folllow
Folllow
TSH0.34.0
TSH0.34.0
U/ml
U/ml
fT4nl
fT4nl
TSH<1U/ml
TSH<1U/ml
Folllow
Folllow
Note:
Note:
PriorPPTepisode
PriorPPTepisode
Familyhistoryofautoimmunedisease
Familyhistoryofautoimmunedisease
Orthyroiddisease
Orthyroiddisease
PositiveantiTPOorantiTgAb
PositiveantiTPOorantiTgAb
Diabetes
Diabetes
Goiter
Goiter
Depression
Depression
Signsandsymptomsofthyroiddisease
Signsandsymptomsofthyroiddisease
fT4
fT4
PossibleHypopituitary
PossibleHypopituitary
?Subclinical
?Subclinical
Hyperthyroid
Hyperthyroid
ExcessiveLT4
ExcessiveLT4
T3toxicosis
T3toxicosis
Toxicthyroidnodule
Toxicthyroidnodule
Glucocorticoids
Glucocorticoids
Dopamine
Dopamine
No.14
No.14
HyperthyroidismManagementwithAntithyroidDrugs
HyperthyroidismGraves Disease
RxAntithyroidDrugs
4weeks
4weeks
TestTSHandfT4
TestTSHandfT4
TSH<0.5U/m
TSH<0.5U/m
ll
fT4High
fT4High
TSH<0.5U/m
TSH<0.5U/m
ll
fT4nl
fT4nl
AvoidPTUifpossible
AvoidPTUifpossible
MildPTU50mg8h
MildPTU50mg8h
MMI10mg12h
MMI10mg12h
SeverePTU100150mg8h
SeverePTU100150mg8h
MMI2030mg12h
MMI2030mg12h
TSH<0.5U/m
TSH<0.5U/m
ll
fT4Low
fT4Low
Reducedose
Reducedose
oraddT4
oraddT4
Continueor
Continueor
Increase
Increase
Antithyroid
Antithyroid
Drugs
Drugs
MonitorEvery
MonitorEvery
12months:
12months:
ReducedoseProgressively
ReducedoseProgressively
ifTSHandfT4normal
ifTSHandfT4normal
48weeks
48weeks
Monitor36and9
Monitor36and9
12Months,
12Months,
thenannually
thenannually
TSH>0.5U/m
TSH>0.5U/m
ll
fT4nlorLow
fT4nlorLow
Signsof
Signsof
remission
remission
ReduceDose
ReduceDose
after612mo.
after612mo.
DiscontinueDrugs
DiscontinueDrugs
after1218mo.
after1218mo.
No.15
No.15
ManagingPrimaryHypothyroidism
TSH>4.0U/ml,fT4lowornl
Patient1550years
Patient>50yearsor
Patient>50yearsor
known/suspectedHeartDisease
known/suspectedHeartDisease
LT450100g/d,48wk
LT450100g/d,48wk
LT42550g/d,48wk
LT42550g/d,48wk
RepeatTSH
RepeatTSH
TSH>4.0U/ml
TSH>4.0U/ml
TSH0.44.0
TSH0.44.0
U/ml
U/ml
TSH<4.0U/ml
TSH<4.0U/ml
IncreaseLT4
IncreaseLT4
doseby
doseby
12.525g/d
12.525g/d
IncreaseLT4
IncreaseLT4
doseby
doseby
12.5g/d
12.5g/d
DecreaseLT4
DecreaseLT4
doseby
doseby
12.525g/d
12.525g/d
68weeks
68weeks
TSH0.52U/ml
TSH0.52U/ml
Continuedose
Continuedose
68weeks
68weeks
ConditionsRequiring
ConditionsRequiring
SpecialAttention:
SpecialAttention:
1.Cardiaccompromised
1.Cardiaccompromised
2.Stupor;coma
2.Stupor;coma
3.Amiodaronetreatment
3.Amiodaronetreatment
4.Preoppatient
4.Preoppatient
5.ICU/CCUpatient
5.ICU/CCUpatient
6.Age<15years
6.Age<15years
7.Sodium<130mEq/l
7.Sodium<130mEq/l
8.Pregnancy
8.Pregnancy
9.Postpartumthyrotoxicosis
9.Postpartumthyrotoxicosis
10.TSHpersistentlyhighor
10.TSHpersistentlyhighor
nonresponsivetoT4
nonresponsivetoT4
11.Symptomsofpituitary
11.Symptomsofpituitary
disease
disease
12.Nonsuppressiblefunction
12.Nonsuppressiblefunction
inHashimotosorGraves
inHashimotosorGraves
13.RememberGRTHandPRTH
13.RememberGRTHandPRTH
Seealso:
Seealso:
CorrectThyroxine
CorrectThyroxine
DosageAlgorithm
DosageAlgorithm
RepeatTSHannually
RepeatTSHannually
OrwhenSymptomatic
OrwhenSymptomatic
No.16
No.16
ScanningafterAblation
>6mo.Postopandpostablation
HighRiskorTgonT4>2ng/ml
LowRiskandTgonT41ng/ml
LowRiskandTgonT41ng/ml
WholebodyScanandTg
OneYear
OneYear
ScanNeg.
Tg 1ng/ml
OneYear
OneYear
Scannegative
Scannegative
Tg
Tg 1ng/ml
1ng/ml
Noclinicaldisease
Noclinicaldisease
Scan+
Tg >1ng/ml
Scan+or
Tg >2ng/ml
(Orotherarbitrarylevel)
(Orotherarbitrarylevel)
ScanandTgneg.
ScanandTgneg.
12X
12X
Annualexam
Annualexam
Periodic
Periodic
NeckUS,Tgtesting
NeckUS,Tgtesting
doseT4
doseT4
T33wk,off23wk
T33wk,off23wk
rhTSH
rhTSH
131IScan
Then
IScan
Then131
(Orotherarbitrarylevel)
(Orotherarbitrarylevel)
ReviewExam
ReviewExam
CXR,US,MRI,chestCT
CXR,US,MRI,chestCT
Bonescanasneeded,
Bonescanasneeded,
131I,Surgery
Consider
I,Surgery
Consider131
SeeCanceralgorithm
SeeCanceralgorithm
131Itreatment
Probable
Probable131
Itreatment
Afterwithdrawalscan
Afterwithdrawalscan
(IndividualizeforRAIUinThyroid
(IndividualizeforRAIUinThyroid
Bedonly)
Bedonly)
PersistentRAIUorelevatedTg
PersistentRAIUorelevatedTg
No.17
No.17
NeonatalThyroidDysfunction(PartA SeealsoPartBandPartC)
Lateonsetofhypoor
hyperthyroidism
Abnormalresultsonscreening
Abnormalresultsonscreening
clinicalsignofthyroidabnormality
clinicalsignofthyroidabnormality
OrTSH,fT4,T4abnormal
OrTSH,fT4,T4abnormal
If<6months,evaluate
If<6months,evaluate
within2days
within2days
Transient
Transient
hypothyroidism
hypothyroidism
withprematurity,
withprematurity,
illness
illness
Normal
Normal or
or
TSH,fT4,T4,Ab,US
?Hyperthyroidism
?Hyperthyroidism
Testsnl
Testsnl
in4weeks
in4weeks
Observe
Observe
Clinically
Clinically
toxic
toxic
fT4,T3,
fT4,T3,
TSH
TSH nlor
nlor
TSH
TSH nl
nl
TSHwithhigh
TSHwithhigh
T3
T3
Clinicallyeuthyroid
Clinicallyeuthyroid
OrHypothyroid
OrHypothyroid
PRTH
PRTH
TRbetasequencing
TRbetasequencing
GRTH
GRTH
ReplaceT4until
ReplaceT4until
CNSmature
CNSmature
StopT44weeks
StopT44weeks
NormalorHypothyroid
NormalorHypothyroid
Thyroidectopicorabsent
Thyroidectopicorabsent
?Hypotyhyroid
?Hypotyhyroid
fT4,
fT4,
T3,TSH
T3,TSH
?Hypotyhyroid
?Hypotyhyroid
fT4,T3,TSH
fT4,T3,TSH
Pituitaryor
Pituitaryor
Hypothalamic
Hypothalamic
Defect
Defect
TSHmutation
TSHmutation
TSHRmutation
TSHRmutation
IImetabolic
metabolic
defect
defect
SeepartC
SeepartC
SeepartB
SeepartB
Ab+
Ab+
MaternalAITD
MaternalAITD
AITD
AITD
Hypothyroidism
Hypothyroidism
No.18
No.18
NeonatalThyroidDysfunction(PartB)
Lateonsetofhypoor
hyperthyroidism
Abnormalresultsonscreening
Abnormalresultsonscreening
clinicalsignofthyroidabnormality
clinicalsignofthyroidabnormality
OrTSH,fT4,T4abnormal
OrTSH,fT4,T4abnormal
If<6months,evaluate
If<6months,evaluate
within2days
within2days
ReplaceT4until
ReplaceT4until
CNSmature
CNSmature
TSH,fT4,T4,Ab,US
Examnl
T4,fT4nl,TSH
nl
Examnl
T4,fT4nl,TSHnl
PresumedTBG
PresumedTBG
ExcludeASA,
ExcludeASA,
Dilantin
Dilantin
AbtoT3orT4
AbtoT3orT4
ConsiderTBG,
ConsiderTBG,
FDH,antibodies,
FDH,antibodies,
estrogen,
estrogen,
AbnormalTTRor
AbnormalTTRor
albumin
albumin
StopT44weeks
StopT44weeks
?Hypertyhyroid
?Hypertyhyroid
fT4,T3,TSH
fT4,T3,TSH
Ab
Ab
Familialhistory+/
Familialhistory+/
Mildonset
Mildonset
Ab+
Ab+
MaternalAITD
MaternalAITD
TSHR
TSHR
activatingmutation
activatingmutation
Graves
Graves disease
disease
No.19
No.19
?CongenitalHypothyroidism(PartC)
OnlyTSH
fT4,T4,T3,TSHnlor or
US,RAIU,IScan
Thyroidabsent
Thyroidabsent
orectopic
orectopic
Absent
Among
Among
Causes
Causes
Pax8,TTF2
Pax8,TTF2
Thyroidpresentorectopic
Thyroidpresentorectopic
Ectopic
ExcessIodide
ExcessIodide
(Rare)
(Rare)
KClO4dischargetest
KClO4dischargetest
RAIU
RAIU or
or
Goiter
Goiter
S/Sratio<4
S/Sratio<4
NIS
NIS
defect
defect
MRI,Pituitary
MRI,Pituitary
tests
tests
Thyroidfunc.
Thyroidfunc.
S/Sratio>4
S/Sratio>4
TSH
TSH
Pit.or
Pit.or
Hypothalamic
Hypothalamic
defect
defect
TRHdefect
TRHdefect
TSHmutation
TSHmutation
Pit1,HesX1,Prop1
Pit1,HesX1,Prop1
Peroxidase
Peroxidase
Defect
Defect
Salivary/SerumI123
Salivary/SerumI123
UrinaryIodide
UrinaryIodide
AmongCauses
AmongCauses
TTF1,?Pax8
TTF1,?Pax8
mutation
mutation
UrinaryIodide
UrinaryIodide
Veryelevated
Veryelevated
RAIU+
RAIU+
or
or
Hearing
Hearing
Normal
Normal
TPOdefect
TPOdefect
Hearing
Hearing
abnormal
abnormal
Pendreds
Pendreds
TSH
TSH
TSHreceptor
TSHreceptor
defect
defect
mutations
mutations
TTF1,Pax8,
TTF1,Pax8,
Gsalpha
Gsalpha
RAIU
RAIU
Rapid
Rapid
turnover
turnover
Deiodinase
Deiodinase
defect
defect
Urine,Serum
Urine,Serum
Iodothyrosine
Iodothyrosine
Tg
Tg
defect
defect
Abnormal
Abnormal
Serum
Serum
Iodoprotein
Iodoprotein
No.20
No.20