eMedicine Specialties > Emergency Medicine > Endocrine & Metabolic

Hyperthyroidism, Thyroid Storm, and Graves Disease: Differential Diagnoses & Workup

Author: Erik D Schraga, MD, Consulting Staff, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates; Consulting Staff, Permanente Medical Group, Kaiser Permanente, Santa Clara Medical Center
Contributor Information and Disclosures

Updated: Jun 3, 2009

Differential Diagnoses

Anxiety
Panic Disorders
Congestive Heart Failure and Pulmonary Edema
Shock, Septic
Delirium Tremens
Toxicity, Anticholinergic
Diabetes Mellitus, Type 1 - A Review
Toxicity, Selective Serotonin Reuptake Inhibitor
Diabetes Mellitus, Type 2 - A Review
Toxicity, Sympathomimetic
Heat Exhaustion and Heatstroke
Withdrawal Syndromes
Munchausen Syndrome
Neuroleptic Malignant Syndrome

Other Problems to Be Considered

Psychosis
Anxiety
Malignancy
Pregnancy
Pheochromocytoma

Workup

Laboratory Studies

  • Thyroid function studies confirm the diagnosis in the appropriate clinical setting.
    • Elevation of free T4 and low to undetectable TSH levels are diagnostic of thyrotoxicosis.
    • Excessive TSH levels in the setting of elevated free T4 indicate hyperthyroidism of pituitary origin.
    • There is little utility in obtaining total T4 levels, as variations in serum thyroid-binding proteins alter the ability to interpret results.
    • Particularly in thyroid storm, the diagnosis must be made on the basis of the clinical examination as rapid assays are not universally available.
    • Thyroid function studies do not distinguish thyrotoxicosis from thyroid storm; however, several laboratory abnormalities may be encountered in thyroid storm.
  • Hyperglycemia
  • Hypercalcemia
  • Hepatic function abnormalities
  • Low serum cortisol
  • Leukocytosis
  • Hypokalemia (in thyrotoxic periodic paralysis)

Imaging Studies

  • Chest radiography may identify congestive heart failure or pulmonary infections, often associated with progression to thyroid storm.
  • Nuclear thyroid scan
    • Diffuse uptake in Graves disease
    • Focal uptake in toxic nodular thyroiditis

Other Tests

  • Electrocardiogram
    • Sinus tachycardia most common
    • Atrial fibrillation (often in elderly patients)
    • Complete heart block (rare)

More on Hyperthyroidism, Thyroid Storm, and Graves Disease

Overview: Hyperthyroidism, Thyroid Storm, and Graves Disease
Differential Diagnoses & Workup: Hyperthyroidism, Thyroid Storm, and Graves Disease
Treatment & Medication: Hyperthyroidism, Thyroid Storm, and Graves Disease
Follow-up: Hyperthyroidism, Thyroid Storm, and Graves Disease
References
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References

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Further Reading

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Contributor Information and Disclosures

Author

Erik D Schraga, MD, Consulting Staff, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates; Consulting Staff, Permanente Medical Group, Kaiser Permanente, Santa Clara Medical Center
Disclosure: Nothing to disclose.

Medical Editor

Robin R Hemphill, MD, MPH, Associate Professor, Director, Disaster Preparedness, Department of Emergency Medicine, Vanderbilt University Medical Center
Robin R Hemphill, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Howard A Bessen, MD, Professor of Medicine, Department of Emergency Medicine, UCLA School of Medicine; Program Director, Harbor-UCLA Medical Center
Howard A Bessen, MD is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
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