GP Referral Pathway

Thyroid

A practical approach to thyroid nodules, goitre, hyperthyroidism and Graves’ disease.

1. Thyroid nodule

Start with TSH

TSH suppressed

Check Free T4 and Free T3 and arrange a thyroid uptake scan.

TSH normal or elevated

Arrange a high-quality thyroid ultrasound with ACR TI-RADS classification.

Ultrasound should include:

ACR TI-RADS classification • three-dimensional measurements • cervical lymph-node assessment • nodule characteristics

Fine needle aspiration
Perform according to ACR TI-RADS recommendations.

2. Hyperthyroidism

Initial investigations:

TSH • Free T4 • Free T3 • TRAb

Consider a thyroid uptake scan if TRAb is negative or the diagnosis remains uncertain.

Key point: A positive TRAb confirms Graves’ disease in the appropriate clinical setting and usually removes the need for a thyroid uptake scan.

3. Goitre

Initial assessment:

TSH • Thyroid ultrasound

Consider non-contrast CT for large or substernal goitre.

When to refer

Thyroid nodules

Suspicious or indeterminate cytology • suspicious cervical lymphadenopathy • confirmed or suspected malignancy • nodules requiring consideration of surgery.

Goitre

Dysphagia • dyspnoea • voice change • large multinodular goitre • substernal extension • cosmetic concern where surgery is being considered.

Graves’ disease

Patient preference for definitive surgery • thyroid eye disease • poor control despite medication • antithyroid drug intolerance • recurrent disease • radioactive iodine unsuitable.

Uncertain pathway

Refer if the diagnosis, need for biopsy, need for surgery or overall management remains uncertain.

Refer a patient

I am happy to assess patients where the appropriate investigation or treatment pathway is unclear.

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