How can one differentiate clinically between subacute thyroiditis, Graves’ disease and toxic multinodular goiters?

Certain features give clues to the underlying etiology of thyrotoxicosis

• Duration of symptoms

• Size, shape of thyroid gland

• Presence or absence of tenderness over thyroid

• Extrathyroidal manifestations of Graves’ disease.

Graves’ disease usually occurs in patients with a family history, has been symptomatic for several weeks to months, have a diffuse goiter, and has symptoms related to extrathyroidal manifestations of Graves’, most commonly ophthalmopathy like feeling of grittiness in the eyes, increasing prominence of eyes. In severe instances, a thyroid bruit can be appreciated over the thyroid. Patients with toxic multinodular goiter are generally older, have had theswelling in front of the neck for many years, have been symptomatic for months and have a nodular goiter with no extrathyroidal features like in Graves’. Subacute thyroiditis mostly have symptoms lasting from few days to weeks, is generally painful, the gland is firm to hard on palpation, and the erythrocyte sedimentation rate (ESR) is almost always >50 and sometimes over 100 mm/h. That being said, it helps to be mindful that not all patients with Graves’ have extrathyroidal features, and about 10% of them might not have a palpable goiter. Not all nodular goiters are toxic multinodular goiters. These are just pointers to suggest one cause more than the other.