First examination (first row):

Clinical presentation: A 29-year-old woman was referred for evaluation of complaints suggesting hyperthyroidism. She had no eye signs.

Palpation: Both lobes were enlarged. No nodule was palpable.

Laboratory examination: see Table.

Ultrasonography: Both lobes were enlarged, moderately hypoechogenic, inhomogeneous and displayed increased vascularization.

Diagnosis: Graves' hyperthyroidism.

Suggestion: daily 30 mg methimazole and after normalization of FT4-level radioiodine therapy. The patient wished to avoid definitive treatment.

Follow-up examinations (rows from 1st to 8th):

Corresponding sonographic images (row)	Months spent after the 1st examination	Volume of the thyroid (mL)	Therapy before examination	Results of laboratory examinations			Suggestion after examination
				TSH (mU/L)	FT4 (pM/L)	TSAb (U/L)
1	0	47.6	Nothing	0.03	71.1		30 mg methimazole
2	12	17.2	10 mg methimazole	1.92	15.9	6.0	10 mg methimazole
3	18	21.7	5 mg methimazole	0.71	16.4	0.3	Discontinuation of methimazole
4	30	16.7	Nothing	0.06	41.5	15	20 mg methimazole
5	32	35.7	Nothing *	0.01	51.4		20 mg methimazole
6	33	15.2	20 mg methimazole	0.03	18.7		10 mg methimazole
7	36	23.9	10 mg methimazole	0.51	13.6		5 mg methimazole
8	40	29.0	5 mg methimazole	6.91	10.7		Plus 50 ug l-tiroxine

* The patient attempted to treat herself with homeopathic products.

Comments:

1. The patient initially presented with a large thyroid, therefore we suggested definitive therapy.

2. Note the relation between volume, echogenicity, vascularization and hormone levels.