# Es Tshd Diagnostic Avoid

> Avoid specific tests for TSHD diagnosis

- Skill: `dromlakhani/es-tshd-diagnostic-avoid` (Agent Skill)
- Install (CLI): `npx skillmds add dromlakhani/es-tshd-diagnostic-avoid`
- Raw SKILL.md: https://api.skillmd.com/api/skills/dromlakhani/es-tshd-diagnostic-avoid/raw
- Safety review: pending (external: skill-scanner PASS, skillspector PASS)
- Works with: Claude Code, Claude.ai, OpenAI Codex
- Category: Coding & Dev Tools
- Author: dromlakhani (https://skillmd.com/u/dromlakhani)
- Updated: 2026-08-19
- Page: https://skillmd.com/skills/dromlakhani/es-tshd-diagnostic-avoid

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# Avoid specific tests for TSHD diagnosis

## STEP 1 — Gather Information
Collect history of childhood cancer treatment focusing on hypothalamic–pituitary axis radiation ≥30 Gy, tumor/surgery in the HP region, or presence of other HP axis deficits; note current free T4 and TSH results if available; identify if the clinician is considering serum T3, TSH surge analysis, or TRH stimulation for TSHD evaluation.

## STEP 2 — Rule In / Rule Out
Rule in if the patient is at risk for TSHD (HP axis radiation ≥30 Gy, HP tumor/surgery, or other HP deficits) **and** the clinician is contemplating use of serum T3, TSH surge analysis, or TRH stimulation to diagnose TSHD; otherwise rule out.

## STEP 3 — Classify or Stratify
Classify the scenario as “prohibited tests considered” when both at-risk status and consideration of the specific tests are present.

## STEP 4 — Decide
Do not order serum triiodothyronine, thyroid-stimulating hormone surge analysis, or TRH stimulation; instead assess TSHD using free T4 and TSH (low/low-normal free T4 with non‑elevated TSH) and, if confirmed, initiate levothyroxine after verifying adequate adrenal function.

## Clinical Guardrails / Mimics / Pitfalls
Do not rely on serum T3, TSH surge analysis, or TRH stimulation as they are not indicative or predictive of TSHD and may yield misleading results; avoid diagnosing TSHD based on a single TSH measurement; ensure free T4 is measured by a reliable method (e.g., equilibrium dialysis if antiepileptics are used); do not start levothyroxine without assessing adrenal axis function.

## Concrete Clinical Example
A 14‑year‑old survivor of medulloblastoma who received 36 Gy craniospinal irradiation presents with mild fatigue and weight gain; free T4 is at the low‑normal limit and TSH is 2.1 mIU/L; the clinician considers ordering a TRH stimulation test. Per the guideline, the test is not recommended; the clinician repeats free T4 in 4–6 weeks, finds it decreased below normal, and initiates low‑dose levothyroxine after confirming normal adrenal function.

**Source:** Hypothalamic Pituitary and Growth Disorders in Survivors of Childhood Cancer: An Endocrine Society Clinical Practice Guideline, Endocrine Society, 2018, DOI:10.1210/jc.2018-01175