A 42-Year-Old with Dry Skin, Fatigue, and Weight Gain – Case Study Analysis
The case presented is of a 42-year-old female with complaints of dry skin, fatigue, and weight gain over the past three months. Assessment findings reveal a BP of 110/70 and TSH levels of 39mU/L.
The first differential diagnosis is hypothyroidism. Hypothyroidism is a medical condition characterized by low levels of thyroid hormone. Autoimmune thyroid disease is the most commonly impacted etiological factor for the disorder in the US. A high index of suspicion for hypothyroidism should be maintained in patients presenting with hypothyroidism; they may present with weight gain, skin dryness, hypotension, fatigue, and menstrual irregularities, among others. A high serum TSH level is often confirmatory of the disease (Alsifri et al., 2022). In subclinical disease, the levels of T3 and T4 levels may be low or normal. In this case, the patient was fatigued and reported complaints of fatigue, dry skin, and weight gain. Assessment findings also revealed high TSH levels and hypotension. This meets the criteria for hypothyroidism warranting its inclusion in the differentials list.
The second differential is thyroid lymphoma. Thyroid lymphoma is a type of cancer affecting the thyroid gland. In primary disease, the thyroid gland is first affected before metastasis to other organs. In the secondary disease, cancers affecting other body parts metastasize to the thyroid gland. Respective of the type, thyroid lymphoma causes may cause Hashimoto thyroiditis with subsequent manifestations of symptoms of hypothyroidism, such as fatigue, skin dryness, cold intolerance, and menstrual irregularities, among others. Notably, the patient in this case had fatigue and skin dryness, warranting its inclusion in the differential list. Pathology and imaging evaluations are necessary to rule out a lymphoma.
The third differential is Riedel thyroiditis. Riedel thyroiditis is a fibrotic condition affecting the thyroid glands, but it may also affect adjacent structures. It is characterized by thyroid inflammation with subsequent fibrotization of the gland (Er-Rahali et al., 2021). People with the condition will manifest hypothyroid and parahypothryroid-like symptoms, such as weight gain, fatigue, cold intolerance, and skin dryness. Assessment findings in Rieldel’s thyroiditis often vary, with TSH values exceeding 100 mIU/L. Ultrasonography of the neck and elastography are required to make a positive diagnosis (Er-Rahali et al., 2021). In patients with the disease, elastography reveals fibrosity, while ultrasonography reveals a hypoechoic hypovascular mass in the extrathyroidal tissues. The patient in the case had fatigue, weight gain, and skin dryness, warranting the inclusion of this differential. Ultrasonography and elastography may be necessary to rule out this condition.
The presumptive diagnosis is hypothyroidism. Lab work may be necessary to evaluate an inflammatory response consistent with autoimmune thyroid disease. Lab work should also evaluate the presence of thyroid antibodies to help ascertain the presence of Hashimoto thyroiditis (Wilson et al., 2021).
The plan for this patient integrates lab work and medications. According to the the AAFP guidelines, evaluative lab work is necessary in patients with abnormal TSH levels (Wilson et al., 2021). In this case, lab work will be ordered to evaluate autoimmune thyroid disease. Thyroid replacement therapy is the mainstay modality in managing hypothyroidism. The AAFP and the Endocrine Society recommend the initiation of levothyroxine in all patients with subclinical hypothyroidism with TSH values of above 10 mIU (Wilson et al., 2021). In this case, the patient will be started on levothyroxine at a starting dose of 1.6 mcg per Kg per day.
References
Alsifri, S., Aljuhani, N., Aljedai, A., Nasser, T., Alsabaan, F., Almudaiheem, H., Amir, A., Baissa, E., Ghannam, N., Aldawish, M., Alshammari, A., & Issak, E. R. (2022). Clinical practice recommendations for assessment and management of hypothyroidism. International Journal of Clinical Medicine, 13(12), 650–678. https://doi.org/10.4236/ijcm.2022.1312046
Er-Rahali, Y., Hammoumi, M. M. E., Issouani, J., Nfad, C. A., Moussaoui, S. E., Kabiri, E. H., & Guerboub, A. A. (2021). Reidel’s thyroiditis, a diagnostic and management challenge: A case report and review of the literature. Case Reports in Endocrinology, 2021, 1–4. https://doi.org/10.1155/2021/5185259
Wilson, S. A., Stem, L. A., & Bruehlman, R. D. (2021, May 15). Hypothyroidism: Diagnosis and treatment. American Family Physician. https://www.aafp.org/pubs/afp/issues/2021/0515/
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Question 
A 42-year-old woman has noticed dry skin, fatigue, and weight gain over the past 3 months. Her blood pressure is 110/70 mm Hg, pulse 60/min, and heart and lungs are normal. Her skin feels rough and dry, but the rest of her examination is normal. Her biochemistry is normal, but the TSH is 39 mU/L. Provide at least 3 possible differential diagnoses and justify your rationale. Develop therapeutic plan options based on quality, evidence-based clinical guidelines.
A 42-Year-Old with Dry Skin, Fatigue, and Weight Gain – Case Study Analysis
As you work through your assignments remember as APRN-FNPs we practice with the use of evidence-based practices and incorporate practice guidelines into treatment plans. The recommended guidelines should be utilized and mentioned throughout the course of your work. Article summaries help support the practice that is out there, but an article does not fully support your method of treatment without mentioning the clinical practice guidelines that should be followed. In addition to the above-mentioned, all submissions of work should be in APA format.
As you formulate your discussions, consider the necessary tools to treat the patient case presented in developing your response. Remember your engagement and collaborative responses reflect your grade in addition to the references and research used. Please adhere to the APA guidelines and rubric requirements for both discussion board posts and assignments.