Clinical Evaluation and Management of Hashimoto’s Thyroiditis
A 52-year-old African American female was seen during a clinical rotation in a primary care facility that referred her with a chief complaint of fatigue that has been gradually progressive over the last four months. She complained of fatigue even after having slept well, and therefore, this limited her ability to perform most activities, thus leaving her routine disrupted. Other symptoms included slow progressive weight gain, sensitivity to cold, change of skin, constipation, and lethargy. She complained of some level of depression, which is manifested by low mood and anhedonia, without suicidal intent. She could not identify any significant alterations in her diet and exercise routine that might have led to the changes in her weight or energy status. Realizing the decline in her health and energy level to perform various tasks, she decided to seek medical evaluation. Due to her symptoms, the analysis was performed to identify the cause and develop the best management plan from the perspective of the advanced practice registered nurse (APRN).
Definition and Prevalence of Symptoms
The patient presented with symptoms of lethargy, weight gain, cold intolerance, dry skin, and constipation, all of which are typical of hypothyroidism. Fatigue, in this regard, is a chronic issue resulting from low metabolism and a deficiency of thyroid hormones, which compromises energy metabolism at the cellular level. Weight increase, without changes to the diet, is also typical and may be caused by depressed thermogenesis and increased fluid accumulation. Cold sensitivity results from inefficient thermogenesis occasioned by ineffective thyroid hormone activity in the body. Dry skin and constipation indicate a decreased metabolic and gastrointestinal activity in the body. According to Lage et al. (2020), hypothyroidism, specifically primary hypothyroidism, is relatively prevalent and is estimated to affect about 4.6% of adults in the United States. However, the disease is particularly more prevalent in middle-aged women.
Interview Format
Review of Systems
A comprehensive review of systems revealed several pertinent positives. There were physical complaints of cold intolerance, dry skin, thinning hair, color change, constipation and brittle nails. The patient also complained of excessive menstrual bleeding (menorrhagia) and also memory loss and poor concentration. There were no complaints of chest pain, palpitations, tremors, diarrhea, insomnia, hot flashes, polyuria, polydipsia, and breathlessness. There were no complaints concerning the visions or alterations in the appetite. Lack of symptoms of the cardiovascular or respiratory system contributed to narrowing down the differential diagnosis to endocrine and metabolic disorders. Symptoms collectively indicated a generalized slowing of metabolic processes and thus raised the possibility of hypothyroidism as a probable cause.
History of Present Illness
The patient started experiencing her symptoms about four months ago, with the initial complaint of fatigue, which tended to get worse. She described the location of the fatigue as generalized and seemed to occupy her whole body, saying that she almost felt like she lacked the energy to do anything during the day. This fatigue persisted throughout the day with no relief despite the patient sleeping throughout the night. She noted that the fatigue was severe and mentally exhausting, which resulted in reduced physical and social interaction. Frequency-aggravating factors encompass the period of activity or work, while frequency-relieving factors point to minimal periods and temporary rest. In terms of time, the fatigue was continuous and occurred at any time of the day, most during the afternoon. On a functional scale, the patient rated the severity of her fatigue to be a 7 out of 10; she noted a significant impact on her quality of life and daily practices.
Family Medical History
The patient’s family history helped to gain a better understanding of her genetic risk factors. Her mother had had hypothyroidism as well as rheumatoid arthritis, a condition which pointed to a hereditary susceptibility to autoimmune disorders. Her father had type 2 diabetes mellitus diagnosed several years ago. These findings were significant because autoimmune thyroid disease, including Hashimoto’s thyroiditis, has been known to have a component of hereditary predisposition and, in most cases, presented with other autoimmune diseases. The maternal history specifically supported a higher suspicion of primary hypothyroidism as a hereditary matter, which makes it essential to perform an endocrine examination.
Spiritual and Cultural Considerations
Spiritually, the patient described herself as a Seventh-day Adventist and preferred a plant-based diet, non-pharmacological treatment, and the overall well-being of the body. On a spiritual level, she preferred not to take medication if there were other options and shared a hope to receive care that would be in harmony with her faith and perceptions of health and illness. She agreed to medical management and wanted pharmaceutical therapy to be described with the potential benefits and adverse effects. This information was critical in implementing cultural sensitivity in care plan formulation with an emphasis on encouraging participation in decision-making and cooperation in treatment through health promotion.
Past Medical and Surgical History
Her past medical history was significant for hypertension, which was diagnosed three years prior and for which the patient had been compliant with taking lisinopril. She did not admit to any previous surgeries or hospitalizations and reported no other medical conditions apart from the ones in her current staging. Her immunizations were in order, and she had not sought any acute care in the past year. This excluded the presence of other significant diseases, which could complicate her clinical picture and make it difficult to decide whether some of the symptoms are due to the medication or not.
Current Medications
At the time of evaluation, the patient was on lisinopril 10 milligrams orally once per day for hypertension management. She said that she had been using a multivitamin besides ferrous sulfate 325mg daily since she was diagnosed with iron deficiency. She reported that she had not taken any herbal supplements, regular over-the-counter pain relievers, or intravenous therapies. She had no history of any drug allergies. The exclusion of iatrogenic hypothyroidism was made possible by the lack of drugs that impact the thyroid, including amiodarone or lithium. However, it was observed that she was taking iron supplements, in which case iron hinders the absorption of levothyroxine major if she is diagnosed with hypothyroidism.
Differential Diagnoses
The primary diagnosis should be hypothyroidism, which is most probably Hashimoto’s thyroiditis because of the presenting features: fatigue, cold intolerance, weight gain, dry skin, constipation, and hair thinning. These are characteristic features of hypothyroidism, particularly affecting middle-aged women with a predisposing genetic background to thyroid autoimmunity (Kaur & Jialal, 2025). The gradual development and duration of several months correlate with hypothyroidism, and therefore, it is the most suitable and likely diagnosis.
The second differential is major depressive disorder (MDD). Symptoms of depressive syndromes appear as fatigue, delayed thinking, low energy, and change in weight. However, this diagnosis is less likely due to the fact that the patient reported denial of basic affective signs like hopelessness, lethargy or suicidal thoughts (Bains & Abdijadid, 2023). Furthermore, cold intolerance and other metabolic signs indicate endocrine etiology rather than primarily psychiatric disorders.
The third and far less probable diagnosis is chronic fatigue syndrome or myalgic encephalomyelitis (ME). It may be associated with chronic fatigue and reduced functional capacity; however, post-exertional malaise, unrefreshing sleep, and musculoskeletal pain, which are other associated symptoms, were not reported by the patient. Moreover, other realistic findings expected to be observed in hypothyroidism, like the disturbances in thyroid profiles, are not found in CFS patients (Graves et al., 2024). Although clinically, CFS belongs to the list of differential diagnoses for fatigue, it is less relevant because the patient demonstrates atypical features and the risk of hypothyroid etiology is higher.
Diagnostic Evaluation and Analysis of Differentials
Appropriate Diagnostic Testing
In the diagnostic evaluation of the patient, the following focused tests were conducted. The notable serum tests included the thyroid-stimulating hormone (TSH), free thyroxine (Free T4), anti-thyroid peroxidase antibodies (TPO-Ab), complete blood count (CBC), and the comprehensive metabolic panel (CMP) (Zamwar & Muneshwar, 2023). Other tests that may also be relevant based on the progressing clinical requirements include serum iron, lipid and Vitamin B12.
Rationale for Diagnostic Testing
The justification for these tests was obtained from clinical consideration based on the suspicion of endocrine abnormality for hypothyroidism since the patient was fatigued, had gained weight, was intolerant to cold, dry skin, and constipation, and was balding. TSH and Free T4 are necessary markers to validate thyroid dysfunctions. TPO antibodies were also measured to screen for autoimmune thyroid disorders such as Hashimoto thyroiditis, which is the common cause of primary hypothyroidism (Zamwar & Muneshwar, 2023). A CBC was necessary to look for anemia, as this is commonly associated with hypothyroidism because of impaired erythropoiesis. To eliminate other possibilities, such as electrolyte depletion, renal disorders, or hepatic disease as the cause of the patient’s fatigue, the CMP was proper.
Analysis of Clinical Data Compared to Normal Values
The laboratory test results were as follows: TSH = 9.8 mIU/L (normal range: 0.4–4.5 mIU/L), which established the presence of hypothyroidism; Free T4 = 0.6 ng/dL (normal range: 0.8–1.8 ng/dL), which showed that the thyroid hormones were low (Chen et al., 2020). TPO antibodies were positive; therefore, autoimmune thyroiditis was considered. CBC demonstrated mild normocytic anemia with hemoglobin of 11.4 g/dL; the normal level for women ranges from 12 to 16 g/dL. CMP showed normal renal function, liver function was normal, and electrolyte levels also worked within normal limits. These findings established the diagnosis of primary hypothyroidism, which was associated with the autoimmune process and mild anemia; it ruled out most of the other metabolic etiologies like hepatic or renal diseases.
Physiologic Rationale for Physical Exam and Diagnostic Values
From a physiologic point of view, the thyroid hormones T3 and T4 control metabolic rate, heat production regulation, gastrointestinal motility, and skin and hair condition. A deficiency, such as hypothyroidism, leads to reduced metabolic rate, hence fatigue, weight gain, intolerance to cold weather and constipation in the patient. An increased TSH is an indication of a low level of thyroid hormone. Therefore, the pituitary gland responds in the usual way, as is evident in primary and not secondary hypothyroidism (Chen et al., 2020). This is evidenced by the fact that TPO antibodies were positive, which indicates that thyroid tissue was destroyed by the immune system, which can be attributed to Hashimoto’s thyroiditis. The anemia presented in hypothyroid patients may be anemic due to a reduced metabolic rate activating erythropoiesis or due to co-existing iron deficiency.
How Results Support or Refute Differential Diagnoses
The parameters signifying hypothyroidism are clearly indicated, especially of an autoimmune nature. This proves the diagnosis of hypothyroidism due to high levels of TSH, low Free T4, and positive TPO antibodies (Pirahanchi et al., 2023). These findings disprove major depressive disorder; while this condition does not affect hormones or antibodies, it might be secondary to hypothyroidism. The results also disprove chronic fatigue syndrome, which is a diagnosis of exclusion, has no specific laboratory test abnormality, and is not associated with endocrine or hematologic enzymes. This further supports the hypothyroid diagnosis more than other conditions that would have been considered differentials.
Additional Resources, Referrals, and the APRN Role
To provide comprehensive care, interdisciplinary collaboration is essential. For the long-term follow-up of autoimmune thyroid disease and optimizing the levothyroxine dose, a referral to endocrinology was made. A registered dietitian was consulted in a bid to counsel the patient on the best ways to manage weight gain without disregarding her Seventh-day Adventist customs (Kaur & Jialal, 2025). She turned to a behavioral health specialist for her mild depressive feelings and for help in choosing techniques to manage them. The APRN was involved in the diagnosing process, explaining the results, prescribing levothyroxine, making further referrals, and explaining to the client the necessity of taking the medications on time, the need for follow-up retesting, and changing of lifestyle.
Diagnosis
The likely diagnosis is primary hypothyroidism of Hashimoto’s thyroiditis. This conclusion is made based on the patient’s symptoms, such as fatigue, increased weight, intolerance to colds, constipation, and dry skin, and based on the laboratory results as well. Her TSH level was 9.8 mIU/L, her FT4 level was 0.6 ng/dL, and her TPO antibodies were reported as positive, which indicates autoimmune thyroid dysfunction (Kaur & Jialal, 2025). In support of this diagnosis, she had a previous family history of hypothyroidism and autoimmune disease.
Management Plan
Pharmacological Treatment
The proposed management strategy for this patient is to start her on pharmacological treatment with levothyroxine, the synthetic T4, to achieve normal thyroid hormone levels. Given her age, weight, and the fact she has no cardiac disease, the patient was started on levothyroxine 50 mcg once daily orally. She was advised to take it on an empty stomach in the morning, 30–60 minutes before eating breakfast, and avoid intake within four hours of either calcium or iron, which alters the absorption of the drug (Eghtedari & Correa, 2023). TSH levels should be checked after 6-8 weeks to evaluate the effectiveness of the treatment and to provide the necessary corrections to the dosage.
Non-Pharmacologic Treatment
Non-pharmacologic interventions entail encouraging dietary changes for weight reduction and low-energy and metabolic purposes. Referral to a registered dietitian enables patients to get the necessary diet within their culture and religion (Kaur & Jialal, 2025). Promoting regular exercise as much as the individual can endure will help enhance energy, mood, and weight regulation.
Patient Education
Patient education is essential. The patient was also clearly explained the nature of the condition: hypothyroidism is actually a chronic condition, and the only treatment is lifelong hormone replacement therapy. She was educated on the dosing schedule and signs of over- or under-treatment, such as palpitations, insomnia, or worsening fatigue (Patil et al., 2024). Thyroid function and its subsequent follow-up, which should be done periodically as a routine, were also taught.
Health Maintenance and Promotion
From the perspective of health maintenance and promotion, the patient was recommended to take a lipid profile annually because hypothyroidism predisposes the patient to hyperlipidemia. Furthermore, she was advised to get her hemoglobin and bone density check-ups and to seek mental health check-ups periodically (Patil, Rehman, Anastasopoulou, Jialal, et al., 2024). Also, APRNs are responsible for overseeing the progress of treatment, dosage adjustments, health education, and interdisciplinary collaboration in order to support the best outcomes possible in the long term.
Conclusion
Conclusively, this case acknowledges a multi-system approach, differential diagnosis, and several evidence-based management strategies in the diagnosis and management of primary hypothyroidism. These investigations provided a background and understanding of the patient’s clinical presentation, leading to a confirmed Hashimoto’s thyroiditis diagnosis. Pharmacological intervention, lifestyle changes, patient counseling and interprofessional practice, which form the key components of the management plan, were initiated. This case also highlights the importance of following the present clinical guidelines and implementing the patient care approaches to optimize patients’ perspectives of endocrine disorders.
References
Bains, N., & Abdijadid, S. (2023, April 10). Major depressive disorder. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK559078/
Chen, X., Deng, S., Sena, C., Zhou, C., & Thaker, V. V. (2020). Relationship of TSH levels with cardiometabolic risk factors in US youth and reference percentiles for thyroid function. The Journal of Clinical Endocrinology & Metabolism, 106(3), e1221–e1230. https://doi.org/10.1210/clinem/dgaa900
Eghtedari, B., & Correa, R. (2023, August 28). Levothyroxine. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK539808/
Graves, B. S., Patel, M., Newgent, H., Parvathy, G., Nasri, A., Moxam, J., Gill, G. S., Sawhney, V., & Gupta, M. (2024). Chronic fatigue syndrome: Diagnosis, treatment, and future direction. Cureus. https://doi.org/10.7759/cureus.70616
Lage, M. J., Espaillat, R., Vora, J., & Hepp, Z. (2020). Hypothyroidism treatment among older adults: Evidence from a claims database. Advances in Therapy, 37(5), 2275–2287. https://doi.org/10.1007/s12325-020-01296-z
Kaur, J., & Jialal, I. (2025, February 9). Hashimoto thyroiditis. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK459262/
Patil, N., Rehman, A., Anastasopoulou, C., & Jialal, I. (2024, February 18). Hypothyroidism. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK519536/
Patil, N., Rehman, A., Anastasopoulou, C., Jialal, I., & Saathoff, A. D. (2024, February 18). Hypothyroidism (Nursing). StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK568746/
Pirahanchi, Y., Toro, F., & Jialal, I. (2023, May 1). Physiology, thyroid stimulating hormone. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK499850/
Zamwar, U. M., & Muneshwar, K. N. (2023). Epidemiology, types, causes, clinical presentation, diagnosis, and treatment of hypothyroidism. Cureus, 15(9). https://doi.org/10.7759/cureus.46241
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Question 
Clinical Evaluation and Management of Hashimoto’s Thyroiditis
Clinical Evaluation and Management of Hashimoto’s Thyroiditis
The purpose of this assignment is to identify a patient from clinical and develop a case presentation based on the chief complaint, diagnosis and management process used for the patient. This assignment is a case study not a clinical encounter note and should be written from a scholarly perspective. The clinical data obtained should be placed in narrative format using the most current
evidenced-based literature (clinical practice guidelines, peer reviewed articles, and research findings) to provide rationale, support, or recommendations. This paper should be presented from the APRN perspective. This is not a group assignment and should reflect individual contribution utilizing diagnostic reasoning, critical analysis, and incorporation of current evidenced-based literature