General principles of anamnesis collection
The patient interview begins with establishing rapport: the doctor introduces themselves, clarifies how the patient prefers to be addressed, and only then proceeds to the complaints. A key skill is using open-ended questions instead of closed-ended ones. Open-ended questions allow the patient to articulate the problem on their own, whereas closed-ended questions narrow the response and may lead to the loss of important information.
Effective interview tactics follow a funnel principle: from open-ended to guiding and then to closed, clarifying questions. A mandatory element is complaint screening—repeating the question "is there anything else bothering you?" until the patient confirms there are no other complaints. At the end of the interview, it is recommended to summarize the complaints aloud and verify their completeness with the patient.
Particular attention is drawn to the "closed door phenomenon": a patient may recall a significant symptom just as the conversation is wrapping up, when the physician is already preparing to conclude the interview. This emphasizes the need to give the patient time and avoid rushing the end of the consultation.
Complaints and history of present illness
A 22-year-old female patient presented with complaints of marked fatigue, increased daytime sleepiness, poor cold tolerance, and periodic weight gain (up to 4-5 kg in winter, 3 kg in the spring of the current year). Symptoms had been noted since age 15-16.
- Past menstrual irregularities associated with weight-loss attempts; regular cycle at the time of examination (26-28 days, duration 2-3 days)
- Episodic sock-band marks, which may indicate tissue edema
- An episode in May of the current year: severe muscle pain in the legs during physical exertion (cycling), forcing her to stop every 100 meters
- History of superficial gastritis, takes lamotrigine (a mood stabilizer) for a neurological condition
On targeted questioning regarding thyroid symptoms, there were no complaints of sore throat, difficulty swallowing, hoarseness, or a lump in the throat. The patient reports no visible enlargement of the thyroid gland.
Past medical history and family history
Past illnesses include a positive Mantux test in childhood, attributed to an allergy to test components (Diaskintest was negative). Denies bad habits.
- Father — history of myocardial infarction
- Mother — hypothyroidism, on replacement therapy
- Brother — overweight/obesity, mild renal dysfunction, episodes of proteinuria (microalbuminuria) of undetermined cause
- Grade 1-2 obesity is common among relatives on both sides
The patient describes her diet as irregular and unbalanced (predominance of fast food), living away from family. Consumes fish and seafood rarely. Resides in Moscow, which is relevant when assessing iodine status.
History of endocrinological disease
The patient has been under the care of an endocrinologist since age 7 due to thyroid enlargement detected during routine health screening. History includes several episodes of TSH elevation of varying severity, with levothyroxine prescribed but taken irregularly due to difficulties adhering to the dosing schedule.
In 2019, critically high TSH levels were recorded (reconfirmed in an independent laboratory, around 80-90), along with decreased T3 and T4, corresponding to overt hypothyroidism. Therapy was resumed and discontinued several times.
The decisive episode occurred in the spring of the current year when a pelvic ultrasound incidentally revealed markedly increased blood flow, prompting further evaluation that showed a TSH level of 45. Since then, the patient has been taking levothyroxine consistently at a dose of 50 mcg, against which TSH levels normalized. Thyroid ultrasound showed diffuse structural changes, decreased gland volume on therapy, and no nodular lesions. Anti-TPO and anti-thyroglobulin antibodies were within normal limits.
Clinical case review and differential diagnosis
During the case review, the localization of the pathological process within the hypothalamus-pituitary-thyroid axis was discussed. An elevated TSH in the setting of decreased T4 indicates preserved pituitary function and points to primary hypothyroidism (disorder of the thyroid gland itself) rather than secondary (pituitary) or tertiary (hypothalamic) etiologies.
Endemic goiter was ruled out due to the diffuse nature of the changes without nodule formation and the absence of clinically significant gland enlargement. Thyroid dysgenesis was also rejected because symptoms were not present from birth. Maternal hereditary hypothyroidism was considered a significant risk factor for autoimmune disease despite the patient's normal antibody levels—it was noted that antibody testing lacks 100% sensitivity, and the diagnosis of Hashimoto's autoimmune thyroiditis remains the primary diagnosis for primary hypothyroidism in the absence of other causes (accounting for up to 95% of primary hypothyroidism cases).
Muscle pain and cramps during exertion were considered an additional clinical sign increasing the probability of hypothyroidism, although not specific to the autoimmune nature of the disease.
Principles of hypothyroidism therapy
Treatment of primary hypothyroidism consists of lifelong hormone replacement therapy with levothyroxine. The drug's half-life is about one week, so TSH monitoring during dose adjustment is performed no earlier than a month and a half to two months after a dosage change.
- After achieving the target TSH level (0.4-4 mIU/L), monitoring is performed every six months
- The starting dose is approximately 1-1.5 mcg/kg of body weight in patients without comorbidities
- In elderly patients and those with angina pectoris, the starting dose should be lower due to the risk of side effects and increased metabolic workload on the heart
- Levothyroxine increases metabolism and heart rate, which requires caution in cardiac pathology
Concomitant narcolepsy was discussed separately as a neurological condition explaining the patient's pronounced daytime sleepiness; no specific effective narcolepsy therapy was used in this case, and sleep hygiene principles along with the limitations of stimulant medications available in Russia were mentioned.
Key points
- Anamnesis collection should begin with open-ended questions, moving to guiding and closed-ended questions to clarify details
- Complaint screening ("is there anything else?") helps prevent missing significant symptoms before concluding the interview
- An elevated TSH with low T4 indicates primary hypothyroidism (thyroid gland disorder)
- Hashimoto's autoimmune thyroiditis is the primary cause of hypothyroidism; the diagnosis does not strictly require antibody confirmation
- Family history (maternal hypothyroidism) significantly increases the likelihood of autoimmune thyroid disease
- Exertional muscle pain can be an additional clinical sign of hypothyroidism
- Hypothyroidism treatment is lifelong replacement therapy with levothyroxine, with TSH monitoring every 1.5-2 months during dose titration
- The starting dose of levothyroxine is reduced in elderly patients and those with angina due to the risk of cardiac complications