{"id":9440,"date":"2026-03-18T00:03:30","date_gmt":"2026-03-18T08:03:30","guid":{"rendered":"https:\/\/www.osmosis.org\/blog\/?p=9440"},"modified":"2026-06-30T14:15:42","modified_gmt":"2026-06-30T22:15:42","slug":"pance-question-of-the-day-fatigued-and-cold","status":"publish","type":"post","link":"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-fatigued-and-cold","title":{"rendered":"PANCE\u00ae Question of the Day: Fatigued and cold"},"content":{"rendered":"<div id=\"ez-toc-container\" class=\"ez-toc-v2_0_80 ez-toc-wrap-center counter-hierarchy ez-toc-counter ez-toc-custom ez-toc-container-direction\">\n<div class=\"ez-toc-title-container\">\n<p class=\"ez-toc-title\" style=\"cursor:inherit\">In This Article<\/p>\n<span class=\"ez-toc-title-toggle\"><a href=\"#\" class=\"ez-toc-pull-right ez-toc-btn ez-toc-btn-xs ez-toc-btn-default ez-toc-toggle\" aria-label=\"Toggle Table of Content\"><span class=\"ez-toc-js-icon-con\"><span class=\"\"><span class=\"eztoc-hide\" style=\"display:none;\">Toggle<\/span><span class=\"ez-toc-icon-toggle-span\"><svg style=\"fill: #999;color:#999\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" class=\"list-377408\" width=\"20px\" height=\"20px\" viewBox=\"0 0 24 24\" fill=\"none\"><path d=\"M6 6H4v2h2V6zm14 0H8v2h12V6zM4 11h2v2H4v-2zm16 0H8v2h12v-2zM4 16h2v2H4v-2zm16 0H8v2h12v-2z\" fill=\"currentColor\"><\/path><\/svg><svg style=\"fill: #999;color:#999\" class=\"arrow-unsorted-368013\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"10px\" height=\"10px\" viewBox=\"0 0 24 24\" version=\"1.2\" baseProfile=\"tiny\"><path d=\"M18.2 9.3l-6.2-6.3-6.2 6.3c-.2.2-.3.4-.3.7s.1.5.3.7c.2.2.4.3.7.3h11c.3 0 .5-.1.7-.3.2-.2.3-.5.3-.7s-.1-.5-.3-.7zM5.8 14.7l6.2 6.3 6.2-6.3c.2-.2.3-.5.3-.7s-.1-.5-.3-.7c-.2-.2-.4-.3-.7-.3h-11c-.3 0-.5.1-.7.3-.2.2-.3.5-.3.7s.1.5.3.7z\"\/><\/svg><\/span><\/span><\/span><\/a><\/span><\/div>\n<nav><ul class='ez-toc-list ez-toc-list-level-1 ' ><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-1\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-fatigued-and-cold\/#The_correct_answer_to_todays_PANCE%C2%AE_Question_is%E2%80%A6\" >The correct answer to today&#8217;s PANCE\u00ae Question is&#8230;<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-2\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-fatigued-and-cold\/#Incorrect_Answer_Explanations\" >Incorrect Answer Explanations<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-3\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-fatigued-and-cold\/#Main_Explanation\" >Main Explanation<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-4\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-fatigued-and-cold\/#Major_Takeaway\" >Major Takeaway<\/a><ul class='ez-toc-list-level-3' ><li class='ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-5\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-fatigued-and-cold\/#Want_to_learn_more_about_this_topic\" >Want to learn more about this topic?<\/a><\/li><\/ul><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-6\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-fatigued-and-cold\/#References\" >References&nbsp;<\/a><\/li><\/ul><\/nav><\/div>\n\n<p class=\"wp-block-paragraph\"><strong><em>Prepare for the PANCE\u00ae with this challenging clinical scenario involving a 32-year-old woman reporting fatigue and weight gain. What&#8217;s the most likely diagnosis?<\/em><\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A 32-year-old woman presents to the primary care office for evaluation of four months of <strong>fatigue<\/strong> and <strong>weight gain<\/strong>. She frequently <strong>feels cold<\/strong>, even when others in the room are comfortable, and her menstrual cycles have been <strong>irregular<\/strong> the last few months. She also has been experiencing <strong>constipation<\/strong> and <strong>dryness of her skin<\/strong>. She has no significant past medical history and takes no medications. Temperature is 37.0\u00b0C (98.6\u00b0F), pulse is <strong>58\/min<\/strong>, respirations are 16\/min, and blood pressure is 118\/80 mmHg. On exam, her skin appears dry and her hair is brittle. There are <strong>no palpable masses<\/strong> at the <strong>anterior neck<\/strong>. Abdominal exam is unremarkable. Initial lab results can be seen below. <\/p>\n\n\n\n<figure class=\"wp-block-table\"><table class=\"has-fixed-layout\"><tbody><tr><td><strong>Laboratory value<\/strong>&nbsp;<\/td><td><strong>Result<\/strong>&nbsp;<\/td><td><strong>Reference range<\/strong>&nbsp;<\/td><\/tr><tr><td>TSH&nbsp;<\/td><td>13.1&nbsp;mIU\/L&nbsp;<\/td><td>0.5-5&nbsp;mIU\/L&nbsp;<\/td><\/tr><tr><td>Serum free T<sub>4<\/sub>&nbsp;<\/td><td>0.6 ng\/dL&nbsp;<\/td><td>0.9-2.3 ng\/dL&nbsp;<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Which of the following tests should be ordered next to help make the diagnosis?<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. TSH receptor antibodies<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B. Anti-centromere antibodies<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C. Thyrotropin-releasing hormone level<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D. Thyroid peroxidase antibodies<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E. Serum glucose level<\/strong><\/p>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\"><em>Scroll down to find the answer!\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0<\/em><\/p>\n\n\n\n<figure class=\"wp-block-embed is-type-video is-provider-youtube wp-block-embed-youtube wp-embed-aspect-16-9 wp-has-aspect-ratio\"><div class=\"wp-block-embed__wrapper\">\n<iframe loading=\"lazy\" title=\"Learn with Osmosis\" width=\"500\" height=\"281\" src=\"https:\/\/www.youtube.com\/embed\/iDxHtjjCMbU?feature=oembed\" frameborder=\"0\" allow=\"accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share\" referrerpolicy=\"strict-origin-when-cross-origin\" allowfullscreen><\/iframe>\n<\/div><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"The_correct_answer_to_todays_PANCE%C2%AE_Question_is%E2%80%A6\"><\/span>The correct answer to today&#8217;s PANCE\u00ae Question is&#8230;<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D. Thyroid peroxidase antibodies<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Correct:<\/strong> See Main Explanation.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Incorrect_Answer_Explanations\"><\/span>Incorrect Answer Explanations<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. TSH receptor antibodies<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong> TSH receptor antibodies can be seen in <strong>Grave disease<\/strong>, which leads to <strong>hyperthyroidism<\/strong>. TSH would be low and serum-free T4 high.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B. Anti-centromere antibodies<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong> <strong>Anti-centromere antibodies<\/strong> may be seen in <strong>scleroderma <\/strong>which can lead to <strong>hypothyroidism <\/strong>and <strong>skin changes<\/strong>; however, <strong>Hashimoto thyroiditis<\/strong> is the <strong>most common cause of hypothyroidism in iodine-sufficient parts of the world<\/strong>, and patients should first be tested for this.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C. Thyrotropin-releasing hormone level<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Incorrect: TRH is the hormone released by the hypothalamus to stimulate TSH from the pituitary and is typically assessed indirectly through <strong>TRH stimulation testing<\/strong>. TSH would typically be low when there is a problem with the hypothalamus leading to hypothyroidism.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E. Serum glucose level<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Incorrect: <strong>Hypoglycemia <\/strong>can be a rare manifestation of <strong>thyroid disease<\/strong> but would not help determine the definitive diagnosis in this case.&nbsp;<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Main_Explanation\"><\/span>Main Explanation<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<figure class=\"wp-block-image size-full\"><img loading=\"lazy\" decoding=\"async\" width=\"975\" height=\"500\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2026\/03\/image-2.png\" alt=\"**Alt text:**\n\nEducational infographic explaining the diagnosis and progression of Hashimoto thyroiditis. On the left, a flow diagram shows: \u201cTSH: High &amp; fT4: Low\u201d leading to \u201cPrimary Hypothyroidism.\u201d Below that, a lab box labeled \u201cLabs: TPOAb, TgAb.\u201d If antibodies are present, it leads to \u201cHashimoto Thyroiditis.\u201d\n\nOn the right, a simplified illustration of the thyroid gland labeled \u201cThyroid hormone,\u201d depicting an initial hyperthyroid phase, followed by an arrow pointing to \u201cChronic hypothyroidism,\u201d indicating disease progression from early transient hyperthyroidism to long-term hypothyroidism.\n\" class=\"wp-image-9443\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2026\/03\/image-2.png 975w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2026\/03\/image-2.png?resize=300,154 300w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2026\/03\/image-2.png?resize=768,394 768w\" sizes=\"auto, (max-width: 975px) 100vw, 975px\" \/><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\">This patient presents with signs, symptoms, and laboratory results consistent with <strong>primary hypothyroidism<\/strong>. <strong>Hashimoto thyroiditis<\/strong> is the most common cause of <strong>primary hypothyroidism<\/strong> in iodine-sufficient parts of the world. It can be diagnosed with findings of <strong>antibodies to thyroid peroxidase<\/strong>. <strong>Anti-thyroglobulin antibodies<\/strong> may also be present.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">For patients with suspected hypothyroidism, testing should begin with <strong>TSH<\/strong> and <strong>serum-free T4<\/strong>. If <strong>TSH<\/strong> is high and <strong>serum-free T4<\/strong> is low, then the patient can be diagnosed with <strong>primary hypothyroidism<\/strong>. The next step is to test for <strong>anti-thyroid peroxidase<\/strong> and <strong>anti-thyroglobulin antibodies<\/strong> which, if positive, can be used to diagnose <strong>Hashimoto thyroiditis<\/strong>. If antibody testing is negative, then the patient should be evaluated for other causes of <strong>primary hypothyroidism<\/strong> including <strong>iatrogenic causes<\/strong> (e.g., thyroidectomy, radioactive iodine treatment, external neck radiation), <strong>iodine deficiency or excess<\/strong>, drugs, and <strong>infiltrative diseases<\/strong>.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">If both <strong>TSH<\/strong> and <strong>serum-free T4<\/strong> are low, then the patient should be evaluated for <strong>central hypothyroidism<\/strong> which can occur when thyroid hormone deficiency is due to a disorder of the <strong>pituitary<\/strong>, <strong>hypothalamus<\/strong>, or <strong>hypothalamic-pituitary circulation<\/strong>. <strong>Pituitary<\/strong> causes include <strong>pituitary adenomas<\/strong>, prior radiation or surgery for pituitary adenomas, as well as infections, inflammation, and infarction (<strong>Sheehan syndrome<\/strong>). <strong>Infiltrative processes<\/strong> like sarcoidosis and brain injury can also affect the <strong>hypothalamic-pituitary axis<\/strong>.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">When <strong>TSH<\/strong> is high but the <strong>serum-free T4<\/strong> is within normal limits, this is referred to as <strong>subclinical hypothyroidism<\/strong>. A significant portion of these patients will eventually go on to develop <strong>clinical hypothyroidism<\/strong>.&nbsp;<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Major_Takeaway\"><\/span>Major Takeaway<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Patients with suspected <strong>hypothyroidism<\/strong> should have <strong>TSH<\/strong> and <strong>serum-free T4<\/strong> checked. If <strong>TSH<\/strong> is elevated and <strong>serum-free T4<\/strong> is low, <strong>primary hypothyroidism<\/strong> can be diagnosed. Patients should be tested for <strong>antibodies to thyroid peroxidase<\/strong> and <strong>anti-thyroglobulin<\/strong> to determine if <strong>Hashimoto thyroiditis<\/strong> is the cause.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Want_to_learn_more_about_this_topic\"><\/span>Want to learn more about this topic?<span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Watch this Osmosis video: <a href=\"https:\/\/www.osmosis.org\/learn\/Hypothyroidism\">Hypothyroidism<\/a><\/strong><\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"References\"><\/span>References&nbsp;<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Klubo-Gwiezdzinska&nbsp;J,&nbsp;Wartofsky&nbsp;L. Hashimoto thyroiditis: an evidence-based guide to etiology,&nbsp;diagnosis&nbsp;and treatment. Pol Arch Intern Med. 2022 Mar 30;132(3):16222.&nbsp;doi: 10.20452\/pamw.16222.&nbsp;Epub&nbsp;2022 Mar 3. PMID: 35243857; PMCID: PMC9478900.<\/li>\n<\/ul>\n\n\n\n<figure class=\"wp-block-image size-large\"><a href=\"https:\/\/www.osmosis.org\/plans\"><img loading=\"lazy\" decoding=\"async\" width=\"700\" height=\"250\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2021\/03\/Blog_Display_Ads_MOBILE3_2023.png?w=700\" alt=\"\" class=\"wp-image-4433\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2021\/03\/Blog_Display_Ads_MOBILE3_2023.png 700w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2021\/03\/Blog_Display_Ads_MOBILE3_2023.png?resize=300,107 300w\" sizes=\"auto, (max-width: 700px) 100vw, 700px\" \/><\/a><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\"><em>Want more <strong>PANCE\u00ae-style practice questions<\/strong>? Try <strong>Osmosis by Elsevier<\/strong> today! Access your&nbsp;<a href=\"http:\/\/osmosis.org\/create\" target=\"_blank\" rel=\"noreferrer noopener\"><strong>free trial<\/strong><\/a>&nbsp;and discover why millions of current and future <strong>clinicians and caregivers<\/strong> love learning by Osmosis.<\/em><a href=\"https:\/\/www.osmosis.org\/plans\/rn\" target=\"_blank\" rel=\"noreferrer noopener\"><\/a><a href=\"https:\/\/www.osmosis.org\/plans\/rn\" target=\"_blank\" rel=\"noreferrer noopener\"><\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n","protected":false},"excerpt":{"rendered":"<p>A 32-year-old woman presents with months of fatigue, weight gain, cold intolerance, and constipation. Explore a structured approach to evaluating suspected thyroid disorders, including which tests to order next and how antibody testing helps clarify autoimmune involvement.<\/p>\n","protected":false},"author":204,"featured_media":9444,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_feature_clip_id":0,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_post_was_ever_published":false},"categories":[20,38,1371,37,1366],"tags":[2802,2801,2799,280,2800,2796,2803,2797,2798],"class_list":["post-9440","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-exam-prep","category-pance","category-pance-questions","category-pa","category-questions","tag-autoimmune-thyroiditis","tag-endocrinology","tag-free-t4","tag-pance","tag-thyroid-antibodies","tag-thyroid-evaluation","tag-thyroid-function-tests","tag-thyroid-testing","tag-tsh"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v23.6 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>PANCE\u00ae Question of the Day: Fatigued and cold - Osmosis Blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.osmosis.org\/blog\/pance-question-of-the-day-fatigued-and-cold\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"PANCE\u00ae Question of the Day: Fatigued and cold - Osmosis Blog\" \/>\n<meta property=\"og:description\" content=\"A 32-year-old woman presents with months of fatigue, weight gain, cold intolerance, and constipation. 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