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Gastrointestinal & Endocrine
For this Discussion, you will take on the role of a clinician who is building a health history for one of the following cases. Your instructor will assign you your case number.
Case 1 | |
Chief Complaint | “neck swelling” |
History of Present Illness (HPI) | A 42-year-old African American female who refers that she has been noticing slow and progressive swelling on her neck for about a year. Also she stated she has lost weight without any food restriction |
PMH | Patient denies |
PSH | Surgical removal of benign left breast nodule 2 years ago |
Drug Hx | No medication at the time |
Allergies | NKA |
Subjective | Mild difficult to shallow, Neck feels tight, Pt states she feels Palpitations |
PE | B/P 158/90; Pulse 102; RR 20; Temp 99.2; Ht 5,4; wt 114; BMI 19.6 |
General | 42-year-old female appears thin. She is anxious – pacing in the room and fidgeting, but in no acute distress. |
HEENT | Bulging eyes |
Neck | Diffuse enlargement of the thyroid gland |
Lungs | CTA AP&L |
Card | S1S2 without rub, Tachycardia |
Abd | benign, normoactive bowel sounds x 4 |
GU | Non contributory |
Ext | no cyanosis, clubbing or edema |
Integument | Thin skin, Increase moisture |
Neuro | No obvious deficits and CN grossly intact II-XII |
Once you received your case number, answer the following questions:
1.
What other subjective data would you obtain?
2.
What other objective findings would you look for?
3.
What diagnostic exams do you want to order?
4.
Name 3 differential diagnoses based on this patient presenting symptoms?
5.
Give rationales for your each differential diagnosis.
Submission Instructions:
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· Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources. Your initial post is worth 8 points.
