Take on the role of a clinician who is building a health history
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
Objective Data
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
A
bd: 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
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.
500 words, APA style, 2 academic resources
