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Gastrointestinalhealthassesmentmod5.docx

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 (CC) 

“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:

· ).

· 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.