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.

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

Vs: 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: EYES: very red sclera with dried, crusty exudates; unable to open eyes in the morning with the left being worse than the right

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

Skin: 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 3 academic sources.