NUR 504 Module 4

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Discussion Topic: Module 4 Discussion

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 3

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.

 Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources within the last 5 years. Your initial post is worth 8 points.