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 | s | 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 | ||
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-XIIa |
answer the following questions:
- What other subjective data would you obtain?
- What other objective findings would you look for?
- What diagnostic exams do you want to order?
- Name 3 differential diagnoses based on this patient presenting symptoms?
- Give rationales for your each differential diagnosis.
Submission Instructions:
- Your initial post should be at least 550 words, formatted and cited in current APA style with support from at least 2 academic sources.
- You should respond to at least two of your peers by extending, refuting/correcting, or adding additional nuance to their posts. Your reply posts are worth 2 points (1 point per response.)
- All replies must be constructive and use literature where possible.