chief complaint: neck swelling
history of present illness: 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
history: Surgical removal of benign left breast nodule 2 years ago
subjective: Mild difficult to shallow, Neck feels tight, Pt states she feels Palpitations
| 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 | ||
| Cardio | 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 |
- 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.
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