Gastrointestinal & Endocrine Module 4 Discussion
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.
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