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.
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