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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 1 |
|
|
Chief Complaint |
“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.
Submission Instructions:
·
).
· Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources. Your initial post is worth 8 points.
