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– negative
Past surgical history-Surgical removal of benign left breast nodule 2 years ago
Medication– none
Allergies- NKA
Subjective-Mild difficult to shallow, Neck feels tight, Pt states she feels Palpitations
V/S- 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
Cardiac-S1S2 without rub, Tachycardia
Abdomen-benign, normoactive bowel sounds x 4
GU-Non contributory
Extremities-no cyanosis, clubbing or edema
Integument-Thin skin, Increase moisture
Neuro-No obvious deficits and CN grossly intact II-XII
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.
post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.
