Take on the role of a clinician who is building a health history Chief Complaint : “neck swelling” History of Present

Take on the role of a clinician who is building a health history

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

Objective Data

 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

A
bd: 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

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.

500 words, APA style, 2 academic resources

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