Case Information
Case 3
Case 3 | |||
|---|---|---|---|
Chief Complaint | “neck swelling” | ||
History of Present Illness (HPI) | A 42-year-old African American female who reports 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 a 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 | ||
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 |
Discussion Prompts
Once you have received your case number, answer the following questions:
- What other subjective data would you obtain?
- What other objective findings would you look for?
- What diagnostic exams do you want to order?