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.
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