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Discuss role of a clinician who is building a health history


Assignment Task: 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

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

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? Need Assignment Help?

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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