Chief complaint -neck swelling”

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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.

 

 

Sample Solution

Subjective Data

  1. Weight Loss:
    • How much weight has she lost?
    • Over what period of time?
    • Has she experienced any changes in appetite or eating habits?
  2. Thyroid Symptoms:
    • Has she noticed any changes in her voice, such as hoarseness or deepening?
    • Has she experienced excessive sweating, heat intolerance, or rapid heartbeat?
    • Has she had any difficulty swallowing or breathing?
  3. Family History:
    • Is there a family history of thyroid disease or other endocrine disorders?
  4. Menstrual History:
    • Has she experienced any changes in her menstrual cycle, such as irregular bleeding or amenorrhea?
  5. Stress:
    • Are there any significant stressors or life changes that she has been experiencing?

Objective Findings

  1. Eyes:
    • Check for exophthalmos (bulging eyes) and lid lag.
    • Assess for any changes in vision, such as blurred vision or double vision.
  2. Skin:
    • Examine the skin for any signs of hyperpigmentation or vitiligo.
    • Assess for any changes in hair texture or growth.
  3. Hands:
    • Check for fine tremors or muscle weakness.
  4. Reflexes:
    • Assess deep tendon reflexes for any signs of hyperreflexia or hyporeflexia.

Diagnostic Exams

  1. Thyroid Function Tests: TSH, T3, T4, free T3, free T4
  2. Thyroid Ultrasound: To evaluate the size, shape, and texture of the thyroid gland and to look for any nodules or masses.
  3. Fine Needle Aspiration (FNA) Biopsy: If a nodule is detected, an FNA biopsy can be performed to determine if it is benign or malignant.
  4. Echocardiogram: To assess the function of the heart and look for any signs of heart failure or cardiomyopathy.
  5. Bone Density Scan: To evaluate for osteoporosis, which can be associated with hyperthyroidism.

Differential Diagnoses

  1. Graves’ Disease: An autoimmune disorder characterized by hyperthyroidism. The patient’s symptoms of weight loss, tachycardia, and exophthalmos are consistent with Graves’ disease.
  2. Toxic Multinodular Goiter (TMNG): A condition in which multiple nodules within the thyroid gland produce excess thyroid hormone. The patient’s diffuse enlargement of the thyroid gland and symptoms of hyperthyroidism suggest TMNG as a possibility.
  3. Thyroid Cancer: While less likely given the patient’s age and symptoms, thyroid cancer should be considered in the differential diagnosis, especially if a nodule is detected.

Rationale for Differential Diagnoses:

  • Graves’ Disease: The patient’s symptoms of weight loss, tachycardia, and exophthalmos are classic manifestations of Graves’ disease.
  • Toxic Multinodular Goiter: The diffuse enlargement of the thyroid gland and symptoms of hyperthyroidism suggest the possibility of TMNG.
  • Thyroid Cancer: While less likely, thyroid cancer cannot be ruled out until further testing is performed, especially if a nodule is detected.

References

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