Nursing

Health Assessment Discussion 5

HAdiscussion5.docx Take on the role of a clinician who is building a health history Chief Complaint : “neck swelling” History of Pres

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HAdiscussion5.docx 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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