Take on the role of a clinician who is building a health history for one of the following cases. Your instructor will assign you your case number.
Case 1
Chief Complaint
(CC) “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
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
Once you 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?
- Name 3 differential diagnoses based on this patient presenting symptoms?
- Give rationales for your each differential diagnosis.
Full Answer Section
- Social History:
- Stress levels, recent life changes, or significant stressors?
- Diet and exercise habits?
Objective Findings
In addition to the physical exam findings already noted, I would focus on:
- Thyroid Function Tests: Assess thyroid hormone levels (TSH, T3, T4) to evaluate thyroid function.
- Thyroid Ultrasound: Visualize the thyroid gland to assess its size, shape, and any nodules or abnormalities.
- Fine-Needle Aspiration Biopsy (FNAB): If a thyroid nodule is present, a FNAB can help determine if it is benign or malignant.
Differential Diagnoses
- Hyperthyroidism:
- Symptoms: Weight loss, tachycardia, anxiety, heat intolerance, and hyperhidrosis.
- Physical Exam: Thyroid enlargement, tachycardia, and hyperreflexia.
- Thyroid Cancer:
- Symptoms: A solitary thyroid nodule, hoarseness, dysphagia, and neck pain.
- Physical Exam: A palpable thyroid nodule, often firm or hard.
- Thyroiditis:
- Symptoms: Painful thyroid enlargement, fever, and fatigue.
- Physical Exam: Tender thyroid gland.
Rationales for Differential Diagnoses
- Hyperthyroidism: The patient's weight loss, tachycardia, anxiety, and hyperhidrosis are consistent with hyperthyroidism.
- Thyroid Cancer: The patient's age, rapid weight loss, and solitary thyroid nodule raise suspicion for thyroid cancer.
- Thyroiditis: The patient's recent onset of symptoms, including neck pain and difficulty swallowing, could suggest thyroiditis.
To confirm the diagnosis and initiate appropriate treatment, further investigations, such as thyroid function tests, thyroid ultrasound, and potentially a fine-needle aspiration biopsy, are essential.