Gastrointestinal and Endocrine

For this Discussion, you will take on the role of a clinician who is building a health history for the following case

Case 3

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

Answer the following questions:

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 each differential diagnosis.

Answer

 

Gastrointestinal and Endocrine

Subjective

History of presenting illness: I would ask about neck pain and tenderness. I would also ask about heat intolerance. This entails feeling uncomfortable at high temperatures and feeling comfortable at temperatures that others may consider cold. I would want to know if the patient sweat a lot. This may be accompanied by drinking lots of water to compensate for the loss. I would also ask about other symptoms such as fine rapid tremors. I would ask about any previous exposure to irradiation around the neck. I would want to know if the patient has any gastrointestinal symptoms. Does she have nausea, vomiting, or increased bowel movements?

Past medical history: I would ask about previous exposure to irradiation or radioactive iodine as a child

Medication history: I would ask about his medication history especially goitrogenic drugs such as Lithium or iodide.

Family history: I would ask for any family history of autoimmune diseases such as Graves’ disease

Menstrual history: I would like to know if the patient has had any changes in her menstrual cycle. These changes include amenorrhea or oligomenorrhea.

Social history: I would like to know if she has any history of smoking. Smoking is one of the causes of hyperthyroidism. I would also want to know about the patient’s residence. Patients living in iodine-deficient areas may present in a similar way as the patient.

Health promotion: I would ask about the patient’s diet. This is relevant as iodine deficiency can play a role in thyroid enlargement, which presents as a neck mass.

Objective

I would examine the head for hair loss and hair thinning. I would examine the eyes for conjunctival redness. I would also examine the eyes for ocular edema, lid lad, and lid retraction. I would examine the neck for pain and tenderness. I would also examine the neck for movement of the swelling with swallowing. I would examine the hands for palmar erythema and warmth.

Diagnostic exams

I would order a complete blood count to check for anemia and thrombocytopenia. These are common findings in Graves’ disease.

To examine for thyroid function, I would order a serum thyroid-stimulating hormone (TSH) level. This should be followed by serum T4 and T3 levels. A diagnosis of hyperthyroidism can be confirmed if TSH levels are suppressed.

TSH receptor antibodies can be used to help identify the etiology of hyperthyroidism. A positive result would confirm a diagnosis of Grave’s disease.

Thyroid Ultrasound could help in determining the etiology of an enlarged thyroid, e.g., by observation of nodules

I would also order an ECG to demonstrate tachycardia.

Differential Diagnoses

  1. Goiter
  2. Graves’ disease
  3. Iodine deficiency

Goiter is the enlargement of the thyroid gland. This can result in thyroid dysfunction. Goiter has a number of causes which include smoking, iodine deficiency, radiation therapy, and medications such as lithium and autoimmune disorders (Yildirim et al., 2020). Patients may complain of neck swelling that causes neck tightness. Patients may complain of swallowing difficulties. Patients may also present with a hyperthyroid state which is characterized by weight loss despite normal food intake, heat intolerance, anxiety, palpitations, nausea, vomiting, and ophthalmopathy.

Graves disease is an autoimmune disease of the thyroid gland. It is one of the most common causes of hyperthyroidism. It is caused by thyroid-stimulating antibodies. Most patients with Graves’ disease have the classic signs and symptoms of hyperthyroidism. The patient may present with weight loss, palpitations, sweating, heat intolerance, and anxiety. Females can have amenorrhea or oligomenorrhea. Neck fullness is also a common symptom. Goiter can also affect the eye with symptoms consisting of lid swelling, conjunctival redness, and double vision. Physical findings include increased blood pressure, tachycardia, tachypnea, and moist skin (Bel Lassen et al., 2019)

Iodine deficiency is a common cause of endemic goiter in regions with low iodine. This presents as neck swelling (Yildirim Simsir et al., 2020).

References

Bel Lassen, P., Kyrilli, A., Lytrivi, M., & Corvilain, B. (2019). Graves’ disease, multinodular goiter and subclinical hyperthyroidism. Annales d’endocrinologie, 80(4), 240–249. https://doi.org/10.1016/j.ando.2018.09.004

Yildirim S. I., Cetinkalp, S., & Kabalak, T. (2020). Review of Factors Contributing to Nodular Goiter and Thyroid Carcinoma. Medical principles and practice: international journal of the Kuwait University, Health Science Centre, 29(1), 1–5. https://doi.org/10.1159/000503575

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