Gastrointestinal and Endocrine Case 3
University:
St. Thomas University
Gastrointestinal and Endocrine Case 3
Paper Instructions
For this Discussion, you will 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
- Case 2
- Case 3
Chief Complaint
(CC) “I am here today due to frequent and watery bowel movements” “I have pain in my belly” “neck swelling”
History of Present Illness (HPI)
A 37-year-old European American female presents to your practice with “loose stools” for about three days. One event about every three hours A 25-year-old female presents to the emergency room (ER) with complaints of severe abdominal pain for 2 weeks . The pain is sharp and crampy It hurts if I run, sit down hard, or if I have sex 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
- No contributory
PSH
- Appendectomy at the age of 14
- Surgical removal of benign left breast nodule 2 years ago
Drug Hx
- No meds
- Birth control
- No medication at the time
Allergies
- Penicillin NKA NKA
Subjective
Fever and chills, Lost appetite Flatulence No mucus or blood on stools Nausea and vomiting, Last menstrual period 5 days ago, New sexual partner about 2 months ago, No condoms, he hates them No pain, blood or difficulty with urination Mild difficult to shallow, Neck feels tight, Pt states she feels Palpitations
Objective Data
PE B/P 188/96; Pulse 89; RR 16; Temp 99.0; Ht 5,6; wt 110; BMI 17.8 B/P 138/90; temperature 99°F; (RR) 20; (HR) 110, regular; oxygen saturation (PO2) 96%; pain 5/10 B/P 158/90; Pulse 102; RR 20; Temp 99.2; Ht 5,4; wt 114; BMI 19.6
General well-developed female in no acute distress, appears slightly fatigued acute distress and severe pain 42-year-old female appears thin. She is anxious – pacing in the room and fidgeting, but in no acute distress.
HEENT Atraumatic, normocephalic, PERRLA, EOMI, arcus senilus bilaterally, conjunctiva and sclera clear, nares patent, nasopharynx clear, edentulous. Atraumatic, normocephalic, PERRLA, EOMI, conjunctiva and sclera clear; nares patent, nasopharynx clear, good dentition. Piercing in her right nostril and lower lip. Bulging eyes
Neck Supple Diffuse enlargement of the thyroid gland
Lungs CTA AP&L CTA AP&L CTA AP&L
Card S1S2 without rub or gallop S1S2 without rub or gallop S1S2 without rub, Tachycardia
Abd positive bowel sounds (BS) in all four quadrants; no masses; no organomegaly noted; diffuse, mild, bilateral lower quadrant pain noted Mild diffuse tenderness.
- INSPECTION no masses or thrills noted; no discoloration and skin is warm to; no tattoos or piercings; abdomen is nondistended and round
- AUSCULTATION bowel sounds (BS) are normal in all four quadrants, no bruits noted
- PALPATION on palpation, abdomen is tender to touch in four quadrants; tenderness noted on light palpation, deep palpation reveals no masses, spleen and liver unremarkable
- PERCUSSION tympany heard in all quadrants, no dullness noted in abdominal area benign, normoactive bowel sounds x 4
GU Non contributory • EXTERNAL mature hair distribution; no external lesions on labia
- INTROITUS slight green-gray discharge, no lesions
- VAGINAL normal rugae; moderate amount of green discharge on vaginal walls
- CERVIX nulliparous os with small amount of purulent discharge from os with positive cervical motion tenderness (CMT)
- UTERUS ante-flexed, normal size, shape, and position
- ADNEXA bilateral tenderness with fullness; both ovaries without masses
- RECTAL deferred
- VAGINAL DISCHARGE green in color Non contributory
Ext no cyanosis, clubbing or edema no cyanosis, clubbing or edema no cyanosis, clubbing or edema
Integument good skin turgor noted, moist mucous membranes intact without lesions masses or rashes Thin skin, Increase moisture
Neuro No obvious deformities, CN grossly intact II-XII No obvious deficits and CN grossly intact II-XII 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.
Submission Instructions
Must use CASE # 3
Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.
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Sample Answer
Neck masses can be a presentation of either a malignant or benign disorder. A detailed history, thorough physical examination, and well-thought diagnostic assessment are required to make a timely diagnosis. Case study 3 is that of a 42-year-old African American woman who presented with progressive neck swelling associated with unintentional weight loss, dysphagia, and palpitations. On examination, she appears to be anxious with bulging eyes and an enlarged thyroid gland. Her blood pressure is elevated with tachycardia.
Subjective Data
Further subjective data to be obtained from the patient include associated complaints such as voice changes e.g., hoarseness of the voice, difficulty. In breathing or difficulty in swallowing. The practitioner should rule out any family history of malignancies or consumption of substances that predispose one to malignancies such as cigarette smoking. A history of heat intolerance, easy fatigability, and warm moist skin with thinning of hair should also be acquired(Doubleday & Sippel, 2020).
A gynecological history of changes in her menstrual patterns such as oligomenorrhea should also be ruled out. The practitioner should also probe if the patient has been experiencing hyperdefecation in the past year since she started noting the neck swelling. History of pain or tenderness should also be ruled out. Infective causes such as tuberculosis should be ruled out by probing for a history of night sweats, cough, or contact with someone who has the disease.
Objective Data
Other objective data to look for is the presence of cervical lymphadenopathy and ruling out tenderness. I would also palpate for any tracheal deviation and percuss for retrosternal extension. I would auscultate for any bruits over the thyroid gland whose presence would be an indication of Graves’ disease(Sui Yeo et al., 2022). I would also check for muscle tone, bulk, and reflexes as hyperthyroidism tends to present with muscle weakness and hyperreflexia.
Diagnostic Exams
Imaging is highly recommended in patients with progressive neck masses. Several imaging modalities such as ultrasound, magnetic resonance imaging (MRI), and CT scan (computed tomography) can be done to visualize the extent of the mass, vascularity, and even the size. Radioactive iodine scans are also recommended. Biopsies for histological evaluation are highly recommended. Fine needle aspiration (FNA) is the gold standard histological evaluation for patients with neck masses(Chorath & Rajasekaran, 2021).
Laboratory tests such as thyroid function tests will evaluate the levels of thyroid stimulating hormone (TSH) the most specific and sensitive hormone that is usually used to test the functionality of the thyroid gland. T3 and T4 levels are also vital in the evaluation of this patient.
Differential Diagnosis
The patient is most likely to be having hyperthyroidism a condition characterized by high secretion of thyroid hormones. This condition is usually characterized by weight loss, increased appetite, and hypertension. They also exhibit eye symptoms which include proptosis which is the bulging of the eyes, lid retraction, periorbital edema, and diplopia(Doubleday & Sippel, 2020).
The patient might also be suffering from goiter the enlargement of the thyroid gland which presets with a neck mass accompanied by signs and symptoms of hyperthyroidism(Sui Yeo et al., 2022).on palpation, the patient’s thyroid gland is also noted to be enlarged. Thyroid cancer is another possible differential diagnosis of the patient as she has neck swelling which is associated with unintentional weight loss and dysphagia.
References.
- Chorath, K., & Rajasekaran, K. (2021). Evaluation and Management of a Neck Mass. The Medical Clinics of North America, 105(5), 827–837. https //doi.org/10.1016/j.mcna.2021.05.005
- Doubleday, A. R., & Sippel, R. S. (2020). Hyperthyroidism. Gland surgery, 9(1), 124–135. https //doi.org/10.21037/gs.2019.11.01
- Sui Yeo, J. L., Min Yong, N. T. W., Junis Mahendran, D. C., & Khng Chia, C. L. (2022). Approach to goiter in family medicine practice. Singapore Medical Journal, 63(10), 604–614. https //doi.org/10.4103/SINGAPOREMEDJ.SMJ-2021-091
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