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Gastrointestinal & Endocrine
42 year old, African American Female patient with a chief complaint of neck swelling that has progressively gotten worse over a period of a year.  She also confirms that she has loss weight without any changes to her diet.  Patient is tachycardic with a pulse of 102, anxious but no acute distress.
What other subjective data would you obtain?
Subjectively we know the patient has complaints of neck swelling, weight loss, and difficulty swallowing.  Additional questions should be asked to gather additional information to aid in reaching a proper diagnosis for this patient.  Initial questions should be general such as any changes in bowel habits, how they feel in hot or cold weather and any changes in energy.  The most common thyroid diseases are Hypothyroid and Hyperthyroid.  These two diseases manifest with opposite symptoms.
What other objective findings would you look for?
With the documented weight loss, tachycardia and anxiety.  Additional questions and testing should be geared towards Hyperthyroidism.  Key objective assessment findings for Hyperthyroidism include tachycardia, palpitations, weight loss, elevated T4 and T3, decreased TSH and diaphoresis.  When you have hyperthyroidism, your body is producing excessive amounts of the thyroid hormones T3 and T4. Since these hormones regulate your metabolism (how your body processes and uses energy), having too high a level will cause symptoms related to a high metabolism (Milas, 2019).
What diagnostic exams do you want to order?
Diagnostic testing includes blood tests, iodine uptake scan and thyroid scan.  Blood tests are preformed to measure the levels of thyroid hormones. T4 and T3, must be high to diagnosis a patient with hyperthyroidism.  Thyroid stimulation hormone (TSH) is also measured and is low in hyperthyroidism.  The iodine uptake scan is used to measure the thyroid function by determining how much iodine is taken up by the thyroid gland.  Normal values are up to 25% in a 24-hour period.  If the percentage is above 35% in 24 hours the abnormal results could indicate hyperthyroidism, hashimoto’s or goiter.  Hyperthyroidism speeds up some of your body’s processes.  Thyroid scan is typically done at the same time as the iodine uptake test.  Thyroid scans use the emissions of gamma rays from radioactive iodine to obtain a picture of the thyroid (UCLA Health, n.d.).
Name 3 differential diagnoses based on this patient presenting symptoms? Give rationales for each differential diagnosis.
Hyperthyroidism is an excessive concentration of thyroid hormones in tissues.  The most common causes of excessive production of thyroid hormones are Graves’ disease, toxic multinodular goiter, and toxic adenoma.  Graves’ disease is an autoimmune process in which antibodies stimulate the TSH receptor leading to overproduction of thyroid hormones.  With Graves’ symptoms include anxiety, moist skin, weight loss, enlarged thyroid gland, bulging eyes and palpitations.
References
Milas, K. (2019). Hyperthyroidism Symptoms. Retrieved November 20, 2020, from https://www.endocrineweb.com/conditions/hyperthyroidism/hyperthyroidism-symptoms (Links to an external site.)
UCLA Health. (n.d.). Radioactive Iodine Uptake Test. Retrieved November 20, 2020, from https://www.uclahealth.org/endocrine-center/radioactive-iodine-uptake-test

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