NURS 6512 Assignment 1: Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat

Patient Information:

Initials, Age, Sex, Race

CC: proptosis and fatigue

HPI: K.N is a 44-year old female who presents for a complete physical examination. She complains of proptosis and feeling fatigued. She reports that her eyes began bulging three weeks ago, and that it affects her vision. She reports that she began experiencing fatigue two weeks ago and she has not been able to complete her daily activities. She also reports a swollen neck and has hyperlipidemia for which she takes atorvastatin. She reports weight gain but denies fever, headache, vomiting or diarrhea.

Current Medications: atorvastatin 20 mg once daily

Allergies: NKDA

PMHx: immunizations are up to date. Received tetanus vaccine 5/10/2021. History of hyperlipidemia

Soc Hx: K.N is an elementary school teacher at a local school. She lives with her husband and two children. Her hobbies include reading novels and traveling. She admits to drinking once in a while. Denies tobacco or illicit drug use.

Fam Hx: Mother: history of hyperlipidemia, type 2 diabetes. Father:hypertension. Her brother is in good health.

ROS:

GENERAL:  Reports weight gain and fatigue. Denies fever or chills.

HEENT:  Eyes: Reports proptosis. Ears, Nose, Throat:  Denies hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN:  Denies rash or itching.

CARDIOVASCULAR:  Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY:  Denies shortness of breath, cough or sputum.

GASTROINTESTINAL:  Denies anorexia, nausea, vomiting or diarrhea. Denies abdominal pain.

GENITOURINARY:  Denies pain on urination.

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NEUROLOGICAL:  Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL:  Denies muscle, back pain, joint pain or stiffness.

HEMATOLOGIC:  Denies anemia, bleeding or bruising.

LYMPHATICS:  Reports enlarged nodes in the neck. No history of splenectomy.

PSYCHIATRIC:  Denies history of depression or anxiety.

ENDOCRINOLOGIC:  Denies sweating, cold or heat intolerance. Denies polyuria or polydipsia.

ALLERGIES:  Denies history of asthma, hives, eczema or rhinitis.

O.

Physical exam:

Vital signs: H 5’5”, W 88 kg, RR 16 HR 89 BP 128/78

HEENT: Bulging eyes noted. Intact ears with good reflex. Enlarged thyroid noted.

Diagnostic results:

TSH test, thyroid antibody test, hemoglobin A1C test results pending

A.

Differential Diagnoses 

1. Graves’ disease: This is an immune system illness that leads to the excess production of thyroid hormones (hyperthyroidism). Even though hyperthyroidism may be caused by a variety of different conditions, Graves’ disease is the most frequent. Graves’ disease manifests itself in a variety of ways because thyroid hormones influence so many different body systems. Protrusion of the eyes, excessive perspiration, fatigue, rapid heart rate, irregular heart rate, goiter, and weight loss are all possible symptoms (Wiersinga, 2019). The major therapeutic objectives are to lower the quantity of thyroid hormones produced by the body and to reduce the severity of the associated symptoms.
2. Hyperthyroidism: When the thyroid gland generates an excessive amount of the hormone thyroxine, this is referred to as hyperthyroidism (overactive thyroid). There are a variety of illnesses that may induce hyperthyroidism, including Graves’ disease, Plummer’s disease, and thyroiditis, among others. It is a condition in which the body’s metabolism is accelerated, resulting in unintentional weight loss as well as a fast or irregular heartbeat. A doctor may have difficulty diagnosing hyperthyroidism since the symptoms might be similar to those of other health disorders. It may also induce a broad range of indications and symptoms, including unintentional weight loss, rapid heartbeat, sweating, tremor, fatigue, and heightened heat sensitivity, to name a few examples. People over the age of 65 are more prone than younger people to have either no signs and symptoms at all or just mo
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