IHuman Case Study Cadull Harn 49 Years Old Male. Reason For Encounter Underwent Thyroidectomy (Neck Swelling and Dysphagia).
COMPREHENSIVE IHUMAN CASE STUDY CADULL HARN 49 YEARS OLD MALE REASON FOR ENCOUNTER UNDERWENT THYROIDECTOMONY (NECK SWELLING AND DYSPHAGIA).
PATIENT PROFILE AGE: 48 YEARS OLD GENDER: MALE
HEIGHT: 5’ 4” (163cm)
WEIGHT: 144.0lb (66.5kg)
MALE REASON FOR ENCOUNTER: UNDERWENT THYROIDECTOMONY
CLINICAL BACKGROUND:
The patient presented with a history of progressive neck swelling and dysphagia.
Imaging studies revealed a large multinodular goiter with signs of compressive
symptoms. Fine needle aspiration (FNA) confirmed the presence of benign thyroid nodules. Given the size of the goiter and associated symptoms, a decision was made to proceed with a total thyroidectomy.
CHIEF COMPLAINANT:
A 49-year-old Male presented with a progressively enlarging anterior neck mass associated with difficulty swallowing (dysphagia). He reported that the swelling had been gradually increasing over several months, leading to noticeable discomfort and challenges during eating and drinking. There was no history of
recent trauma, fever, or significant weight changes.
Upon examination, the patient exhibited a firm, non-tender goiter extending from the thyroid region towards the lower neck. Ultrasound imaging confirmed a large multinodular goiter with signs of compressive effects on adjacent structures.
Given the size of the goiter and associated symptoms, a decision was made to proceed with a total thyroidectomy
HISTORY OF PRESENT ILLNESS (HPI):
• When did you first notice the neck swelling?
• How long has it been present?
• Has the swelling increased in size over time?
• Have you experienced any difficulty swallowing (dysphagia), breathing
difficulties, hoarseness, or pain in the neck?
• Have you noticed any changes in weight, energy levels, skin texture, or
temperature sensitivity?
PAST MEDICAL HISTORY [PMH]:
• Have you had any previous thyroid issues, such as hyperthyroidism or
hypothyroidism?
• Do you have a history of diabetes, hypertension, or cardiovascular diseases?
• Have you undergone any other surgeries, particularly in the neck or
endocrine system?
FAMILY HISTORY:
• Is there a family history of thyroid conditions, including goiter, Hashimoto's
thyroiditis, or thyroid cancer?
• Any familial occurrences of other endocrine disorders?
SOCIAL HISTORY:
• Is your diet rich in iodine, or have you had any dietary restrictions?
• Do you smoke or consume alcohol?
• Have you been exposed to radiation or other environmental factors that
could affect thyroid health?
REVIEW OF SYSTEMS (ROS):
Constitutional: No fever, chills, night sweats, or significant weight changes.
Eyes: No visual disturbances, eye pain, or redness
Ears, Nose, Throat (ENT): No hearing loss, tinnitus, nasal congestion, or sore throat
Cardiovascular: No chest pain, palpitations, or edema
Respiratory: No cough, shortness of breath, or wheezing
Gastrointestinal: No nausea, vomiting, abdominal pain, or changes in bowel habits
Genitourinary: No dysuria, hematuria, or urinary frequency Musculoskeletal: No joint pain, stiffness, or muscle weakness Neurologic: No headaches, dizziness, or numbness.
Psychiatric: No depression, anxiety, or sleep disturbances.
Endocrine: No heat or cold intolerance, excessive thirst, or frequent urination. Hematologic/Lymphatic: No easy bruising, bleeding, or swollen lymph nodes. Allergic/Immunologic: No known allergies or recent infections
HISTORY OF PRESENT ILLNESS (HPI):
Reason for Encounter (RFE):
The patient, a 49-year-old Male, sought medical attention due to a progressively enlarging anterior neck mass that had been present for several months. He
experienced associated symptoms, including difficulty swallowing (dysphagia) and a sensation of fullness in the neck. These symptoms prompted her to consult a
healthcare provider for evaluation and management.
History of Present Illness:
A 49-year-old Male presented with a progressively enlarging anterior neck mass associated with difficulty swallowing (dysphagia). He reported that the swelling had been gradually increasing over several months, leading to noticeable discomfort and challenges during eating and drinking. There was no history of
recent trauma, fever, or significant weight changes.
Upon examination, the patient exhibited a firm, non-tender goiter extending from the thyroid region towards the lower neck. Ultrasound imaging confirmed a large multinodular goiter with signs of compressive effects on adjacent structures. Fine needle aspiration (FNA) confirmed the presence of benign thyroid nodules. Given the size of the goiter and associated symptoms, a decision was made to proceed with a total thyroidectomy.