21-year-old female case study in nursing

EB, a 21-year-old female, appears with fever, anxiety, and a strong cough that has continued for more than seven days. She claims she had nausea and vomiting for two days. Additional problems included sleeplessness, palpitation, heat sensitivity, and a three-week weight loss. To assist in developing the history of the presenting illness, the patient must report the reason for her visit to the hospital; this information serves as the foundation for obtaining subjective data. Other important information includes how long she has been experiencing the symptoms and any relating or aggravating factors.

Physical examination is essential in obtaining data on the presentations of any disease(Bickley & Szilagyi, 2012). Some of the important aspects that must be taken for this patient include observation of the general status of the patient to determine the level of consciousness, whether there are tremors and if she appears febrile. Examination of the neck is crucial in the diagnosis of thyroid storm; some of the features to be identified include swelling on the neck and presence of a bruit. Auscultation of the heart reveals tachycardia and a murmur during systolic ejection, and also lung sounds are also determined if there are crackles. Moreover, the skin assessment is done to determine if the patient has diaphoresis.

Negative physical findings

Some of the positive physical examination results that have aided in the making of the diagnosis include the general weakness of the patient, presence of a neck swelling, bruit, a murmur, and diaphoresis. The negative of some features during the assessment that has helped in ruling out majority of other conditions include: absence of photophobia and visual disturbances, chest pain, lower extremities’ swelling, negative for light headedness and dizziness

Differential ad final diagnosis

The following differential diagnosis can be deduced from the case study: Sepsis, Drug intoxication, Hyperthyroidism, Central nervous system infections and Pneumonia. With proper physical examination, history taking and laboratory results, a final diagnosis is made, Thyroid storm/ thyrotoxic crisis.

References

Bickley, L., & Szilagyi, P. (2012). Bates’ guide to physical examination and history-taking. Home Healthcare Nurse The Journal for the Home Care and Hospice Professional, 13(6), 992. https://doi.org/10.1111/j.1748-0159.2009.00159.x