St Thomas University Patient with Neck Pain Case Study

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Health Medical

ST Thomas University


Case Study

Chief Complaint - Neck Pain

History Present Illness - 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.

Past Medical History - Patient denies

PSH -Surgical Removal of benign left breast nodule 2 years ago

Drug Hx - No medication at the time

Allergies - No known allergies

Subjective - Mild difficult to shallow, neck feels tight, pt states feeling palpitations

PE - B/P158/90, Pulse 102,RR 20, Temp 99.2,ht 5,4 wt 114, bmi 19.6

General - 42-year-old female appears thin. She is anxious – pacing in the room and fidgeting, but in no acute distress.

HEENT - Bulging eyes

Neck - Diffuse enlargement of the thyroid gland.

Lungs - CTA AP&L

Cardio - S1/S2 without rub, Tachycardia

Abd - benign, normoactive bowel sounds x 4

GU - Non Contributory

Ext - No cyanosis, clubbing or edema

Integument - Think skin, Increase moisture

Neuro - No obvious deficits and CN grossly intact II-XII

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Explanation & Answer

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Subjective Data
Subjective data are information obtained from the patient. They are also called
symptoms, and they explain literally how the patient feels. They are obtained through an
interview with the patient (Toney-Butler, 2019).
Some of the other subjective data that would be obtained include;
Pain: in this case, ask the patient to rate the neck pain on a scale of 1-10, I which 1implies no
pain at all and 10 being the worst pain. Ask the patient about what aggravates the pain and what
relieves the pain. Also, ask about the nature of the pain, whether sharp, dull or radiative in nature
(McGrow, 2019).
Dizziness: ask t...

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