History
Thyroid Diseases
(History )
How to take history from a patient with thyroid disease?
1) P
ersonal data
: which includes (name, age, sex, nationality, from where the patient admitted , from clinic or emergency department, and for how long he is in the hospital) e.g: A 40 years old saudi female patient admitted 2 days ago through the clinic C\O of.....
2)
The chief complaint and the duration
,
e.g C\O neck swelling of 4 monthes duration.
3)
History of the present illness
, it shuold include the history of a- The swelling ( how and when the patient discovers it, any changes in the size, any associated symptoms as pain, difficulty in swallowing or breathing, fever,, and any other swelling in the neck) b-Symptoms of Hyper. and Hypothyrodism( as wieght changes, heat intollerance.......)
4) R.O.S:
CVS, respiratory, CNS,...
5) Past medical or surgical history:
- History of any previous surgery, if present( what operation, when and where was done).
- History of chronic illness as D.M, hypertension, ischemic heart disease, if present
(duration and medication ).
- History of exposure to irriadiation to the neck ,e.g(neck lymphoma treaeted by neck irriadiation is a predisposing factor for thyroid cancer).
6)
Past family history
: of similer illness as Goiter, Hashimoto`s thyroditis .., of endocrine tumers as MENsyndrom.History of chronic illness as D.M, Hypertension ...
7)
Drug history, allergy and social history.
8)
Summery. (
which include the positve point in the history )
e.g of history of a patient with thyroid disease:
A 40 years old saudi female patient admitted through the clinic 2 days ago
C\O neck swelling for 6 monthes duration
H.P.I / The patient notice the swelling incidently during looking to the mirror, in the right side of the neck 6 monthes ago. It was small but increasing in the size by time, no pain, no difficulty in swallowing or breathing, no fever, and no other lumbs noticed, there are no symptoms of hyper or hypothyroidism as weight changes, heat or cold intolerance, no disturbance in the menesteral cycle ...,no other complaints, and other systems as
CVS,respiratory ,CNS....were unremarkable.
Past medical and surgical history :
No history of exposure to neck irriadiation
The patient is known D.M for 2 years on oral hypoglycemic medication (1 tab. P.O
O.D)
No other significant past medical or chronic illness as hypertension,I.H.D...
Family history :
No history of thyroid cancer or Goiter.
His father is diabetics for 10 years ago on Insulin.
No other significant family disease.
Drug history :
The patient on Doanil 5mg P.O OD.
No history of allergy to drugs or food.
Social : married, has 3 children and she is a teacher.
IN SUMMERY:
This is a 40 years old Saudi female patient admitted 2 days ago through the clinic
C\O of neck swelling for 6 months , which was small and increasing in the size by time, and no symptoms of hyper or hypo thyroidism . The patient is known D.M for 2 years on oral hypoglycemic and she did laparoscopic cholesystectomy 3 years ago.
