Chief Complaint
(CC) “I had a severe headache yesterday with difficulty to speak”
History of Present Illness (HPI)A 64-year-old African American female who reports having a severe pulsatile diffuse headache yesterday with sudden difficulty to talk with last for about two hours. She did not seek medical attention. This morning she woke up with no problems but is here today due her husband advise.
PMHAtrial Fibrillation, Hypertension. Is allergic to Non-steroidal Anti-inflammatory drugs Aspirin
Drug Hx
Losartan 50 mg
Xarelto 15 mg BID
Subjective
Feels Palpitations, joint pain with yesterday’s episode
Objective Data
VSB/P 131/80; temperature 98.2°F; (RR) 18; (HR) 84, irregular; oxygen saturation (PO2) 96%;
Generalwell-developed female, no acute distress
HEENTAtraumatic, normocephalic, PERRLA, EOMI, conjunctiva and sclera clear; nares patent, nasopharynx clear, good dentition.
LungsCTA AP&L
AbdNo tenderness normoactive bowel sounds x 4;
Rectal examNon contributory
Integumentintact without lesions masses or rashes.
NeuroNo obvious deficits and CN grossly intact II-XII
Your initial post should be at least 500 words, formatted and cited in the current APA style with support from at least 2 academic sources other than your textbook. Your initial post is worth 8 points.
What other subjective data would you obtain?
What other objective findings would you look for?
What diagnostic exams do you want to order?
Name 3 differential diagnoses based on this patient’s presenting symptoms.
Give rationales for each differential diagnosis.
What teachings will you provide?
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