17 Aug History of Present Illness (HPI)
Case 2
Case 2
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.
PMH
Atrial 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
VS
B/P 131/80; temperature 98.2°F; (RR) 18; (HR) 84, irregular; oxygen saturation (PO2) 96%;
General
well-developed female, no acute distress
HEENT
Atraumatic, normocephalic, PERRLA, EOMI, conjunctiva and sclera clear; nares patent, nasopharynx clear, good dentition.
Lungs
CTA AP&L
Card
Irregular heart beat with normal rate
Abd
No tenderness normoactive bowel sounds x 4;
Rectal exam
Non contributory
Integument
intact without lesions masses or rashes.
Neuro
No obvious deficits and CN grossly intact II-XII
Once you received your case number, answer the following questions:
- 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 presenting symptoms?
- Give rationales for your each differential diagnosis.
- What teachings will you provide?
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