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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