D5 Chief Complaint: “I had a severe headache yesterday with difficulty to speak”   History Of Prese

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Asked by cmois006128

D5

Chief Complaint:

“I had a severe headache yesterday with difficulty to speak”

History Of Present Illness:

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 Data:

Feels Palpitations, joint pain with yesterday’s episode

Objective Data:

B/P 131/80; temperature 98.2°F;  (RR) 18;  (HR) 84, irregular; oxygen saturation (PO2) 96%;

well-developed female, no acute distress

Atraumatic, normocephalic, PERRLA, EOMI, conjunctiva and sclera clear; nares patent, nasopharynx clear, good dentition.

CTA AP&L

Irregular heart beat with normal rate

No tenderness normoactive bowel sounds x 4;

Non contributory

intact without lesions masses or rashes.

No obvious deficits and CN grossly intact II-XII

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?

Please include references

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