Learning Goal: I’m working on a nursing case study and need an explanation and answer to help me learn.
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?
Submission Instructions:
- Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources.
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