Case 2: Health History

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 reports experiencing a severe, pulsatile, diffuse headache yesterday. This headache was accompanied by a sudden difficulty to talk, which lasted for approximately two hours. She did not seek medical attention at the time. This morning, she woke up with no problems but is presenting today at her husband’s advice.

Past Medical History (PMH):

• Atrial Fibrillation (AFib)
• Hypertension (HTN)
• Allergy: Non-steroidal Anti-inflammatory Drugs (NSAIDs), Aspirin

Drug History (Drug Hx):

• Losartan 50 mg (for Hypertension)
• Xarelto 15 mg BID (Rivaroxaban, an anticoagulant, likely for Atrial Fibrillation)

Subjective Data Reported:

• Feels palpitations
• Joint pain with yesterday’s episode

1. What other subjective data would you obtain?

To fully understand the patient’s condition and risk factors, I would gather more detailed subjective data, specifically focusing on the headache, speech difficulty, associated symptoms, and overall health.

• Regarding the Headache:
  • Onset and Progression: Was the onset truly sudden, or did it build up? What was she doing when it started? Did it gradually resolve, or was it abrupt?
  • Characteristics: Could she describe the “pulsatile” nature more specifically (e.g., throbbing, pounding)? Was it always diffuse, or did it start in one area and spread?
  • Severity: On a scale of 0-10, what was the peak pain intensity?
  • Associated Symptoms: Did she experience any:
    • Visual changes (e.g., blurred vision, double vision, loss of vision, flashing lights, aura)?
    • Nausea, vomiting, light sensitivity (photophobia), sound sensitivity (phonophobia)?
    • Weakness, numbness, or tingling on one side of the body?
    • Dizziness, vertigo, loss of balance?
    • Changes in consciousness, confusion, or disorientation?
    • Any other neurological symptoms (e.g., difficulty understanding speech, difficulty reading/writing, facial droop)?
    • Neck stiffness?
    • Fevers or chills?
  • Aggravating/Relieving Factors: Did anything make it worse or better? Did rest help?
  • Preceding Factors: Was there any stress, specific foods, activities, or sleep deprivation before the headache?
  • Previous Headaches: Has she ever experienced a headache like this before? If so, when, and what was the outcome? How do these headaches compare to her usual headaches, if any?
• Regarding Difficulty Speaking (Dysphasia/Aphasia):
  • Exact Nature: What kind of difficulty did she have? Was it expressive (difficulty forming words, finding words) or receptive (difficulty understanding others)? Was it slurred speech (dysarthria)?
  • Onset and Duration: Confirm the sudden onset and the 2-hour duration. Was it constant for two hours, or intermittent?
  • Associated with Headache: Did the speech difficulty start at the same time as the headache, before, or after?
  • Impact: How did this affect her ability to communicate?
• Regarding Palpitations:
  • Frequency and Duration: How often does she feel them? How long do they last?
  • Character: Are they fluttering, pounding, skipped beats?
  • Associated Symptoms: Dizziness, lightheadedness, chest pain, shortness of breath, fatigue?
  • Relationship to Activity/Stress: Do they occur at rest, with exertion, or with stress?
  • Since Yesterday’s Episode: Has she felt palpitations since the episode yesterday, or just generally?
• Regarding Joint Pain:
  • Location: Which joints were affected?
  • Character: Was it aching, sharp, dull?