History of Present Illness
A 49 y.o. woman, accompanied by her husband, comes into the primary care clinic complaining of a significant headache since that morning. Patient describes the headache as 8/10 and states that it started suddenly this morning after she attended a breakfast at the garden club. While she was sitting at the table, she felt an urge to have a BM, went to the bathroom, and returned to the table. Shortly after that, her HA started. She states she felt nauseous, but there was no vomiting. She drove home and tried to lie down.
Past Medical/Surgical History
Remarkable for two normal pregnancies with uncomplicated deliveries
Denies any prior surgeries
Nasacort and Allegra for seasonal allergies
Paxil for menopause symptoms
Ca+ and Vitamin D
Denies illicit drug use, tobacco use; occasional ETOH consumption.
General: Patient appears uncomfortable due to HA, but not in acute distress.
Vital Signs: BP 150/80 (high for her), HR 78, RR 20
HEENT: Head normal on inspection, without any areas of tenderness. Ears, nose, and throat clear. Pupils both small at 2 mm but reactive to light. Symmetrical extra-ocular movements and no nystagmus. Slight photophobia. Fundi and optic discs appear normal. No masses detected on examination of neck, no carotid bruits. Mild nuchal rigidity.
CV: Heart RR&R.
Abdomen soft and non-tender.
Respiratory: Lungs clear to auscultation bilaterally and normal respiratory effort.
Neuro: Patient fully alert, oriented, and calm. CNs intact. Motor strength symmetrical, with brisk and symmetric deep tendon reflexes without clonus. Cerebellar function and sensory systems normal.
Case Study Discussion – Part I:
Identify three conditions that you would consider in your differential diagnosis, with the most likely condition listed first. Provide rationale for each differential with supporting evidence from the case study.
What further history should be considered in order to explore your differential diagnosis and confirm your suspicions?