Case Scenario: Ms. Jones is a 78-year old woman who presents to your clinic complaining of headache and right arm weakness.
Vital signs: BP 168/95 mmHg; HR 90 bpm, regular; RR 16 rpm; Temp 99.2°F
Differential Diagnoses: List at least 4 differential diagnoses that should be included for the above chief complaint.
- Subarachnoid hemorrhage
- Cerebral Venous Thrombosis
- Subdural hematoma
- Acute hypertension
History: Use the space below to list the questions you would ask to obtain a full history of present illness (HPI).
- When did the headache start?
- How frequently does the headache occur?
- How severe is the pain?
- What are the characteristics of the headache?
- Where is the pain located? Is it localized or does it radiate?
- Any previous history of headache?
- What are characteristics of past headaches?
- Any recent history of trauma/injury?
- When did the trauma/injury occur?
- Any associated symptoms from the recent injury such as nausea, vomiting, or loss of consciousness?
- Is there any triggering factors such as:
- Any associated signs and symptoms such as:
- Change in appetite
- Did you notice any mood or personality changes?
- Any recent infection or history of immunocompromise?
- Any family history of heart or neurologic problems?
- Do you have any muscle aches or pains, particularly in the neck and shoulder?
- Can you walk normally?
- Do you have any numbness in any part of your body?
- Do you feel any weakness in any part of your body?
- Can you move your arms and legs normally?
- Epidemiologic factors:
- Do you currently smoke?
- How many packs of cigarette in a day?
- When did you start smoking
- If not smoking, did you have a history of being a smoker? If yes, how many packs a day and for how many years?
- Do you currently smoke?
- Alcohol consumption
- What are your current medications?
- Type of medications
- When did you start taking these medications?
- Vital signs
- BP 168/95 mmHg
- HR 90 bpm, regular
- RR 16 rpm
- Temp 99.2°F
- Decreased level of consciousness or alertness
- Cranial nerve testing – to determine space-occupying lesions
- Loss of balance or coordination
- Severe headache
- Mood changes
- Vision problems such as double vision, temporary loss of vision or blind spots
- Anisocoria or difference in size of pupils
- Stiff neck
- Opisthotonos or sudden stiffening of both back and neck along with arching of the back
- Hemiparesis or weakness of a limb
- Difficulty speaking or aphasia
Diagnosis: Subarachnoid Hemorrhage
- Laboratory tests
- Chemistry panel – to establish baseline data and to compare current result to tests that were previously taken.
- Complete blood count – to evaluate possible infection or detect any hematologic abnormalities.
- Prothrombin time and activated partial thromboplastin time – to determine possible clotting problems
- Blood screening and typing – to determine blood type and in preparation for possible use, particularly if patient will undergo surgery.
- Cardiac enzymes – to detect any cardiac problems or ischemia
- Arterial blood gas – essential in patients who have decreasing level of consciousness and who are at risk for pulmonary compromise.
- Imaging test
- Computed Tomography Scan without contrast
CT Scan without contrast, within 6 hours of onset, is the most sensitive method to detect subarachnoid hemorrhage. However, sensitivity of this imaging test declines with the time from onset. The CT scan of the brain provides information about the location and prognosis of the bleed.