Client Presenting Case

Client Presenting Case

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

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.

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Atrial Fibrillation, Hypertension. Is allergic to Non-steroidal Anti-inflammatory drugs Aspirin

Losartan 50 mg

Xarelto 15 mg BID

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.

Client Presenting Case

CTA AP&L

Irregular heart beat with normal rate

No tenderness normoactive bowel sounds x 4;

Client Presenting Case

Non contributory

intact without lesions masses or rashes.

No obvious deficits and CN grossly intact II-XII

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Answer Questions:

  1. What other subjective data would you obtain?
  2. What other objective findings would you look for?
  3. What diagnostic exams do you want to order?
  4. Name 3 differential diagnoses based on this patient presenting symptoms?
  5. Give rationales for each differential diagnosis.
  6. What teachings will you provide?

Client Presenting Case

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.
  • Please include introduction and conclusion paragraphs
  • Please write in paragraph form, no bullet points
  • Incorporate a minimum of 2 current (published within the last five years) scholarly journal articles or primary legal sources (statutes, court opinions) within your work. Journal articles should be referenced according to the current APA style (the online library has an abbreviated version of the APA Manual).
  • Please ensure APA formatting is correct
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