Brad Banerjee New iHuman Case latest update

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This is a 31 year old male with a past medical history significant for untreated hypertension for 2 years, a recent smoker who quit 2 weeks ago and 2 days ago visited the ED with a right-sided heada... che and vertigo symptoms with Excedrin and Tylenol as the treatment plan for which he states has not helped. He presents today with the chief compliant of a sudden onset, deep, sharplike pain right-sided headache rated 6/10. He denies a history of migraines and in fact a history of any types of headaches. He states he rarely has headaches and has never had a headache like this before. This began 2 days ago while sitting at his desk at work when he felt this sharp pain suddenly. He also states when he stood up from his desk the “room was spinning” or he was spinning” and had to sit back down to keep from falling. The onset of vertigo began immediately after he felt the sharp pain in his head and has been constant ever since. He states moving his head and standing makes it worse and lying down and not moving makes it a little better. Yesterday he noticed a gradual onset of double vision which has not changed since it has started. He has moderate nausea that started around the same time as the other complaints did 2 days ago, however he denies vomiting. Also, last night he started hiccupping and it has not stopped. He has noticed that over the course of the past 2 days the right side of his face and left hand “feels strange” and his left leg “feels heavy”. He states he cannot walk without help, he stumbles from side to side, and he is consistently falling to the left side. Problem Statement: This is a 31 year old male with a past medical history significant for untreated hypertension for 2 years, a recent smoker who quit 2 weeks ago and 2 days ago visited the ED with a right-sided headache and vertigo symptoms with Excedrin and Tylenol as the treatment plan for which he states has not helped. He presents today with the chief compliant of a sudden onset, deep, sharplike pain right-sided headache rated 6/10. This began 2 days ago while sitting at his desk at work when he felt this sharp pain suddenly. He also states when he stood up from his desk the “room was spinning” or he was spinning” and had to sit back down to keep from falling. Other HPI complaints: Nausea; decreased appetite; right-side face and hand feels "strange; leftleg heaviness-having trouble walking; hiccups PE: pink conjunctiva, nystagmus, + romberg test, sitting ataxia-falling to the right PE-CHART eyes: nystagmus noted, conjunctiva pink, sclerae non-icteric, pupils equal round and reactive to light and accommodation, no drainage or discharge Musc: moves all extremities, normal bulk and tone, no rigidity, normal stability, asymmetric strength, weak left hand grip and left leg raise Neuro: Awake, alert, and fully oriented, cranial nerves I-XII intact, sensory grossly normal to touch and pin prick, deep tendon reflexes symmetrical 2+ throughout, no involuntary movements noted; broad-based stance & gait w/ falling toward right and sitting ataxia with falling to the right noted, + romberg's test [Show More]

Last updated: 1 year ago

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