Severe headache

Date: 2024-07-04

Admitting Physician: Dr. Michael Lee, MD

Chief Complaint: Severe headache

HPI:

The patient is a 45-year-old female presenting with a sudden onset of severe headache described as "the worst headache of her life." The pain is diffuse and associated with photophobia and nausea. The patient has no history of similar headaches.

ROS:

• Neurological: Severe headache, photophobia.
• Cardiovascular: No chest pain, no palpitations.
• Respiratory: No cough, no dyspnea.
• Gastrointestinal: Nausea present, no vomiting.

PFSH:

• Past Medical History: Migraine headaches.
• Family History: No relevant family history.
• Social History: Non-smoker, no alcohol use.

Physical Examination:

• Vital Signs: BP 145/95, HR 95, RR 18, Temp 98.6°F.
• Neurological: Alert, oriented, photophobia present, no focal deficits.
• Cardiovascular: S1, S2 normal.
• Respiratory: Clear to auscultation bilaterally.

MDM:

• CT scan of the head shows subarachnoid hemorrhage.
• Lumbar puncture confirms elevated opening pressure.
• Diagnosis: Subarachnoid hemorrhage.

Plan:

• Admit to neurology intensive care unit (NICU).
• Start nimodipine.
• Consult neurosurgery.