Case 2i: Had A Severe Headache Yesterday With Difficulty Swa

Case 2i Had A Severe Headache Yesterday With Difficulty To Speaka 64

Case 2 “I had a severe headache yesterday with difficulty to speak”—a 64-year-old African American female reports experiencing a severe pulsatile, diffuse headache accompanied by sudden difficulty speaking that lasted approximately two hours. The patient did not seek immediate medical attention at the time but was brought to the clinic the following day upon her husband's advice. Her past medical history includes atrial fibrillation (AFib) and hypertension (HTN). She reports being allergic to non-steroidal anti-inflammatory drugs (NSAIDs) and aspirin. Her current medications include Losartan 50 mg and Xarelto 15 mg BID. She also reports experiencing palpitations and joint pain following her episode. On examination, her vital signs include a blood pressure of 131/80 mm Hg, temperature 98.2°F, respiratory rate of 18 breaths per minute, and an irregular pulse rate of 84 beats per minute. Oxygen saturation is 96%. The patient appears well-developed, in no acute distress, and has a normocephalic head without evident trauma. Her pupils are equal, round, and reactive to light and accommodation (PERRLA), with extraocular movements intact (EOMI), and her conjunctiva and sclera are clear. Nares are patent, and her oropharynx reveals good dentition with no signs of infection or lesions. Cardiac examination shows an irregular rhythm with a normal rate, and no tenderness on palpation. Gastrointestinal assessment indicates normoactive bowel sounds in all four quadrants, and the abdomen is soft, non-distended, without palpable masses, lesions, or rashes. Neurological assessment finds no obvious deficits; cranial nerves II-XII are grossly intact.

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The patient's presentation of a sudden, severe, pulsatile headache combined with transient speech difficulties warrants a thorough evaluation for cerebrovascular events, particularly ischemic or hemorrhagic stroke. Her medical history features atrial fibrillation and hypertension—both significant risk factors for stroke (Benjamin et al., 2019). Atrial fibrillation predisposes patients to cardioembolic stroke due to the formation of thrombi within the atria, which can dislodge and occlude cerebral arteries (Kamel & Healey, 2017). Hypertension remains the most prevalent modifiable risk factor for both ischemic and hemorrhagic strokes (O'Donnell et al., 2016). The episode's duration and the symptom profile suggest a transient ischemic attack (TIA), although actual stroke cannot be ruled out without further diagnostic testing.

Her pharmacological regimen, including Losartan and Xarelto, indicates ongoing management of her hypertension and atrial fibrillation respectively. Xarelto (rivaroxaban), a direct oral anticoagulant, reduces stroke risk in atrial fibrillation patients by inhibiting coagulation factors (Patoj et al., 2018). Nonetheless, anticoagulation increases bleeding risk, which is pertinent considering the concern for intracranial hemorrhage in her presentation.

In evaluating her condition, neuroimaging is essential. A non-contrast computed tomography (CT) scan of the head is typically the initial modality used to rule out hemorrhage, which could explain a severe headache (Powers et al., 2018). If initial CT is inconclusive and suspicion remains high for ischemic stroke, magnetic resonance imaging (MRI) with diffusion-weighted imaging (DWI) offers increased sensitivity for early ischemia. Carotid duplex ultrasound and echocardiography with bubble studies might also be indicated to identify embolic sources.

Her vital signs, including a blood pressure of 131/80 mm Hg and oxygen saturation of 96%, are relatively stable, but the irregular pulse warrants further cardiac evaluation. An electrocardiogram (ECG) can identify ongoing atrial fibrillation or other arrhythmias, and telemetry monitoring can detect paroxysmal episodes. Given her history and current presentation, controlling her blood pressure and rate in her atrial fibrillation is crucial to reducing future cerebrovascular events (Benjamin et al., 2019).

The management of her acute presentation involves stabilization and prompt investigation. If imaging confirms ischemic stroke, thrombolytic therapy with tissue plasminogen activator (tPA) could be considered within the appropriate therapeutic window, assuming no contraindications such as bleeding (Powers et al., 2018). For suspected hemorrhagic stroke, neurosurgical or neurology interventions are necessary. Post-stroke care should incorporate anticoagulation management, blood pressure control, and secondary prevention strategies, including lifestyle modifications and medication adherence.

Furthermore, addressing her reported palpitations and joint pains may involve further cardiological assessment to evaluate possible atrial fibrillation episodes or other arrhythmias that contribute to her stroke risk. It is also essential to review her medication regimen to ensure optimal control while minimizing bleeding risk, especially given her anticoagulation therapy. Patient education about recognizing stroke symptoms and seeking immediate medical attention is critical.

In conclusion, her presentation underscores the importance of rapid assessment and intervention in patients with transient neurological symptoms and high stroke risk factors. An interdisciplinary approach involving neurology, cardiology, and primary care is vital to optimize outcome and prevent recurrent cerebrovascular events.

References

• Benjamin, E. J., Muntner, P., Alonso, A., et al. (2019). Heart Disease and Stroke Statistics—2019 Update: A Report From the American Heart Association. Circulation, 139(10), e56–e528.
• Kamel, H., & Healey, J. S. (2017). Cardioembolic Stroke. Circulation Research, 120(3), 514–526.
• O'Donnell, M. J., Chin, S. L., Rangarajan, S., et al. (2016). Global and regional effects of potentially modifiable risk factors associated with acute stroke in 32 countries (INTERSTROKE): a case-control study. The Lancet, 388(10054), 761–775.
• Patoj, A., Vasireddy, S., & Shetty, A. K. (2018). Rivaroxaban: A Review of Pharmacology and Clinical Data. Clinical Therapeutics, 40(8), 1340–1349.
• Powers, W. J., Rabinstein, A. A., Ackerson, T., et al. (2018). Guidelines for the Early Management of Patients With Acute Ischemic Stroke. Stroke, 49(3), e46–e110.