Physician H&P

Chief Complaint: Evaluation of acute onset severe headache and neurological deficits. History of Presenting Illness: The patient is a 55-year-old male with a known history of uncontrolled hypertension who presented to the emergency department with a sudden onset, severe headache described as the "worst headache of his life," accompanied by left-sided weakness and difficulty speaking, which began approximately 3 hours prior to arrival. The headache was throbbing in quality, rated 9/10 in severity, and radiated to the neck. There were no specific provoking factors mentioned. He also experienced a brief episode of blurred vision prior to the onset of motor deficits. In the emergency department, the patient received IV fluids (Normal Saline 1L) and analgesia (Paracetamol 1g IV) with minimal improvement in headache. A head CT scan was performed, revealing an acute right temporoparietal intraparenchymal haemorrhage with significant surrounding oedema and midline shift. Given the severity of the neurological deficits and imaging findings, the patient was admitted to the ward for inpatient neurological management and further evaluation. Past Medical History: Hypertension (diagnosed 10 years ago, poorly controlled) Hyperlipidaemia (on statin therapy) Previous appendectomy (childhood) Home Medications: Amlodipine 10 mg daily Hydrochlorothiazide 25 mg daily Atorvastatin 20 mg daily Allergies: Penicillin (rash) Social History: Married, lives with wife and two adult children. Works as a retired engineer. Smokes 10 pack-years, quit 5 years ago. Occasional alcohol use (1-2 units per week). Denies illicit drug use. Has access to private medical aid. Family History: Father died of myocardial infarction at age 60. Mother has type 2 diabetes and hypertension. Paternal uncle had a stroke at age 65. Review of Systems: Constitutional symptoms: Denies weight change, fever, chills, night sweats. Reports mild fatigue since headache onset. Eyes: Reports transient blurred vision prior to headache. No eye pain, redness, or discharge. Ears, Nose, Mouth, Throat: Denies ear pain, nasal congestion, sore throat. Cardiovascular: Denies chest pain, shortness of breath, orthopnoea, palpitations. Respiratory: Denies cough, sputum, dyspnoea, wheezing. Gastrointestinal: Denies nausea, vomiting, diarrhoea, abdominal pain. Genitourinary: Denies dysuria, frequency, flank pain, vaginal symptoms. Musculoskeletal: Denies joint pain, back pain, stiffness. Skin: Denies rash, skin lesions, itching. Neurological: Reports left-sided weakness, difficulty speaking (aphasia), severe headache. Denies numbness, falls, confusion. Psychiatric: Denies anxiety, mood symptoms, hallucinations, suicidal ideation. Endocrine: Denies polyuria, polydipsia, heat or cold intolerance. Hematologic/Lymphatic: Denies easy bruising, bleeding, swollen glands. Allergic/Immunologic: History of penicillin allergy. No known autoimmune conditions. Physical Exam: Findings from vitals: Temperature 37.1°C, BP 180/100 mmHg, Pulse 98 bpm, RR 18 bpm, SpO₂ 97% on room air, Weight 85 kg. Findings from general and system-specific physical examination: General: Appears acutely unwell, in mild distress due to headache. Neurological: GCS 14 (E4V4M6). Pupils equal and reactive to light. Left facial droop. Left upper and lower limb weakness (power 2/5). Deep tendon reflexes brisk symmetrically. Plantar reflexes flexor bilaterally. Expressive aphasia noted. Cranial nerves otherwise intact. Cardiovascular: Regular rhythm, no murmurs. Respiratory: Clear to auscultation bilaterally. Abdomen: Soft, non-tender, no organomegaly. Lab Results: Full Blood Count: WCC 10.5 x 10^9/L, Hb 14.2 g/dL, Platelets 250 x 10^9/L. Urea/Electrolytes: Urea 5.6 mmol/L, Creatinine 88 µmol/L, Na 138 mmol/L, K 4.1 mmol/L. Liver Function: ALT 30 U/L, AST 25 U/L, ALP 80 U/L, Bilirubin 10 µmol/L. Coagulation profile: PT 11.5s, APTT 30s, INR 1.0. Imaging Results: Head CT (1 November 2024): Acute right temporoparietal intraparenchymal haemorrhage measuring approximately 4 cm x 3 cm, with associated significant perilesional oedema causing 5 mm leftward midline shift. No evidence of hydrocephalus. Underlying chronic microangiopathic changes noted. Assessment/Plan: 1. Acute Intracerebral Haemorrhage (ICH) secondary to uncontrolled hypertension Impression, likely diagnosis for Issue 1: Acute Intracerebral Haemorrhage Differential diagnosis for Issue 1: Ischaemic stroke with haemorrhagic transformation, AVM rupture, Aneurysmal rupture (less likely given location) Investigations planned for Issue 1: CT Angiography of brain, Repeat Head CT in 24 hours, ECG, Cardiac enzymes, Lipid panel. Treatment planned for Issue 1: Strict blood pressure control (goal SBP <140 mmHg) using IV labetalol; Neurological monitoring; Head of bed elevation 30 degrees; Seizure prophylaxis with levetiracetam; Neurosurgery consultation for evaluation of potential intervention. Relevant referrals for Issue 1: Neurosurgery, Physical Therapy, Occupational Therapy, Speech and Language Therapy. 2. Uncontrolled Hypertension Impression, likely diagnosis for Issue 2: Chronic uncontrolled hypertension contributing to ICH. Investigations planned for Issue 2: 24-hour ambulatory blood pressure monitoring post-discharge. Treatment planned for Issue 2: Optimise antihypertensive regimen; Patient education on medication adherence and lifestyle modifications. Two Midnight Documentation: The patient's stay will likely span more than 2 midnights in the hospital because of the severity of illness. Time Spent: 30 minutes