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 symp
...
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. 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.
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