History of Present Illness (HPI)
The patient is a 38-year-old female who was involved in a car accident 14 days ago. She reports that a stop sign was blown down, and they were traveling at a high speed. The car flew into the air, and she lost consciousness. She mentions that she was drinking at the time of the accident, but the driver was not. Since the accident, she has been experiencing nausea. She also reports having severe headaches (10/10) that have occurred only twice in the last two days.
Differential Diagnosis
- Single Most Likely Diagnosis
- Post-Concussive Syndrome: Given the patient's history of a car accident, loss of consciousness, and symptoms of nausea and severe headaches, post-concussive syndrome is a likely diagnosis. This condition is characterized by a range of symptoms that can occur after a head injury, including headaches, dizziness, nausea, and cognitive difficulties.
- Other Likely Diagnoses
- Post-Traumatic Stress Disorder (PTSD): The patient's experience of a traumatic event, such as a car accident, increases her risk of developing PTSD. Symptoms of PTSD can include flashbacks, nightmares, and severe anxiety, as well as physical symptoms like headaches and nausea.
- Whiplash or Cervical Strain: The patient's report of a high-speed car accident and loss of consciousness suggests that she may have suffered a whiplash or cervical strain injury. This can cause symptoms like headaches, neck pain, and nausea.
- Do Not Miss Diagnoses
- Subdural Hematoma or Other Intracranial Hemorrhage: Although the patient's symptoms may seem mild, it is essential to consider the possibility of an intracranial hemorrhage, particularly given her history of loss of consciousness and severe headaches. This is a life-threatening condition that requires immediate medical attention.
- Cervical Spine Fracture or Instability: The patient's report of a high-speed car accident and loss of consciousness increases her risk of a cervical spine fracture or instability. This is a potentially life-threatening condition that requires prompt diagnosis and treatment.
- Rare Diagnoses
- Arteriovenous Malformation (AVM) or Other Vascular Anomalies: Although rare, it is possible that the patient's headaches and nausea are symptoms of an underlying vascular anomaly, such as an AVM. This is a condition that requires prompt medical attention to prevent further complications.
- Chronic Subdural Hematoma: This is a rare condition that can occur after a head injury, particularly in older adults or individuals with a history of bleeding disorders. It is essential to consider this diagnosis in patients with a history of head trauma and persistent or worsening symptoms.