Chief Complaint: Reported having headaches relieved by dimming lights and resting for a few hours within the past three months coupled with instances of feeling as if she may “fall when walking, but it only happens every few weeks. ” The client has fallen twice and also complains of a “funny sensation in her feet and hands, but it goes away within a week or two. ” Present Illness: Mrs. W is a 42-year-old married woman who complains of headaches relieved by rest and dimming of lights. The client also reported having funny sensation in both hands and feet that resolves within a couple of weeks.
The client also reported of having fallen twice. Past Medical History: None noted. Family History: Grandfather had an undiagnosed disease characterized by the inability to get out of bed for several months. Obstetric History: Mrs. W is G6P6 Personal and Social History: Mrs. “W” is a 42-year-old female who has been married for 22 years. She has 6 children between the ages of 4 and 20-years old. She enjoys gardening. Mrs. “W” also volunteers at the local library for 4 hours each week and teaches a Sunday school class at her church. Additional Information Needed
It would be necessary for the nurse to inquire about the experienced headache. Ask the patient to describe in her own words what the pain is like. When does the pain start? Where does it hurt most? Does the pain seem to travel? W hat activity was she doing just prior to the headache? Also, it is important to ask if the patient feels dizzy or faint when she experiences these sensations. What does the patient do to relieve these sensations? Does the patient experience some loss of coordination? Ask the patient to describe the “funny sensations” felt at the hands and feet.
Inquire if the patient experiences other sensory problems such as dizziness and blurring of vision. Look for the presence of tremors or dysfunctional reflexes. Systems Taking into consideration the symptoms of Mrs. “W”, a thorough examination of the neurological and sensory system would be necessary to determine if the headaches are a result of acute migraines or other sensory alterations such as failing vision or another underlying disease. An assessment of the muscular system would also help determine if there is loss of function, coordination or if atrophy is present.